Rapid HIV Testing at Gay Pride Events to Reach Previously Untested MSM: U.S., 2009–2010

We offered rapid HIV testing at social events frequented by young men who have sex with men (MSM), a group disproportionately affected by the HIV epidemic. We tested 1,312 MSM; of those MSM, 1,072 (81.7%) reported HIV testing history. Of those reporting HIV testing history, 550 (51.3%) were non-Hispanic black and 404 (37.7%) were aged <25 years. One hundred twenty-eight (11.9%) had never tested for HIV; 77 (7.2%) were preliminarily positive, with 15 (19.5%) being first-time testers. Factors associated with no previous HIV test included young age (13–24 years) (adjusted odds ratio [AOR] = 3.5, 95% confidence interval [CI] 1.9, 6.5) and non-Hispanic black (AOR=3.2, 95% CI 1.6, 6.4) or Hispanic (AOR=2.8, 95% CI 1.2, 6.3) race/ethnicity. HIV testing at Gay Pride events reaches young, previously untested MSM. This venue-based HIV testing approach at nonclinical sociocultural events is an additional strategy for HIV prevention goals to increase the number of people aware of their HIV infection with subsequent linkage to HIV care.An estimated 20% of 1.2 million people living with human immunodeficiency virus (HIV) infection in the United States are unaware of their HIV infection.¹ Among people living with HIV, young non-Hispanic black men who have sex with men (MSM) are the only group with significant increases in incident HIV cases in recent years.² Although young non-Hispanic black and Hispanic MSM are more likely to report being tested, they are also more likely to be unaware of an HIV infection than their white counterparts.³ A recent analysis reported that 44% of MSM in 21 cities were unaware of their infection; non-Hispanic black MSM comprised 59% of that group.⁴ People unaware of their HIV infection transmit approximately half of incident HIV infections.⁵Although young non-Hispanic black MSM do not engage in risky behaviors more than young non-Hispanic white or Hispanic men,⁶ they are more vulnerable to becoming HIV-infected than MSM from other racial/ethnic groups. Reasons for this disproportionate impact on young MSM of color are unclear, but include high community prevalence of HIV, social and structural barriers to routine screening and treatment (e.g., less health insurance, higher unemployment, and higher rate of incarceration), and stigma and homophobia.⁷ MSM with increased risk of HIV exposure may benefit from increased access to HIV screening in nontraditional/clinical settings.Early diagnosis and effective treatment with antiretroviral therapy are important components of reducing HIV transmission risk and incident HIV infections.³ Current recommendations support routine HIV screenings in health-care settings for people aged 13–64 years to provide opportunities for early diagnosis and linkage to care.⁸ Gaps in the implementation of these recommendations remain, however, and data suggest that opportunities to diagnose HIV infections in health-care settings, particularly among young MSM of color, may frequently be missed.⁹ Young MSM at increased risk of HIV exposure may benefit from more frequent testing intervals (i.e., every 3–6 months).^6,10HIV testing in nonclinical community settings is an additional prevention strategy to reach young minority MSM who disproportionately lack health-care access.^10,11 Nonclinical social events where large numbers of at-risk people may gather at locations perceived to be culturally sensitive, such as Gay Pride festivals, offer expanded opportunities for HIV testing. In addition, from the provider perspective, analyses have shown that community-based efforts for HIV testing cost less than testing in clinical settings.¹² These efforts are crucial as we work toward goals of the National HIV/AIDS Strategy.¹³Previous reports of HIV testing outreach have supported the feasibility of this approach with racial/ethnic minority MSM.^14,15 However, factors associated with having not been previously tested among MSM reached at these events are poorly understood.¹⁴ In this article, we summarize findings from the Behavioral Assessment and Rapid Testing (BART) project,¹⁶ a community-based HIV testing project that was implemented in multiple U.S. cities. Our objectives were to (1) describe characteristics of MSM who accepted HIV testing, (2) examine differences in time since previous HIV test for participants, and (3) describe factors associated with not having been previously tested for HIV.     

Online Hookup Sites for Meeting Sexual Partners Among Men Who Have Sex with Men in Rhode Island, 2013: A Call for Public Health Action

Frequent use of websites and mobile telephone applications (apps) by men who have sex with men (MSM) to meet sexual partners, commonly referred to as “hookup” sites, make them ideal platforms for HIV prevention messaging. This Rhode Island case study demonstrated widespread use of hookup sites among MSM recently diagnosed with HIV. We present the advertising prices and corporate social responsibility (CSR) programs of the top five sites used by newly diagnosed HIV-positive MSM to meet sexual partners: Grindr, Adam4Adam, Manhunt, Scruff, and Craigslist. Craigslist offered universal free advertising. Scruff offered free online advertising to selected nonprofit organizations. Grindr and Manhunt offered reduced, but widely varying, pricing for nonprofit advertisers. More than half (60%, 26/43) of newly diagnosed MSM reported meeting sexual partners online in the 12 months prior to their diagnosis. Opportunities for public health agencies to promote HIV-related health messaging on these sites were limited. Partnering with hookup sites to reach high-risk MSM for HIV prevention and treatment messaging is an important public health opportunity for reducing disease transmission risks in Rhode Island and across the United States.An estimated 1.2 million people in the United States live with human immunodeficiency virus (HIV) according to 2015 estimates published by the Centers for Disease Control and Prevention (CDC).¹ Although men who have sex with men (MSM) represent 4% of the U.S. male population, they account for 61% of all new HIV infections.² Sexual behaviors contributing to HIV transmission among MSM may be facilitated by websites and mobile telephone applications (apps), which are increasingly popular vehicles for MSM to meet sexual partners.^3–8 Although websites and apps differ in services offered and message delivery, many have the primary purpose of facilitating sexual encounters. Hereinafter, we collectively refer to websites and apps that MSM use to meet sexual partners as “hookup sites.” Some hookup sites use global positioning system software to allow subscribers to identify nearby sexual partners.⁸Use of hookup sites to meet sexual partners among MSM is more prevalent than among other populations. MSM are up to seven times more likely than non-MSM to have sex with a partner they met online,⁵ and an estimated 3–6 million MSM meet sexual partners using Internet-based technology.⁷ A meta-analysis found that nearly half of MSM surveyed had met sexual partners online;⁷ another study found that 85% of MSM use the Internet to meet other men for sex.⁵ The anonymity, affordability, and accessibility of meeting partners online appeals to many MSM, for whom meeting partners in traditional social settings may pose challenges because of stigma associated with having sex with other men.⁹MSM who use the Internet to meet sexual partners are more likely to engage in higher-risk behavior than men who do not meet partners online, including having more frequent condomless anal intercourse, having more sexual partners, having more sex with anonymous or non-main partners, having more sex with HIV-positive partners, and more often using drugs and alcohol during sex.^4,8,10,11 Hookup sites can be used to locate partners for “barebacking,” or intentional condomless sex.^3,8 Men who meet partners online may have limited knowledge of HIV prevention tools; a 2012 study found that MSM who met partners online had limited knowledge about pre-exposure prophylaxis (PrEP) and postexposure prophylaxis.¹²Despite the growing body of research linking hookup sites to high-risk behavior, few studies have explored the associations between these sites and disease transmission. A 2014 study found that MSM who used apps to meet sexual partners had greater odds of testing positive for gonorrhea and chlamydia compared with MSM who did not meet their partners online, but did not find any increased risk for syphilis or HIV.⁴ Although another 2014 article posited that Craigslist advertisements for sexual encounters were correlated with HIV infection, a closer review of the analyses suggested that transmission was not correlated with Craigslist use at the individual level.⁶ These findings suggest that hookup sites may facilitate disease transmission by expediting the process of meeting sexual partners,⁹ but this issue warrants further scientific exploration and public policy attention.     

HIV Testing Among Men at Risk for Acquiring HIV Infection Before and After the 2006 CDC Recommendations

Objectives

Testing for human immunodeficiency virus (HIV) is the key first step in HIV treatment and prevention. In 2006, the Centers for Disease Control and Prevention (CDC) recommended annual HIV testing for people at high risk for HIV infection. We evaluated HIV testing among men with high-risk heterosexual (HRH) contact and sexually active men who have sex with men (MSM) before and after the CDC recommendations.

Methods

We used data from the National Survey of Family Growth, 2002 and 2006–2010, to assess proportions of HRH respondents and MSM reporting HIV testing in the prior 12 months, compare rates of testing before and after release of the 2006 CDC HIV testing guidelines, and examine demographic variables and receipt of health-care services as correlates of HIV testing.

Results

Among MSM, the proportion tested was 37.2% (95% confidence interval [CI] 28.2, 47.2) in 2002, 38.2% (95% CI 25.9, 52.2) in 2006–2008, and 41.7% (95% CI 29.2, 55.3) in 2008–2010; among HRH respondents, the proportion was 23.7% (95% CI 20.5, 27.3) in 2002, 24.5% (95% CI 20.9, 28.7) in 2006–2008, and 23.9% (95% CI 20.2, 28.1) in 2008–2010. HIV testing was more likely among MSM and HRH respondents who received testing or treatment for sexually transmitted disease in the prior 12 months, received a physical examination in the prior 12 months (MSM only), or were incarcerated in the prior 12 months.

