Men who have sex with men (MSM) are at increased risk for infection with human immunodeficiency virus (HIV).1 The Centers for Disease Control and Prevention (CDC) estimates that MSM represent 2% of the US population.1 However, MSM accounted for 57% of new HIV infections during 2006.2 A recent CDC study reported that approximately 1 in 5 (19%) MSM were infected with HIV, but half were unaware of their infection.3
Early diagnosis of HIV infection is associated with reduced morbidity, mortality, and HIV transmission and can be achieved through regular testing.4,5 In 2006, CDC recommended offering HIV testing at least annually to sexually active MSM and every 3 to 6 months to MSM who have multiple or anonymous partners, have sex in conjunction with illicit drug use, use methamphetamine, or whose sex partners participate in these activities.6 However, studies rarely have assessed adherence to these testing recommendations among MSM in the United States. A recent US study based on a national online survey demonstrated that only 30% of MSM who visited health care providers during the previous year were offered HIV testing.7
In 2007 in the St. Louis metropolitan area, Missouri, an estimated 78% of new HIV diagnoses were attributed to MSM; 65% of MSM with newly diagnosed HIV infection were black; and an estimated 22% of new HIV diagnoses among MSM in St. Louis were late in the course of disease (i.e., ≤12 months from an acquired immunodeficiency syndrome diagnosis).8 The estimated HIV prevalence among MSM in St. Louis in 2008 was 14%, and one-third of HIV-infected MSM were unaware of their infection.3 These findings indicated that a substantial proportion of MSM in St. Louis might not have tested for HIV recently and thus did not benefit from earlier HIV diagnoses. However, the adherence of MSM in St. Louis to CDC's recommendations of annual HIV testing was unknown. We examined the prevalence of HIV testing during the previous 12 months and factors associated with recent testing among sexually active MSM in the St. Louis metropolitan area.
MATERIALS AND METHODS
Study Setting and Location
CDC's National HIV Behavioral Surveillance (NHBS) system monitors prevalence and trends of HIV-related characteristics, including risk behaviors and HIV testing among populations at high risk for HIV infection (MSM, injection-drug users, and heterosexuals practicing risky behaviors) in annual rotating cycles.9 The first cycle of NHBS among MSM was conducted during 2004–2005 in 15 US metropolitan statistical areas (MSAs) that did not include the St. Louis MSA.10 The second cycle of NHBS among MSM was conducted in 2008 in 21 US MSAs, including St. Louis MSA.3
The White House Office of Management and Budget has defined the St. Louis MSA as the area comprising St. Louis City, MO; 7 counties in Missouri (Franklin, Jefferson, Lincoln, St. Charles, St. Louis, Warren, and Washington); 8 counties in Illinois (Bond, Calhoun, Clinton, Jersey, Macoupin, Madison, Monroe, and St. Clair); and the part of Sullivan City in Crawford County, MO.11 The Mississippi river is the state boundary between Missouri and Illinois within the St. Louis MSA. In 2008, the St. Louis MSA had an estimated population of 2.82 million and was the 18th largest MSA in the United States.12 Approximately 75% of the St. Louis MSA population lives on the Missouri side and 25% on the Illinois side.13,14
Sampling and Eligibility
NHBS used venue-based, time–space sampling and developed a standardized approach to recruit ≥500 MSM in each MSA.3,10 The sample size was based on feasibility of recruiting ≥500 MSM with allocated resources and time and to estimate prevalence of HIV-related characteristics with adequate precision.10 During September–December 2008, Missouri Department of Health and Senior Services (MDHSS) and NHBS staff in St. Louis followed the standardized approach to identify venues attended by MSM for purposes other than receiving medical, mental health, social, or HIV and sexually transmitted disease (STD) diagnostic testing or prevention services. Typical venues included bars, dance clubs, social organizations, bathhouses, and street locations. Days and times when MSM frequented these venues were identified to develop a sampling frame; venues and the corresponding days/times were randomly selected to approach men at the venues.10 Although such venues were identified on both Missouri and Illinois sides of the St. Louis MSA, MDHSS and NHBS staff had jurisdiction to sample venues located on the Missouri side only.
Eligible participants were men who were aged ≥18 years residing in the St. Louis MSA in Missouri or Illinois and able to complete the interview in English or Spanish. After the participant gave informed consent, NHBS interviewers administered a standardized, anonymous questionnaire by using a handheld computer to collect information comprising the participants' demographic characteristics, sexual identity and behaviors, and HIV-testing history. CDC determined that NHBS was not research.15 The 2008 NHBS activity in St. Louis MSA was approved by MDHSS Institutional Review Board.
