This study demonstrated that HIV and STD testing in a bathhouse environment was feasible and acceptable, leading to the diagnosis of new HIV and STD infections. This approach has been found to be a successful way to screen high-risk MSM populations in other cities across the United States.13-15, 18
The HIV prevalence among 1,063 MSM tested was 2.3%, which is higher than any other voluntary counseling/testing site in New England. In addition, the ability to screen for other STDs allowed for the detection of a substantial number of individuals with syphilis, as well as urethral chlamydia and hepatitis C.
One of the unique features of the MSM who tested was their wide geographic dispersion. Rhode Island hosts the only two bathhouses in New England; and thus, individuals who were interested in meeting partners in this setting had no other local choices. In addition, the study underscored the mobile nature of at-risk MSM, with participants being seen from nine non-New England states and the District of Columbia. These individuals reported behaviors that put them at increased risk for HIV and STDs, suggesting the need for a regional approach to understand the social and sexual networks of MSM who meet sexual partners in these venues.
This study also found that many men who sought services in the bathhouse had female partners, thus, this venue might be only one of a few places where these individuals could receive health information, and could be educated about ways in which they could most optimally protect their partners. With the demonstration of the efficacy of antiretroviral chemoprophylaxis,19
bathhouses may provide an optimal setting to educate at risk MSM about the benefits and risks of this approach. Spielberg and colleagues found that MSM who patronized Seattle bathhouses were amenable to receiving education and counseling in those venues20
. The current study also found that the riskiest men met partners on the Internet and other venues, but it is possible that health education accessed on line could be reinforced by venue-based health educators who could offer on site testing. Many participants also reported having unprotected sex while under the influence of alcohol and/or other drugs, suggesting the need to develop interventions that address the interaction of substance and sexual activity.
Only a minority of the men tested in the bathhouse indicated that they had a primary care physician and would be comfortable being tested for HIV and syphilis by their provider, a finding noted previously among New England MSM21
. These data suggest the need for increased primary care provider training to enhance cultural awareness, so that at-risk MSM patients become more comfortable in discussing their risks in primary health care settings,22
so they can avail themselves of testing services. However, in the meantime, the scaling up of testing in venues that high-risk men frequent, such as bathhouses, may be able to further arrest the spread of HIV and STDs among MSM.
One of the limitations of this study stemmed from the ability of the men to choose to be tested without answering the demographic and behavioral questionnaire, in order to avoid creating impediments to testing when it was offered. Since less than 50% of the men tested chose to provide additional demographic and behavioral information, the findings in this study may under represent the true prevalence of HIV and STDs at the bathhouse. Furthermore, the behavioral assessment of study participants is likely to be a conservative estimate of the complete bathhouse population, since individuals who did not want to think about their risks would be more likely to avoid testing. Future interventions in this setting will need to focus on the optimal ways to reach men who haven’t been tested in this, or other settings.
Public funding for HIV and STD programs has often been categorical, with grants to individual state health departments to focus on either HIV or specific STDs. The findings from this study suggest the need for a regional and a more comprehensive approach to decrease HIV and STD prevalence and incidence among New England MSM.. The funding for this project was quite limited, resulting in testing being available only 6 to12 hours per month, so it is hoped that these data will encourage public health authorities to increase support for this kind of work, so that HIV and STD testing services can be offered in these venues more frequently, in hopes of decreasing HIV and STD transmission in this population.