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research-article2014
HPPXXX10.1177/1524839914537493Health Promotion PracticeJoseph et al. / SHORT TITLE
Sexual and Reproductive Health
HIV Testing Among Sexually Active Hispanic/ Latino MSM in Miami-Dade County and New York City: Opportunities for Increasing Acceptance and Frequency of Testing Heather A. Joseph, MPH1 Lisa Belcher, PhD1 Lydia O’Donnell, PhD2 M. Isabel Fernandez, PhD3 Pilgrim S. Spikes, PhD1 Stephen A. Flores, PhD1
HIV testing behavior is important in understanding the high rates of undiagnosed infection among Hispanic/ Latino men who have sex with men (MSM). Correlates of repeat/recent testing (within the past year and ≥5 tests during lifetime) and test avoidance (never or >5 years earlier) were examined among 608 sexually active Hispanic/Latino MSM (Miami-Dade County and New York City). Those who reported repeat/recent testing were more likely to have incomes over $30,000, speak English predominately, and have visited and disclosed same-sex behavior to a health care provider (HCP) in the past year. Those who were classified as test avoiders were less likely to have incomes over $10,000 and to have seen an HCP in the past year. The main reason for not testing (in both groups) was fear of HIV positivity; however, twice as many test avoiders considered this their main reason, and more test avoiders had confidentiality concerns. Results suggest that messages to encourage testing among Hispanic/ Latino MSM may be most effective if past testing patterns and reasons for not testing are considered. HCPs can play an important role by consistently offering HIV tests to MSM and tailoring messages based on prior testing histories.
Health Promotion Practice November 2014 Vol. 15, No. (6) 867–880 DOI: 10.1177/1524839914537493 © 2014 Society for Public Health Education
Keywords: behavior change; HIV/AIDS; Latino; minority health; LGBT; sexual health; social marketing/health communication
I
n the United States, HIV infection disproportionately affects the Hispanic/Latino community: The rate of new infections among this population in 2009 was three times that of Whites (Prejean et al., 2011). Hispanic/ Latino men who have sex with men (MSM) represent 81% of new infections among all Hispanic/Latino men (Prejean et al., 2011) and nearly 19% among all MSM (Centers for Disease Control and Prevention [CDC], 2008). One possible explanation for the disproportionate number of new HIV infections among Hispanic/Latino MSM may be exposure to men with undiagnosed infection. 1
Centers for Disease Control and Prevention, Atlanta, GA, USA 2 Education Development Center, Waltham, MA, USA 3 Nova Southeastern University, Miami, FL, USA Authors’ Note: This work was supported by the Centers for Disease Control and Prevention (Grant/Award No. PS 06-006). We thank the study participants as well as study staff, including Stephen Bowen, Alex Carballo-Diéguez, Nilda Hernandez, Robin Jacobs, Maria Lago, Jocelyn Patterson, Alexi San Doval, Ann Stueve, and Ilya Teplinskiy. Please address correspondence to Heather A. Joseph, Centers for Disease Control and Prevention/ Division of HIV/AIDS Prevention, Mailstop E-37, 1600 Clifton Road NE, Atlanta, GA 30333, USA; e-mail: [email protected].
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According to the 2008 National HIV Behavioral Surveillance (NHBS) system among MSM in 21 highprevalence cities, 46% of HIV-infected Hispanic/Latino MSM were unaware of their infection. Among Hispanic/ Latino MSM ages 18 to 29 years, the rate of undiagnosed infection was 63% (CDC, 2010). Mathematical modeling studies have estimated that 49% of transmissions in 2008 were from the 20% of persons with HIV who were unaware of their infection (Hall, Holtgrave, & Maulsby, 2012). Persons who are unaware of their HIV infection do not receive timely and appropriate medical care and prevention services and, compared with persons who know that they are HIV-positive, are more likely to engage in behaviors that can result in transmission (Weinhardt, Carey, Johnson, & Bickham, 1999). Effective treatment decreases the chance of sexual transmission by as much as 96% (Cohen et al., 2011). Advances in testing and treatment make it particularly important to understand the HIV testing behavior of groups at high risk transmission and acquisition. This insight can be applied to the development of effective strategies for promoting the acceptance of testing and increasing the frequency of testing. In 2006, CDC recommended routine, opt-out screening for all patients (ages 13 to 64) in health care settings and at least annual testing for persons at high risk of HIV infection (CDC, 2006). In 2007, through the Expanded Testing Initiative, CDC funded 25 health departments to improve the availability and accessibility of HIV testing services, facilitate adoption of HIV screening in health care settings, and increase identification of undiagnosed infection in populations disproportionately affected by HIV (CDC, 2011c). The 2008 NHBS data indicated that 61% of MSM had tested for HIV during the past year (CDC, 2011b). Because 45% of MSM who were unaware of their infection had been tested within the past year, investigators suggested that sexually active MSM should be tested more frequently (CDC, 2010). Subsequent analysis indicated that compared with testing annually, testing at 3 and 6 months is likely to be cost-saving (Hutchinson, Sansom, & Farnham, 2012). In response to these data and increasing incidence among young MSM, some local health departments have suggested that sexually active MSM test more frequently (e.g., New York City recommends every 6 months; New York City Department of Health, 2012). Given the substantial support for expansion of testing efforts, research is needed to identify correlates of testing behavior. The 2006 CDC guidelines for health care settings recommend annual testing for MSM who
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have had, or whose sex partners have had, more than one partner since their most recent HIV test; however, this recommendation requires that MSM disclose their sexual behavior to their health care provider (HCP). In one study, only 30% of MSM who visited a HCP in the past year were offered an HIV test (Wall, Khosropour, & Sullivan, 2010). In two studies, approximately 30% to 40% of MSM had not disclosed their sexual orientation or behavior to their HCP (Bernstein et al., 2008; Lo, Turabelidze, Lin, & Friedberg, 2012); in New York City, twice as many white men, compared with Hispanic/ Latino men (48% vs. 18%), disclosed to their HCP (Bernstein et al., 2008). In both studies, disclosure of sexual orientation to an HCP was positively associated with recent HIV testing and negatively associated with never testing. Other correlates of testing have been identified. Factors positively associated with recent testing include younger age, higher income and education, gay identification, being “out,” multiple partners, disclosure of HIV status to partners, recent drug use, exposure to more types of HIV prevention, knowing about a testing site, social support, and perception of low risk of HIV infection (Lo, Turabelidze, Lin, & Friedberg, 2012; Mimiaga et al., 2009; Sumartojo et al., 2008; Wall et al., 2010). Fewer studies have focused on MSM who have never tested or explored how these men may differ from those with testing experience. Reported rates of never testing among at-risk MSM range from 7% to 22% (CDC, 2011b; Lo et al., 2012; Margolis, Joseph, Belcher, Hirshfield, & Chiasson, 2011; Sumartojo et al., 2008). Correlates of never testing include self-identification as bisexual or heterosexual, living outside a metropolitan area, not having an HCP, unemployment, and poorer self-reported health (Margolis et al., 2011; Mimiaga, Landers, & Conron, 2011). Correlates of ever having an HIV test include older age, having social support, knowing where to get tested, exposure to more types of HIV prevention, and a previous diagnosis of a sexually transmitted infection (STI; Sifakis et al., 2010; Sumartojo et al., 2008). Research on testing correlates is complemented by studies that have focused on self-reported reasons for not testing. Common reasons for not testing include low perceived risk of HIV infection, fear of testing HIVpositive, worry about lack of confidentiality, and structural issues (e.g., not having enough money; Campsmith et al., 1997; CDC, 2011a; Kellerman et al., 2002; Lo et al., 2012). MacKellar et al. (2011) found that younger MSM who had never tested, as well as Hispanic/Latino MSM, were more likely to name structural issues. Compared with White MSM, more Hispanic/Latino MSM reported fear of testing positive as the primary
reason for not testing. Understanding the reasons for not testing may aid in developing more effective social marketing campaigns for Latino MSM, who may have distinct values, attitudes, and barriers related to HIV testing. Effective social marketing campaigns promote “the voluntary behavior of target audiences by offering benefits they want, reducing barriers they are concerned about, and using persuasion to motivate their participation” (Kotler & Robtero, 1989, p. 24). Thus, it is important to understand the target audience’s desired benefits, perceptions of barriers, and most persuasive motivations. Applying functional theory to HIV testing, Hullet (2006) found that persuasive messages were more effective when they targeted the reason a person held a particular attitude regarding personal health (getting tested for oneself) and benevolence (getting tested to protect others). In sum, high rates of undiagnosed infection among Hispanic/Latino MSM require public health intervention, yet little research has been focused on HIV testing among this particular population. This report presents data on HIV testing behavior among sexually active Hispanic/ Latino MSM in New York City and Miami-Dade County. The exploratory analysis identifies factors associated with testing patterns as well as self-reported reasons for not testing in order to inform the development of effective interventions, messages, and marketing campaigns to increase HIV testing uptake among Hispanic/Latino MSM.
