Differences and Similarities in HIV Testing Among Men Who have Sex with Men and Women (MSMW) and Men Who Have Sex with Men Only (MSMO)

BACKGROUND

In 2006, the Centers for Disease Control (CDC) recommended that sexually active men who have sex with men (MSM) be tested for HIV at least annually [1]. However, recent CDC analyses suggest that MSM should test more frequently. CDC surveillance found that among MSM who had been tested in the past year and who did not report a previous HIV positive test result, 7% were newly diagnosed seropositive. This high prevalence of new HIV infections among MSM who had been tested during the past year suggests that sexually active MSM might benefit from testing every three to six months [2].

HIV testing is a key component of HIV prevention efforts because knowledge of HIV positivity leads to decreases in HIV transmission [3-4]. HIV testing is also associated with early diagnoses of HIV and, when coupled with appropriate interventions, early diagnosis of HIV has been found to improve health outcomes, including slower clinical progression and reduced mortality [5].

Research suggests that compared to men who have sex with men only (MSMO), men who have sex with men and women (MSMW) are less likely to be tested for HIV [6-8], less likely to be exposed to HIV prevention [8] and more likely to be undiagnosed seropositive [9, 10]. Despite these findings, very little is known about the HIV testing behaviors of MSMW. Most research on HIV testing among MSM has combined samples of MSMO and MSMW [7, 11-13] or has assessed differences by sexual identity rather than by sexual behavior [14-18]. These studies indicate that HIV testing is associated with factors such as perception of risk, fear of testing positive, structural barriers [13], health status [18], availability of rapid testing, intensive peer counseling [19], socioeconomic factors, race/ethnicity and urban residence [7].

We found no studies that assessed multivariate associations with HIV testing among MSMW. Understanding the factors associated with HIV testing among MSMW provides important information on who is being reached by current HIV testing interventions and how to strengthen current HIV testing initiatives. To address these gaps, this paper 1) describes HIV testing behaviors and use of HIV-related services among MSMW 2) compares HIV testing behaviors and use of HIV-related services of MSMW to MSMO and 3) assesses bivariate and multivariate associations between HIV risk behaviors, use of health services, and HIV testing in the past six months among MSMW.

METHODS

The National HIV Behavioral Surveillance System (NHBS) is an on-going surveillance system implemented by the CDC that allows for ongoing collection, analysis, and interpretation of HIV risk and prevention behaviors. The Baltimore portion of NHBS is referred to as BESURE and is implemented annually by the Johns Hopkins Bloomberg School of Public Health in collaboration with Maryland Department of Health and Mental Hygiene. BESURE targets three populations at increased risk for HIV: MSM, injection drug users, and heterosexuals. From July to October 2008, the second wave of BESURE-MSM, called BESURE-MSM2, was conducted using venue-based time-space sampling.

The first step in venue-based sampling is developing a sampling frame. This was done by conducting a series of focus groups with MSM and key stakeholders to identify recruitment venues and corresponding time periods. Venues included bars, restaurants, street locations, festivals, and parks. These venues and times were then randomly selected from the sampling frame to create a sampling events calendar. At these venue and time-specific sampling events, the attendance of all potentially eligible participants was enumerated by counting all individuals who crossed a designated sampling line or area, such as the entrance to a bar. Study recruiters intercepted men who crossed into the sampling area to assess eligibility. Eligibility criteria for men participating in BESURE-MSM2 included (1) being 18 years of age or older, (2) living in Baltimore MSA (metropolitan statistical area), and (3) speaking English or Spanish. MSM behavior was not an eligibility requirement for BESURE-MSM2 so as to not bias the study against men who were not comfortable disclosing same sex behaviors at enrollment [20].

Study staff read through the consent form with each participant and addressed any questions. Because the study was anonymous, informed consent was given verbally by the participant and then documented on the consent form by the signature of the study staff member who participated in the consent process. Participants gave informed consent to an interviewer-administered survey and optional HIV test. After consent, eligible participants were given a forty-five minute behavioral risk surveillance survey by trained interviewers and an optional HIV test that included pre-and post-test counseling. Both the survey and the HIV testing took place in a private and secure mobile van. Blood specimens were tested for HIV-1 antibodies with ELISA and a confirmatory Western Blot. After the blood draw, participants scheduled appointments to get their test results and were also given information about BESURE drop-in hours [20].