Conclusions

The rate of annual HIV testing was low for men with sexual risk for HIV infection, and little improvement took place from 2002 to 2006–2010. Interventions aimed at men at risk, especially MSM, in both nonmedical and health-care settings, likely could increase HIV testing.New infections of human immunodeficiency virus (HIV) occur in the United States at a rate of approximately 50,000 per year, driven mostly by sexual transmission, particularly among men who have sex with men (MSM).¹ In 2010, male-to-male sexual contact accounted for 63% of new HIV infections (78% among males), and heterosexual contact accounted for 25% of new HIV infections (11% among males).^1,2 Although overall incidence has been relatively stable since 2006, among young MSM, particularly young black MSM, new infections continue to increase.^1,3An estimated 14% of adults and adolescents living with HIV infection in the United States are undiagnosed, of whom 11% are males with high-risk heterosexual (HRH) contact and 62% are MSM.⁴ To increase the proportion of HIV-infected people who are aware of their status and link them to treatment and prevention services, the Centers for Disease Control and Prevention (CDC) recommended in 2006 that all people aged 13–64 years be tested at least once for HIV infection and that people at high risk for HIV infection, including men with HRH contact and sexually active MSM,⁵ be tested annually.Using data from multiple waves of a nationally representative survey, we examined the percentage of HRH and MSM respondents who reported having been tested for HIV in the prior 12 months. We compared rates of testing before and after the revised HIV testing guidelines⁵ were released by CDC in 2006. Additionally, because the 2006 CDC guidelines recommended that HIV screening be conducted as part of routine clinical care in all health-care settings,⁵ we examined HIV testing among men stratified by their reported use of health-care services in the prior 12 months and by several sociodemographic variables.     

Who Are California's Late HIV Testers? An Analysis of State AIDS Surveillance Data, 2000–2006

Objectives

Late HIV testing leads to preventable, severe clinical and public health outcomes. California, lacking a mature HIV surveillance system, has been excluded from documented analyses of late HIV testers in the United States. We identified factors associated with late HIV testing in the California AIDS surveillance data to inform programs of HIV testing and access to treatment.

Methods

We analyzed data from California AIDS cases diagnosed between 2000 and 2006 and reported through November 1, 2007. Late testers were people diagnosed with HIV within 12 months before their AIDS diagnosis. We identified factors significantly associated with late HIV testing using multivariable logistic regression.

Results

Among 28,382 AIDS cases, 61.2% were late HIV testers. Late testing was significantly associated with those ≥35 years of age, heterosexual contact or unknown/other reported transmission risk, and being born outside of the U.S. When further classified by country of birth, people born in Mexico were most likely to be HIV late testers who progressed to AIDS.

Conclusions

Our findings support wider implementation of opt-out HIV testing and HIV testing based in emergency departments. Services for HIV testing and treatment should be inclusive of all populations, but especially targeted to populations that may have more limited access.Among the more than one million people in the United States estimated to be infected with human immunodeficiency virus (HIV), nearly one-quarter remain undiagnosed.¹ Increasing evidence suggests that earlier antiretroviral therapy (ART) for HIV improves survival compared with deferred therapy.^2,3 The benefits of HIV diagnosis well before acquired immunodeficiency syndrome (AIDS) diagnosis are clearly documented and include survival benefit for asymptomatic HIV-infected people with early initiation as compared with deferred initiation of ART,² decreased viral transmission due to lower-serum HIV-1 ribonucleic acid levels⁴ as well as risk modification in people who know their HIV serostatus,⁵ and decreased health expenditures.⁶ In Canada, the estimated annual medical cost of a late presenter, after adjusting for patient characteristics, was more than twice that of a non-late presenter, with a difference of more than $8,000 per person. This discrepancy is mostly due to hospital care costs, which are 15 times higher for those diagnosed late.⁷Given that the period from primary HIV infection to AIDS is estimated at seven to eight years⁸ and the Centers for Disease Control and Prevention (CDC) guidelines advocate routine HIV testing for all U.S. adults,⁹ late HIV testing (defined as the first diagnosis of HIV within one year of an AIDS diagnosis)¹⁰ should be an unusual clinical outcome. However, national estimates from CDC reported that 45% of people with AIDS at 16 sites in the U.S. were late testers.¹⁰ Among AIDS surveillance cases in San Francisco and South Carolina, 39% and 41%, respectively, were late testers.^11,12 In the U.S., AIDS diagnoses can be arguably regarded as a measure of diagnostic or treatment failure.In California, approximately 85% of adult HIV cases are male, 28% are Hispanic, 20% are African American, and 50% are white. Men who have sex with men (MSM) comprise the main risk exposure for men (77%). For women, heterosexual contact is the main risk exposure (52%), followed by injection drug use (23%).¹³ California is home to about 4.4 million Mexican immigrants, about 40% of the total immigrant population in the U.S., and is a key destination for Mexican migrants.^11,14 Both the U.S. and Mexico have concentrated HIV epidemics, where prevention and testing campaigns prioritize traditionally high-risk groups such as MSM and injection drug users (IDUs).The role of migration on the vulnerability of immigrants in California, historically considered a low-risk group, is complex and poorly understood but may have a significant impact on the likelihood of becoming infected with HIV while in the U.S.¹⁵ The denominator of Mexican immigrants in California likely varies by structural factors such as agricultural season. The effect and extent of this varying denominator on HIV/AIDS estimates is not well characterized. In this analysis of California AIDS surveillance data, we identified factors that are significantly associated with late HIV testing in the state.     

Recruitment-adjusted estimates of HIV prevalence and risk among men who have sex with men: effects of weighting venue-based sampling data

Objectives

We investigated the impact of recruitment bias within the venue-based sampling (VBS) method, which is widely used to estimate disease prevalence and risk factors among groups, such as men who have sex with men (MSM), that congregate at social venues.

Methods

In a 2008 VBS study of 479 MSM in New York City, we calculated venue-specific approach rates (MSM approached/MSM counted) and response rates (MSM interviewed/MSM approached), and then compared crude estimates of HIV risk factors and seroprevalence with estimates weighted to address the lower selection probabilities of MSM who attend social venues infrequently or were recruited at high-volume venues.

Results

Our approach rates were lowest at dance clubs, gay pride events, and public sex strolls, where venue volumes were highest; response rates ranged from 39% at gay pride events to 95% at community-based organizations. Sixty-seven percent of respondents attended MSM-oriented social venues at least weekly, and 21% attended such events once a month or less often in the past year. In estimates adjusted for these variations, the prevalence of several past-year risk factors (e.g., unprotected anal intercourse with casual/exchange partners, ≥5 total partners, group sex encounters, at least weekly binge drinking, and hard-drug use) was significantly lower compared with crude estimates. Adjusted HIV prevalence was lower than unadjusted prevalence (15% vs. 18%), but not significantly.

Conclusions

Not adjusting VBS data for recruitment biases could overestimate HIV risk and prevalence when the selection probability is greater for higher-risk MSM. While further examination of recruitment-adjustment methods for VBS data is needed, presentation of both unadjusted and adjusted estimates is currently indicated.Venue-based sampling (VBS), also called time-location or time-space sampling, is a study design that is widely used to provide estimates of risk factors and disease outcomes.¹ Although it can be used to study any target population that congregates at known venues associated with the population,² it has been primarily used for behavioral research of groups at risk for human immunodeficiency virus (HIV) or sexually transmitted diseases, such as men who have sex with men (MSM) and drug users.³ Because these populations are often “hidden” from probabilistic sampling (i.e., a population sampling frame cannot be constructed),⁴ using traditional probability designs may be inefficient or infeasible.⁵Several variations of VBS exist, but all introduce elements of randomness in recruitment that improve upon convenience sampling. In the Young Men''s Survey of MSM in seven U.S. cities, for example, a universe of MSM-oriented venues was created, venues were randomly selected, and presumed MSM entering a selected venue were non-preferentially approached to participate.⁶ Sampling efficiency is a chief strength of VBS, as selected recruitment venues contain a high density of the target population. But a corresponding weakness is that the group able to be sampled (e.g., MSM who visit MSM-oriented social venues) may be different from the larger target population (e.g., all sexually active MSM). VBS-based estimates are not generalizable to that larger population when the venue-attending subpopulation exhibits differential characteristics.⁷ Nonetheless, VBS data are often useful in designing outreach-based HIV prevention programs because the venue-attending subpopulation is inherently accessible.⁸Increasing the validity of VBS-based estimates for that subpopulation, however, is a persistent goal. Statistical adjustment of VBS data may be used to correct unequal selection probabilities arising from at least two VBS recruitment biases. First, someone who attends venues frequently is more likely to be sampled than someone who attends venues infrequently. If outcome variables such as partner number or alcohol consumption are also related to attendance frequency, then unweighted data will overestimate population prevalence of these variables. Second, individual selection probability is inversely related to the volume of the target population at each recruitment venue. For example, MSM at low-volume bars have higher selection probabilities than MSM at high-volume gay pride events. Not accounting for these variations may bias estimates if outcome variables are associated with recruitment venue characteristics. Ideally, venue volume would be accounted for a priori in a study design such as probability-proportional-to-size (PPS) sampling, which adjusts second-stage (i.e., participant) selection probability by the size of a first-stage sampling unit.⁹ But PPS requires precise volume enumeration before recruitment, which is often infeasible for social venues. Post hoc statistical adjustment is an alternative approach. True selection probability will always be unknown in the VBS design because the population sampling frame is undefined, but adjustment for the two aforementioned biases may serve as an appropriate proxy in the absence of that gold standard.While several studies have compared VBS estimates with those using another study design,¹⁰ few VBS-based studies have used statistical adjustment for weighted analyses. Adjustment methods were developed for the Young Men''s Survey, but study analyses have only used unweighted data because weighting did not influence HIV prevalence estimates.¹¹ Other VBS studies have presented data weighted to account for differences in venue volume but not attendance frequency.¹² To our knowledge, no VBS studies have reported comparisons of unweighted and weighted estimates of the same data. In this study, we examined the impact of adjustment for the two previously mentioned recruitment biases and compared weighted and unweighted prevalence estimates of HIV risk factors and seroprevalence in a VBS-based sample of MSM.     