boards at CDC, the Education Development Center, and Nova Southeastern University approved the study protocol. Study Procedures Participants were enrolled from May 2007 through September 2008. Hispanic/Latino MSM were actively recruited in multiple venues (e.g., bars, clubs, cafés, college campuses, and online chat rooms) and through referrals from agencies that serve this population. Passive recruitment included print and electronic advertisements. Eligibility was restricted to Hispanic/ Latino men who were ages 18 to 49 years and reported being HIV-negative or of unknown status. Inclusion criteria encompassed one or more unprotected anal sex acts with a male partner in the past 3 months in addition to multiple sex partners in the past 3 months (the Miami study site required multiple male partners; New York required only one partner to be male). Men were ineligible if they self-identified as transgender, planned to move during the study period, or had participated in an HIV prevention study in the past 6 months. Study activities were conducted in both English and Spanish. All participants provided written informed consent and received a cash incentive ($60 in New York City and $50 in Miami) for completing the baseline audio computer-assisted self-interview (ACASI). Measures
Method >> Data from two study sites that evaluated HIV prevention interventions for Latino MSM were combined for analysis. New York City and Miami-Dade County were selected as study cities, in part, due to the high prevalence rates of diagnosed HIV infection (758 and 879/100,000, respectively) and large Latino/Hispanic populations in these jurisdictions (CDC, 2013a). The sites developed and tested their own interventions but adhered to a common protocol for recruitment, eligibility criteria, and data collection to facilitate the pooling of baseline data. At both sites, the control condition consisted of a single, standard HIV counseling session with the offer of HIV testing. In New York City, men were randomly assigned to the control condition or a single-session intervention with the offer of HIV testing. In Miami-Dade County, men were randomly assigned to the control condition or a foursession intervention with the offer of HIV testing. The study sites collected participant data at baseline and 3 months after the intervention. The institutional review
Sociodemographics. Sociodemographic variables included age, place of birth, work status, education, and annual income. Participants were asked about their sexual identity; responses of “homosexual/gay/same gender loving” and “queer” were categorized as “gay identified” in a new dichotomous variable. Use of Spanish versus English was measured by a 4-item scale adapted from the language-use scale of Marin (1989); a higher score indicates more exclusive English use. The Multigroup Ethnic Identity Measure (Yoon, 2011) was used to measure acculturation via two subscales: Ethnic Identification Search (five items; alpha = .73) and Affirmation, Belonging, and Commitment (seven items; alpha = .88). (Note: All Cronbach’s alpha statistics were calculated using this data set.) Binge drinking included any report of consuming six or more alcoholic beverages on one occasion in the past 3 months. Drug use was classified as any use of ecstasy, cocaine, crack, methamphetamines, poppers, club drugs, heroin, or another recreational drug (other than marijuana) in the past 3 months.
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Psychosocial Factors. Psychosocial factors were measured as follows: ••
••
•• •• •• •• •• ••
Responses to the question, “In general, how worried are you about getting HIV?” were collected by using a 4-point Likert-type scale. For analysis, responses were dichotomized into “not at all/a little” and “some/a lot.” Participants were asked, “In general, what do you think the chance is that you will get HIV in your lifetime?” Responses were collected using a 4-point Likert-type scale and dichotomized into “no chance/small chance” and “medium chance/large chance.” A similar question addressed HIV risk perception over the next 6 months. Psychological distress was assessed by a 10-item scale (alpha = .92; Kessler et al., 2002). Social isolation was measured through a scale developed for Hispanic/Latino MSM (seven items; alpha = .89; Diaz, Ayala, Bein, Henne, & Marin, 2001). Gay identity was assessed by Crawford, Allison, Zamboni, & Soto’s (2002) Gay Identity Scale (four items; alpha = .65). “Outness” was measured with a 3-item scale developed for this study (alpha = .86). Community connection was measured by a single question, “How connected do you feel to the Latino community of gay/bisexual men?” Internalized homonegativity was assessed by a 4-item scale developed by Bell and Weinberg (1978; alpha = .89).
Distress, gay identity, outness, connection to gay community, and homonegativity were treated as continuous variables. Sexual Risk Behaviors. Participants were asked about their sexual behavior with male, female, and transgender partners in the past 3 months. The number of receptive and insertive anal sex and vaginal sex episodes, as well as condom use, was asked for most recent partner and other partners by partner HIV serostatus. Any unprotected anal intercourse (UAI) with main and casual male partners, number of male anal sex partners, and any vaginal sex with a woman were included in the analysis. HIV Testing. Participants were asked whether they had ever been tested for HIV and, if yes, the date and result of their most recent test. Men who reported both a test in the past year and five or more tests in their lifetime were classified as recent/repeat testers. The cutoff—five tests—was based on the sample distribution (M = 4.8).
