This study examined HIV testing and its relationship to healthcare utilization among a sample of young African-American men at risk for HIV acquisition. Participants were recruited from areas with locally high rates of HIV (approximately 0.5% overall, but up to 1.6% in young adults) and 4% of the surveyed men reported being HIV-positive (these men were excluded from the analyses). This study found that approximately half of the men reported being tested during the prior 12 months. This rate is greater than the 22% to 41% rates found in many national surveys involving young African-American men recruited from the general population.29–31
This finding may be due to either an increased awareness of HIV risk on the part of these men who were recruited from a geographic location with an elevated HIV prevalence or an increased awareness by the healthcare providers serving this population of men.
Many respondents’ sexual behaviors placed them at risk for HIV acquisition: 70% reported engaging in unprotected intercourse in the prior 12 months, 52% had multiple sex partners, and 27% reported unprotected sex with multiple partners. In light of this relatively high HIV risk, the study population would be an appropriate target for structural interventions to increase HIV testing. Our examination of these men’s HIV testing patterns, preferences for HIV testing sites, and perceived barriers to testing could help inform the design of such interventions.
This study highlights the fact that attempts to increase HIV testing will require a multifaceted approach. First, despite known barriers to healthcare access among African-American men, a significant proportion of the inner-city men surveyed reported contact with the healthcare system. Having any healthcare encounter, having a primary care doctor, and having a primary doctor recommend an HIV test were all associated with receiving testing. Among those associations, however, a doctor’s recommendation was the strongest. Therefore, expanding HIV testing into all aspects of the healthcare system and instituting routine and universal HIV screening may result in increased testing rates. Such changes would capitalize on the association between a doctor’s recommendation and the receipt of HIV testing, thus increasing the likelihood of testing, even among those individuals who do not specifically intend to be tested for HIV or actively seek HIV testing.
Encouraging healthcare visits among those who have access to the healthcare system and increasing access among those currently without access could further enhance testing rates. Improving providers’ skill and comfort recommending HIV testing may also result in increased testing rates. The strong influence that doctors’ recommendations have on testing should be made known to primary and other providers. Higher-level interventions could be directed toward changing policies to routinize HIV testing at clinics serving populations with an elevated HIV prevalence.
Our findings also confirmed the suboptimal results that have been shown with risk-based testing.16
In our study, doctors did not recommend testing more often to those men at higher risk for HIV. Barriers that prevent doctors from obtaining risk information from patients and recommending HIV tests need to be studied, especially in light of the more streamlined HIV testing process that is currently recommended.18
Second, study participants indicated a strong preference for HIV testing in medical settings, especially doctors’ offices, public health clinics, and hospitals. This finding held true even among those who previously had not been tested and those who did not have a primary doctor. One method of utilizing these findings, for example, would be to offer free, rapid HIV tests in currently established medical settings without requiring a visit with a healthcare provider. Tests could be offered on a walk-in basis at hospitals and clinics, performed by the trained staff of that facility. This model could allow access to testing to those without insurance, those without a primary physician, and those who do not otherwise wish to see a physician. This strategy would utilize the stability and reputation of existing healthcare centers within communities, while simplifying the testing process. The cost of testing and the potential for reimbursement would need to be considered. On-site, rapid testing would avoid some of the costs and difficulties associated with outreach testing, such as the transportation of staff and equipment, the logistical challenges of securing appropriate outreach facilities, and the advertising necessary to promote testing at impermanent sites. In addition, on-site testing could facilitate easier connection to HIV-specific medical care and social or legal services for those who test positive, provide a gateway to primary medical care for those who test negative, and raise awareness of HIV among the staff of those facilities.
Finally, although these men reported a relatively low rate of testing in community settings, community-based testing remains a feasible way to expand testing capacity. Some community testing sites may be underutilized, such as community centers, drugstores, or churches. These sites were acceptable to the majority of men in this study, especially among those who did not have a primary doctor. Utilizing community venues may reduce some logistical barriers associated with healthcare facility-based testing for some individuals, such as service hours, proximity, and cost, barriers to health-seeking behavior identified among African Americans.32
In addition, providing testing opportunities in community settings would be another method to reach those persons who would accept HIV testing if they encountered a testing site, but who might not specifically seek testing.
There are several limitations to this research study. Study data were collected using a self-administered, pen-and-paper survey tool. The survey included questions about some activities that may be stigmatized, hence underreported, such as anal sex with other men. In addition, the survey did not include items assessing HIV-related knowledge or previous or future testing intentions. Regarding testing site preferences for future testing, “hospital” was the most common response. However, no distinction was made regarding particular departments within a hospital. Therefore, it remains unclear whether, for instance, testing in an emergency department was more desirable than other hospital departments. Furthermore, no distinction was made in this question to determine whether participants would be tested if they were already at a particular location or whether they would intentionally seek testing at that location.
Study data were collected only during daytime hours, which may have limited participation by men with daytime employment. Whether the findings of this study can be generalized to a population of employed individuals is unclear. Finally, recruitment was done outside of drugstores, which may have biased the sample toward individuals with health-seeking behavior. However, any individuals walking past the recruitment sites were approached for recruitment. Therefore, it is unclear how many individuals were planning to enter the stores.
In summary, the present study found higher HIV testing rates than those reported in many previously published studies. The majority of persons tested for HIV were tested at doctors’ offices and the results of the location preference items indicated that an overwhelming majority of participants would be willing to be tested in doctors’ offices or other traditional healthcare settings. HIV testing was associated with healthcare visits, having a primary doctor, having a history of an STD, and most strongly with a primary doctor’s recommendation for HIV testing. Still, a substantial proportion of persons were not tested for HIV, even if they had been seen by a doctor. Study findings suggest that the proportion of the population tested for HIV within the healthcare system could be increased by encouraging providers to recommend HIV tests when appropriate. Until such time when all persons have access to the healthcare system and HIV testing is offered universally and routinely, other strategies, such as offering HIV testing at healthcare facilities without a doctor visit or at conveniently located and accessible community venues may enhance HIV testing rates.