HIV Testing:
Characteristics of Specific Populations
Latino Men who Have Sex with Men
A Workshop to Identify Facilitators and
Barriers to HIV Testing
Institute of Medicine
15 April 2010
Manya Magnus, PhD, MPH
Associate Professor
George Washington University
School of Public Health and Health Services
Department of Epidemiology and Biostatistics
1
Outline
•
•
•
•
Epidemiology of HIV/AIDS among
Latino MSM
Heterogeneity of population
Methodological challenges
HIV testing among Latino MSM
– Facilitators
– Barriers
•
Recommendations
2
3
4
5
6
Heterogeneity of the population (1)
•
Latino/Hispanic MSM in the US not
just one group—highly heterogeneous
– Puerto Rico, Mexico, Cuba, Central and
South America
– Different risk behaviors, different barriers
and facilitators
•
Example: among persons diagnosed with AIDS in
2005, 51% were MSM MOT from Central/South
America, 52% Cuba, 59% Mexico, 17% Puerto Rico,
44% US. IDU for Puerto Rico was 42%
7
Heterogeneity of the population (2)
•
Not “one size fits all”
– Behavioral correlates differ by place of
birth, cultural environment while in US
– Openly gay, men who have sex with
men and women (MSM/W), nongay/bi-identified
– Transgender, gender non-conforming
– Substance abuse, mental health
8
Heterogeneity of the population (3)
•
Substantial differences between
populations of Latino MSM contribute to
difficulty in research, testing, and
prevention
–
–
–
–
Behavioral—HIV-related risk behaviors
Self-identification—gender, sexual
orientation, cultural
Social support—family, community, spiritual
Cultural norms—acculturation, past/current
9
Access
•
Lower level acculturation measures associated with less HIV
testing and reduced access to care
–
•
Kinsler 2009
MD recommendation may assist
–
•
Fernandez 2003a
HCSUS Latinos with HIV/AIDS were more likely to be publicly
insured or uninsured than whites; half with Medicaid
compared to 32% of whites. 24% Latinos were uninsured vs.
17% whites. Latinos less likely to be privately insured than
whites (23% compared to 44%)
–
Cunningham 1999
10
Testing
•
5% Latino MSM unaware of HIV status (vs. 17% black)
–
•
Marks 2009
Repeat testers due to increased sexual risk taking, STD.
Regular testers lower risk behaviors
–
•
Fernandez 2003b
92% ever test (vs. 90% AA, 93%W); 80% last 12 months
(vs.79% AA, 73%W)
–
•
Sanchez 2006
More late testers, undiagnosed HIV infection, later post-test
counseling
–
•
Duran 2005
Non-risk based testing for AA and Hispanic MSM
–
•
MacKellar 2006
Latino men less likely than others to be repeat testers, less
likely to first time test
–
Fernyak 2002
11
Approaches (1)
•
Venue attending MSM/W (primarily sex with
women) more likely to select multiscreening than primarily MSM; urban bars
less than suburban
–
•
Galvan 2006
Need to incorporate social structures of
Latino MSM and address issues of poverty,
social discrimination, and other societal
issues affecting sexual and health-related
behavior
–
Diaz 2001; Jarama 2005
12
Approaches (2)
•
Hispanic MSM more likely to perceive importance
of prevention services and to receive prevention
services at healthcare provider than white MSM;
also more likely to report that HIV counseling was
important to them
–
•
Behel 2008
Effective identification of at risk Latino immigrant
individuals via door-to-door
–
•
Seña 2010
Social marketing campaign exposure associated
with improved HIV testing behavior
–
•
Martinez-Donate 2009
Few peer reviewed papers, more information
needed on testing behaviors among MSM
–
Sanchez 2004
13
Methodological challenges (1)
Venue attending
men eligible for
study
Venue attending
MSM willing to
participate
Venue attending
men not eligible
for study
Non-venue
attending MSM
Example: venue-based sampling
14
Methodological challenges (2)
•
Challenges in including Latino MSM in
research, prevention, and HIV testing
– Stigma
•
•
HIV
MSM
– Language, translation
•
Not just one language—many languages,
dialects
– Religious aspects, attitudes, community
15
Methodological challenges (3)
– Fears of immigration laws, police
(non-citizens, citizens)
– Concerns about research
• Disclosure, knowing staff, word
getting out
– Poverty, unemployment
– Lack of health insurance
• May be offset by use of public systems
and community health centers
16
Barriers (1)
•
Inadequate healthcare access, health
insurance
–
–
–
•
•
•
•
HIV testing may be free but not part of routine
healthcare
Value of prevention and healthcare services,
referral of physician to test
In absence of health insurance, may not be
possible
Stigma
Disclosure skills
Poverty, unemployment
Fear of immigration
17
Barriers (2)
•
Methods of recruitment
– VBS vs. RDS/social network vs.