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Those who reported never testing or that their most recent test was more than 5 years ago were classified as test avoiders. Participants who reported previous testing, but not in the past year, were asked to select all the reasons for not having tested recently (e.g., “I don’t know where to get tested”; Marks et al., 2009). A parallel question was posed to men who had never tested. Data Analysis The two outcome variables of interest were (a) recent/repeat testing (testing in the past year and five or more tests in lifetime vs. not testing in the past year or four or fewer lifetime tests) and (b) test avoiding (never testing or most recent test ≥5 years earlier vs. testing >
Participant Characteristics Sociodemographic characteristics of the 608 participants are presented in Table 1. The mean age was 34.6 (SD = 9.45; range = 18-52). Sixty-one percent were born outside the United States; of those, most were born in the Caribbean or South America. More than 25% of the sample had never been tested, and almost 50% had not been tested in the past year. Figures 1 and 2 reflect testing behavior according to the two discrete classifications used in this analysis; about one third (30.8%) were repeat/recent testers (Figure 1) and 30.8% were test avoiders (Figure 2). Recent/Repeat Testing and Test Avoidance Bivariate and multivariate analyses were performed for the two outcomes of interest (Table 2 and Table 3). Compared to men who had not tested in the past year or who had fewer than five lifetime tests, recent/repeat testers were more likely to reside in Miami-Dade County, report an income of more than $30,000, and use English more exclusively. They were also more likely to have seen an HCP in the past year and to have disclosed same-sex behavior. Compared to men who tested High school Employment status Employed (full- or part-time) Unemployed Income (US$) >
Increasing the proportion of persons who know their HIV status is one of the primary strategies of the National HIV/AIDS Strategy (NHAS; White House Office of National AIDS Policy, 2010). As indicated in the recent modeling study by Holtgrave, Hall, Wehrmeyer, and Maulsby (2012), scaling up HIV care and treatment without also expanding testing services
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is unlikely to achieve the NHAS goal to reduce incidence. These findings, along with those from nationally representative samples, suggest that HIV testing rates among Hispanic/Latino MSM are suboptimal. Although CDC recommends at least annual testing for at-risk MSM, national epidemiologic data suggest that sexually active MSM may benefit from testing every 3 to 6 months (CDC, 2010). In this convenience sample of at-risk Hispanic/Latino MSM from Miami-Dade County and New York City, about 25% had never been tested for HIV, and 50% had not tested in the past year. Additional efforts will be required to increase testing frequency among this population. Tailoring Messages According to Testing Typology Public health interventions to increase HIV testing may be more successful if they directly address the fundamental reasons for not testing. Among the Hispanic/Latino MSM in this study, nonrecent testers and test avoiders did not give uniform reasons for not testing. In this study and others (MacKellar et al., 2006), the most frequently reported reason for not testing (both groups) was fear of being HIV-positive. However, test avoiders were more than twice as likely as nonrecent testers to cite this reason. Test avoiders were also more likely to cite confidentiality concerns and less likely to report lack of access as reasons for not testing, whereas nonrecent testers’ reasons were more equally distributed among fear, confidentiality concerns, lack of access, and low perceived risk. Messages may be most effective if they are tailored according to a testing typology that considers individuals’ testing patterns and reasons for not testing (Figure 4). For example, test avoiders who share fear-based concerns may benefit most from messages that directly and specifically address the availability and effectiveness of early HIV treatment and the ability to have a long life with HIV. Concerns about stigma and confidentiality may be addressed through messages highlighting standards for protecting client confidentiality, the availability of social support and resources for persons with HIV, and the availability of private testing facilities. CDC’s Act Against AIDS campaign highlights these messages (CDC, 2012). Fear appeals, which are focused on increasing perceptions of risk and severity, may be ineffectual for test avoiders who lack testing self-efficacy. Such messages may be more influential among previous testers who have a vested interest in believing that testing is worth the effort already expended (Bourne, 2010; Kunda, 1990). Given that nonrecent testers cited multiple reasons, multifaceted approaches and messages are needed. CDC’s Reasons/Razones
Table 2 Sociodemographic, Psychological, and Behavioral Factors Associated With Recent/Repeat Testing and Test Avoiding Among Hispanic/Latino MSM (N = 608) Recent/Repeat Testing Characteristic Site New York City Miami-Dade County Sociodemographics and drug/alcohol use Age 18-29 30-39 ≥40 Born outside United States No Yes Place of birth United States Mexico Central America South America Puerto Rico Cuba Other Caribbean country Other English use Ethnic identity Ethnic identity search Affirmation/belonging Education ≤High school >High school Employment status Employed Unemployed Income (US$) Despite these limitations, results suggest the need for more effective strategies to increase HIV testing among Hispanic/Latino MSM. Promising strategies may include developing messages that address fears of being HIV-positive for test avoiders, increasing the number of HCPs who routinely discuss sexual health and offer testing to MSM patients, and implementing interventions to decrease homophobia, which may remove barriers to testing, especially among Hispanic/ Latino MSM. References Bell, A. P., & Weinberg, M. S. (1978). Homosexualities: A study of diversity among men and women. New York, NY: Simon & Schuster. Bernstein, K., Liu, K.-L., Begier, E., Koblin, B., Karpati, A., & Murrill, C. (2008). Same-sex attraction disclosure to health care providers among New York City men who have sex with men: Implications for HIV testing approaches. Archives of Internal Medicine, 168(13), 1458-1464. Bond, L., Lauby, J., & Batson, H. (2005). HIV testing and the role of individual- and structural-level barriers and facilitators. AIDS Care, 17(2), 125-140. Bourne, A. (2010). The role of fear in HIV prevention. London, UK: Sigma Research. Burke, R., Sepkowitz, K., Bernstein, K., Karpati, A., Myers, J., Tsoi, B., & Begier, E. (2007). Why don’t physicians test for HIV? A review of the US literature. AIDS, 21(12), 1617-1624. Campsmith, M. L., Goldbaum, G. M., Brackbill, R. M., Tollestrup, K., Wood, R. W., & Weybright, J. E. (1997). HIV testing among men
