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Men Who Have Sex With Men: Perceptions About Sexual Risk, HIV and Sexually Transmitted Disease Testing, and Provider Communication

Mimiaga, Matthew J. MPH*†; Goldhammer, Hilary ScM*; Belanoff, Candice MPH; Tetu, Ashley M. BS*‡; Mayer, Kenneth H. MD

doi: 10.1097/01.olq.0000225327.13214.bf
Article

Objectives: This study was designed to gain a deeper understanding of the barriers and facilitators related to sexually transmitted diseases (STDs) and HIV screening among at-risk Boston men who have sex with men (MSM).

Study Design: The cohort was recruited by a modified respondent-driven sampling technique and used one-on-one semistructured interviews and a quantitative survey to examine participants' understanding of STDs and HIV, perceptions of risk for disease, reasons for getting (or not getting) tested, and experiences with testing.

Results: The study found that although most of the MSM knew the signs and symptoms of HIV, they were less familiar with STDs. MSM were most likely to be screened if they had symptoms or were told by a partner of a recent exposure. However, many barriers to STD/HIV screening among MSM still exist, including lack of awareness of symptoms, misperceptions about the ways STDs are transmitted, and perceived impediments from the healthcare system, including misgivings about provider sensitivity.

Conclusions: To decrease current increases in HIV/STDs among MSM, new strategies that include community and provider education are needed.

A qualitative study was conducted of men who have sex with men regarding perceptions and understanding of HIV and sexually transmitted disease risk and testing, which found that significant gaps in knowledge and misperceptions are still pervasive.

From *The Fenway Institute, Fenway Community Health, Boston, Massachusetts; †Harvard University, School of Public Health, Boston, Massachusetts; ‡Boston University, School of Public Health, Boston, Massachusetts; and §Brown University, School of Medicine/Miriam Hospital, Providence, Rhode Island

The authors thank the Community Advisory Board of Fenway Community Health; the staff of Online Buddies; AIDS Action; Sydney Borum Health Center; Latin American Health Institute; The Living Center; Wayne Wright Resource Center; Meg Stone, Rob Fredericksen, Jake Tinsley, Jim Maynard, Roger Cuevas, Rek Kwawer, Julie Ebin, and Chris Grasso of The Fenway Institute, Fenway Community Health; and the participants who made this study possible.

This work was supported by the HIV/AIDS Bureau, MA, Department of Public Health and the Communicable Disease Bureau, STD Prevention Division of the Massachusetts Department of Public Health.

Correspondence: Kenneth H. Mayer, MD, The Fenway Institute, Fenway Community Health, Prudential Tower, 4th Floor, 800 Boylston Street, Boston, MA 02199. E-mail: Kenneth_mayer@brown.edu

Received for publication January 20, 2006, and accepted April 24, 2006.

MEN WHO HAVE SEX WITH men (MSM) continue to be at increased risk for HIV infection and other sexually transmitted diseases (STDs).1,2 According to national surveillance data, MSM accounted for 47% of all HIV/AIDS cases diagnosed in 2004.1 Rates of syphilis among MSM appear to have risen dramatically in the United States since 2000,2 including in Massachusetts, where there was a greater than 5-fold increase in infectious syphilis cases among MSM between 2000 and 2003 (N = 178). Access to timely, culturally competent testing and treatment for HIV and other STDs can bring about better health outcomes and reduce transmission to sexual partners. The Centers for Disease Control and Prevention (CDC) recommends that all sexually active MSM receive annual screening tests for HIV, syphilis, and gonorrhea, and that highest-risk MSM be tested every 3 to 6 months.3 Nonetheless, many MSM do not get tested regularly.4 In particular, MSM who are younger than 25, black,4,5 and/or with lower income6 are less likely to be aware they are HIV-infected than other MSM.