Evaluation of a Community Health Worker Intervention to Reduce HIV/AIDS Stigma and Increase HIV Testing Among Underserved Latinos in the Southwestern U.S.

Objectives

Latinos are at an elevated risk for HIV infection. Continued HIV/AIDS stigma presents barriers to HIV testing and affects the quality of life of HIV-positive individuals, yet few interventions addressing HIV/AIDS stigma have been developed for Latinos.

Methods

An intervention led by community health workers (promotores de salud, or promotores) targeting underserved Latinos in three southwestern U.S. communities was developed to decrease HIV/AIDS stigma and increase HIV knowledge and perception of risk. The intervention was led by HIV-positive and HIV-affected (i.e., those who have, or have had, a close family member or friend with HIV/AIDS) promotores, who delivered interactive group-based educational sessions to groups of Latinos in Spanish and English. To decrease stigma and motivate behavioral and attitudinal change, the educational sessions emphasized positive Latino cultural values and community assets. The participant pool comprised 579 Latino adults recruited in El Paso, Texas (n=204); San Ysidro, California (n=175); and Los Angeles, California (n=200).

Results

From pretest to posttest, HIV/AIDS stigma scores decreased significantly (p<0.001). Significant increases were observed in HIV/AIDS knowledge (p<0.001), willingness to discuss HIV/AIDS with one''s sexual partner (p<0.001), and HIV risk perception (p=0.006). Willingness to test for HIV in the three months following the intervention did not increase. Women demonstrated a greater reduction in HIV/AIDS stigma scores when compared with their male counterparts, which may have been related to a greater increase in HIV/AIDS knowledge scores (p=0.016 and p=0.007, respectively).

Conclusion

Promotores interventions to reduce HIV/AIDS stigma and increase HIV-related knowledge, perception of risk, and willingness to discuss sexual risk with partners show promise in reaching underserved Latino communities.Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) has disproportionately affected U.S. Latinos during the last 25 years. Although Latinos constitute 16% of the U.S. population, they account for 19% of those living with HIV and 21% of new HIV infections.¹ Since 2006, the Centers for Disease Control and Prevention (CDC) has recommended HIV testing for all people aged 13–64 years.² However, nearly half (46%) of Latino adults aged 18–64 years have never been tested, compared with 23% of black and 50% of white adults.³ Additionally, HIV testing often occurs at a late stage among HIV-positive Latinos. More than one-third (36%) of HIV-positive Latinos were diagnosed with AIDS within one year of learning their HIV status, compared with 32% of white people and 31% of black people.³ Late HIV testing hinders treatment options and may contribute to unknowing HIV transmission.Factors contributing to low HIV testing rates among Latinos include poverty, lack of health-care access, and limited availability of culturally and linguistically responsive services.^1,4–6 HIV/AIDS stigma is another factor.^7,8 UNAIDS (Joint United Nations Programme on AIDS) defines HIV stigma as the “devaluation of people either living with or associated with HIV/AIDS.”⁹ Stigma often results from fears about HIV as well as the associations of HIV with stigmatized groups such as homosexuals, sex workers, and injection drug users.^9,10HIV/AIDS stigma has negative consequences both at a population level and for individuals who are its targets, including people living with HIV/AIDS. Stigmatizing attitudes toward people living with HIV/AIDS are associated with decreased HIV testing, limited utilization of HIV prevention services, and high-risk sexual behaviors.^7,10,11 Additionally, for people living with HIV/AIDS, the stigma associated with HIV/AIDS contributes to unwillingness to disclose HIV status, unsafe sexual behaviors, delays in care seeking, reduced treatment adherence, mental health issues, and difficulties obtaining social support.^9,11–14Despite significant implications, few interventions have been developed to reduce HIV/AIDS stigma.^10,11,15 Existing interventions have often focused on specific populations (e.g., university students and health-care providers), with few interventions focused on Latinos,^11,15,16 who have high levels of stigmatizing attitudes toward people living with HIV/AIDS^1,17,18 that contribute to negative outcomes.^7,19Among Latinos, research indicates that community health workers (promotores de salud, hereinafter “promotores”) are an effective and culturally acceptable means of reaching the population with health information and motivating health behaviors.^20,21 Promotores are well positioned to promote changes in their communities because they share language and cultural values, are held in high esteem, and are perceived as role models.²¹ Promotores have been used to address health conditions ranging from chronic diseases to preventive screenings.^20–22 Several interventions have incorporated promotores into HIV prevention, finding significant changes in HIV risk behaviors, HIV counseling and testing, and other psychosocial constructs important to prevention.^16,23–29 To date, few studies have used promotores in interventions to reduce HIV stigma among Latinos.¹⁶We describe and report findings of an intervention using promotores to reduce HIV/AIDS stigma and increase willingness to seek HIV testing among Latinos in three communities in the southwestern United States: Los Angeles, California; San Ysidro, California; and El Paso, Texas.     

Barriers to routine HIV testing among Massachusetts community health center personnel

Objectives

We assessed the extent to which Centers for Disease Control and Prevention (CDC) recommendations have influenced routine HIV testing among Massachusetts community health center (CHC) personnel, and identified specific barriers and facilitators to routine testing.

Methods

Thirty-one CHCs were enrolled in the study. We compared those that did and did not receive funding support from the federal Ryan White HIV/AIDS Program. An anonymous survey was administered to a maximum five personnel from each CHC, including a senior administrator, the medical director, and three medical providers. Overall, 137 participants completed the survey.

Results

Among all CHCs, 53% of administrators reported having implemented routine HIV testing at their CHCs; however, only 33% of medical directors/providers reported having implemented routine HIV testing in their practices (p<0.05). Among administrators, 60% of those from Ryan White-supported CHCs indicated that both they and their CHCs were aware of CDC''s recommendations, compared with 27% of administrators from non-Ryan White-supported CHCs. The five most frequently reported barriers to the implementation of routine HIV testing were (1) constraints on providers'' time (68%), (2) time required to administer counseling (65%), (3) time required to administer informed consent (52%), (4) lack of funding (35%), and (5) need for additional training (34%). In a multivariable logistic regression model, the provision of on-site HIV testing by nonmedical staff resulted in increased odds of conducting routine HIV testing (odds ratio [OR] = 9.84, 95% confidence interval [CI] 1.77, 54.70). However, the amount of time needed to administer informed consent was associated with decreased odds of providing routine testing (OR=0.21, 95% CI 0.05, 0.92).

