Among men who had never previously tested, proportionally more infected-unaware (n = 79) than noninfected MSM (n = 1200) reported not ever testing because they feared learning their results (65 vs. 38%, P < 0.01). In phase 2, high proportions of both infected-unaware (n = 113) and noninfected (n = 1334) MSM who tested in the past year reported that they did not receive any counseling at their most recent HIV test (49 vs. 40%, P = 0.24).
Potential Locations to Expand Testing
Similar high proportions of noninfected and infected-unaware MSM reported using a regular source of health care (Table 2). Of the 79 infected-unaware MSM who had never previously tested, 58 (73%) also reported using a regular source of health care. Of health care users in phase 2, no differences were observed in the reported number of provider visits since age 20 between infected-unaware (n = 161) and non-infected MSM (n = 1595) (for both groups, median: 5; inter-quartile range: 2-10). However, proportionally more infected-unaware than noninfected MSM reported that their provider had ever discussed whether they should be tested for HIV (69 vs. 55%; P < 0.01).
Compared with noninfected MSM, infected-unaware MSM were more likely to be recruited at bars, dance clubs, and other locations in MSM neighborhoods (Table 2). In phase 2, 32% of both noninfected (n = 2529) and infected-unaware (n = 271) MSM reported participating in YMS at these and other venues to obtain free tests for HIV and other sexually transmitted infections (STIs).
Prevalence and Correlates of Perceived Low Risk for Infection
Of the 439 infected-unaware MSM, 258 (59%) perceived themselves at low risk for being infected and 193 (44%) perceived themselves at low risk for ever becoming infected. However, proportionally fewer infected-unaware than noninfected MSM perceived themselves at low risk for being or becoming infected (Table 2). Among infected-unaware MSM, perceived low risk for being infected was associated with being younger (phase 1 participants), having previously tested HIV negative, never having an STI, having fewer lifetime male partners, and not having UAI in the 6 months preceding the survey interview (Table 3). Within each study phase, perceived low risk for being infected remained associated with younger age (data not shown).
Prevalence of Risk Behaviors and Correlates of UAI
Proportionally more infected-unaware than noninfected MSM reported having >5 male partners and ever engaging in anal intercourse and injecting drugs (Table 2). In the 6 months preceding the survey interview, the 439 infected-unaware MSM reported a total of 722 steady and 1531 casual male sex partners (median number of male partners: 2; interquartile range: 1-5). During the same period, the 60 (14%) infected-unaware MSM who reported having female partners reported a total of 233 female sex partners. During this period, 222 (51%) infected-unaware MSM reported having UAI with men (37% unprotected insertive; 39% unprotected receptive), and 31 (7%) reported having unprotected vaginal or anal intercourse with women. Of those who engaged in UAI, 106 (48%) reported not using condoms because either they “knew” they were HIV negative, “knew” their partners were HIV negative, or perceived their partners were at low risk for infection.
Among infected-unaware MSM, UAI was most highly associated with having a steady partner (Table 3). Other associations with UAI included self-perceived moderate to high risk for infection, and being unemployed, identifying as gay, and having a casual partner (Table 3). Compared with MSM who were aware of their infection in the 6 months preceding the survey (n = 92), proportionally more infected-unaware MSM reported having UAI because they thought their partners were HIV negative or at low risk for infection (21 vs. 11%; AOR: 2.7; P < 0.05).
Our findings suggest that in 5 of 6 US cities surveyed, approximately three-quarters of HIV-infected MSM 15-29 years of age who attend MSM venues are unaware of their infection, and of these, many unknowingly engage in behaviors that can transmit HIV to their male and female sex partners. Affirming our earlier report of very high prevalence of unrecognized infection among 15- to 22-year-old black MSM in the United States, we found that compared with white MSM, black MSM had nearly 7 times greater odds of having unrecognized HIV infection.20 Despite reporting multiple partners and considerable exposure risks, many MSM with unrecognized infection misperceived that they were at low risk for having or acquiring HIV, and because of their misperceptions, many engaged in behaviors that could transmit HIV. Finally, although most MSM with unrecognized infection had previously tested for HIV, few had tested regularly and over half had not tested in the previous year. These findings underscore the urgency of improving federal, state, and local prevention programs for MSM through interventions that help clarify perceived risk for infection and by increasing the availability of and demand for HIV testing services.