who have sex with men—results of a telephone survey. Preventive Medicine, 26(6), 839-844. Centers for Disease Control and Prevention. (1994). HIV prevention practices of primary-care physicians: United States, 1992. MMWR, 42(51/52), 988-992. Centers for Disease Control and Prevention. (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR, 55(14), 1-17. Centers for Disease Control and Prevention. (2008). Subpopulation estimates from the HIV incidence surveillance system: United States, 2006. MMWR, 57(36), 985-989. Centers for Disease Control and Prevention. (2010). Prevalence and awareness of HIV infection among men who have sex with men: 21 cities, United States, 2008. MMWR, 59(37), 1202-1209. Centers for Disease Control and Prevention. (2011a). HIV risk, prevention, and testing behaviors among men who have sex with men: National HIV Behavioral Surveillance System, 21 U.S. cities, United States, 2008. MMWR, 60(14). Centers for Disease Control and Prevention. (2011b). HIV testing among men who have sex with men: 21 cities, United States, 2008. MMWR, 60(21), 694-699. Centers for Disease Control and Prevention. (2011c). Results of the Expanded HIV Testing Initiative: 25 jurisdictions, United States, 2007-2010. MMWR, 60(24), 805-810. Centers for Disease Control and Prevention. (2012). Act against AIDS. Retrieved from http://wwwdev.actagainstaids.org/consumer/together/gettested.html Centers for Disease Control and Prevention. (2013a). HIV Surveillance Report, 2011. Retrieved from http://www.cdc.gov/ hiv/topics/surveillance/resources/reports/. Centers for Disease Control and Prevention. (2013b). My reasons for getting an HIV test. Retrieved from http://hivtest.cdc.gov/reasons/ Cohen, M., Chen, Y., McCauley, M., Gamble, T., Hosseinipour, M., Kumarasamy, N., . . . Fleming, T. (2011). Prevention of HIV-1 infection with early antiretroviral therapy. New England Journal of Medicine, 365(6), 493-505. Crawford, I., Allison, K., Zamboni, B., & Soto, T. (2002). The influence of dual-identity development on the psychosocial functioning of African-American gay and bisexual men. Journal of Sex Research, 39(3), 179-189. Diaz, R. M., Ayala, G., Bein, E., Henne, J., & Marin, B. V. (2001). The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: Findings from 3 US cities. American Journal of Public Health, 91(6), 927-932. Diaz, R. M., Ayala, G., & Marin, B. V. (2000). Latino gay men and HIV: Risk behavior as a sign of oppression. FOCUS: A Guide to AIDS Research and Counseling, 15, 1-4. Diverse & Resilient. (2012). Acceptance journeys: Whose life can you change with love? Retrieved from from http://journey2accept. org/ Gay Men’s Health Crisis. (2010). GMHC hosts launch for new antihomophobia campaign, “I Love My Boo” in NYC subways. Retrieved from http://www.gmhc.org/news-and-events/pressreleases/gmhc-hosts-launch-for-new-anti-homophobia-campaigni-love-my-boo-in-nyc-subways-2
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Hall, H., Holtgrave, D., & Maulsby, C. (2012). HIV transmission rates from persons living with HIV who are aware and unaware of their infection, United States. AIDS, 26. Advance online publication. Holtgrave, D. R., Hall, H. I., Wehrmeyer, L., & Maulsby, C. (2012). Costs, consequences and feasibility of strategies for achieving the goals of the National HIV/AIDS Strategy in the United States: A closing window for success? AIDS and Behavior, 16(6), 1365-1372. Hullett, C. R. (2006). Using functional theory to promote HIV testing: The impact of value-expressive messages, uncertainty, and fear. Health Communication, 20(1), 56-67. Hutchinson, A., Sansom, S., & Farnham, F. (2012, July). Costeffectiveness of more frequent HIV screening of men who have sex with men in the United States. Paper presented at the 19th International AIDS Conference, Washington, DC. Kellerman, S., Lehman, J. S., Lansky, A., Stevens, M., Hecht, F., Bindman, A., & Wortley, P. (2002). HIV testing within at-risk populations in the United States and the reasons for seeking or avoiding HIV testing. JAIDS, 31(2), 202-210. Kessler, R. C., Andrews, G., Colpe, L. J., Hiripi, E., Mroczek, D. K., Normand, S. L. T., . . . Zaslavsky, A. M. (2002). Short screening scales to monitor population prevalences and trends in nonspecific psychological distress. Psychological Medicine, 32(6), 959-976. Kinsler, J., Lee, S.-J., Sayles, J., Newman, P., Diamant, A., & Cunningham, W. (2009). The impact of acculturation on utilization of HIV prevention services and access to care among an atrisk Hispanic population. Journal of Health Care for the Poor and Underserved, 20(4), 996-1011. Kotler, P., & Robtero, E. L. (1989). Social marketing strategies for changing public behavior. New York, NY: Free Press. Kunda, Z. (1990). The case for motivated reasoning. Psychological Bulletin, 108(3), 480-498. Lo, Y. C., Turabelidze, G., Lin, M., & Friedberg, Y. (2012). Prevalence and determinants of recent HIV testing among sexually active men who have sex with men in the St. Louis metropolitan area, Missouri, 2008. Sexually Transmitted Diseases, 39(4), 306-311. Mackellar, D. A., Hou, S. I., Whalen, C. C., Samuelsen, K., Sanchez, T., Smith, A., . . . the WHBS Study Group. (2011). Reasons for not HIV testing, testing intentions, and potential use of an over-the-counter rapid HIV test in an internet sample of men who have sex with men who have never tested for HIV. Sexually Transmitted Diseases, 38(5), 419-428. MacKellar, D., Valleroy, L., Anderson, J., Behel, S., Secura, G., Bingham, T., . . . Janssen, R. (2006). Recent HIV testing among young men who have sex with men: Correlates, contexts, and HIV seroconversion. Sexually Transmitted Diseases, 33(3), 183-192. Margolis, A. D., Joseph, H., Belcher, L., Hirshfield, S., & Chiasson, M. A. (2011). “Never testing for HIV” among men who have sex with men recruited from a sexual networking website, United States. AIDS and Behavior. Advance online publication.
880 HEALTH PROMOTION PRACTICE / November 2014
Marin, G. (1989). AIDS prevention among Hispanics: Needs, risk behaviors, and cultural values. Public Health Reports, 104(5), 411-415. Marks, G., Millett, G., Bingham, T., Bond, L., Lauby, J., Liau, A., . . . Stueve, A. (2009). Understanding differences in HIV sexual transmission among Latino and Black men who have sex with men: The Brothers y Hermanos Study. AIDS and Behavior, 13(4), 682-690. Martnez-Donate, A., Zellner, J., Fernndez-Cerdeo, A., Saudo, F., Hovell, M., Sipan, C., . . . Ji, M. (2009). Hombres Sanos: Exposure and response to a social marketing HIV prevention campaign targeting heterosexually identified Latino men who have sex with men and women. AIDS Education and Prevention, 21(5 Suppl.), 124-136. Mimiaga, M., Landers, S., & Conron, K. (2011). Prevalence and correlates of lifetime HIV testing in a population-based sample of men who have sex with men in Massachusetts. AIDS Patient Care and STDs, 25(6), 323-326. Mimiaga, M., Reisner, S., Bland, S., Skeer, M., Cranston, K., Isenberg, D., . . . Mayer, K. (2009). Health system and personal barriers resulting in decreased utilization of HIV and STD testing services among at-risk Black men who have sex with men in Massachusetts. AIDS Patient Care and STDs, 23(10), 825-835. New York City Department of Health. (2012). HIV, gay men, and other men who have sex with other men (Vol. 2012). Retrieved from http://www.nyc.gov/html/doh/downloads/pdf/ah/hiv-msmbrochure.pdf. Prejean, J., Song, R., Hernandez, A., Ziebell, R., Green, T., Walker, F., . . . Hall, H. I. (2011). Estimated HIV incidence in the United States, 2006-2009. PLoS ONE, 6(8), e17502-e17502. Sifakis, F., Hylton, J., Flynn, C., Solomon, L., MacKellar, D., Valleroy, L., & Celentano, D. (2010). Prevalence of HIV infection and prior HIV testing among young men who have sex with men. The Baltimore Young Men’s Survey. AIDS and Behavior, 14(4), 904-912. Sumartojo, E., Lyles, C., Choi, K., Clark, L., Collins, C., Grey, C. G., . . . Remafedi, G. (2008). Prevalence and correlates of HIV testing in a multi-site sample of young men who have sex with men. AIDS Care, 20(1), 1-14. Wall, K., Khosropour, C., & Sullivan, P. (2010). Offering of HIV screening to men who have sex with men by their health care providers and associated factors. Journal of the International Association of Physicians in AIDS Care, 9(5), 284-288. Weinhardt, L. S., Carey, M. P., Johnson, B. T., & Bickham, N. L. (1999). Effects of HIV counseling and testing on sexual risk behavior: A meta-analytic review of published research, 1985-1997. American Journal of Public Health, 89(9), 1397-1405. The White House Office of National AIDS Policy. (2010). National HIV/AIDS Strategy for the United States. Retrieved from http:// www.whitehouse.gov/administration/eop/onap/nhas. Yoon, E. (2011). Measuring ethnic identity in the Ethnic Identity Scale and the Multigroup Ethnic Identity Measure–Revised. Cultural Diversity and Ethnic Minority Psychology, 17(2), 144-155.