Conclusions

Routine HIV testing is not currently being implemented uniformly among Massachusetts CHCs. Future efforts to increase implementation should address personnel concerns regarding time and staff availability.In the United States, more than one million people are estimated to be living with human immunodeficiency virus (HIV); 21% are undiagnosed and/or remain unaware of their HIV infection.^1–3 Almost 40% are diagnosed late in the course of infection and receive an acquired immunodeficiency syndrome (AIDS) diagnosis within one year of their first positive HIV test result.³ To address the large number of undiagnosed HIV cases and high proportion of individuals presenting late to care, the Centers for Disease Control and Prevention (CDC) published revised recommendations in September 2006 that sought to establish HIV testing as a routine component of medical care similar to other screening procedures. Specifically, the CDC guidelines recommend that providers in all health-care settings, including hospital emergency departments, primary care practices, and community clinics, offer voluntary HIV testing to all patients aged 13–64 years and all pregnant women as an opt-out procedure, meaning that patients are to be notified that an HIV test will be conducted unless the patient declines.⁴ Separate written consent and prevention counseling as prerequisites for testing are no longer recommended.Release of the revised recommendations has sparked a national debate, and responses among the medical community have been mixed, with a majority of U.S. health professional organizations endorsing all or parts of the CDC recommendations.^5–7 While potentially increasing rates of HIV testing by streamlining consent⁸ and reducing associated stigma through normalization as a routine clinical procedure,^9,10 the elimination of a separate consent process and mandatory prevention counseling remains incompatible with several state laws or regulations and has been met with some concern.^5,11–14 Physician barriers to HIV testing include insufficient time, burdensome consent process, lack of knowledge/training about HIV testing and the CDC revised recommendations, difficulty locating HIV testing consent forms, lack of patient acceptance, competing priorities, and inadequate reimbursement.^15,16A growing body of research has examined efforts to improve HIV testing rates in a variety of health-care settings, including a public, urban medical care system,¹⁷ U.S. Department of Veterans Affairs health-care facilities,^18,19 hospital emergency departments,²⁰ a sexually transmitted disease (STD) clinic,²¹ and community health centers (CHCs).^22–24 However, while studies of CHCs have described programs to implement routine testing and largely reported patient-level data, little research to date has examined barriers to implementation among CHC personnel. CHCs represent an important source of primary care for people who are low-income, from racial/ethnic and sexual minority groups, immigrants, and those seeking mental health and substance abuse treatment services.²⁵ These populations are also disproportionately affected by HIV/AIDS, suggesting that CHCs can and do serve as an important resource for HIV/AIDS prevention and treatment.²⁶ In fact, from 1999 to 2004, CHCs conducted 7% of the total HIV tests supported by CDC yet identified 12% of the total HIV-positive results.²⁷In Massachusetts, providers face unique barriers to implementing routine testing. Despite the issuance of a June 2009 clinical advisory by the state health department supporting routine HIV testing in primary and urgent care settings, state law requires specific written informed consent before testing a patient for HIV, which is inconsistent with CDC''s recommendation to no longer require separate informed consent.^28–31 Consequently, written informed consent may be perceived as a barrier for providers to offer routine testing to patients, as this process typically requires a detailed conversation and providers are often working under already limited time constraints.^8,16 Understanding the facilitators and barriers to the implementation of routine HIV testing among CHCs in Massachusetts may have relevance to other U.S. states, where laws remain inconsistent with CDC HIV testing guidelines.^30,31We sought to gain a better understanding of HIV testing efforts among Massachusetts CHC personnel, including awareness of the CDC revised recommendations and any efforts to implement and support routine HIV testing in primary care settings. Analyses were stratified by respondent type (i.e., medical provider, administrator, and director) and funding mechanism, comparing health centers that did and did not receive support from the Ryan White HIV/AIDS Program, the federal program primarily responsible for HIV-related health services.³² Understanding the barriers and facilitators to implementing CDC''s revised recommendations may prove useful for designing educational materials and structural or individual-level interventions that will aid in conducting testing procedures in a more effective and efficient way.     

Differences in the social networks of African American men who have sex with men only and those who have sex with men and women

Objectives. We compared social network characteristics of African American men who have sex with men only (MSMO) with social network characteristics of African American men who have sex with men and women (MSMW).Methods. Study participants were 234 African American men who have sex with men who completed a baseline social network assessment for a pilot behavioral HIV prevention intervention in Baltimore, Maryland, from 2006 through 2009. We surveyed the men to elicit the characteristics of their social networks, and we used logistic regression models to assess differences in network characteristics.Results. MSMO were significantly more likely than were MSMW to be HIV-positive (52% vs 31%). We found no differences between MSMO and MSMW in the size of kin networks or emotional and material support networks. MSMW had denser sexual networks, reported more concurrent and exchange partners, used condoms with more sexual partners, and reported interaction with a larger number of sexual partners at least once a week.Conclusions. Although there were many similarities in the social and sexual network characteristics of MSMO and MSMW, differences did exist. HIV prevention interventions should address the unique needs of African American MSMW.Recent epidemiological data suggest that the highest rates of HIV infection in the United States are found among African American men who have sex with men (MSM).¹ According to the National HIV Behavioral Surveillance survey in 2004–2005, among 5 cities studied, Baltimore, Maryland, had the highest HIV rates among African American MSM, with a prevalence of 51% and an estimated incidence rate of 8% per year.² African American MSM are also more likely than are MSM of other racial/ethnic groups to report bisexual identity.^3–9Some studies have focused on men who have sex with men and women (MSMW) as a potential bridge group to heterosexual transmission.^10,11 Several investigators have found that MSMW have lower HIV rates than do men who have sex with men only (MSMO).^11–13 Some studies have found that MSMW report more sexual partners than do MSMO,^11,14 although another has found that not to be true.¹⁵Social network factors have been linked to transmission of HIV and other sexually transmitted infections.^16–18 Indeed, there is evidence that network structural characteristics, such as network density (the extent to which social network members know one another) and partner concurrency, may lead to high rates of sexually transmitted infectious diseases.^19–21 Network dynamics have also been used to explain the greater burden of HIV and AIDS among African Americans compared with other racial groups in the United States.²² Network characteristics such as network size, composition, and density have been found to be associated with HIV risk behaviors, such as sharing injection equipment,^23–27 having multiple partners, engaging in unprotected sex, and exchanging sex for money or drugs.^28–31Social network analysis is a useful method to assess amounts, types, and sources of emotional and instrumental social support³² without assuming that social support is derived from specific role relationships, such as spouse, coworker, main sexual partner, or friend. In different populations, specific role relationships may not exist, or the same role may provide different types of social support. Few studies have examined the social networks of MSM,^33,34 and there is even less information on the social networks of African American MSM. Miller et al.³⁵ conducted in-depth interviews with 21 African American MSM and inquired about the composition of their social networks. They found that African American MSM listed twice as many non-MSM male friends as MSM friends. Few listed MSM friends with whom they did not have sex. A study of HIV-positive men and women reported that African American MSM received more social support from friends and health care providers than they did from family members.³⁶ It has been suggested that some African American MSM perceive that their community consists of their social network members rather than a physical location.³⁷We examined differences in social network composition between African American MSMO and African American MSMW. Examining social network composition is critical not only for assessing the dynamics of transmission of HIV but also for assessing the social and economic support available to people with HIV. Support issues are especially important among impoverished urban populations. Understanding social network composition is also critical for developing and sustaining appropriate HIV prevention and care programs. In these analyses we were specifically interested in examining the sources and functions of social support within participants'' social networks, the sexual risk behaviors participants engaged in with network members, and the overlap between social support networks and sexual networks. We anticipated that MSMO would report more dense social networks than MSMW but less social support.     

HIV risk among young African American men who have sex with men: a case-control study in Mississippi

Objectives. We conducted a case–control study in the Jackson, Mississippi, area to identify factors associated with HIV infection among young African American men who have sex with men (MSM).Methods. During February to April 2008, we used surveillance records to identify young (16–25 years old) African American MSM diagnosed with HIV between 2006 and 2008 (case participants) and recruited young African American MSM who did not have HIV (controls). Logistic regression analysis was used to assess factors associated with HIV infection.Results. In a multivariable analysis of 25 case participants and 85 controls, having older male partners (adjusted odds ratio [OR] = 5.5; 95% confidence interval [CI] = 1.8, 17.3), engaging in unprotected anal intercourse with casual male partners (adjusted OR = 6.3; 95% CI = 1.8, 22.3), and being likely to give in to a partner who wanted to have unprotected sex (adjusted OR = 5.0; 95% CI = 1.2, 20.6) were associated with HIV infection.Conclusions. Given the high prevalence of risk behaviors among the young African American MSM in our study, HIV prevention efforts must begin before or during early adolescence and need to focus on improving negotiation and communication regarding sex.African American men who have sex with men (MSM) are at high risk of HIV infection.^1,2 In the United States, half of all prevalent and incident HIV infections occur among MSM,^3,4 and Black MSM account for a disproportionate number of new HIV infections among MSM.⁵ Data from the National HIV Behavioral Surveillance System show that the HIV prevalence among Black MSM in 21 US cities in 2008 was 28% and that 59% of Black MSM with HIV surveyed in these cities were unaware of their infection.⁶ HIV prevalence was also high among young Black MSM, who had a prevalence of 17% by the age of 18 to 24 years.⁶Furthermore, the number of new HIV diagnoses is increasing among MSM, particularly young Black MSM. From 2001 to 2006, the number of HIV/AIDS cases among Black MSM aged 13 to 24 years in 33 states with long-term, confidential, name-based HIV reporting increased by 93%.⁷In the fall of 2007, clinicians at a sexually transmitted disease (STD) clinic in Jackson, Mississippi, noted that diagnoses of HIV infection were increasing among young African American MSM. A subsequent review of surveillance data revealed a 38% rise in newly diagnosed HIV infections among African American MSM aged 16 to 25 years in the Jackson area during 2006–2007 relative to 2004–2005.Although many studies have assessed the prevalence of HIV risk behaviors among young African American MSM,^8,9 few have focused on young African American MSM in Mississippi. Between February and April 2008, the Centers for Disease Control and Prevention and the Mississippi State Department of Health conducted an investigation that included, among other components, a case–control study designed to identify demographic characteristics and behavioral factors associated with HIV infection among young African American MSM in the Jackson area.¹⁰     

Receipt and Use of Free Condoms Among U.S. Men Who Have Sex with Men

Objectives

Despite large public investments in condom distribution programs for HIV prevention among men who have sex with men (MSM), few evaluations have documented the reach of condom distribution programs or whether free condoms distributed to MSM are actually used. Among MSM recruited from social networking and dating websites, we examined the proportion who reported acquiring and using free condoms, and associations between select characteristics and reported acquisition and use of free condoms.