Increase Availability of HIV Testing Services
Our findings suggest that nearly three-quarters of MSM with unrecognized infection, including those who had never tested, use health-care services. Although proportionally more infected-unaware than noninfected MSM reported discussing the need for testing with their providers (phase 2), nearly a third reported that their providers never discussed HIV testing. To identify and link more infected persons into care, HIV testing should be routinely recommended for all patients in health-care settings where HIV prevalence is ≥1%.39,40 To increase the proportion of patients who receive their results, providers should consider using rapid HIV tests that are accurate, acceptable, and provide results in approximately 20 minutes.41-43 In health-care settings where HIV prevalence is <1%, health-care providers should routinely assess patient risks and encourage at-risk MSM to test for HIV and other STIs at least annually.39,44
Although increasing the availability of testing at clinical settings may reach many MSM with unrecognized infection, our findings suggest that some young MSM use health care infrequently, some delay testing because they do not use a regular source of health care, and as also suggested by other reports,45,46 many will take advantage of free testing at MSM-identified venues. Our data suggest that expansion of HIV testing at clubs, bars, and other locations in MSM neighborhoods, rather than at parks and social organizations, may reach more men with unrecognized infection. Although we tested few men at bathhouses, other studies suggest that expansion of testing at these venues may be particularly important in reaching infected-unaware MSM who might not test elsewhere.47,48
Partner Counseling, Testing, and Referral
Our finding that most MSM with unrecognized infection have ongoing or recent steady partners suggests that partner counseling and referral services (PCRS) might be an effective strategy to reach MSM with unrecognized infection.49,50 While most infected-aware MSM inform current steady partners,18,19 those who are younger or asymptomatic are less likely to do so,51,52 and many do not inform previous partners.53 The urgency to provide PCRS especially to current and previous steady partners is underscored by our finding that UAI among infected-unaware MSM was strongly associated with having a steady partner. This finding is corroborated by many studies suggesting that UAI is more prevalent among steady partners,29,32 and 2 recent reports suggesting that a large majority of new infections among younger MSM might be attributed to steady partners.54,55
Increase Demand for Testing
Of MSM with unrecognized infection, we found that nearly 6 of 10 thought they were at low risk for being infected and approximately 4 of 10 thought they were at low risk for ever becoming infected. Thus, perceived low risk for infection might explain, in part, why few had regularly tested for HIV.13,56 However, our findings also suggest that some infected-unaware MSM delayed testing because they perceived themselves at risk for HIV and feared learning their results. These findings suggest that demand for testing might be increased by efforts that increase awareness of personal risks for infection and the potential uncertainty in determining these risks given the magnitude of unrecognized infection, as well as by efforts that address concerns about testing positive. While additional research is needed to clarify these concerns, they might be addressed, in part, by marketing the benefits of early diagnosis and advancements in HIV care, and emphasizing that access to treatment is available to many without insurance and that laws and organizations exist to help protect against discrimination for those with HIV.13,43,56
Improve Prevention Counseling
Among infected-unaware MSM, we found that (1) nearly half who had been tested within the past year (phase 2) did not receive any counseling, (2) that perceived low risk for infection was associated with having tested HIV negative, and (3) of those who engaged in UAI, approximately half did so because they perceived themselves or their partners to be HIV negative or at low risk for infection. Our findings, thus, support several reports suggesting that many persons who voluntarily test for HIV are not counseled39,57-59 and that the combination of testing negative with inadequate or no counseling can reinforce behaviors that lead to HIV acquisition and transmission.60-62
In accordance with current guidelines, persons who test for HIV should receive high-quality prevention counseling that clarifies risks for infection and steps to reduce those risks.39 Our data suggest that prevention counselors should inform MSM that many men are HIV infected despite perceiving themselves to be negative based on previous tests or recent “lower-risk” behavior. Among MSM who had previously tested HIV negative, we found that nearly 1 in 10 were infected overall; among blacks, 1 in 5 were infected. Thus, MSM should be encouraged to consistently use condoms with all partners unless they are in a mutually monogamous relationship in which both partners have recently tested HIV negative. Counselors should refer clients who have difficulty in initiating or sustaining safer behavior for more intensive individualized prevention counseling and support services.63
Comparative Findings, Limitations, and Biases
Our reported magnitude of unrecognized infection among young MSM is similar to findings from 1 contemporary and 2 previous venue-based surveys and differs from the national estimate and from 2 previous household surveys. Of venue-based surveys, 70-81% of young HIV-infected MSM recruited in San Diego (2000-2002), San Francisco (1992-1993), and New York City (1990) were unaware of their infection.64-66 These findings stand in contrast to the national estimate that 25% of all HIV-infected persons are thought to be unaware of their infection.67 Similarly, 25 and 33%, respectively, of young HIV-infected MSM sampled in households in San Francisco (1992-1993) and South Beach, FL (1996) were found to be unaware of their infection.68,69 Differences in these findings are likely attributable to sample-size differences, target populations, and the limitations and biases of each method.
Since our survey was limited to 15- to 29-year-old men who attended MSM-identified venues in 6 cities, our findings may not generalize to MSM who are older, who reside in other cities, and who do not attend MSM-identified venues. Our finding on the magnitude of unrecognized infection is also subject to 3 potential upward biases. First, our finding would be biased upwards if proportionally fewer infected-aware MSM attend venues or attend venues as often as infected-unaware MSM. However, of 563 18- to 29-year-old MSM who participated in a household-based telephone survey in 4 US cities from 1996-1998, similar high proportions of infected-aware MSM (n = 53) and HIV-negative or unknown MSM (n = 474) attended a bar, night club, or dance club in the previous 12 months (94 vs. 97%; P = 0.41) (Lance Pollack, PhD, personal communication, November 10, 2003). Also, we observed no difference in monthly or more frequent attendance at gay clubs between infected-aware and infected-unaware participants (84 vs. 81%; P = 0.36).
