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Testing for HIV and other sexually transmitted diseases (STD) remains a cornerstone of public health prevention interventions. This analysis was designed to explore the frequency of testing, as well as health system and personal barriers to testing, among a community-recruited sample of Black men who have sex with men (MSM) at risk for HIV and STDs. Black MSM (n=197) recruited via modified respondent-driven sampling between January and July 2008 completed an interviewer-administered assessment, with optional voluntary HIV counseling and testing. Logistic regression procedures examined factors associated with not having tested in the 2 years prior to study enrollment for: (1) HIV (among HIV-uninfected participants, n=145) and (2) STDs (among the entire mixed serostatus sample, n=197). The odds ratios and their 95% confidence intervals obtained from this analysis were converted to relative risks. (1) HIV: Overall, 33% of HIV-uninfected Black MSM had not been tested for HIV in the 2 years prior to study enrollment. Factors uniquely associated with not having a recent HIV test included: being less educated; engaging in serodiscordant unprotected sex; and never having been HIV tested at a community health clinic, STD clinic, or jail. (2) STDs: Sixty percent had not been tested for STDs in the 2 years prior to study enrollment, and 24% of the sample had never been tested for STDs. Factors uniquely associated with not having a recent STD test included: older age; having had a prior STD; and never having been tested at an emergency department or urgent care clinic. Overlapping factors associated with both not having had a recent HIV or STD test included: substance use during sex; feeling that using a condom during sex is “very difficult”; less frequent contact with other MSM; not visiting a health care provider (HCP) in the past 12 months; having a HCP not recommend HIV or STD testing at their last visit; not having a primary care provider (PCP); current PCP never recommending they get tested for HIV or STDs. In multivariable models adjusting for relevant demographic and behavioral factors, Black MSM who reported that a HCP recommended getting an HIV test (adjusted relative risk [ARR]=0.26; p=0.01) or STD test (ARR=0.11; p=0.0004) at their last visit in the past 12 months were significantly less likely to have not been tested for HIV or STDs in the past 2 years. Many sexually active Black MSM do not regularly test for HIV or STDs. HCPs play a pivotal role in encouraging testing for Black MSM. Additional provider training is warranted to educate HCPs about the specific health care needs of Black MSM, in order to facilitate access to timely, culturally competent HIV and STD testing and treatment services for this population.
With the HIV and sexually transmitted diseases (STD) epidemics continuing for the foreseeable future, HIV and STD testing are an important part of strategies designed to decrease the rates of new infections. Not only can HIV testing lead to early diagnosis and access to treatment and prevention services,1,2 but knowledge of serostatus can positively affect a variety of health behaviors, including enhanced self-care and reduced sexual risk-taking.3–7 HIV testing is a particular public health concern among men who have sex with men (MSM), who continue to be the group at greatest risk for HIV in the United States.8 Although rates of HIV testing among MSM have been shown to be as high as 60% to 88%,9–11 suboptimal rates of testing among MSM remain common after engaging in risk-taking behavior.12
MSM are even less likely to be tested for STDs than HIV. Data from the National HIV Behavioral Surveillance System demonstrated that among a venue-based sample of 10,030 MSM, 39% and 36% had been tested for syphilis and gonorrhea in the past year, respectively.13 Johnson and colleagues14 found that whereas 81% of MSM has been recently tested for HIV, only 61% had been screened for STDs. Similar results were found in another sample of MSM in Massachusetts.15 In light of recent increases in syphilis and drug-resistant gonorrhea among MSM,16–18 research on STD testing behavior is timely.
While black MSM appear equally or more likely than other MSM to get tested for HIV in some studies,19–22 other research suggests that, compared to other MSM, Black MSM are tested less frequently and are less likely to be aware of their HIV infection.19,21,23–25 Recently, the Centers for Disease Control and Prevention (CDC) found that 67% of Black MSM were unaware of their HIV infection, compared to 48% of Latino MSM and 18% of White MSM.19 In a study of 5649 young MSM ages 15 to 29, MacKellar and colleagues25 reported as many as 91% of HIV-infected Black MSM were unaware of their infection. Given that Black men bear a disproportionate burden of incident HIV and STDs and male-to-male sexual contact is the primary transmission category,8,16 these infrequent testing behaviors and high rates of unrecognized infections among Black MSM are a source of concern, and may partially explain the increased HIV prevalence and incidence among Black MSM compared to other MSM in general.