Research studies suggest that MSM may not screen for HIV as a result of perceived low risk for infection, as well as fear of testing positive, with associated concerns over losing employment, insurance, family concerns, lack of time, worry that someone will find out, fear of needles, and fear of discrimination.4–9 Programmatic and policy factors are also influential; anonymous test availability and convenience, as well as inability to pay for treatment, may also affect screening behaviors.8,9 Qualitative research on barriers and motivators to screening for STDs other than HIV is somewhat limited and has focused primarily on adolescents and heterosexuals.10,11

Primary care clinicians are in a strategic position to provide HIV and STD screening and counseling services to MSM. CDC data suggest that most MSM (65–85%) receive primary health care from a private provider, with far fewer (2–5%) receiving their care from public health and community clinics.12 Moreover, one study found that MSM were more likely to have been tested for HIV during the preceding year if they had visited a healthcare provider and their provider recommended an HIV test.4 A few small studies suggest that ease of communication with medical providers about sexual orientation may promote preventive screenings.13–15 However, MSM may be reluctant to disclose to providers as a result of concerns about confidentiality and/or discrimination.13,16,17 Providers may not inquire about these issues as a result of lack of time, discomfort with discussions of sexual behavior, and presumptions about sexuality and behavior,18 reflecting systematic deficiencies in training providers to provide culturally competent care for sexual minorities.13,17

The study described here examines how MSM in the Boston area perceive and experience barriers and motivators to getting tested for STDs and HIV. It was designed to elicit data on factors that directly influence testing behavior as well factors that might indirectly influence testing behavior, including discussion of sexual behavior with primary care providers and self-perception of risk behavior. A qualitative design was used to more deeply understand these issues from the perspective of MSM at risk for STDs and HIV. In addition, a quantitative survey of demographics, sexual and drug risk behavior, and healthcare access was administered to provide context for the qualitative portion of the study. Using a modified respondent-driven sampling method,19 the study was able to solicit data from different social networks of MSM in the Boston area, including young MSM and black and Latino MSM.

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Materials and Methods

Study Design

Between January and early April 2005, 50 individuals participated in a one-on-one, open-ended, semistructured interview with one of 2 trained interviewers. Participants were eligible if they self-reported as being 18 years of age or older, a Massachusetts resident, and a man who has had anal or oral sex (protected or unprotected) with at least 3 male partners in the prior 12 months. Interviewers were trained together and met regularly with study staff to discuss emerging themes and to minimize bias caused by differential interviewer methods. Each interview was digitally recorded and then transcribed verbatim by a professional transcription company. At the completion of each qualitative interview, participants were administered a written quantitative survey on demographics, sexual and drug use behavior, access to health care and HIV/STD testing, and psychological distress. The written survey was administered in this order in an attempt not to bias what was shared during the qualitative interview.

All study activities took place at Fenway Community Health (FCH), a freestanding healthcare and research facility specializing in HIV/AIDS care and serving the needs of the lesbian, gay, bisexual, and transgender community in the greater Boston area.20,21 The FCH Institutional Review Board approved the study, and each study participant completed an informed consent process.

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Recruitment

The study used a modified respondent-driven sampling (RDS) method19 to reach a diverse variety of social networks and to test the potential of this methodology for future studies of MSM in Boston. An initial set of 4 study participants, known as “seeds,” were recruited through key informants at community-based organizations for MSM in Boston. Seeds are “subgroup members from whom the desired data are gathered; they are study staff recruited respondents, to help identify other subgroup members (i.e., individuals who engage in the same types of behaviors) to be included in the sample.”19 Additional seeds were recruited through an advertisement on an Internet MSM sexual web site. Selected seeds were evaluated for their commitment to the goals of the study and were motivated to recruit 3 eligible peers within their social network. In addition, the initial seeds were selected based on demographic characteristics (e.g., age, race/ethnicity, and HIV serostatus). To meet a sample size of 50 within the study period, 6 study seeds were added after 1.5 months.

Seeds were asked to recruit up to a maximum of 3 participants, who in turn were asked to recruit a subsequent wave of up to 3 participants, and so on, until the target sample size of 50 had been reached. Eligible participants were those who met the same enrollment criteria as the seeds. To minimize confounding by temporal trends, the study recruitment period was restricted to 3 months. For sampling frame purposes, only acquaintances and friends of the recruiters were eligible. Each participant was given 10 cards with study information to hand out to potential recruits. To keep track of social networks, each card had a number code that connected participants back to the initial seeds. Participants were compensated for their participation in the study as well as for recruiting an eligible participant who completed an interview.

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Development of Study Instruments

Questions for the open-ended, semistructured interview guide were based on needs identified by a literature review and by MSM health specialists at FCH and the Massachusetts Department of Public Health. Portions of the interview guide were adapted from an instrument developed for Project Access, a qualitative study on HIV testing conducted at the UCSF Center for AIDS Prevention Studies.22 The interview guide was reviewed by the FCH Community Advisory Board and pilot-tested with 5 MSM who met inclusion criteria; pilot data were not used in the analysis of this study.