research-article2014
HPPXXX10.1177/1524839914537493Health Promotion PracticeJoseph et al. / SHORT TITLE
Sexual and Reproductive Health
HIV Testing Among Sexually Active Hispanic/ Latino MSM in Miami-Dade County and New York City: Opportunities for Increasing Acceptance and Frequency of Testing Heather A. Joseph, MPH1 Lisa Belcher, PhD1 Lydia O’Donnell, PhD2 M. Isabel Fernandez, PhD3 Pilgrim S. Spikes, PhD1 Stephen A. Flores, PhD1
HIV testing behavior is important in understanding the high rates of undiagnosed infection among Hispanic/ Latino men who have sex with men (MSM). Correlates of repeat/recent testing (within the past year and ≥5 tests during lifetime) and test avoidance (never or >5 years earlier) were examined among 608 sexually active Hispanic/Latino MSM (Miami-Dade County and New York City). Those who reported repeat/recent testing were more likely to have incomes over $30,000, speak English predominately, and have visited and disclosed same-sex behavior to a health care provider (HCP) in the past year. Those who were classified as test avoiders were less likely to have incomes over $10,000 and to have seen an HCP in the past year. The main reason for not testing (in both groups) was fear of HIV positivity; however, twice as many test avoiders considered this their main reason, and more test avoiders had confidentiality concerns. Results suggest that messages to encourage testing among Hispanic/ Latino MSM may be most effective if past testing patterns and reasons for not testing are considered. HCPs can play an important role by consistently offering HIV tests to MSM and tailoring messages based on prior testing histories.
Health Promotion Practice November 2014 Vol. 15, No. (6) 867–880 DOI: 10.1177/1524839914537493 © 2014 Society for Public Health Education
Keywords: behavior change; HIV/AIDS; Latino; minority health; LGBT; sexual health; social marketing/health communication
I
n the United States, HIV infection disproportionately affects the Hispanic/Latino community: The rate of new infections among this population in 2009 was three times that of Whites (Prejean et al., 2011). Hispanic/ Latino men who have sex with men (MSM) represent 81% of new infections among all Hispanic/Latino men (Prejean et al., 2011) and nearly 19% among all MSM (Centers for Disease Control and Prevention [CDC], 2008). One possible explanation for the disproportionate number of new HIV infections among Hispanic/Latino MSM may be exposure to men with undiagnosed infection. 1
Centers for Disease Control and Prevention, Atlanta, GA, USA 2 Education Development Center, Waltham, MA, USA 3 Nova Southeastern University, Miami, FL, USA Authors’ Note: This work was supported by the Centers for Disease Control and Prevention (Grant/Award No. PS 06-006). We thank the study participants as well as study staff, including Stephen Bowen, Alex Carballo-Diéguez, Nilda Hernandez, Robin Jacobs, Maria Lago, Jocelyn Patterson, Alexi San Doval, Ann Stueve, and Ilya Teplinskiy. Please address correspondence to Heather A. Joseph, Centers for Disease Control and Prevention/ Division of HIV/AIDS Prevention, Mailstop E-37, 1600 Clifton Road NE, Atlanta, GA 30333, USA; e-mail: [email protected].
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According to the 2008 National HIV Behavioral Surveillance (NHBS) system among MSM in 21 highprevalence cities, 46% of HIV-infected Hispanic/Latino MSM were unaware of their infection. Among Hispanic/ Latino MSM ages 18 to 29 years, the rate of undiagnosed infection was 63% (CDC, 2010). Mathematical modeling studies have estimated that 49% of transmissions in 2008 were from the 20% of persons with HIV who were unaware of their infection (Hall, Holtgrave, & Maulsby, 2012). Persons who are unaware of their HIV infection do not receive timely and appropriate medical care and prevention services and, compared with persons who know that they are HIV-positive, are more likely to engage in behaviors that can result in transmission (Weinhardt, Carey, Johnson, & Bickham, 1999). Effective treatment decreases the chance of sexual transmission by as much as 96% (Cohen et al., 2011). Advances in testing and treatment make it particularly important to understand the HIV testing behavior of groups at high risk transmission and acquisition. This insight can be applied to the development of effective strategies for promoting the acceptance of testing and increasing the frequency of testing. In 2006, CDC recommended routine, opt-out screening for all patients (ages 13 to 64) in health care settings and at least annual testing for persons at high risk of HIV infection (CDC, 2006). In 2007, through the Expanded Testing Initiative, CDC funded 25 health departments to improve the availability and accessibility of HIV testing services, facilitate adoption of HIV screening in health care settings, and increase identification of undiagnosed infection in populations disproportionately affected by HIV (CDC, 2011c). The 2008 NHBS data indicated that 61% of MSM had tested for HIV during the past year (CDC, 2011b). Because 45% of MSM who were unaware of their infection had been tested within the past year, investigators suggested that sexually active MSM should be tested more frequently (CDC, 2010). Subsequent analysis indicated that compared with testing annually, testing at 3 and 6 months is likely to be cost-saving (Hutchinson, Sansom, & Farnham, 2012). In response to these data and increasing incidence among young MSM, some local health departments have suggested that sexually active MSM test more frequently (e.g., New York City recommends every 6 months; New York City Department of Health, 2012). Given the substantial support for expansion of testing efforts, research is needed to identify correlates of testing behavior. The 2006 CDC guidelines for health care settings recommend annual testing for MSM who
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have had, or whose sex partners have had, more than one partner since their most recent HIV test; however, this recommendation requires that MSM disclose their sexual behavior to their health care provider (HCP). In one study, only 30% of MSM who visited a HCP in the past year were offered an HIV test (Wall, Khosropour, & Sullivan, 2010). In two studies, approximately 30% to 40% of MSM had not disclosed their sexual orientation or behavior to their HCP (Bernstein et al., 2008; Lo, Turabelidze, Lin, & Friedberg, 2012); in New York City, twice as many white men, compared with Hispanic/ Latino men (48% vs. 18%), disclosed to their HCP (Bernstein et al., 2008). In both studies, disclosure of sexual orientation to an HCP was positively associated with recent HIV testing and negatively associated with never testing. Other correlates of testing have been identified. Factors positively associated with recent testing include younger age, higher income and education, gay identification, being “out,” multiple partners, disclosure of HIV status to partners, recent drug use, exposure to more types of HIV prevention, knowing about a testing site, social support, and perception of low risk of HIV infection (Lo, Turabelidze, Lin, & Friedberg, 2012; Mimiaga et al., 2009; Sumartojo et al., 2008; Wall et al., 2010). Fewer studies have focused on MSM who have never tested or explored how these men may differ from those with testing experience. Reported rates of never testing among at-risk MSM range from 7% to 22% (CDC, 2011b; Lo et al., 2012; Margolis, Joseph, Belcher, Hirshfield, & Chiasson, 2011; Sumartojo et al., 2008). Correlates of never testing include self-identification as bisexual or heterosexual, living outside a metropolitan area, not having an HCP, unemployment, and poorer self-reported health (Margolis et al., 2011; Mimiaga, Landers, & Conron, 2011). Correlates of ever having an HIV test include older age, having social support, knowing where to get tested, exposure to more types of HIV prevention, and a previous diagnosis of a sexually transmitted infection (STI; Sifakis et al., 2010; Sumartojo et al., 2008). Research on testing correlates is complemented by studies that have focused on self-reported reasons for not testing. Common reasons for not testing include low perceived risk of HIV infection, fear of testing HIVpositive, worry about lack of confidentiality, and structural issues (e.g., not having enough money; Campsmith et al., 1997; CDC, 2011a; Kellerman et al., 2002; Lo et al., 2012). MacKellar et al. (2011) found that younger MSM who had never tested, as well as Hispanic/Latino MSM, were more likely to name structural issues. Compared with White MSM, more Hispanic/Latino MSM reported fear of testing positive as the primary
reason for not testing. Understanding the reasons for not testing may aid in developing more effective social marketing campaigns for Latino MSM, who may have distinct values, attitudes, and barriers related to HIV testing. Effective social marketing campaigns promote “the voluntary behavior of target audiences by offering benefits they want, reducing barriers they are concerned about, and using persuasion to motivate their participation” (Kotler & Robtero, 1989, p. 24). Thus, it is important to understand the target audience’s desired benefits, perceptions of barriers, and most persuasive motivations. Applying functional theory to HIV testing, Hullet (2006) found that persuasive messages were more effective when they targeted the reason a person held a particular attitude regarding personal health (getting tested for oneself) and benevolence (getting tested to protect others). In sum, high rates of undiagnosed infection among Hispanic/Latino MSM require public health intervention, yet little research has been focused on HIV testing among this particular population. This report presents data on HIV testing behavior among sexually active Hispanic/ Latino MSM in New York City and Miami-Dade County. The exploratory analysis identifies factors associated with testing patterns as well as self-reported reasons for not testing in order to inform the development of effective interventions, messages, and marketing campaigns to increase HIV testing uptake among Hispanic/Latino MSM.