Numerous studies have sought to explain differential rates of HIV testing among MSM. The likelihood of testing has been associated with a variety of sociodemographic and behavioral factors, including younger age,26–30 gay sexual orientation,31,32 disclosure of sexual identity to health care provider,33 social support,32,34–37 sexual risk behavior,5,31,34,37–41 and drug behavior,34,36 as well as knowledge of and access to a comfortable testing site.15,32,35,37 Rates of HIV testing have also been shown to differ by partner type.32,35–37 MSM with a main male partner are more likely to get tested for HIV than those with no main partner.32,36 Sumartojo and colleagues37 demonstrated that rates of HIV testing increased with greater sexual risk with main partners, but were lowest among men engaging in risk behavior with casual partners.
Correlates of testing for STDs other than HIV have received less attention but, like HIV testing, STD testing among MSM has been associated with younger age, minority race, gay orientation, disclosure of sexual identity to health care provider, sexual risk, and alcohol and substance use.13–15,42 Studies also suggest that MSM may not screen for HIV and STDs due to perceived low risk for infection and fear of a positive result, as well as concerns over test access, affordability, and confidentiality.15,19,43–45
Few studies to date, however, have examined HIV and STD testing with exclusively Black MSM samples. Mashburn and colleagues35 found that among Black MSM, recent sex with both main male partners and nonmain male partners was associated with higher rates of testing than sex with nonmain partners only. Wilton42 reported that among a sample of 481 mixed HIV serostatus Black gay and bisexual men, nearly all of them (91%) indicated previous HIV testing and 83% indicated previous STD testing. Moreover, alcohol use before or during sex was associated with being tested for an STD but not HIV.42
The current study examined HIV testing experience among HIV-uninfected Black MSM in Massachusetts, and STD testing experience among mixed serostatus Black MSM. The primary objectives were to: 1) determine the frequency of HIV and STD testing in the sample, and 2) investigate the association of sexual risk, substance use, and other behavioral factors with not testing for HIV or STDs in the two years prior to study enrollment. Identifying the Black MSM at highest risk for not getting tested for HIV or STDs and additional factors associated with not testing may help inform how to tailor HIV prevention and intervention strategies for this population.
Between January and July 2008, 197 participants were recruited via modified respondent-driven sampling,14,15,46 and completed a quantitative assessment with a trained interviewer, which included open-ended questions, and were offered voluntary HIV counseling and testing. The study was a joint collaboration between Fenway Community Health,47 the Multicultural AIDS Coalition (MAC), the Justice Resource Institute (JRI), and the Massachusetts Department of Public Health (MDPH) Office of HIV/AIDS. The Institutional Review Boards at Fenway and JRI approved the study and all study activities took place at two participating study sites in Boston, Massachusetts.
Individuals were eligible for the study if they (1) identified as African American or Black, (2) identified as male, (3) were age 18 years or older, (4) reported living in Massachusetts, and (5) reported oral or anal sex with a man in the preceding 12 months. Each study participant was screened for study eligibility prior to enrollment.
A modified respondent-driven sampling (RDS) method,48 conducted with previous studies of MSM in Massachusetts,14,15,46 was used to recruit participants. Initially study participants were selected to function as recruiter seeds (17 seeds at JRI and four at MAC). In order to qualify, seeds had to meet the study eligibility criteria outlined above and had the potential to recruit up to five of their social/sexual network members (all prospective participants were queried as to the total number of study eligible men they had in their personal social/sexual network). Tracking social networks was accomplished using cards with a number code that connected participants back to recruits and initial seeds. A dual incentive system was used; participants were compensated $25 for the survey, $25 for the HIV testing (optional), and $10 for each eligible peer they recruited (up to five). Recruitment procedures have been described in detail elsewhere.49
Demographic, sexual risk-taking, substance use, and STD history questions were adapted from the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance Survey, MSM cycle.50 Demographic information included age, ethnicity, education, health insurance, housing, religious affiliation, sexual identification, disclosure of MSM status (i.e., “outness”), and how often MSM “hang out” with other MSM. Questions assessed substance use during sex in the prior 12 months, including use and frequency of nonparenteral and injection drugs. Participants were asked about their lifetime STD history, and recent STD history in the previous 12 months.