Sexual behavior, demographic, and recreational drug use questions for the quantitative survey were adapted from the CDC's MSM Behavioral Surveillance Survey,4 FCH's Behavioral Surveillance Survey,23 and the NIDA R-O1 Club Drug Study Survey.24 The survey also included the CAGE questionnaire,25–27 a clinical screening instrument for alcohol abuse, and the CES-D Scale,28 a validated survey to assess the presence of clinically relevant depression.

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Data Analysis

The qualitative data from this study were analyzed using content analysis.31 After transcripts were reviewed for errors and omissions, study staff developed a thematic codebook and, using NVIVO software, organized transcripts according to each code. A team of 2 analysts then individually reviewed the coded transcripts to determine emerging themes and then together agreed on final themes. Data were reexamined and ongoing discussion between coders and study investigators allowed for further theorizing and making interconnections between research questions, coding categories, and crude data.31 Demographic survey data were entered into a Microsoft Access database and analyzed with SPSS. Chi-squared global tests of independence were used to test independent associations between variables. Mean group comparisons were made using one-way analysis of variance (ANOVA).

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Results

Participants ranged in age from 20 to 56 years (mean = 37.9 years, standard deviation = 11.5); 30% were in their 20s and 46% in their 40s. Forty percent were white, 30% black, 12% Latino/Hispanic, 12% mixed race/ethnicity, and 6% Asian/Pacific Islander/other. Yearly income before taxes ranged from less than $6000 to $60,000 or more, with 45% reporting a yearly income less than $12,000. Sixty-seven percent reported less than a college education. Participants came from a wide range of geographic locales representing 26 zip codes within the greater Boston area. Thirty-three (66%) participants were HIV-infected, 16 (32%) were HIV-uninfected, and one (2%) did not know his HIV status. Most identified as homosexual/gay (80%); others identified as bisexual (14%), heterosexual (2%), and other (e.g., queer) (4%).

Eighty-one percent of participants scored ≥16 on the CES-D, suggesting a high prevalence of depression.28 Those who reported being HIV-infected were more likely to have a CES-D score of ≥16 versus those who reported being HIV uninfected (P < 0.03, chi-squared = 4.613, df = 1). In addition, 31% of the cohort reported 2 or more positive responses on the CAGE questionnaire, consistent with chronic alcohol dependence.25–27

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Respondent-Driven Sampling and Social Networks

RDS is a recruitment strategy designed to tap more deeply into social networks, allowing for a more representative sample through participant waves.19 The goal of recruitment in the current study was to maximize demographic diversity of the sample using a modified RDS strategy compared with other samples recruited at Fenway that have typically yielded a 15% to 30% ethnic/racial minority composition. Four waves emerged from the current study. To increase group size for an analysis of variance and chi-squared analyses comparing differences between waves and the group of seeds (n = 10), waves 1 and 2 were combined (n = 14) as well as waves 3 and 4 (n = 26). ANOVA showed significant differences in age between the 3 groups (F [2,45] = 6.37, P = 0.04); post hoc testing revealed that participants in the first set of waves were significantly older than those in the second set (P = 0.02). There were also significant differences in having versus not having insurance coverage across the 3 groups (P < 0.007, chi-squared = 10.07, df = 2). Differences in education level—having versus not having a high school diploma—approached significance across the 3 groups (P < 0.057, chi-squared = 5.74, df = 2). No significant differences were found in race, income level, or sexual orientation. Overall diversity of the sample indicates the ability of modified RDS to recruit a maximally diverse sample; the present sample was composed of 60% minority participants. Although not representative of the broader MSM population, recruitment using a modified RDS strategy may be useful in reaching minority MSM who are otherwise inaccessible.

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Access to Health Care and HIV/Sexually Transmitted Disease Testing

Ninety-two percent of participants reported having some form of health insurance coverage; of these, 36% had private insurance coverage with the others insured by Medicaid (24%), Medicare (18%), or another form of government-funded care. Eighty-eight percent reported having a primary care provider, and 92% reported they had visited a doctor, nurse, or other healthcare provider in the past 12 months. Of those who reported being HIV-uninfected, 12% reported that during their last visit a healthcare provider recommended getting tested for HIV and 22% of the overall sample for STDs. Notably, when asked if any healthcare provider has ever recommended they get tested for HIV, only 20% of the entire sample answered “yes,” whereas 40% answered “yes” for STD screening (other than HIV).