Methods

We used baseline data from a prospective, online cohort of U.S. MSM. Participants reported acquiring free condoms in the 12 months before interview and, for those who acquired condoms and had anal intercourse, use of the free condoms they acquired. We used multivariable log binomial regression models to describe factors associated with self-reported acquisition and use of condoms.

Results

Of the 2,893 men in the analytic sample, 1,701 (59%) reported acquiring free condoms in the past year. Acquisition of free condoms was higher for men who were younger, more educated, recently tested for HIV, and had higher numbers of sex partners. Seventy-three percent of men who acquired free condoms reported using them; use was higher for men who were black, had been recently tested for HIV, and reported greater numbers of sex partners.

Conclusions

Most MSM in our online sample reported receiving free condoms, and most who acquired free condoms reported using them. These data suggest that condom distribution programs have reasonable reach and utility as part of a comprehensive package of HIV prevention interventions for U.S. MSM.Men who have sex with men (MSM) are the group at highest risk for HIV infection in the U.S. In 2010, 61% of all new human immunodeficiency virus (HIV) diagnoses in the U.S. were among MSM,¹ who only account for an estimated 2% of the U.S. population.² Further, MSM have been the only risk group in which HIV incidence has been increasing since the early 1990s.³Condoms have been identified as a method to prevent sexual transmission of HIV since the early phases of the HIV epidemic in the U.S. In 1986, the Centers for Disease Control and Prevention issued a recommendation for the use of condoms to prevent sexual transmission of HIV, even prior to definitive findings of the effectiveness of condoms to prevent HIV transmission had been released.⁴ Since that time, condoms have been recognized as the most effective method to prevent the sexual transmission of HIV, aside from abstinence,^5–8 and condom promotion remains a mainstay of HIV prevention strategies, including the National HIV/Acquired Immunodeficiency Syndrome (AIDS) Strategy for the United States.⁹Although the effectiveness of condoms to prevent HIV transmission is well recognized, studies have noted that barriers to obtaining condoms, such as cost¹⁰ and embarrassment associated with purchasing condoms,¹¹ may prevent condom use. Given the demonstrated benefits of condoms coupled with the fact that barriers to purchasing condoms may prevent condom acquisition, many health departments, clinics, community-based organizations, and AIDS service organizations have implemented free condom distribution programs to ensure those individuals most at risk for HIV infection, such as MSM, have access to condoms.^12–14 Regardless of the size of the program, distributing free condoms requires the dedication of significant resources. For example, Louisiana''s statewide condom availability program, which distributed more than 33 million condoms from 1994 to 1996, cost an estimated $3 million during the three-year period.¹⁵ The Free Condom Initiative by the New York City Department of Health and Mental Hygiene (NYC DOHMH) distributed 17.3 million condoms in 2006 at a cost of $1.59 million.¹³Because of the considerable financial and organizational commitment involved in distributing free condoms, understanding the impact of free condom distribution is essential. Although it is important to define key indicators, such as the number of condoms distributed,¹⁶ to measure a program''s success, it is critical to determine the type of individuals receiving free condoms to ensure that those most at risk for HIV infection both have access to and make use of free condoms. To date, few studies have examined factors associated with acquisition and use of free condoms among MSM; those studies that have been conducted have been limited in geographic region to either one state¹⁷ or to urban areas.¹⁸ To address these research gaps, we examined characteristics associated with acquisition and use of free condoms using data from a national online HIV prevention survey.     

High Risk for HIV Following Syphilis Diagnosis Among Men in Florida, 2000–2011

Objective

Multiple interventions have been shown to reduce the risk of HIV acquisition, including preexposure prophylaxis with antiretroviral medications, but high costs require targeting interventions to people at the highest risk. We identified the risk of HIV following a syphilis diagnosis for men in Florida.

Methods

We analyzed surveillance records of 13- to 59-year-old men in Florida who were reported as having syphilis from January 1, 2000, to December 31, 2009. We excluded men who had HIV infection reported before their syphilis diagnosis (and within 60 days after), then searched the database to see if the remaining men were reported as having HIV infection by December 31, 2011.

Results

Of the 9,512 men with syphilis we followed, 1,323 were subsequently diagnosed as having HIV infection 60–3,753 days after their syphilis diagnosis. The risk of a subsequent diagnosis of HIV infection was 3.6% in the first year after syphilis was diagnosed and reached 17.5% 10 years after a syphilis diagnosis. The risk of HIV was higher for non-Hispanic white men (3.4% per year) than for non-Hispanic black men (1.8% per year). The likelihood of developing HIV was slightly lower for men diagnosed with syphilis in 2000 and 2001 compared with subsequent years. Of men diagnosed with syphilis in 2003, 21.5% were reported as having a new HIV diagnosis by December 31, 2011.

Conclusion

Men who acquire syphilis are at very high risk of HIV infection.Antiretroviral medications have reduced acquired immunodeficiency syndrome mortality in the United States from 50,260 adults in 1995 to 17,770 adults in 2009.^1,2 However, the risk of acquiring human immunodeficiency virus (HIV) infection remains high, particularly for men who have sex with men (MSM). An estimated 30,000 MSM have acquired HIV in each of the past several years.^3,4 The White House''s National HIV/AIDS Strategy states that to reduce HIV incidence, we must (1) intensify HIV prevention efforts in communities where HIV is most heavily concentrated and (2) expand targeted efforts to prevent HIV infection using a combination of effective, evidence-based approaches.⁵ By estimating the percentage of men in the population who are MSM, researchers have estimated the HIV incidence for all MSM as 0.66% per year in Florida (in 2006)⁶ and 0.67% per year in 37 states (in 2008).⁷ This risk might be reduced by a variety of interventions, including antiretroviral preexposure prophylaxis (PrEP), which reduced the incidence of HIV by 44% among MSM in a blinded randomized controlled trial.⁸ If PrEP could be widely implemented with high-use effectiveness, it could have an impact on HIV incidence; however, the high cost of PrEP will require targeting MSM at highest risk.⁹ Some groups of high-risk MSM have been identified. For example, MSM recruited into HIV vaccine efficacy studies have had incidence rates as high as 2.7% per year.¹⁰People diagnosed with other sexually transmitted infections (STIs) have long been known to be at increased risk for having HIV coinfection.¹¹ Among 212 men with early syphilis in Los Angeles, California, in 2002–2004, 35% had HIV coinfection, and HIV incidence was estimated to be 17% in the preceding year.¹² Among 363 MSM with early syphilis in Atlanta, Georgia; San Francisco, California; or Los Angeles in 2004–2005, 47% had HIV coinfection, and 10 of these coinfections were recently diagnosed, suggesting an incidence of 12%.¹³ However, preventing infection requires identifying high-risk people before they acquire HIV. A recent study in San Francisco''s City Clinic retrospectively followed MSM for two years after they were diagnosed with rectal gonorrhea or chlamydia and found that 27 acquired HIV, for an incidence of 2.3% per year.¹⁴In Florida, all syphilis, gonorrhea, and chlamydia infections are reportable to the state health department, and the reports are maintained in a common database. This database is routinely cross-matched with the HIV surveillance database to determine if any of the people with other STIs have been reported as having HIV. Gender of sex partners is not available for all reported cases of STI, but since the early 2000s, syphilis cases have been increasingly concentrated among MSM.¹⁵ We used this database to study all men in Florida who were reported as having early syphilis and to determine their risk of subsequent diagnosis and report of HIV infection.     