household
•
•
Focus on behavioral intervention with
perhaps insufficient focus on structural
intervention
Late testing substantial problem
18
Facilitators (1)
•
Routine testing
–
–
–
•
Need to improve healthcare access overall
Health maintenance instead of singled out or
risk-based testing
Prevention messages and education remain
important
Alternate methods for recruitment (e.g.,
peer referral, social network approaches)
19
Facilitators (2)
•
Adequate translations
– Media, consents, brochures, referrals
•
•
•
Ethnographic research to inform
strategies to promote HIV testing
Culturally appropriate messages and
mode of dissemination
Confidentiality, training
20
Recommendations
•
Ongoing work to identify effective
means to engage Latino MSM in
testing and counseling
– Ethnography, formative, cultural
awareness building and action
– Think local
•
Local epidemic, subpopulations, specific
needs
– Innovative approaches needed
– Community and structural interventions
21
Discussion
• Role of local and other agencies
to facilitate testing
• Appreciation for challenges in
programs
• Acknowledging growing epidemic
• Work towards innovative program
development
• More research required
22
Thank you
23
References (1)
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References (2)
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Cunningham WE et al., The Impact of Competing Subsistence Needs and Barriers to
Access to Medical Care for Persons with Human Immunodeficiency Virus Receiving
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De Santis JP, Vasquez EP, Weidel JJ, Watson S, Sanchez M. A comparison of
depressive symptoms, self-esteem, and sexual behaviors between foreign-born and
U.S.-born Hispanic men who have sex with men: Implications for HIV prevention.
Hispanic Health Care International. 2009;7:80-87.
Diaz RM, Ayala G. Social discrimination and health: the case of Latino gay men and HIV
risk. The Policy Institute of the National Gay and Lesbian Task Force.
Diaz RM, Ayala G, Bein E, et al. The Impact of Homophobia, Poverty, and Racism on the
Mental Health of Gay and Bisexual Latino Men: Findings From 3 US Cities. AJPH
2001;91:927-32.
Duran H, Usman HR,Beltrami J, et al. HIV Counseling and Testing among Hispanic
Adolescents and Adults in the United States, Puerto Rico, and the U.S. Virgin Islands,
2005National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. 2005.
Erausquin JT, Duan N, Grusky O, et al. Increasing the Reach of HIV Testing to Young
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Hispanic Men: A
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Fernandez MI, Perrino T, Bowen GS, Royal S, Varga L. Repeat HIV Testing Among
Hispanic Men Who Have Sex With Men--A Sign Of Risk, Prevention, or Reassurance?.
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Fernyak SE, Page-Shafer K, Kellogg TA. Risk Behaviors and HIV Incidence Among
Repeat Testers at Publicly Funded HIV Testing Sites in San Francisco. JAIDS
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References (3)
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Flores SA, Bakeman R, Millett GA, et al. HIV Risk Among Bisexually and Homosexually
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Galvan FH, Blumenthal RN, Chizobam A, et al. Increasing HIV testing among Latinos by
bundling HIV testing with other tests. Journal of Urban Health. 2006;83:849-59.
George S, Garth B, Wohl AR, et al. Sources and Types of Social Support that Influence
Engagement in HIV Care among Latinos and African Americans. Journal of Health Care
for the Poor and Underserved. 2009;20:1012-35.
Harawa NT, Greenland S, Bingham TA, et al. Associations of Race/Ethnicity With HIV
Prevalence and HIV-Related Behaviors Among Young Men Who Have Sex
With Men in 7 Urban Centers in the United States. JAIDS 2004;35:526–36.
Herbst JH, Kay LS, Passin WF, et al. A Systematic Review and Meta-Analysis of
Behavioral Interventions to Reduce HIV Risk Behaviors of Hispanics in the United States
and Puerto Rico. AIDS and Behavior 2007;11:25-47.
Janssen R. CDC’s HIV Prevention Priorities and Activities for Hispanics/Latinos.
Conslultation Slides 2008. Centers for Disease Control and Prevention.
Jarama SL, Kennamer JD, Poppen PJ, Hendricks M, Bradford J. Psychosocial,
Behavioral, and Cultural Predictors of Sexual Risk for HIV Infection Among Latino Men
Who Have Sex with Men. AIDS Behav. 2005;9:513-523.
Katz JL, Orellana ER, Walker DD, et al. The sex check the development of an HIVprevention service to address the needs of Latino MSM. Journal of Gay and Lesbian
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References (4)
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Latino/Hispanic AIDS Action Agenda. Latino/Hispanic HIV/AIDS Federal
Policy Recommendations Addressing the Latino AIDS Crisis.
(http://www.latinoaidsagenda.org/documents/nlaan_recommendations_eng.p
df, Accessed 4/10.)