boards at CDC, the Education Development Center, and Nova Southeastern University approved the study protocol. Study Procedures Participants were enrolled from May 2007 through September 2008. Hispanic/Latino MSM were actively recruited in multiple venues (e.g., bars, clubs, cafés, college campuses, and online chat rooms) and through referrals from agencies that serve this population. Passive recruitment included print and electronic advertisements. Eligibility was restricted to Hispanic/ Latino men who were ages 18 to 49 years and reported being HIV-negative or of unknown status. Inclusion criteria encompassed one or more unprotected anal sex acts with a male partner in the past 3 months in addition to multiple sex partners in the past 3 months (the Miami study site required multiple male partners; New York required only one partner to be male). Men were ineligible if they self-identified as transgender, planned to move during the study period, or had participated in an HIV prevention study in the past 6 months. Study activities were conducted in both English and Spanish. All participants provided written informed consent and received a cash incentive ($60 in New York City and $50 in Miami) for completing the baseline audio computer-assisted self-interview (ACASI). Measures
Method >> Data from two study sites that evaluated HIV prevention interventions for Latino MSM were combined for analysis. New York City and Miami-Dade County were selected as study cities, in part, due to the high prevalence rates of diagnosed HIV infection (758 and 879/100,000, respectively) and large Latino/Hispanic populations in these jurisdictions (CDC, 2013a). The sites developed and tested their own interventions but adhered to a common protocol for recruitment, eligibility criteria, and data collection to facilitate the pooling of baseline data. At both sites, the control condition consisted of a single, standard HIV counseling session with the offer of HIV testing. In New York City, men were randomly assigned to the control condition or a single-session intervention with the offer of HIV testing. In Miami-Dade County, men were randomly assigned to the control condition or a foursession intervention with the offer of HIV testing. The study sites collected participant data at baseline and 3 months after the intervention. The institutional review
Sociodemographics. Sociodemographic variables included age, place of birth, work status, education, and annual income. Participants were asked about their sexual identity; responses of “homosexual/gay/same gender loving” and “queer” were categorized as “gay identified” in a new dichotomous variable. Use of Spanish versus English was measured by a 4-item scale adapted from the language-use scale of Marin (1989); a higher score indicates more exclusive English use. The Multigroup Ethnic Identity Measure (Yoon, 2011) was used to measure acculturation via two subscales: Ethnic Identification Search (five items; alpha = .73) and Affirmation, Belonging, and Commitment (seven items; alpha = .88). (Note: All Cronbach’s alpha statistics were calculated using this data set.) Binge drinking included any report of consuming six or more alcoholic beverages on one occasion in the past 3 months. Drug use was classified as any use of ecstasy, cocaine, crack, methamphetamines, poppers, club drugs, heroin, or another recreational drug (other than marijuana) in the past 3 months.
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Psychosocial Factors. Psychosocial factors were measured as follows: ••
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•• •• •• •• •• ••
Responses to the question, “In general, how worried are you about getting HIV?” were collected by using a 4-point Likert-type scale. For analysis, responses were dichotomized into “not at all/a little” and “some/a lot.” Participants were asked, “In general, what do you think the chance is that you will get HIV in your lifetime?” Responses were collected using a 4-point Likert-type scale and dichotomized into “no chance/small chance” and “medium chance/large chance.” A similar question addressed HIV risk perception over the next 6 months. Psychological distress was assessed by a 10-item scale (alpha = .92; Kessler et al., 2002). Social isolation was measured through a scale developed for Hispanic/Latino MSM (seven items; alpha = .89; Diaz, Ayala, Bein, Henne, & Marin, 2001). Gay identity was assessed by Crawford, Allison, Zamboni, & Soto’s (2002) Gay Identity Scale (four items; alpha = .65). “Outness” was measured with a 3-item scale developed for this study (alpha = .86). Community connection was measured by a single question, “How connected do you feel to the Latino community of gay/bisexual men?” Internalized homonegativity was assessed by a 4-item scale developed by Bell and Weinberg (1978; alpha = .89).
Distress, gay identity, outness, connection to gay community, and homonegativity were treated as continuous variables. Sexual Risk Behaviors. Participants were asked about their sexual behavior with male, female, and transgender partners in the past 3 months. The number of receptive and insertive anal sex and vaginal sex episodes, as well as condom use, was asked for most recent partner and other partners by partner HIV serostatus. Any unprotected anal intercourse (UAI) with main and casual male partners, number of male anal sex partners, and any vaginal sex with a woman were included in the analysis. HIV Testing. Participants were asked whether they had ever been tested for HIV and, if yes, the date and result of their most recent test. Men who reported both a test in the past year and five or more tests in their lifetime were classified as recent/repeat testers. The cutoff—five tests—was based on the sample distribution (M = 4.8).