HIV Testing Preferences Among Young Men of Color Who Have Sex With Men

Objectives. We assessed awareness of and preferences for rapid HIV testing among young, urban men of color who have sex with men and are engaged in high-risk behaviors for HIV.Methods. A cross-sectional survey was conducted in New York City among 177 young men who have sex with men (MSM).Results. Among the 85% of the participants who had previously undergone HIV testing, 43% reported rapid testing at their most recent test. In terms of future tests, 64% would seek rapid testing, as compared with 36% who preferred traditional testing. Those who preferred rapid testing were significantly more likely to have attended at least some college, to have discussed HIV testing with a sexual partner, to be aware of rapid testing, and to have had a previous HIV test.Conclusions. In general, young MSM of color seem aware of rapid testing. However, our results indicate the need to carefully consider the unique needs of those who are particularly disenfranchised or engaged in high-risk behaviors and who may need concerted efforts around HIV counseling and testing. Likewise, our findings point to a need for more effective education and social marketing strategies.According to recent Centers for Disease Control and Prevention (CDC) surveillance data, HIV infection rates in the United States remain high among men who have sex with men (MSM). In 2005, MSM accounted for more than half (53%) of all HIV/AIDS diagnoses and 71% of reported adult male and adolescent HIV infections.¹ Racial disparities have emerged within the MSM population as the AIDS epidemic has shifted increasingly toward minorities. Despite representing only 13% of the US population in 2000, Blacks accounted for 49% of cumulative HIV/AIDS diagnoses in 2005, with same-sex contact the primary mode of infection transmission.²At the same time, young adult members of minority groups have also exhibited greater rates of HIV infection. In 2006, Black young adults accounted for 60% of HIV/AIDS diagnoses among adolescents and young adults aged 13 to 24 years. Although Black adolescents make up only 16% of the US adolescent population, they accounted for 69% of new AIDS cases reported for that age group in 2006.³Research has shown that young minority MSM are at particular risk for infection, with consistent reports of risky sexual behaviors⁴ reflected in high rates of HIV prevalence, incidence, and undiagnosed infections.^5–7 Nationally, 52% of new infections among Black MSM occur among those aged 13 to 29 years, as compared with 25% among their White MSM counterparts.⁸ A study analyzing data from the CDC''s Young Men''s Survey, a cross-sectional survey of MSM aged 15 to 22 years in Baltimore, Maryland, and New York City, New York, revealed HIV prevalence to be 10 times higher among Blacks (17.7%) than among Whites (1.7%).⁹Although HIV incidence and prevalence are high among young minority MSM, many are unaware of their status² and unknowingly expose their partners to HIV.⁷ CDC guidelines recommend at minimum annual HIV testing for sexually active MSM,⁵ especially younger MSM and those from minority groups.¹⁰ Despite these recommendations, however, testing frequency remains low. In a study assessing HIV testing behaviors among MSM, the CDC analyzed data from 5 cities participating in the National HIV Behavioral Surveillance System. Results showed that nearly half (48%) of those found to be HIV positive were unaware of their infections, with the proportions highest among MSM aged 18 to 30 years and minority MSM. In fact, 64% of those with unrecognized infections were Black, and 58% had not taken an HIV test in the preceding year.²Another study analyzing data from the Young Men''s Survey revealed similar results among participating MSM aged 15 to 29 years. The odds of having an unrecognized HIV infection were nearly 7 times greater among Black MSM than they were among White MSM. Fifty-five percent of those with unrecognized infections had not undergone an HIV test during the preceding year.⁷To advance HIV prevention efforts in the United States, prevention programs must reduce unrecognized infection among young MSM by increasing the demand for and availability of HIV testing.⁷ In an effort to increase testing rates, the CDC announced in 2003 a set of new prevention strategies. A main component of this initiative is to expand HIV testing to increase the numbers of HIV-infected individuals who are aware of their status.¹¹ New HIV testing technologies have made it possible to reach and test a larger, more diverse population in nontraditional venues. The OraQuick (Orasure Technologies, Bethlehem, PA) rapid HIV test, approved by the Food and Drug Administration, allows for presumptive diagnoses of HIV infection within 20 minutes, and the test can be performed outside clinical settings with either finger-stick whole blood or oral swabs.In a 2007 literature review summarizing the available research on rapid HIV testing, Roberts et al. found considerable variation in clients'' rates of acceptance of rapid testing, ranging from 14.1% to 98%.¹² Several studies assessing acceptance rates for rapid testing technology have revealed rates upwards of 65%.^13–15 Focus group data from Black adults showed that although the rapid test was preferred over traditional HIV testing as a result of the shorter turnaround time for results, concerns were raised about the test''s accuracy.¹⁶Another study conducted with MSM, injection drug users, and high-risk heterosexuals revealed that only 13% of the participants were aware of rapid HIV tests and that, among those who were aware, only 14% had actually been tested via this modality. Preference for the standard test was reported as a primary reason for not undergoing rapid testing.¹⁷ Studies with Black young adults aged 18 to 24 years have produced similar findings. Although a majority of respondents report a preference for receiving results in 1 session, many continue to express concern about the accuracy of the test.^18,19HIV testing preferences have been well-documented among older MSM, who have shown an inclination toward anonymous over confidential testing,^20,21 as well as a preference for testing at sex clubs over clinic settings.²² Not being of minority race or ethnicity, having completed more years of schooling, and having access to testing services have been found to be factors associated with increased likelihood of testing among MSM.²³ Reasons for avoiding or delaying HIV tests include fear of positive test results and concern that others might learn about the results.²³The need to increase rates of acceptance of HIV testing among populations of color is clear, particularly among young MSM. However, relatively little is known about the factors that influence their decision to test or the circumstances that prevent them from being tested. Although 1 recent study attempted to assess the correlates of HIV testing among young minority MSM,²³ it did not explore preferences with respect to HIV testing method, which could potentially have a large impact on HIV testing rates. The researchers did find that awareness of a comfortable testing site and greater perceived social support concerning HIV were strongly associated with HIV testing among their sample.²³Given the high rates of unrecognized infection and the potential to reach greater numbers of affected individuals through rapid HIV testing, it is important to understand the awareness and acceptability of this testing modality among young minority MSM. We attempted to fill the gaps in the available literature by assessing awareness of and preferences for rapid HIV testing among a sample of young MSM of color engaged in high-risk behaviors for HIV.     

Sexual Partner Selection and HIV Risk Reduction Among Black and White Men Who Have Sex With Men

Objectives. We examined differences in sexual partner selection between Black and White men who have sex with men (MSM) to better understand how HIV status of participants'' sexual partners and related psychosocial measures influence risk taking among these men.Methods. We collected cross-sectional surveys from self-reported HIV-negative Black MSM and White MSM attending a gay pride festival in Atlanta, Georgia.Results. HIV-negative White MSM were more likely than were HIV-negative Black MSM to report having unprotected anal intercourse with HIV-negative men, and HIV-negative Black MSM were more likely than were HIV-negative White MSM to report having unprotected anal intercourse with HIV status unknown partners. Furthermore, White MSM were more likely to endorse serosorting (limiting unprotected partners to those who have the same HIV status) beliefs and favorable HIV disclosure beliefs than were Black MSM.Conclusions. White MSM appear to use sexual partner–related risk reduction strategies to reduce the likelihood of HIV infection more than do Black MSM. Partner selection strategies have serious limitations; however, they may explain in part the disproportionate number of HIV infections among Black MSM.Men who have sex with men (MSM) continue to make up the majority of people who are HIV infected in the United States. About one third of US HIV infections among MSM occur in Black men¹; however, Black men account for only 13% of the US male population.² Several published reports of HIV risks that stratify risk behavior by race do not demonstrate elevated risk behavior among Black MSM as compared with White MSM.^3,4 For example, Black MSM overall report fewer sexual partners and similar rates of unprotected anal intercourse when compared with White MSM. Because rates of risk behaviors fail to explain the racial disparities in HIV infections, contextual factors may offer important information for explaining the disproportionate HIV infections. Alarming rates of HIV among Black MSM have led this group to be among the top priority HIV prevention populations in the United States.⁵ Thus, a comprehensive understanding of HIV risk factors relevant to this population is warranted.Multiple contextual factors potentially drive disparities in HIV/AIDS between Black MSM and White MSM. Perceived HIV prevention strategies such as selecting unprotected sexual partners thought to have the same HIV status, or serosorting, may play a role in explaining racial disparities in HIV infections. Many HIV-infected and non–HIV-infected men believe serosorting makes HIV transmission less likely and, thus, condom use unnecessary.^6,7 This relationship may stem from the tendency for people to dislike using condoms^8–10 and to practice alternative behaviors they believe are protective, such as serosorting. As a result, partner HIV serostatus is often a determining factor in sexual risk decision making.^11,12 Several studies have found that MSM commonly use serosorting in general, but less is known about serosorting among MSM of various ethnicities.^7,13–15Data on the effectiveness of serosorting are somewhat mixed, but it is known that serosorting can lead to HIV exposure.¹⁶ Although some studies have noted the potential for serosorting to reduce overall HIV rates,^17,18 limitations of this practice, including infrequent HIV testing, lack of open communication about HIV status, and acute HIV infection place MSM who serosort at risk for HIV transmission.^19,20There are at least 2 factors that directly influence whether or not an individual is motivated to serosort. First, individuals who serosort likely do so to lower their perceived risk for HIV infection, that is, to make them feel safe while not using condoms. In this sense, serosorting can reduce HIV transmission anxiety. Hence, the perception that serosorting makes unprotected sex safer is most likely driving sexual behavior risk taking. Notably, risk perceptions have been previously demonstrated to play an important role in predicting other health-related behaviors.^21–23 Second, serosorting requires explicit verbal discussion about HIV status. As such, those who engage in serosorting need to be capable of discussing their own and their partners'' HIV status.⁷ When serosorting, merely assuming the HIV status of a partner is often substituted for explicit disclosure²⁰; however, serosorting cannot be effective under these conditions.We sought to examine partner selection practices that potentially contribute to disparate HIV infection rates among Black MSM and White MSM. First, we examined the sexual behavior of Black MSM versus that of White MSM. On the basis of previous studies, we hypothesized that Black MSM and White MSM would report similar numbers of unprotected anal intercourse partners. However, because the HIV status of partners men choose may drive the differences in HIV infection rates, we hypothesized that Black MSM would report more partners of unknown or positive HIV status than would White MSM and that White MSM would report more partners of negative HIV status than would Black MSM. In keeping with these hypotheses, we also predicted that Black MSM would report less favorable beliefs about serosorting and HIV status disclosure. Finally, we predicted that Black MSM would report higher HIV perceived risk because of their choosing serodiscordant partners.     