Overall, 100% of the sample had been tested for HIV at least once and 75% for an STD other than HIV, although only 14% had received their last STD test between 2003 and 2005 and some had not been tested since 1970. HIV testing locations included: private physician office (30%), community health clinic (57%), STD clinic (13%), emergency room or urgent care clinic (15%), prison/jail (11%), and other (15%). STD testing also occurred in diverse settings: private physician's office (44%), community health clinic (51%), STD clinic (28%), emergency room or urgent care clinic (15%), and other (15%).

Forty-three percent of all participants reported a prior STD diagnosis: 14% syphilis, 35% gonorrhea, 5% chlamydia, and 20% other (human papillomavirus, herpes simplex virus, crabs). HIV-infected participants were more likely to report ever being tested for an STD compared with HIV-uninfected participants (P < 0.05, chi-squared = 3.627, df = 1). Similarly, HIV-infected men were more likely to report ever being diagnosed with an STD versus the HIV-uninfected men (P < 0.01, chi-squared = 5.738, df = 1).

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Reasons Why Men Who Have Sex With Men Get Tested

In the qualitative interview, participants were asked to explain what led them to get their most recent STD and/or HIV test. Primary reasons for seeking testing fell into 3 categories: 1) event-driven: experiencing symptoms or illness, having engaged in “risky” sex, or finding out a partner was infected; 2) prevention-driven: being tested as a matter of routine care; and 3) socially driven: entering a new relationship/being tested with a new partner, being encouraged by, and often accompanied by, a friend(s), or family member, and following peer norms. The prevention-driven and socially driven categories were more prevalent in discussion of HIV testing compared with STD testing. Less frequently mentioned reasons for being tested for HIV included participation in a research study, seeing advertisements, or recommendations by hospital or prison staff.

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Perceived Motivators to HIV/Sexually Transmitted Disease Testing

Participants were also asked why they thought other MSM in their peer group might get tested for HIV and other STDs. Most participants provided answers similar to personal reasons for testing, as listed previously. Another common theme that emerged was the desire to know one's own status. For some, this meant gaining reassurance from a negative result; however, others believed their MSM peers got tested because they “just want to know” and desire “peace of mind,” no matter the result. A few participants also noted that access to anonymous, free, and culturally sensitive testing was an incentive to be screened. Two younger participants believed that older men tested more because they tend to be more careful with their health and better educated about options, whereas one younger respondent perceived testing as being more normative among his peers as a result of aggressive media campaigns.

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Reasons Why Men Who Have Sex With Men Do Not Get Tested

All participants had been tested at least once for HIV (one did not return for his results), whereas 24% had never been tested for an STD other than HIV. Among those who had never been tested for an STD, reasons for not seeking testing included not experiencing symptoms, not considering themselves at risk, as well as dislike of urethral swabs, lack of access to free and anonymous testing, and not knowing how to go about getting a test. Two participants described encounters with clinicians who were reticent to give STD tests routinely, discouraging patients from having them unless they had a particular reason to be concerned. This presented a dilemma for men who felt uncomfortable divulging sexual behaviors to clinicians.

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Perceived Barriers to HIV/Sexually Transmitted Disease Testing

Participants were also asked why MSM in their peer group might avoid testing for HIV and other STDs. The most common barriers mentioned were individual factors: fear of knowing, denial of risk, being addicted to drugs or alcohol, and an unwillingness to alter sexual activities. Lack of knowledge also was perceived as an important factor, specifically not knowing where or how to get tested and not knowing that treatments are available. Four percent also mentioned concerns over confidentiality. Younger men were seen as less attentive to their health or as not viewing themselves at risk. Social stigma was also considered to be an important barrier to testing by 18% of participants; concerns about discrimination by healthcare personnel were reported by 4%. Antigay bias and the fear of social rejection within their communities were reported by 2%.

Men who do not identify as “gay” or who are actively hiding their sexual activity with other men may face greater barriers to testing. Several respondents cited “being on the down low” as a reason some men avoid testing. However, one respondent thought that MSM who are concurrently in relationships with women might be more vigilant about testing.