As part of the study procedures, HIV testing and pre- and post-test counseling were offered via rapid HIV antibody test (see procedures below).
Participants were asked to report their past testing behaviors separately for HIV and STDs. For each, questions included: (1) the location(s) they had ever tested, (2) who, if anyone, had ever recommended that they get tested (e.g., medical or mental health provider, friend, family, sexual partner), (3) the result of their last test, and (4) the number of times they had been tested in the 2 years prior to study enrollment.
In addition, when applicable, participants were asked the following open-ended questions regarding their testing behaviors separately for HIV and STDs: (1) “What were your motivations for HIV/STD testing during the last time you were tested?”, (2) “What do you think are some of the reasons why you have not gotten tested for HIV/STDs?”, and (3) “What would be some reasons why you might get tested for HIV/STDs in the future?”
The 18-item HIV Knowledge Questionnaire (HIV-KQ-18), a brief self-report measure shown to have internal consistency across samples (Cronbach α=0.75–0.89), was used to assess participants' HIV-related knowledge.51 The 27-item STD-Knowledge Questionnaire (STD-KQ), a comprehensive self-report measure of knowledge about STDs demonstrating good internal consistency reliability (Cronbach α=0.86) was used to assess STD knowledge.52 For both HIV and STD scales, responses were “true,” “false,” or “don't know.” In scoring, each correct answer was awarded one point; incorrect and “don't know” responses were scored zero. A single summary score was obtained for each scale by summing the number of items correctly answered. Higher scores indicated greater HIV or STD knowledge.
Depressive symptoms were assessed with the Center for Epidemiologic Studies Depression Scale (CES-D), which has been validated in many populations to assess clinically significant depressive symptoms (Cronbach α=0.89).56,57 The 20 items were scored on a 4-point Likert scale from 0 to 3, with a score of 16 or greater indicative of clinically significant depressive symptoms; we also used the scale score as a continuous variable.
After both the consent process and administration of the quantitative assessment, each participant had the option to have a voluntary confidential rapid HIV antibody test. Overall, 91% of the sample (n=180) opted to have a rapid HIV test during their study visit (those who did not test already knew their HIV-positive status). The FDA-approved OraQuick® ADVANCE™ HIV-1/2 Antibody Test (OraSure Technologies, Inc., Bethlehem, PA) was used for HIV testing (sensitivity: 99.6% [98.5–99.9]; specificity: 100% [99.7–100]). Like conventional HIV enzyme immunoassays (EIAs), rapid HIV tests are screening tests that require confirmation if reactive (rapid reactive). Reactive rapid HIV test results were confirmed by confirmatory Western blot testing. Each participant who consented to HIV testing received standard-of-care, pretest and posttest HIV counseling. Clients were referred to medical and psychosocial support services as appropriate and at the discretion of study staff. All HIV test counselors were certified in HIV counseling and testing according to Massachusetts' state standards prior to meeting with participants.
Data presented in the analysis of HIV testing were restricted to MSM who were HIV-uninfected at their enrollment visit (n=145), confirmed via testing as part of this study. Analyses of STD testing included the entire sample (including 52 HIV-infected participants, n=197).
SAS version 9.1 statistical software was used to perform each analysis,58 where statistical significance was determined at the p<0.05 level. The distribution and range of each variable was assessed, both by whether or not the participant self-reported being tested for HIV/STDs in the 2 years prior to study enrollment.