MacKellar DA, Valleroy LA, Secura GM, et al. Unrecognized HIV Infection,
Risk Behaviors,and Perceptions of Risk Among Young Men Who Have Sex
With Men: Opportunities for Advancing HIV Prevention in the Third Decade of
HIV/AIDS. J Acq Immun Def Synd. 2005;38:603-614.
Martínez-Donate AP, Zellner JA, Fernández-Cerdeño A. Hombres Sanos:
Exposure and Response to a Social Marketing HIV Prevention Campaign
Targeting Heterosexually identified Latino Men Who Have Sex with Men and
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Millett GA. HIV Prevention and MSM of Color. www.cdc.gov (Accessed 3/10).
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Sifakis F, Hylton JB, Flynn C, et al. Racial Disparities in HIV Incidence Among Young
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populations: the development and application of respondent-driven sampling among
IDUs and Latino gay men. AIDS Behav 2005; 9(4):387-402
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Mexican Migrants and Recent Immigrants in California and Mexico
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Rapid HIV Testing Among Latino Immigrants and Their HIV Risk Factors in North
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28
Selected studies (1)
Three stage, clinic based,
probability sample of N=600
Hispanics (12% MSM, MSM/W)
Lower level acculturation
measures associated with less
HIV testing and reduced access
to care (Kinsler 2009)
Brothers y Hermanos RDS
sample of N=1,081 Latino MSM
5% Latino MSM unaware of HIV
status (17% black) (Marks 2009)
Community-based sample of
N=255 never tested Hispanic
MSM
MD recommendation may assist
Venue-based sample of N=538
HIV- Hispanic MSM
Repeat testers due to increased
sexual risk taking, STD. Regular
testers lower risk behaviors
(Fernandez 2003a)
(Fernandez 2003b)
*Terminology displayed is each author’s
29
Selected studies (2)
National HIV behavioral
surveillance-MSM1 venue
based sample of N=2,660;
27% Latino
Young Men’s Survey
venue-based sample of
N=2,797 23 to 29 yo; 24%
Hispanic
Venue-based sample of
394 Latino MSM
92% ever test (vs. 90% AA,
93%W); 80% last 12
months (vs.79% AA,
73%W) (Sanchez 2006)
Non-risk based testing for
AA and Hispanic MSM
(MacKellar 2006)
Venue attending MSM/W
(primarily sex with women)
more likely to select multiscreening than primarily
MSM; urban bars less than
suburban (Galvan 2006)
30
Selected studies (3)
Nuestras Voces/Our
Voices. Venue based
sample of N=912 Latino
gay men plus N=300
qualitative interviews.
Follow on study N=250.
Need to incorporate social
structures of Latino MSM
and address issues of
poverty, social
discrimination, and other
societal issues affecting
sexual and health-related
behavior (Diaz 2001; Jarama
2005)
Examination of N=57,505 Latino men less likely than
publicly funded HIV tests in others to be repeat testers,
SF; 13.6% Latino
less likely to first time test
(Fernyak 2002)
31
Selected studies (4)
Community-outreach
survey at social events
NYC N=177 18 to 24 yo;
24.1% Latino
85% previously tested;
non-testers d/t time, fear,
confidentiality, discomfort,
forgetting. Behaviors
motivated testing. 64%
preferred rapid testing. (not
Latino subanalyses) (Cohall
2010)
Examination of N=57,505 Latino men less likely than
publicly funded HIV tests in others to be repeat testers,
SF; 13.6% Latino
less likely to first time test
(Fernyak 2002)
32
Selected studies (5)
Systematic review of
epidemiology of HIV
among Mexican migrants
and recent immigrants in
California and Mexico
Young Men’s Survey
venue-based sample of
N=2,797 23 to 29 yo; 24%
Hispanic
Few peer reviewed papers,
more information needed
on testing behaviors
among MSM (Sanchez 2004)
Hispanic MSM more likely
to perceive importance of
prevention services and to
receive prevention services
at healthcare provider than
white MSM; also more
likely to report that HIV
counseling was important
to them (Behel 2008)
33
Selected studies (6)
Door-to-door sample of
N=228 (Latino men and
women, not only MSM)
Effective identification of at
risk Latino immigrant
individuals via door-to-door
(Seña 2010)
Venue-based pre-post
social marketing campaign
for N=1,137 Latino men
(6% heterosexual identified
MSM/W)
Social marketing campaign
exposure associated with
improved HIV testing
behavior (Martinez-Donate 2009)
34
Selected studies (7)
Analysis of HIV testing data
Hispanics twice as likely as nonHispanic whites to be late
testers, confidential testers.
Hispanic MSM less likely to have
HIV tests than non-Hispanic
White MSM (8.6% vs. 13.7%).
Hispanics more likely to have
undiagnosed HIV infection (0.9%
vs. 0.6%) and receive posttest
counseling >2 weeks post test
than non Hispanic Whites (40%
vs. 29%) (Duran 2005).
35
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