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Features of an Ideal HIV/Sexually Transmitted Disease Testing Scenario

Participants were asked to describe what they would consider an ideal testing scenario. Overall, participants desired a testing environment that was community-based, friendly, culturally competent, gay-positive, and that normalized sexuality and STD/HIV testing. They liked to see providers that were compassionate, respectful, and nonjudgmental, and wanted counseling and informational materials available on site. Anonymous testing was thought to be of particular importance to younger people who might want to avoid having parents find out (through insurance documents). Some viewed hospital clinics as undesirable as a result of the “overly clinical” setting as well as clinics that were conspicuously for STDs and/or HIV. However, some believed that accessible clinics with walk-in hours would encourage testing.

Although most participants who tested recently expressed satisfaction with their experiences, suggested improvements to services included: shorter waiting time for results, less painful specimen collection (e.g., alternatives to the urethral swab and needles such as oral testing), eliminating the need for answering sexual behavior questions, home-testing kits, and being able to call in for results.

Recommendations specific to HIV testing included being able to get an emergency appointment and normalizing testing by making it part of a routine examination. Many of the participants also emphasized the importance of having adequate supports on site for HIV testing.

Some suggested having HIV-infected peers on site to share their experiences would be helpful, and sites should offer counseling support at all stages of testing: during specimen collection, during the waiting period, and when receiving results.

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Sexual Risk Behavior and Perceptions

Data from the quantitative survey suggest that a majority of participants had engaged in sexual behavior that put them at moderate to high risk of acquiring an STD (and HIV, if uninfected). In the previous 12 months, 67% had engaged in unprotected receptive anal (URA) intercourse, 59% had engaged in unprotected insertive anal intercourse, and 88% had engaged in unprotected receptive oral intercourse with ejaculation in one's mouth. Ninety percent of the participants reported having at least 4 male sex partners in the previous 12 months, with the total number of reported male sex partners ranging from 3 to 100 (mean = 15, standard deviation = 23); thus, this sample is at particularly high risk for HIV and STD acquisition. In addition, some participants met their sexual partners at venues that could put them at higher risk of infection, including bathhouses (15%), sex clubs (8%), public cruising areas (29%), the Internet (38%), and private sex parties (13%).32 Alcohol and substance abuse were also prevalent in this sample. In the previous 12 months, 40% reported having used poppers (amyl nitrate), 8% crystal methamphetamine, and 8% ecstasy (MDMA) while engaging in oral and/or anal sex (protected or unprotected); and 50% reported they were “drunk” when engaging in oral and/or anal sex (protected or unprotected).

During the qualitative interviews, participants were asked to rate their risk of getting an STD (and HIV, if uninfected) on a scale of one to 10, with one being not risky at all to 10 being extremely risky, and then to explain their self-rating. Interestingly, the majority of participants perceived themselves at low to moderate risk. They also had widely varying concepts of what constituted “risk” and how their own sexual practices related to self-assessed risk for HIV and STDs. For example, the possibility of contracting an STD through unprotected oral sex was subject to divergent beliefs with some perceiving it as quite safe and others believing it the source of their elevated risk. In another example, one man who rated himself a “low risk (1)” described similar practices (anal receptive intercourse with a condom) as another man who rated himself at “moderate risk (6).”

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Sexual Risk Behavior and HIV/Sexually Transmitted Disease Testing Recommendations

The majority of men who engaged in unprotected intercourse reported that their providers had not recommended they get screened for HIV (92%) and/or STDs (94%). Of those who did and did not engage in URA intercourse in the previous 12 months, when asked if any healthcare provider “has ever recommended getting tested for HIV,” only 17% and 33%, respectively, answered “yes,” whereas 43% and 50%, respectively, answered “yes” for STDs. Moreover, the same trend emerged about insertive anal intercourse. The men perceived providers as not very likely to suggest screening for those at most risk for HIV and STDs.

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Discussion of Sexual Behaviors With Primary Care Providers

Nearly three fourths (74%) of the overall sample reported telling their current primary healthcare provider (PCP) that they have sex with men. However, only approximately half of the respondents reported having discussions about sexual behaviors with their PCP. Twenty-six percent reported the conversation being prompted by a specific issue—a risk taken, a test needed. Thirty-eight percent reported discussions as a matter of routine care (such as general checkups or yearly physical). Their provider was important to get optimal care.