Two separate dichotomous outcomes were examined: (1) not having been tested for HIV in the 2 years prior to study enrollment and (2) not having been tested for STDs in the 2 years prior to study enrollment.
For all variables, bivariate logistic regression analyses were conducted to establish which variables resulted in statistically significant parameter estimates with each separate outcome. A multivariable logistic regression model was constructed for each outcome. Variables with a p value of <0.05 in the bivariate models were retained in the final multivariable models,59 and were adjusted for age and education regardless of their significance in the bivariate procedures. Model fit was assessed using the −2Log Likelihood test statistic. The odds ratios and their 95% confidence intervals obtained from this analysis were converted to relative risks using the formula suggested by Zhang et al. 60 This procedure is recommended to obtain unbiased estimates of relative risks when the outcome event is common (10% or more). Because there were multiple, potentially correlated indicators of variables in this analysis, multicollinearity among these variables was assessed; intercorrelation among the independents above 0.80 were considered to be problematic. For significant bivariate predictors that were multicollinear with each other, the variable thought to be theoretically most important in the analysis was chosen and retained in each final multivariable model, whereas the others were dropped.59
Data from open-ended questions were analyzed using content analysis.61 After written responses were reviewed for errors and omissions, the study staff developed thematic codes in a series of iterative steps. Data were reexamined and ongoing consultation among the coders helped to determine themes and refine coding categories.
Overall, 33% (48/145) of HIV-uninfected Black MSM had not been tested for HIV in the 2 years prior to study enrollment. Of those who had been tested for HIV in the past 2 years (n=97), 41% tested twice, and 42% tested three or more times. Ten participants (6.9%) had never been tested for HIV in their lifetime. Demographic characteristics of men by whether or not they have tested for HIV in the prior 2 years are presented in Table 1. As a result of HIV testing as part of this study, there was only one new identifiable case of HIV.
Participants reported a variety of locations where they had ever been tested for HIV, including an emergency room or urgent care clinic (53%), a private physician's office (34%), a community health clinic (32%), an STD clinic (28%), in jail/prison (20%), or via an HIV street outreach event or mobile testing unit (10%).
The primary reasons for participants seeking their last HIV test were: (1) person-driven: having the desire to know one's own status and being tested as a matter of regular self-care (46%); (2) event-driven: having engaged in risky sex, finding out a partner was HIV-infected, or experiencing symptoms or illness (28%); (3) provider-driven: having the test offered and often being encouraged by a doctor or other medical staff (9%); and (4) socially driven: getting tested with a partner, being recommended by a friend, and following peer norms (6%). In addition, some participants (7%) mentioned getting tested for compulsory reasons (e.g., in jail, in the military, for a drug program, as a job requirement, as an insurance or hospital policy, for visa purposes, etc.). Less frequently mentioned reasons for HIV testing were clinic compensation and participation in a research study or prevention services.
Nearly all participants (94%) reported having a relatively positive perception of HIV testing. Among those with a recent negative testing experience, the most commonly cited complaints were the staff being “cold,” distant,” and “judgmental.” A few participants mentioned that very little was explained to them and suggested more HIV counseling in the testing process. Additionally, among participants who had never tested for HIV, reasons for not seeking testing included considering themselves at low risk for HIV and being scared to learn their status. One participant expressed specific concern about privacy. Nontesters believed they would get tested in the future if they engage in perceived risky sex, feel sick, or “just want to know.”
Bivariate associations with not having been tested for HIV in the 2 years prior to study enrollment are presented in Table 2.
In a multivariable model adjusting for relevant demographic and behavioral factors, Black MSM reporting that a HCP recommended HIV testing at their last visit sometime in the past 12 months (adjusted relative risk [ARR]=0.15; p=0.01) were less likely to not have been tested for HIV in the past 2 years.
Overall, 60% (118/197) of Black MSM had not been tested for any STDs in the 2 years prior to study enrollment. Of those who had been tested for STDs in the past 2 years, 44% tested twice, and 16% tested three or more times. Demographic characteristics of men by whether or not they tested for STDs in the prior 2 years are presented in Table 1.