Second, our finding on unrecognized infection would be biased upwards if many infected-aware participants chose not to report that they had tested HIV positive. We did not use computer-assisted self-interviews, which have been found to obtain more sensitive information than face-to-face interviews.70 Our interviewers, however, did not report that participants were troubled when asked to disclose their most recent test result, and only 2 of 4370 men who had previously tested refused to answer this question.
Lastly, our finding on unrecognized infection would be biased upwards if proportionally fewer infected-aware than infected-unaware MSM chose to participate in our survey. This bias may be important because 41% of all identified eligible men declined to participate. However, HIV status was not assessed during recruitment and was not a condition of enrollment. Second, a high proportion of unrecognized infection is expected in groups with high HIV incidence and low testing rates. Our sample of young MSM meets both conditions.7,27 Third, we found that unrecognized HIV infection varied in expected directions in groups with similar testing rates: highest among black MSM with highest HIV incidence, and lowest among white MSM with lowest HIV incidence. Although a lower proportion of HIV-infected MSM from Seattle were unaware of their infection, compared with other cities, proportionally more were white. Moreover, participants from Seattle were more likely to have ever, repeatedly, and recently tested for HIV (data not shown). Finally, in spite of considerable differences in unrecognized infection between black and white MSM in our survey, participation rates between these 2 groups were nearly identical (blacks: 58%; whites: 57%).
Given these limitations and plausible biases, we realize that our reported magnitude of unrecognized infection among young MSM is upwardly biased to some unknown extent. This upward bias, however, probably does not account for the entire difference in magnitude of unrecognized infection reported between venue- and household-based surveys, and with the overall national estimate. Although population-based, household surveys of MSM underrepresent minorities and in particular young black MSM.6,68,69 Since HIV incidence and magnitude of unrecognized infection are greatest among black MSM, findings on unrecognized infection from these surveys are most likely biased downwards. Similarly, the overall national estimate cannot be applicable to all population segments, especially those with high HIV incidence such as young MSM.
Our findings suggest that the HIV epidemic among young MSM in the United States continues unabated, in part, because many young HIV-infected MSM are unaware of their infection and unknowingly expose many of their partners to HIV. Consistent with previous research,14-17 we found that proportionally fewer infected-aware than infected-unaware MSM reported HIV transmission behavior with at-risk partners. Clearly, persons who are unaware of their infection can neither take advantage of effective therapies, take steps to reduce transmission to others, nor facilitate testing of partners who might also be infected. To advance HIV prevention in the third decade of HIV/AIDS, national, state, and local prevention efforts must take advantage of opportunities to increase the demand for and availability of testing to reduce the burden of unrecognized HIV infection among young MSM.
The authors thank the young men who volunteered for this research project and the dedicated staff who contributed to its success. We are especially grateful to the YMS coordinators: John Kiriacon, Al Bay, David Forest, Henry Artiguez (Miami), Vincent Guilin (New York City); John Hylton, Karen Yen (Baltimore), Tom Perdue (Seattle), Douglas Shehan and Santiago Pedraza (Dallas), and Sue Stoyanoff and Denise Johnson (Los Angeles). We appreciate and acknowledge the dedicated effort of laboratory and data management staff in all cities.
The following organizations participated in the Young Men's Survey: Baltimore: Johns Hopkins School of Hygiene and Public Health, Baltimore City Health Department, Maryland Department of Health and Mental Hygiene; Dallas: University of Texas Southwestern Medical Center at Dallas, Texas Department of Health; Los Angeles: Los Angeles County Department of Health Services; Miami: Health Crisis Network, University of Miami, Florida Department of Health; New York City: New York Blood Center, New York City Department of Health; San Francisco: San Francisco Department of Public Health; Seattle: Public Health-Seattle and King County, HIV/AIDS.
The members of the Young Men's Survey Group are Baltimore: David D. Celentano, ScD; John B. Hylton, MHS; Dallas: Anne C. Freeman, MSPH; Douglas Shehan; Santiago Pedraza; Eugene Thompson, MS; Los Angeles: Peter R. Kerndt, MD, MPH; Wesley L. Ford, MA, MPH; Susan R. Stoyanoff, MPH; Denise Johnson, MPH; Bobby Gatson; Miami: Al Bay, PhD; John Kiriacon; Marlene LaLota, MPH; Thomas Liberti; New York City: Vincent Guilin; Beryl A. Koblin, PhD; Lucia V. Torian, PhD; San Francisco: William McFarland, MD, PhD; Seattle: Thomas Perdue, MPH; Hanne Thiede, DVM, MPH; CDC: Bradford N. Bartholow, MA; Stephanie Behel; Robert S. Janssen, MD; Duncan A. MacKellar, MA, MPH; Gina M. Secura, MPH; Linda A. Valleroy, PhD.
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Keywords:© 2005 Lippincott Williams & Wilkins, Inc.
unrecognized HIV infection; young men who have sex with men