Those who discussed sexual behaviors with their PCPs perceived their experience as positive (feeling comfortable and not judged) or negative (feeling judged or embarrassed), depending on the communication style of the clinician. Positive experiences involved clinicians who approached the subject in a matter-of-fact way, were conversational, took time to really talk with the patient, and showed no judgment or discomfort in their body language or manner of speech. In addition, some reported liking when a clinician was proactive in asking about sexual behaviors rather than the patient needing to bring up the subject. Including gay-specific questions on an intake form was also perceived as a way to make subsequent discussions of sexual behavior more acceptable. Participants reported that these clinicians also showed compassion and seemed to care about the patients' lives. In addition to communication style, some participants found it helpful if they had been with the same provider for a long time or if the clinician sees a lot of gay patients, is affiliated with a gay organization, or was gay him- or herself.

Providers whose communication styles were perceived as negative included: clinicians who emphasized the risks of their patent's sexual behavior, thereby “scaring” the patient; clinicians who were seen as judgmental based on body language and speaking style (especially when coming in for STD testing); and clinicians who expressed shock after the participant “came out” to them. Some participants said that they felt embarrassment during a first conversation with their provider about sexual behavior or orientation, but then subsequently felt comfortable as they built a sense of rapport (this was particularly relevant for some younger patients who still received care from a pediatrician or family doctor). One participant felt offended when his physician told him he had given more information than the doctor said “he needed to know.” Another did not like that the clinician asked the same questions every visit because this signaled to the patient that his clinician did not know him well.

Among people (34%) who reported not discussing sexual behaviors with their PCP, many said it simply never came up but that it would be fine if it did. However, some reported they would not want to discuss sexual behaviors with their PCP. Reasons included: fear of being judged, fear of shocking the clinician, the perception of the PCP as incapable of broaching or “dealing with” the subject, the belief that such discussions were better left to sexual health counselors, and the belief that they were already well informed about sexual risk behavior and testing. For some, the characteristics of the PCP (e.g., the physician is heterosexual and/or female) prevented the participant from feeling comfortable. Notably, only one person expressed concerns over confidentiality and future insurance coverage.

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Discussion

By using a sampling method adapted from RDS,19 the study was able to recruit an MSM population that would not necessarily have been reached through more traditional recruiting techniques such as advertising in MSM-frequented venues. The results from this study underscore some new areas that need to be addressed to decrease the marked increase in HIV and STDs among MSM and highlight the need for clinician training to emphasize a nonjudgmental disposition in caring for this population.

Although the use of RDS helped to obtain an ethnically diverse sample, the initiation of the process through the selection of seeds recommended by local AIDS service organizations meant that the cohort was more gay-identified with a higher prevalence of HIV infection than the wider Greater Boston area MSM population. Thus, some of the strategies to enhance HIV and STD screening that emerged from the comments of this study population such as local advertising may not be as relevant for MSM who are not gay-identified (e.g., men on the down low). Thus, further studies of less gay-identified communities may be needed to derive more comprehensive suggestions as to how to enhance HIV and STD screening in diverse populations.

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Patient/Provider Communication

Respondents frequently reported positive interactions with healthcare providers, generally attributable to culturally competent care provided in a gay-friendly setting, which reduced stigma and normalized the sexual health needs of MSM. Many of the respondents indicated that they were comfortable with providers inquiring about their sexual practices as long as the discussion was done in a conversational, nonjudgmental manner. Those who reported unsatisfactory experiences had encountered insensitive or judgmental providers and insufficient support or resources in place. Corroborating earlier findings,13–15 several respondents indicated that the perceived level of comfort among providers in treating gay or MSM patients may determine the extent to which a patient will disclose particular health needs and risks. Furthermore, younger men, men of color, and/or MSM who do not identify as gay may require particularly sensitive practitioners who are able to identify those at risk for STDs and to fully meet their healthcare needs.

Although the majority of MSM in this study reported having a current primary healthcare provider (88%), and the majority of these (82%) were “‘out” about their sexual practices with their providers, men who were at increased risk for HIV and STDs—defined as engaging in unprotected anal intercourse—were often unlikely to receive HIV and/or STD testing from their healthcare providers. Although all participants' recent sexual behaviors would make them candidates for STD screening,33 only 14% were tested for an STD in last 2 years, although the majority had good access to health care (reported primary provider care visits in the past year).