Analysis Criteria, Outcome, and Definitions
For this analysis, we included sexually active MSM with negative or unknown HIV status as of 12 months before the interview, and we examined their prevalence of HIV testing during the 12 months before the interview. Therefore, we excluded men who did not report having had sex with a man during the previous year and men who had tested HIV-positive >12 months before the interviews. We did not exclude men who had tested HIV-positive during the previous 12 months because such exclusion would lead to an underestimated prevalence of HIV testing for that 12-month period. Men who did not complete the interview were also excluded.
The outcome variable for this study, HIV testing during the previous 12 months, was assessed by participants' answers to the questions, “Have you ever been tested for HIV?” and, if the answer was yes, “When did you have your most recent HIV test?”
In this analysis, participants were categorized as having health insurance if they reported having any private or public health insurance. A health care provider was defined as any doctor or nurse visited by the participant. A male casual sex partner was defined as a man with whom the participant had had sex, but to whom he did not feel committed to or whom he did not know well.
Bivariate analyses were conducted by using χ2 test or Fisher exact test to compare prevalence of HIV testing during the previous 12 months by demographic and behavioral factors. A multivariable log-binomial regression model was used to identify factors independently associated with HIV testing and to estimate adjusted prevalence ratios (APRs) and 95% confidence intervals (CIs) for HIV testing in relation to individual factors. Variables that were associated with HIV testing in bivariate analyses (P < 0.2) were considered candidates for inclusion in the multivariable model. The analyses were conducted by using the statistical software package SAS version 9.2 (SAS Institute, Inc., Cary, NC).
During September–December 2008, NHBS staff approached 530 men for interviews at 40 venues located on the Missouri side of the St. Louis MSA. Of 447 (84%) eligible participants who consented to the interview, 108 men were excluded from analysis, including 71 who did not report having had sex with a man during the previous 12 months, 12 who had tested HIV-positive >12 months before the interview, and 25 who did not complete the interview. Excluded and included participants did not differ statistically regarding age, race/ethnicity, education, and annual household incomes (data not shown).
A total of 339 (76%) participants were included in the analysis (Table 1). Median age was 35 years (range, 18–80 years); 238 (70%) were non-Hispanic white, 58 (17%) non-Hispanic black, 13 (4%) Hispanic, and 30 (9%) were multiracial or other. Of the participants, 136 (40%) had a college education or higher, and 53 (16%) reported an annual household income <$20,000. A total of 249 (73%) had health insurance; 281 (83%) had visited a health care provider, including doctors during the previous 12 months, and 246 (73%) had ever disclosed same-sex attractions or male-male sex to health care providers. During the previous 12 months, 245 (72%) had had >1 male sex partner, and 216 (64%) had had ≥1 male casual sex partner. Anal sex was reported by 280 (83%) and unprotected anal sex by 186 (55%) participants.
Of the 339 participants, 198 (58%) had been tested for HIV during the previous 12 months, among whom 15 (8%) reported a positive test result; 141 (42%) participants had not been tested for HIV, among whom 25 (18%) had never been tested. In bivariate analysis, factors positively associated (P < 0.2) with HIV testing during the previous 12 months were being of non-Hispanic black race; having health insurance; having visited a health care provider; having ever disclosed same-sex attractions or male-male sex to health care providers; having had >1 male sex partner; and having had anal sex (Table 1). These 6 variables were included and dichotomized in the multivariable model. In our multivariable analysis, participants were more likely to have been tested during the previous 12 months if they were non-Hispanic black (APR: 1.6; 95% CI: 1.0–2.5); had visited a health care provider (APR: 1.6; 95% CI: 1.3–2.1); or had ever disclosed same-sex attractions or male-male sex to health care providers (APR: 1.6; 95% CI: 1.2–2.0) (Table 2). No statistically significant interaction terms were discovered.
Of 281 participants who had visited a health care provider during the previous 12 months, 183 (65%) had been tested for HIV. Of participants who had both visited a health care provider and ever disclosed same-sex attractions or male-male sex to health care providers, 71% had been tested. Only 15% of the participants who had neither visited a health care provider nor disclosed same-sex attractions or male-male sex to health care providers had been tested during the past 12 months (Table 3).
Of 198 participants who had been tested for HIV during the previous 12 months, the majority had been tested to ensure they were still HIV-negative (73%) or because they had received testing on a regular basis (68%) (Table 4). The facility types reported as the most recent place of HIV testing included private doctor's office (n = 86; 43%), public health clinic or community health center (n = 25; 13%), HIV counseling and testing site (n = 23; 12%), hospital (inpatient) (n = 11; 6%), HIV street outreach program or mobile unit (n = 10; 5%), STD clinic (n = 9; 5%), emergency department (n = 5; 3%), other outpatient clinic (n = 4; 2%), home (n = 3; 2%), or other (n = 19; 10%). Of 141 participants who had not been tested during the previous 12 months, the most common reasons for not being tested were perceived low HIV risk (63%) and fear of knowing a positive result (31%) (Table 4).