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Those who reported never testing or that their most recent test was more than 5 years ago were classified as test avoiders. Participants who reported previous testing, but not in the past year, were asked to select all the reasons for not having tested recently (e.g., “I don’t know where to get tested”; Marks et al., 2009). A parallel question was posed to men who had never tested. Data Analysis The two outcome variables of interest were (a) recent/repeat testing (testing in the past year and five or more tests in lifetime vs. not testing in the past year or four or fewer lifetime tests) and (b) test avoiding (never testing or most recent test ≥5 years earlier vs. testing >
Participant Characteristics Sociodemographic characteristics of the 608 participants are presented in Table 1. The mean age was 34.6 (SD = 9.45; range = 18-52). Sixty-one percent were born outside the United States; of those, most were born in the Caribbean or South America. More than 25% of the sample had never been tested, and almost 50% had not been tested in the past year. Figures 1 and 2 reflect testing behavior according to the two discrete classifications used in this analysis; about one third (30.8%) were repeat/recent testers (Figure 1) and 30.8% were test avoiders (Figure 2). Recent/Repeat Testing and Test Avoidance Bivariate and multivariate analyses were performed for the two outcomes of interest (Table 2 and Table 3). Compared to men who had not tested in the past year or who had fewer than five lifetime tests, recent/repeat testers were more likely to reside in Miami-Dade County, report an income of more than $30,000, and use English more exclusively. They were also more likely to have seen an HCP in the past year and to have disclosed same-sex behavior. Compared to men who tested High school Employment status Employed (full- or part-time) Unemployed Income (US$) >
Increasing the proportion of persons who know their HIV status is one of the primary strategies of the National HIV/AIDS Strategy (NHAS; White House Office of National AIDS Policy, 2010). As indicated in the recent modeling study by Holtgrave, Hall, Wehrmeyer, and Maulsby (2012), scaling up HIV care and treatment without also expanding testing services
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is unlikely to achieve the NHAS goal to reduce incidence. These findings, along with those from nationally representative samples, suggest that HIV testing rates among Hispanic/Latino MSM are suboptimal. Although CDC recommends at least annual testing for at-risk MSM, national epidemiologic data suggest that sexually active MSM may benefit from testing every 3 to 6 months (CDC, 2010). In this convenience sample of at-risk Hispanic/Latino MSM from Miami-Dade County and New York City, about 25% had never been tested for HIV, and 50% had not tested in the past year. Additional efforts will be required to increase testing frequency among this population. Tailoring Messages According to Testing Typology Public health interventions to increase HIV testing may be more successful if they directly address the fundamental reasons for not testing. Among the Hispanic/Latino MSM in this study, nonrecent testers and test avoiders did not give uniform reasons for not testing. In this study and others (MacKellar et al., 2006), the most frequently reported reason for not testing (both groups) was fear of being HIV-positive. However, test avoiders were more than twice as likely as nonrecent testers to cite this reason. Test avoiders were also more likely to cite confidentiality concerns and less likely to report lack of access as reasons for not testing, whereas nonrecent testers’ reasons were more equally distributed among fear, confidentiality concerns, lack of access, and low perceived risk. Messages may be most effective if they are tailored according to a testing typology that considers individuals’ testing patterns and reasons for not testing (Figure 4). For example, test avoiders who share fear-based concerns may benefit most from messages that directly and specifically address the availability and effectiveness of early HIV treatment and the ability to have a long life with HIV. Concerns about stigma and confidentiality may be addressed through messages highlighting standards for protecting client confidentiality, the availability of social support and resources for persons with HIV, and the availability of private testing facilities. CDC’s Act Against AIDS campaign highlights these messages (CDC, 2012). Fear appeals, which are focused on increasing perceptions of risk and severity, may be ineffectual for test avoiders who lack testing self-efficacy. Such messages may be more influential among previous testers who have a vested interest in believing that testing is worth the effort already expended (Bourne, 2010; Kunda, 1990). Given that nonrecent testers cited multiple reasons, multifaceted approaches and messages are needed. CDC’s Reasons/Razones
Table 2 Sociodemographic, Psychological, and Behavioral Factors Associated With Recent/Repeat Testing and Test Avoiding Among Hispanic/Latino MSM (N = 608) Recent/Repeat Testing Characteristic Site New York City Miami-Dade County Sociodemographics and drug/alcohol use Age 18-29 30-39 ≥40 Born outside United States No Yes Place of birth United States Mexico Central America South America Puerto Rico Cuba Other Caribbean country Other English use Ethnic identity Ethnic identity search Affirmation/belonging Education ≤High school >High school Employment status Employed Unemployed Income (US$) Despite these limitations, results suggest the need for more effective strategies to increase HIV testing among Hispanic/Latino MSM. Promising strategies may include developing messages that address fears of being HIV-positive for test avoiders, increasing the number of HCPs who routinely discuss sexual health and offer testing to MSM patients, and implementing interventions to decrease homophobia, which may remove barriers to testing, especially among Hispanic/ Latino MSM. References Bell, A. P., & Weinberg, M. S. (1978). Homosexualities: A study of diversity among men and women. New York, NY: Simon & Schuster. Bernstein, K., Liu, K.-L., Begier, E., Koblin, B., Karpati, A., & Murrill, C. (2008). Same-sex attraction disclosure to health care providers among New York City men who have sex with men: Implications for HIV testing approaches. Archives of Internal Medicine, 168(13), 1458-1464. Bond, L., Lauby, J., & Batson, H. (2005). HIV testing and the role of individual- and structural-level barriers and facilitators. AIDS Care, 17(2), 125-140. Bourne, A. (2010). The role of fear in HIV prevention. London, UK: Sigma Research. Burke, R., Sepkowitz, K., Bernstein, K., Karpati, A., Myers, J., Tsoi, B., & Begier, E. (2007). Why don’t physicians test for HIV? A review of the US literature. AIDS, 21(12), 1617-1624. Campsmith, M. L., Goldbaum, G. M., Brackbill, R. M., Tollestrup, K., Wood, R. W., & Weybright, J. E. (1997). HIV testing among men