Hombres Sanos: evaluation of a social marketing campaign for heterosexually identified Latino men who have sex with men and women

Objectives. We evaluated the effectiveness of Hombres Sanos [Healthy Men] a social marketing campaign to increase condom use and HIV testing among heterosexually identified Latino men, especially among heterosexually identified Latino men who have sex with men and women (MSMW).Methods. Hombres Sanos was implemented in northern San Diego County, California, from June 2006 through December 2006. Every other month we conducted cross-sectional surveys with independent samples of heterosexually identified Latino men before (n = 626), during (n = 752), and after (n = 385) the campaign. Respondents were randomly selected from 12 targeted community venues to complete an anonymous, self-administered survey on sexual practices and testing for HIV and other sexually transmitted infections. About 5.6% of respondents (n = 98) were heterosexually identified Latino MSMW.Results. The intervention was associated with reduced rates of recent unprotected sex with both females and males among heterosexually identified Latino MSMW. The campaign was also associated with increases in perception of HIV risk, knowledge of testing locations, and condom carrying among heterosexual Latinos.Conclusions. Social marketing represents a promising approach for abating HIV transmission among heterosexually identified Latinos, particularly for heterosexually identified Latino MSMW. Given the scarcity of evidence-based HIV prevention interventions for these populations, this prevention strategy warrants further investigation.In the United States, adult and adolescent Latino males represent 5.6% of the total population¹ but 18.7% of HIV/AIDS cases.² Low rates of condom use^3–5 and limited HIV testing^5–7 likely contribute to the risk for infection and transmission among Latinos.Sex between men continues to account for the majority of new HIV infections in the United States.² HIV prevention efforts have traditionally targeted gay and bisexual men. However, individuals’ self-identified sexual orientation frequently does not correspond to their sexual behavior,^8–12 and recent research has been focused on men who self-identify as heterosexual but have sex with men. The results of studies on men who have sex with both men and women (MSMW) suggest that, regardless of sexual identity, this population is at greater risk for HIV than are men who exclusively have sex with men; likewise, MSMW are at greater risk than are men who exclusively have sex with women (MSW).^11,13–16 Reasons for greater risk among MSMW may include lower rates of condom use^11,16 and having sexual partners who engage in high-risk sexual practices.¹¹Previous studies have suggested that Latino men are more likely than are White men to engage in bisexual sexual behavior^9,11,17,18 but less likely than are White men to self-identify as gay or bisexual or to disclose their sexual orientation.^19–23 Cultural factors such as homophobia, social stigma related to same-sex practices, and sexual conservatism may inhibit Latino men from self-identifying as homosexual or bisexual.^{10,13,23–26} The degree to which Latinos integrate same-sex sexual practices into their sexual identities may influence their risk for HIV infection.²⁷ Latino MSMW who identify as heterosexual may perceive that they are at lower risk for sexually transmitted infections (STIs) than are gay or bisexual men, and Latino MSMW may thus be less likely to use condoms to protect themselves or their partners. Latino MSMW who identify as heterosexual may also be more likely to resort to substance use to reduce sexual inhibition, thus increasing the likelihood that they will engage in unsafe sex.^19,27Nondisclosure of same-sex sexual practices among MSMW also has significant implications for the health of their female sexual partners.^9,17 More than 70% of Latinas living with HIV/AIDS in the United States were infected via heterosexual contact.² Most cases of heterosexual transmission to Latinas are related to sex with partners who use injection drugs,²⁸ but unprotected sex with men who have multiple partners, including MSMW, has likely contributed to a subset of HIV cases among Latina women.^2,29Social marketing involves applying the principles and techniques of commercial marketing to the promotion of behavioral change for the good of a target audience.^30,31 Social marketing has been successfully used for HIV prevention with gay and bisexual males,^32,33 racial and ethnic minorities,³⁴ and youths.^35–38 Interventions using social marketing have been associated with improvements in HIV/STI testing^32,34 and condom use.^36,37,39,40 To our knowledge, no social marketing campaigns have been designed to reduce HIV risk among heterosexually identified Latino MSMW. Because of the secrecy of their sexual practices and the perceived association of HIV infection with homosexuality,^24,41,42 heterosexually identified Latino MSMW are difficult to reach with HIV prevention efforts. This population is not likely to be exposed to prevention messages or programs targeted to the gay and bisexual communities.¹⁸ Moreover, interventions requiring active recruitment of heterosexually identified MSMW may fail to reach sufficient numbers or may not reach those who are most secretive about their same-sex sexual practices.⁴¹ We sought to evaluate the effectiveness of a social marketing campaign to increase condom use and HIV testing among heterosexual Latino men in northern San Diego County, California, with a special emphasis on heterosexually identified Latino MSMW.     

The Young Men's Survey phase II: hepatitis B immunization and infection among young men who have sex with men

Objectives. We measured the prevalence of hepatitis B virus (HBV) immunization and HBV infection among men aged 23 to 29 years who have sex with men.Methods. We analyzed data from 2834 men who have sex with men in 6 US metropolitan areas. Participants were interviewed and tested for serologic markers of immunization and HBV infection in 1998 through 2000.Results. Immunization prevalence was 17.2%; coverage was 21.0% among participants with private physicians or health maintenance organizations and 12.6% among those with no source of health care. Overall, 20.6% had markers of HBV infection, ranging from 13.7% among the youngest to 31.0% among the oldest participants. Among those susceptible to HBV, 93.5% had regular sources of health care, had been tested for HIV, or had been treated for a sexually transmitted disease.Conclusions. Although many young men who have sex with men have access to health care, most are not immunized against HBV. To reduce morbidity from HBV in this population, providers of health care, including sexually transmitted disease and HIV prevention services, should provide vaccinations or referrals for vaccination.Although the incidence of hepatitis B virus (HBV) infection has declined more than 70% since it peaked in the mid-1980s, an estimated 60000 Americans were newly infected with HBV in 2004.1 Men who have sex with men (MSM) are at high risk for HBV infection: those aged 20 to 39 years have the highest rate of reported acute HBV infection, and from 1996 to 2002 the percentage of reported acute cases among MSM increased.2 Data also continue to show high incidence of hepatitis A and other sexually transmitted diseases (STDs) and high prevalence of HIV infections among MSM.3^–7 Because of these facts, integration of prevention services for MSM such as STD testing and treatment, HIV testing, and hepatitis A and B vaccinations has become a public health priority.5 Many MSM diagnosed with acute hepatitis A or B infection report visiting primary health care providers within the past year8 or using a regular source of health care.9^,10 These infections could have been prevented by vaccination.The need for improved vaccination coverage against HBV among young MSM was shown by the results of the Young Men’s Survey (YMS).9 Phase 1 of the YMS was conducted in 7 US cities in the mid-1990s, and results show that only 9% of 3432 MSM aged 15 to 22 years had serologic evidence of immunization and self-reported vaccination. Eleven percent of these young men had serologic markers of previous HBV infection. Prevalence of past or current infection ranged from 2% among those aged 15 years to 17% among those aged 22 years, indicating a high annual incidence of infection.9To determine whether trends in the prevalence of HBV infection and immunization found among young MSM in YMS phase 1 continued among older MSM, we analyzed the results of YMS phase 2 and compared them with the results of phase 1.     