These findings represent a tremendous opportunity for improving health services to MSM. Healthcare providers must receive training around the special needs and vulnerabilities of MSM.17 Medical histories and examinations can be conducted in ways that do not presume heterosexuality but are inclusive of various sexual identities, family/relationship arrangements, and sexual behaviors.34 For instance, medical intake forms that make it clear that same-sex, spousal arrangements, including “gay civil union,” are valid relationship categories, or clinicians who ask about sexuality as a matter of routine, may communicate a level of comfort with gay patients which, in turn, could allow for more candid and thorough examinations. Furthermore, clinicians who serve adolescents and young adults as well as minority populations should be especially attuned to patients who may be reticent to fully disclose issues around sexuality, health risks, and exposures.35,36

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Further Sexually Transmitted Disease/HIV Testing Issues

Various structural and interpersonal facilitators and barriers to STD/HIV testing were identified, reflecting previous work in this area.10,11 As others have found, the most frequently reported personal barriers to testing included fear of a positive finding, thinking oneself invulnerable to infection, and fear of stigma and rejection from both healthcare providers as well as peers. Structural barriers to testing included not knowing where to access MSM-friendly, anonymous, and/or low-cost testing facilities; having to go specifically to an STD clinic for testing; having to answer too many questions; or having to disclose details of sexual activity to obtain a test. Future public health interventions should explore ways to make HIV and STD testing more accessible, provide information on where and how to obtain HIV/STD testing, and should focus on prevention and socially driven facilitators to STD testing.

A prevailing theme throughout these study results is the need for normalization around sexual health and testing. Again, clinicians must demonstrate their comfort in addressing health issues tied to sexuality to draw people into testing and treatment.34 Integrating STD/HIV testing into routine care by having primary care providers offer testing proactively and/or not having segregated clinical settings for testing could reduce the difficulty of patients having to define their sexuality. Participants indicated that other structural changes to facilitate more screening could include flexible clinic hours, use of less invasive screening techniques (e.g., urine for nucleic acid amplification), and being able to receive results by phone.

Depression was extremely common in this cohort. Eighty-one percent of participants scored ≥16 on the CES-D, suggesting a clinically significant level of psychologic distress.28–30 Epidemiologic studies estimate the lifetime prevalence of major depressive disorder to be between 4.9% and 17.9%37,38 in the general population. Epidemiologic and sample studies reveal rates of depressive disorders up to 37% among persons with HIV,39–42 and studies of patients in primary care clinics have found rates of approximately 20%.43–47 When broken down by HIV status, 89% and 63% of those who reported being HIV-infected and HIV-uninfected scored ≥16 on the CES-D, respectively. Elicitation of histories of depression and appropriate treatment may be important for the care of high risk MSM with STDs, because depression is associated with increased sexual risk-taking48 and could affect communication between healthcare providers and patients. Moreover, it is possible that the high rate of depression found in the current study might be a consequence of sexually compulsive behavior given the high number of partners reported by the men enrolled.49

Alcoholism among MSM has been shown to be 2 to 3 times higher than that reported by the general population.25,50 Epidemiologic and sample studies of excessive drinking and alcohol dependence among MSM have been estimated to be on the order of 30%,51 whereas a similar study assessing CAGE positivity found that 23% of MSM in Boston met criteria for alcoholism.25 In the current study, 31% were CAGE-positive (2 or more positive responses), consistent with chronic alcohol dependence.25–27 These results point to the importance of addressing alcohol dependence, in addition to recreational drug use, when designing medical, psychosocial, and/or behavioral interventions for MSM at increased risk for STDs and HIV.

The findings in this study pose several challenges for public health officials who are trying to curb the recent increases in STDs and HIV among MSM. In addition to the lack of knowledge about the signs and symptoms of STDs, many MSM felt that their providers were not well-informed and/or were unsympathetic to their lifestyle issues so that they were uncomfortable in presenting for routine screening in the primary care setting. In addition to the need for frontline clinicians to be better informed about the clinical presentation of STDs among MSM, and to project a nonjudgmental manner when performing STD screening, providers also need to be trained to understand that STD and HIV risk-taking behavior among MSM is often occurring in the context of intertwined syndemics.52 The coexistent excessive substance use and untreated depression that are often associated with sexual risk-taking behavior need to be addressed for the STD or HIV screening visit to be optimally used to decrease further infection, acquisition, or transmission. Effective STD/HIV programs for MSM need to have well-established linkages with mental health and substance use treatment programs to provide “one stop shopping” for individuals whose unmet needs may predispose themselves to recurrent risk-taking behavior.

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