This study of MSM in the St. Louis MSA determined that only 58% of sexually active MSM had been tested for HIV during the previous 12 months. A recent analysis of the 2008 NHBS data revealed that only 61% of sexually active MSM in 21 US MSAs had been tested for HIV during the previous 12 months.16 Our results, consistent with the findings from the national data, indicate suboptimal adherence of sexually active MSM to CDC's recommendations regarding annual HIV testing.
We demonstrated that non-Hispanic black participants were more likely to have been tested for HIV during the previous 12 months than those of other race/ethnicities. Racial/ethnic differences in proportions of MSM tested for HIV during the previous year were not demonstrated from the analysis of the 2008 NHBS data.16 Although our findings might reflect increased local efforts to encourage testing among black MSM, cautions are needed because black MSM sampled by this survey might not be representative of all black MSM in the St. Louis MSA. During the survey, staff learned that certain venues frequented by black MSM were located on the Illinois side of the St. Louis MSA, but staff were only permitted to sample venues in Missouri because of jurisdictional coverage. Observations during the survey indicated that black MSM who frequented venues on the Illinois side of the St. Louis MSA might have different sociodemographic characteristics than those who frequented venues on the Missouri side, which likely affects the representativeness of black MSM in our sample and the accuracy of estimated prevalence of HIV testing among black MSM in the St. Louis MSA.
Among the participants included in our analysis, 73% had health insurance and 83% had visited a health care provider in the preceding year. The 2008 NHBS data revealed that 66% of participants nationwide had health insurance and 76% had visited a health care provider in the preceding year.3 The higher insured rate in our sample might reflect regional differences in health insurance coverage in the United States; in 2008, the Midwest and the Northeast had higher insured rates (88%) than the West (83%) and the South (82%).17 Despite a higher insured rate in our study participants, HIV testing remained underutilized.
Previous studies have demonstrated barriers to HIV testing for sexually active MSM, including denial of risk; fear of knowing a positive result; fear of stigma and rejection from health care providers and peers; and not knowing where to access friendly, anonymous, and low-cost HIV testing.18 In our analysis, perceived low risk for HIV infection and fear of knowing a positive result were the 2 most commonly reported reasons for not being tested during the previous 12 months. To reduce these barriers and facilitate HIV testing, efforts are needed to educate MSM about behavioral risks, benefits of testing, and management of a positive result.
Studies have consistently indicated the crucial role of health care providers in offering HIV testing to MSM.7,9,19,20 Our results demonstrate that participants were tested at private doctor's offices most commonly and were more likely to be tested if they had had a recent visit to a health care provider or had ever disclosed same-sex attractions or male-male sex to a health care provider. An analysis of the 2004–2005 NHBS data in New York City also reported that MSM who had ever disclosed same-sex attraction or male-male sex to health care providers were more likely to be tested for HIV.19 A recent online survey of US MSM nationwide also demonstrated a strong association between disclosure of male-male sex to a health care provider and being offered HIV testing with health care visits during the previous year.7 In our analysis, 83% of participants had visited a health care provider during the previous 12 months, but 35% of them still were untested, representing missed opportunities for testing in the health care settings. We determined that 27% of the participants had never disclosed same-sex attractions or male-male sex to a health care provider. MSM might be reluctant to disclose sexual identity or behaviors to health care providers because of concerns about confidentiality or discrimination.21–23 To reduce the difficulty for spontaneous disclosure, CDC recommends clinicians assess STD/HIV risk for all male patients, including a routine inquiry about the sex of sex partners.6,24 However, health care providers might not adopt these recommendations because of insufficient time, discomfort with discussion of sexual behavior, and presumptions about sexuality and behaviors of male patients.25
This analysis is subject to at least 2 limitations. First, the survey was administered through face-to-face interviews, which might have led to social desirability bias. Respondents might not have disclosed male-male sex and thereby been falsely excluded from analysis. Participants also might have underreported the number of sex partners or engagement in anal sex, leading to misclassification. Participants might have overreported HIV testing, leading to an overestimated prevalence of HIV testing during the previous 12 months. Second, the survey did not include questions on the temporal associations between visits to health care providers, disclosure of same-sex attractions or male-male sex, and HIV testing. We cannot determine whether HIV testing was offered by the health care provider to whom the participant had disclosed same-sex attractions or male-male sex.
In conclusion, although sexually active MSM are at increased risk for HIV infection, and CDC recommends that MSM be tested for HIV at least annually, nearly half of MSM in this analysis were not tested for HIV during the previous year. Missed opportunities for MSM to receive HIV testing from health care providers still exist. Annual visits to health care providers with whom sexual identity and behaviors are discussed might help increase HIV testing among MSM. We recommend health care providers include sexual risk as part of routine periodic assessment of all male patients and to offer HIV testing at least annually to sexually active MSM.
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