Participants reported an array of locations where they had been tested for STDs, including an emergency room or urgent care clinic (40%), an STD clinic (28%), a community health clinic (20%), a private physician's office (19%), via street outreach event or mobile testing unit (8%), or in jail/prison (7%).
The most frequently discussed reasons for STD testing were event-driven, in particular, presenting symptoms or feeling sick (45%). A few participants noted that STD partner notification provided the initial motivation to seek testing. Other main reasons for seeking STD testing were: (1) person-driven (39%); (2) provider-driven (7%); and (3) and socially driven (5%).
Overall, 24% (48/197) of the sample had never been tested for STDs in their lifetime. Reasons for not seeking an STD test included not experiencing symptoms, not considering themselves at risk, and the belief that their partners are “clean.” Individual factors such as fear of knowing one's status and lack of motivation to seek testing were also frequently mentioned. A few participants cited time constraints (e.g., “don't have time,” “never got around to it,” etc.) and concerns over confidentiality as additional barriers to STD testing.
The majority of participants (79%) identified presenting symptoms and engaging in risk behavior as reasons to get tested for STDs in the future. Another perceived motivator to STD testing was the desire “just to know” and “make sure everything is ok.” One respondent thought that he might get tested in the future if a doctor insisted he do so.
Bivariate associations with not having tested for STDs in the 2 years prior to study enrollment are presented in Table 3.
In a multivariable model adjusting for relevant demographic and behavioral factors, Black MSM reporting that a HCP recommended STD testing at their last visit sometime in the past 12 months (ARR=0.06; p=0.0004) and those who reported frequently hanging out with MSM (once per month or more versus less than once per month; ARR=0.18; p=0.04) were less likely to not have been tested for STDs in the past 2 years.
Despite the CDC's recommendation that all sexually active MSM receive annual screening tests for HIV, syphilis, and gonorrhea,62 findings from this study suggest that many Black MSM do not regularly get tested and continue to remain unaware of their HIV and STD status. One in three HIV-uninfected Black MSM had not been tested for HIV in the previous 2 years, and almost two out of three of the full sample of Black MSM (26.4% of whom were HIV-infected) had not been tested for STDs in the 2 years prior to study enrollment. Given that rates of HIV and STDs are on the rise among Black MSM,8,16 and that STDs have been shown to facilitate transmission and acquisition of HIV infection at least twofold to fivefold,63,64 the high percentage of Black MSM having not recently tested highlights an urgent need to provide access to timely, culturally competent HIV and STD testing and treatment services for this population. Given that testing for HIV and other STDs remains a cornerstone of public health prevention interventions, increasing testing rates using strategies such as universal testing in accordance with CDC recommendations may be warranted.65
Prior research has documented that HCPs are trusted sources of information about HIV and STDs,66 and can play a significant role in the diagnosis, treatment, and prevention of HIV/STDs among MSM.14,15,19,25,62 Findings from the current study underscore the pivotal role HCPs play in testing among Black MSM. Ninety-five percent of all enrolled participants were covered by some type of health insurance, and 82% had visited a HCP at least once during the previous 12 months. After adjusting for relevant demographic and behavioral factors, participants whose HCP recommended HIV or STD testing during their last visit were more likely to have been recently tested for these, relative to Black MSM whose providers had not recommended getting tested. These findings illustrate the need for clinicians and other health care providers to adopt a proactive approach to HIV and STD counseling and screening, regardless of race, ethnicity, or how men identify or present themselves. Additional training is warranted so providers understand the specific health care needs of MSM,14,15,67–69 in particular the need for routine and regular HIV and STD screening.