From July to October 2008, BESURE-MSM2 approached 1,326 men to participate in the study. Sixty-five percent (860) of these men agreed to be screened for eligibility, of these 76% (654) were eligible, and, of these, 99% (648) were enrolled. Ninety-three percent of the enrolled participants completed survey and serologic information. Four hundred and forty-eight of enrolled participants reported sex with a man in the past twelve months [20]. Of these 448 men, 43 were known seropositive and were excluded from the analysis, resulting in a final sample of 405 MSM.

RESULTS

DISCUSSION

When we looked at differences between MSMO and MSMW in likelihood of testing, we found that MSMO and MSMW were equally likely to have been tested in the past three, six, and twelve months. Previous research has found that MSMW were less likely than MSMO to have been tested ever [6, 8, 25] or in the past five years [26]. Our finding that MSMO and MSMW are equally likely to have been tested is encouraging. The implementation of HIV screening in health care settings combined with testing in non-clinical settings such as mobile vans and shelters might help to explain these findings. Because we do not have information on where respondents were tested, we were not able to assess if MSMW and MSMO are being testing in the same locations. This represents an area in need of further study.

Our finding that MSMW were less likely to disclose same-sex behavior to a health care provider (HCP) than MSMO supports earlier research [27, 28]. In bivariate analyses our data indicated a positive but non-significant relationship between disclosing same-sex behavior to a HCP and HIV testing among MSMW. Past research has found that disclosure of same-sex behavior was positively associated with HIV testing [6, 27, 28]. Theory suggests that decision-making about disclosure of same-sex behavior is driven by the characteristics of the health care provider, the health care environment, and the individual considering disclosure. Factors that inhibit disclosure of same-sex behavior include: fear of poor care, discrimination, rejection, hostility and judgment from the provider, perceptions that the provider may not be able “to handle” the subject matter or that the provider might be uncomfortable with same-sex behavior, and concerns about confidentiality [28-30].

In multivariate analyses, we found that attending a one-on-one HIV counseling session was associated with HIV testing. Previous research suggests that counseling is an effective intervention for health behavior change among MSM [31-34]. Our findings suggest that one-on-one counseling that is not part of HIV testing is positively associated with HIV testing, and therefore might be a useful strategy for increasing HIV testing in Baltimore. In Baltimore, the prevalence of undiagnosed seropositivity among HIV positive MSMW is estimated to be 87.9% [10]. We found that predictors of HIV testing did not differ for MSMO and MSMW populations. However, the unique needs of MSMW and the degree of marginalization that this population faces, warrant tailored HIV testing and prevention interventions.

Our study has multiple limitations. First, the behavioral study data was self-reported by participants and the validity of self-report data has been questioned. Participants may have underreported stigmatized behaviors and over reported normative behaviors [35]. A literature review conducted by National Institutes of Health in 1998 found that well-designed interviews and questionnaires can provide acceptable data when administered appropriately [36]. Steps recommended in this article were followed during the implementation of BESURE-MSM2, such as conducting formative research, using easy to understand language, and using time sequence techniques. An additional limitation of this study is that it is cross-sectional and does not assess causality. The sample size for the analyses presented in this paper is small, which might have limited our ability to detect significant differences. We would like to note that the confidence intervals for visiting a health care provider and attending a one-to-one HIV counseling session in our multivariate analysis are wide, which might suggest that our sample population was not large enough. Finally, individuals who opted to not participate in BESURE might be systematically different from those who did. For example, participants who agreed to participant in the study might be of lower income that individuals who did not participate in the study, resulting in selection bias.

The findings from this study represent MSMW and MSMO over 18 who live in Baltimore, who attend the type venues included in this study (bars, parks, and street corners) and who are not known HIV seropositive. Generalizability beyond these characteristics and settings is unknown [20].

Despite the study limitations, our findings have important implications for future research and for HIV prevention programs. Further research is needed to better understand the factors, including social contextual factors that influence HIV testing, knowing one’s HIV results and delayed HIV diagnosis among MSMW. One-on-one HIV counseling prevention programs might be an effective strategy to increase HIV testing among MSMW, a highly marginalized sub-population of MSM at increased risk for undiagnosed seropositivity.

REFERENCES