who have sex with men—results of a telephone survey. Preventive Medicine, 26(6), 839-844. Centers for Disease Control and Prevention. (1994). HIV prevention practices of primary-care physicians: United States, 1992. MMWR, 42(51/52), 988-992. Centers for Disease Control and Prevention. (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR, 55(14), 1-17. Centers for Disease Control and Prevention. (2008). Subpopulation estimates from the HIV incidence surveillance system: United States, 2006. MMWR, 57(36), 985-989. Centers for Disease Control and Prevention. (2010). Prevalence and awareness of HIV infection among men who have sex with men: 21 cities, United States, 2008. MMWR, 59(37), 1202-1209. Centers for Disease Control and Prevention. (2011a). HIV risk, prevention, and testing behaviors among men who have sex with men: National HIV Behavioral Surveillance System, 21 U.S. cities, United States, 2008. MMWR, 60(14). Centers for Disease Control and Prevention. (2011b). HIV testing among men who have sex with men: 21 cities, United States, 2008. MMWR, 60(21), 694-699. Centers for Disease Control and Prevention. (2011c). Results of the Expanded HIV Testing Initiative: 25 jurisdictions, United States, 2007-2010. MMWR, 60(24), 805-810. Centers for Disease Control and Prevention. (2012). Act against AIDS. Retrieved from http://wwwdev.actagainstaids.org/consumer/together/gettested.html Centers for Disease Control and Prevention. (2013a). HIV Surveillance Report, 2011. Retrieved from http://www.cdc.gov/ hiv/topics/surveillance/resources/reports/. Centers for Disease Control and Prevention. (2013b). My reasons for getting an HIV test. Retrieved from http://hivtest.cdc.gov/reasons/ Cohen, M., Chen, Y., McCauley, M., Gamble, T., Hosseinipour, M., Kumarasamy, N., . . . Fleming, T. (2011). Prevention of HIV-1 infection with early antiretroviral therapy. New England Journal of Medicine, 365(6), 493-505. Crawford, I., Allison, K., Zamboni, B., & Soto, T. (2002). The influence of dual-identity development on the psychosocial functioning of African-American gay and bisexual men. Journal of Sex Research, 39(3), 179-189. Diaz, R. M., Ayala, G., Bein, E., Henne, J., & Marin, B. V. (2001). The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: Findings from 3 US cities. American Journal of Public Health, 91(6), 927-932. Diaz, R. M., Ayala, G., & Marin, B. V. (2000). Latino gay men and HIV: Risk behavior as a sign of oppression. FOCUS: A Guide to AIDS Research and Counseling, 15, 1-4. Diverse & Resilient. (2012). Acceptance journeys: Whose life can you change with love? Retrieved from from http://journey2accept. org/ Gay Men’s Health Crisis. (2010). GMHC hosts launch for new antihomophobia campaign, “I Love My Boo” in NYC subways. Retrieved from http://www.gmhc.org/news-and-events/pressreleases/gmhc-hosts-launch-for-new-anti-homophobia-campaigni-love-my-boo-in-nyc-subways-2
Joseph et al. / HIV Testing Among Sexually Active Hispanic/Latino MSM 879
Hall, H., Holtgrave, D., & Maulsby, C. (2012). HIV transmission rates from persons living with HIV who are aware and unaware of their infection, United States. AIDS, 26. Advance online publication. Holtgrave, D. R., Hall, H. I., Wehrmeyer, L., & Maulsby, C. (2012). Costs, consequences and feasibility of strategies for achieving the goals of the National HIV/AIDS Strategy in the United States: A closing window for success? AIDS and Behavior, 16(6), 1365-1372. Hullett, C. R. (2006). Using functional theory to promote HIV testing: The impact of value-expressive messages, uncertainty, and fear. Health Communication, 20(1), 56-67. Hutchinson, A., Sansom, S., & Farnham, F. (2012, July). Costeffectiveness of more frequent HIV screening of men who have sex with men in the United States. Paper presented at the 19th International AIDS Conference, Washington, DC. Kellerman, S., Lehman, J. S., Lansky, A., Stevens, M., Hecht, F., Bindman, A., & Wortley, P. (2002). HIV testing within at-risk populations in the United States and the reasons for seeking or avoiding HIV testing. JAIDS, 31(2), 202-210. Kessler, R. C., Andrews, G., Colpe, L. J., Hiripi, E., Mroczek, D. K., Normand, S. L. T., . . . Zaslavsky, A. M. (2002). Short screening scales to monitor population prevalences and trends in nonspecific psychological distress. Psychological Medicine, 32(6), 959-976. Kinsler, J., Lee, S.-J., Sayles, J., Newman, P., Diamant, A., & Cunningham, W. (2009). The impact of acculturation on utilization of HIV prevention services and access to care among an atrisk Hispanic population. Journal of Health Care for the Poor and Underserved, 20(4), 996-1011. Kotler, P., & Robtero, E. L. (1989). Social marketing strategies for changing public behavior. New York, NY: Free Press. Kunda, Z. (1990). The case for motivated reasoning. Psychological Bulletin, 108(3), 480-498. Lo, Y. C., Turabelidze, G., Lin, M., & Friedberg, Y. (2012). Prevalence and determinants of recent HIV testing among sexually active men who have sex with men in the St. Louis metropolitan area, Missouri, 2008. Sexually Transmitted Diseases, 39(4), 306-311. Mackellar, D. A., Hou, S. I., Whalen, C. C., Samuelsen, K., Sanchez, T., Smith, A., . . . the WHBS Study Group. (2011). Reasons for not HIV testing, testing intentions, and potential use of an over-the-counter rapid HIV test in an internet sample of men who have sex with men who have never tested for HIV. Sexually Transmitted Diseases, 38(5), 419-428. MacKellar, D., Valleroy, L., Anderson, J., Behel, S., Secura, G., Bingham, T., . . . Janssen, R. (2006). Recent HIV testing among young men who have sex with men: Correlates, contexts, and HIV seroconversion. Sexually Transmitted Diseases, 33(3), 183-192. Margolis, A. D., Joseph, H., Belcher, L., Hirshfield, S., & Chiasson, M. A. (2011). “Never testing for HIV” among men who have sex with men recruited from a sexual networking website, United States. AIDS and Behavior. Advance online publication.
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Marin, G. (1989). AIDS prevention among Hispanics: Needs, risk behaviors, and cultural values. Public Health Reports, 104(5), 411-415. Marks, G., Millett, G., Bingham, T., Bond, L., Lauby, J., Liau, A., . . . Stueve, A. (2009). Understanding differences in HIV sexual transmission among Latino and Black men who have sex with men: The Brothers y Hermanos Study. AIDS and Behavior, 13(4), 682-690. Martnez-Donate, A., Zellner, J., Fernndez-Cerdeo, A., Saudo, F., Hovell, M., Sipan, C., . . . Ji, M. (2009). Hombres Sanos: Exposure and response to a social marketing HIV prevention campaign targeting heterosexually identified Latino men who have sex with men and women. AIDS Education and Prevention, 21(5 Suppl.), 124-136. Mimiaga, M., Landers, S., & Conron, K. (2011). Prevalence and correlates of lifetime HIV testing in a population-based sample of men who have sex with men in Massachusetts. AIDS Patient Care and STDs, 25(6), 323-326. Mimiaga, M., Reisner, S., Bland, S., Skeer, M., Cranston, K., Isenberg, D., . . . Mayer, K. (2009). Health system and personal barriers resulting in decreased utilization of HIV and STD testing services among at-risk Black men who have sex with men in Massachusetts. AIDS Patient Care and STDs, 23(10), 825-835. New York City Department of Health. (2012). HIV, gay men, and other men who have sex with other men (Vol. 2012). Retrieved from http://www.nyc.gov/html/doh/downloads/pdf/ah/hiv-msmbrochure.pdf. Prejean, J., Song, R., Hernandez, A., Ziebell, R., Green, T., Walker, F., . . . Hall, H. I. (2011). Estimated HIV incidence in the United States, 2006-2009. PLoS ONE, 6(8), e17502-e17502. Sifakis, F., Hylton, J., Flynn, C., Solomon, L., MacKellar, D., Valleroy, L., & Celentano, D. (2010). Prevalence of HIV infection and prior HIV testing among young men who have sex with men. The Baltimore Young Men’s Survey. AIDS and Behavior, 14(4), 904-912. Sumartojo, E., Lyles, C., Choi, K., Clark, L., Collins, C., Grey, C. G., . . . Remafedi, G. (2008). Prevalence and correlates of HIV testing in a multi-site sample of young men who have sex with men. AIDS Care, 20(1), 1-14. Wall, K., Khosropour, C., & Sullivan, P. (2010). Offering of HIV screening to men who have sex with men by their health care providers and associated factors. Journal of the International Association of Physicians in AIDS Care, 9(5), 284-288. Weinhardt, L. S., Carey, M. P., Johnson, B. T., & Bickham, N. L. (1999). Effects of HIV counseling and testing on sexual risk behavior: A meta-analytic review of published research, 1985-1997. American Journal of Public Health, 89(9), 1397-1405. The White House Office of National AIDS Policy. (2010). National HIV/AIDS Strategy for the United States. Retrieved from http:// www.whitehouse.gov/administration/eop/onap/nhas. Yoon, E. (2011). Measuring ethnic identity in the Ethnic Identity Scale and the Multigroup Ethnic Identity Measure–Revised. Cultural Diversity and Ethnic Minority Psychology, 17(2), 144-155.