Although findings principally highlight the role of HCPs in HIV and STD testing and suggest universal screening, they also present a more complex portrait of those issues pertaining to Black MSM.69 First, many Black MSM face socioeconomic disadvantage that may prevent access to basic health care, and in this study, not being in care was associated with not being tested for HIV or STDs. As such, a universal testing approach runs the risk of continuing to underserve those populations at greatest risk for HIV and STD infection and would benefit from rigorous efforts to link and retain Black MSM into clinical care. Financial stress may further be a barrier to Black MSM receiving care. Second, as evident in the open-ended response data, some Black MSM may face issues surrounding fear about knowing their status and HIV-related stigma and discrimination. Third, Black MSM may have differential challenges related to substance use and mental health. In the current study, use of cocaine was associated with not having had an HIV test in the past 2 years. Having sex while both high and drunk was also associated with not recently having an HIV or STD test. These host of issues—socioeconomic disadvantage, fear of knowing one's status, HIV stigma and discrimination, substance abuse, and mental health factors—must be taken into account when trying to triage and improve access to and utilization of HIV and STD testing among Black MSM.70
Although HIV and STD testing is recommended for MSM at highest risk (e.g., those having multiple partners, having sex while using drugs, or those whose partners engage in these activities) every 3 to 6 months,62 many of the Black MSM meeting these “highest risk” criteria in this study had not been tested in more than 2 years, suggesting that the riskiest Black MSM are not being tested for HIV and STDs regularly. Factors associated with not having a recent HIV or STD test were substance use during sex; feeling that using a condom during sex is “very difficult”; and less frequent contact with other MSM. Lower levels of education; serodiscordant unprotected sex during last sex with a casual male partner; and not having ever been HIV tested at a community health clinic, STD clinic, or jail were all uniquely associated with not having a recent HIV test in bivariate analyses. Factors uniquely associated with not having a recent STD test in bivariate analyses were older age, a lifetime history of one or more STDs, and not having ever been tested at an emergency department or urgent clinics. Future prevention and intervention programs should focus efforts to address the complex and varied contextual and behavioral factors faced by this group.
Concerning motivations and reasons for HIV testing among Black MSM, the most commonly reported motivations for recent HIV testing were person-driven (i.e., having the desire to know one's own status and being tested as a matter of regular self-care). In contrast, event-driven reasons were most frequently discussed for STD testing, in particular, presenting with symptoms or feeling sick. Differences in reasons for HIV or STD testing may reflect differing perceptions about HIV or STDs, in particular the incorrect assumption that STDs are always symptomatic.15 Education for MSM about asymptomatic infections should be incorporated into the provision of regular HIV and STD counseling and testing and/or public health education campaigns.
Few study limitations bear mention. First, because the survey was interviewer-administered, responses could have been biased toward social desirability, which may be especially pertinent because participants self-reported on sexual risk behaviors. However, if this happened it would likely bias estimates such that these behaviors are an underreporting of the true effects. Second, in contrast to traditional RDS, this study did not weight the final sample according to the population being studied. Modifications to the traditional RDS technique included ending recruitment prior to the achievement of equilibrium to harness the in-group recruitment tendencies of seeds, and hence the generalizability of study finding may be limited. Last, the use of incentives may have contributed to a sample of more socially marginalized Black MSM, potentially further limiting generalizability of findings.
Findings suggest that many Black MSM in Massachusetts do not regularly get tested for HIV or STDs and continue to remain unaware of their status, despite being at increased risk for these infections. HCPs play a pivotal role in testing for Black MSM, and additional provider training is warranted so HCPs understand the specific health care needs of MSM, in particular the urgent need to provide access to timely, culturally competent HIV and STD testing and treatment services for this population. It is possible that HCPs willt not be able to discern whether or not their Black male patients are engaging in sexual behaviors with other men, and hence increasing testing rates using strategies such as universal testing in accordance with CDC recommendations may be warranted.65
We would like to thank the following individuals who contributed time and energy to this project: Tom Barker, Donna Bright, Garry Daffin, Maura Driscoll, William Graves, Pam McMorrow, Brandon Perkovich, Ashley Tetu, and Rodney VanDerwarker.
This work was funded by the Office of HIV/AIDS, Massachusetts Department of Public Health. Some of the investigator time on this project was supported by grant number R03DA023393 from the National Institute on Drug Abuse (PI: M. Mimiaga). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
No competing financial interests exist.