STD Prevalence, Risky Sexual Behaviors, and Sex With Women in a National Sample of Chinese Men Who Have Sex With Men

We describe the behavioral characteristics and sexually transmitted disease (STD) prevalence of Chinese men who have sex with men (MSM) (n = 41) from a national probability sample of men (n = 1861). Most MSM were partnered with females (97%) and had a low rate of consistent condom use (7%). More MSM than heterosexual men self-reported a prior STD and risky sexual behaviors. MSM may act as a bridge for HIV transmission to female partners. Targeted interventions may help prevent a generalized HIV epidemic in China.In some parts of China, HIV prevalence has exceeded 1% of the general population.^1,2 Men who have sex with men (MSM) accounted for 7.3% of HIV infections³ and 11% of new HIV infections in 2007.⁴ The proportion of HIV infections among MSM is likely to grow, as studies have documented increasing HIV prevalence and high prevalence of risky sexual behaviors and of sexually transmitted diseases (STDs) among this population.^5–12MSM may serve as a bridge population for transmitting HIV to the general population. Empirical data have shown that a large proportion of Chinese MSM are either married or have female sex partners.^5,13 High-risk sexual behaviors with both male and female partners among MSM are also common. Surveys have documented extremely high rates of inconsistent condom use with female partners.^13–15 We report the sociodemographic and sexual behavioral characteristics and the STD prevalence of a national probability sample of Chinese heterosexual men and men who had homosexual experiences.     

Comparative Mortality Among People Diagnosed with HIV Infection or AIDS in the U.S., 2001–2010

ObjectiveThe comparative mortality figure (CMF) is the expected number of deaths in the standard population compared with those observed. We assessed state-based CMFs for people with HIV infection to allow standardized assessment of mortality in all states.MethodsWe used National HIV Surveillance System data to compute CMFs for people diagnosed with HIV and AIDS from 2001 to 2010 who met the CDC HIV case definition; were alive on December 31, 2009; and died during 2010.ResultsIn 33 U.S. states with name-based HIV reporting since 2001, the 2010 CMF for people with an HIV diagnosis was 2.8 compared with 4.5 for those with an AIDS diagnosis. CMFs for males were higher than for females (3.4 vs. 3.1) and black people had higher CMFs than white people for HIV (3.2 vs. 2.2) and AIDS (4.7 vs. 4.3). CMFs by state ranged from 0.9 to 4.2 for HIV and 1.9 to 9.7 for AIDS. In 50 states and the District of Columbia with AIDS reporting, CMFs for males and females were similar (4.5 and 4.6, respectively), CMFs for black people remained higher than for white people (5.0 and 3.9, respectively), and the range for states remained broad (1.2–9.4).ConclusionState mortality figures varied based on population composition and disease stage at diagnosis, possibly indicating a need for state-specific testing, linkage to care, and viral suppression strategies to reduce mortality.State mortality rates for people infected with human immunodeficiency virus (HIV) vary greatly, and comparability among states will benefit from enhanced standardization. The 2010 death rate of HIV-infected people aged ≥13 years in the United States was 7.5 per 100,000 population, with state rates ranging broadly from 0.4 per 100,000 population in Maine to 38.8 per 100,000 population in the District of Columbia (DC).¹ Similarly, in the same age group of people diagnosed with HIV infection, those with stage 3 infection (i.e., acquired immunodeficiency syndrome [AIDS])² had a death rate of 6.1 per 100,000 population in 2010, with state rates also ranging broadly from 0.3 per 100,000 population in Maine to 33.7 per 100,000 population in DC. The large disparity among state death rates for people with HIV infection, and the disproportionate impact on some racial/ethnic, risk factor, and age groups,³ indicates a need for standardization of each state rate to a fixed population to enhance comparability. This study provides those results.Testing for HIV infection is recommended by the U.S. Preventive Services Task Force for all adolescents and adults aged 15–65 years and for all pregnant women⁴ to increase early detection, facilitate treatment, reduce transmission, and reduce mortality.^5,6 While testing with rapid tests, in-home, and at other nonmedical facilities has increased the number of people with HIV infection who know their status, it is estimated that in 2010, one in six people with HIV infection did not know they were infected.⁷In addition, despite implementation of a variety of prevention strategies,⁸ increased testing, linkage-to-care activities, and improved HIV infection treatments aimed at viral load suppression have resulted in increased prevalence of people living with HIV infection. The 2013 Presidential Continuum of Care Initiative recommends further enhancements to identify and address gaps in care along the continuum, beginning with diagnosis and moving though sequential stages for linkage to care, retention in care, and antiretroviral treatment (ART) utilization, resulting in viral suppression.⁹Comparisons of state mortality, the ultimate indicator of success along the continuum of care, can inform HIV infection testing and care initiatives, and evaluate the impact of linkage to and retention-in-care activities. However, the method selected for analysis can significantly affect the results.¹⁰ Standardized methods for presenting state death rates are necessary to ensure comparability of state mortality.Numerous methodologies for assessing standardized mortality rates have been documented.^10,11 The standardized mortality ratio for indirect standardization is commonly reported, although the comparative mortality figure (CMF) (or comparative mortality ratio [CMR] derived from CMFs) for direct standardization is recommended for geographic comparisons among heterogeneous populations.^12–14 While the CMF has been used for mortality studies of chronic disease and disability,^15–19 it has not previously been used to compare state-level CMFs for people diagnosed with HIV infection using data from a national HIV surveillance system.     

Legionnaires' Disease and Associated Comorbid Conditions as Causes of Death in the U.S., 2000–2010

ObjectiveRecent U.S. outbreaks of Legionnaires'' disease (LD) underscore the virulent nature of this infectious pneumonia. To date, only a paucity of literature has described the mortality burden of LD. This study updates LD mortality using U.S. multiple-cause-of-death data from 2000–2010.MethodsWe calculated crude and age-adjusted rates for LD mortality for age, sex, race, state, Census region, and year. We conducted Poisson regression to assess seasonal and temporal trends. We generated matched odds ratios (MORs) to describe the association between LD-related deaths and other comorbid conditions listed on the death certificates.ResultsWe identified a total of 1,171 LD-related deaths during 2000–2010. The age-adjusted mortality rate remained relatively static from 2000 (0.038 per 100,000 population, 95% confidence interval [CI] 0.031, 0.046) to 2010 (0.040 per 100,000 population, 95% CI 0.033, 0.047). The absolute number increased from 107 to 135 deaths during this period, with adults ≥45 years of age having the highest caseload. Overall, LD mortality rates were 2.2 times higher in men than in women. White people accounted for nearly 83.3% of all LD-related deaths, but the age-adjusted mortality rates for black and white people were similar. Comorbid conditions such as leukemia (MOR=4.8, 95% CI 3.5, 6.6) and rheumatoid arthritis (MOR=5.6, 95% CI 3.3, 9.4) were associated with LD diagnosis on death certificates.ConclusionComorbid conditions that could lead to an immunocompromised state were associated with fatal LD on U.S. death certificates. Characterization of LD mortality burden and related comorbidities has practice implications for clinical medicine and public health surveillance.Legionnaires'' disease (LD) is a severe form of pneumonia that can become fatal in vulnerable individuals.^1–5 The condition is caused by the gram-negative bacterium Legionella pneumophila, a naturally occurring organism found in water.^2,3 The organism is primarily transmitted to humans through inhalation of contaminated aerosolized water droplets. Typical sources of outbreaks include, but are not limited to, hot tubs, hot water tanks, large plumbing systems, decorative fountains, and cooling towers. The pneumophila species is generally not found in car or window air-conditioners.^1–4 To date, no person-to-person transmission has been documented.^1–4,6,7Risk factors that increase susceptibility to LD include advanced age, smoking, chronic lung disease, and having a weak or suppressed immune system.^1–4,6,7 Among individuals with a weakened immunity, those with cancer, diabetes, or kidney failure are particularly at risk. Although human immunodeficiency virus (HIV) infection has been linked to more severe infections, LD is generally not more common among people with HIV/acquired immunodeficiency syndrome (AIDS).^1,8,9 More than 20% of cases in the United States reported to the Centers for Disease Control and Prevention (CDC) each year are travel-related.³ Nosocomial transmissions of LD can be problematic, as at-risk individuals are plentiful and plumbing in hospital facilities is often old.^1,4 Because in-house diagnostic testing is readily available, detection of LD is more likely in the hospital setting.⁴ Currently, CDC recommends urinary antigen assay and a culture of respiratory secretions on selective media as the diagnostic tests of choice for confirming Legionella infection.³Annually, CDC estimates that as many as 18,000 individuals are hospitalized with LD in the U.S.³ However, this number is considered an underestimate, as the disease is often underreported due in part to its diagnostic complexity and its resemblance to other pneumonias with similar symptom presentations.^3,7 Symptoms of LD include cough, shortness of breath, fever, muscle aches, and headaches; they often start shortly after exposure to the bacteria.^1–4,6Recent LD outbreaks in the Veterans Affairs (VA) Medical Center in Pittsburgh, Pennsylvania, and in a retirement community in Ohio affirm the virulent nature of this infection and underscore the importance of the causative infectious pathogen to clinical practice and public health surveillance.^10,11 Based on hospitalizations and treatment data, the annual costs for LD have been estimated at nearly $684 million.¹² Few studies have recently examined LD mortality and its associated comorbid conditions. This study contributes to the closing of this gap in the literature by analyzing the national multiple-cause-of-death (MCD) data to describe the current mortality profile of LD in the U.S., for the period 2000–2010.