AIDS Education and Prevention, 27(1), 15–26, 2015 © 2015 The Guilford Press PROVIDER INTERACTIONS MEANLEY ET AL.
THE ROLE OF PROVIDER INTERACTIONS ON COMPREHENSIVE SEXUAL HEALTHCARE AMONG YOUNG MEN WHO HAVE SEX WITH MEN Steven Meanley, Alyssa Gale, Chelsea Harmell, Laura Jadwin-Cakmak, Emily Pingel, and José A. Bauermeister
Testing for both HIV and STIs is an essential component of comprehensive sexual healthcare for young men who have sex with men (YMSM). Using data collected from YMSM living in the Detroit metropolitan area (N = 304, ages 18–29; 51% Black, 25% White, 14% Latino), we examined YMSM’s access to a medical provider in the prior year and tested whether a provider’s conversation regarding HIV/STI prevention was associated with their type of testing behavior: Non-Testers, HIV-Only Testing, and HIV and STI Testing. Over half (56.7%) reported a routine provider visit in the previous year. Visits were associated with having insurance, provider comfort, and prior HIV and/or STI testing. Among YMSM who visited a doctor, our multinomial regression exhibited that those whose provider discussed HIV/ STI prevention were most likely to have tested for both HIV and STIs, as compared to the HIV Only and Never Tester categories. Patient-provider communication regarding HIV/STI prevention is critical to motivate comprehensive sexual healthcare access among YMSM. Strategies that enable providers to discuss HIV/STI prevention with YMSM in a sex-positive manner may help maximize comprehensive testing.
A third of all HIV infections are among adolescents and young adults aged 13–19 years, with 91% of these infections attributed to male-to-male sexual contact (U.S. Centers for Disease Control and Prevention, 2014). These numbers only continue to increase; between 2008 and 2010, the estimated number of new HIV infections among young men who have sex with men (YMSM) aged 13–24 rose by 22% (U.S. Centers for Disease Control and Prevention, 2012). Black and Latino YMSM carry Steven Meanley, M.P.H., Alyssa Gale, M.P.H., Chelsea Harmell, M.P.H., Laura Jadwin-Cakmak, M.P.H., Emily Pingel, M.P.H., and José A. Bauermeister, M.P.H., PhD, are affiliated with The Center for Sexuality & Health Disparities, University of Michigan School of Public Health, Ann Arbor, Michigan. The UHIP academic-community partnership included representatives from AIDS Partnership Michigan, the HIV/AIDS Resource Center, Detroit Latin@z, Ruth Ellis Center, and the University of Michigan’s Center for Sexuality & Health Disparities. This work was supported by the MAC AIDS Fund (PI: Bauermeister). Dr. Bauermeister was supported by a Career Development Award (K01-MH087242) from the National Institutes of Mental Health. The content is solely the responsibility of the authors and does not represent the official views of the funding agencies. Address correspondence to José A. Bauermeister, M.P.H., PhD, 300 North Ingalls St., 9th Floor, Wing D, Ann Arbor, MI 48109. E-mail: [email protected]
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the greatest burden of infection (U.S. Centers for Disease Control and Prevention, 2014), accounting for 63% and 18% of HIV positive youth aged 13–24 years, respectively. Given that STI infections may increase risks for HIV infection (Fleming & Wasserheit, 1999), there is an urgent need to encourage testing and other preventive measures (e.g., vaccinations) for HIV and STIs concurrently. Testing for HIV and other STIs can be an effective means of both primary and secondary prevention (Dean & Fenton, 2010). Routine STI testing is all the more pressing given the frequently asymptomatic nature of some of the most common STIs, including gonorrhea, syphilis, and chlamydia. Early detection of HIV and STIs through routine testing has proven a successful means of secondary prevention, facilitating better clinical outcomes through earlier entry into care (Ickovics & Meade, 2002). Although HIV testing may be accessible through community-based organizations and/or home kits, STI testing requires access to a medical setting and access to health insurance coverage (unlike HIV tests, STI testing is not free in most venues). These barriers may be particularly salient among the most socially vulnerable, including residentially unstable and homeless YMSM (Corliss, Goodenow, Nichols, & Austin, 2011; Kipke, Weiss, & Wong, 2007; Woods, Samples, Melchiono, & Harris, 2003). Taken together, these findings underscore the importance of examining how structural barriers may hinder YMSM’s ability to seek medical care and access comprehensive testing (e.g., HIV and STI tests) within these settings. Although access to care has been identified as a barrier to prevention services among YMSM (Garofalo, Mustanski, Johnson & Emerson, 2010), the implementation of the Affordable Care Act (ACA) is expected to aid in reducing barriers to comprehensive preventive care, including HIV and STI screening. Medical service providers may promote HIV/STI status awareness among YMSM by encouraging HIV/STI testing during routine medical visits. In order to be effective, however, patient-provider interactions must provide opportunities for patients to feel safe disclosing their sexuality and sexual behaviors. In prior research, patients’ comfort and willingness to disclose their sexual orientation to providers has been associated with health promotive behaviors (Bernstein et al., 2008). For example, patients who report greater comfort in disclosing their sexual orientation and/or behaviors to their physician are more likely to receive testing recommendations during their medical encounter (Wall, Khosropour, & Sullivan, 2010), and are also more likely to test for STIs (Tai et al., 2008). Therefore, creating opportunities for HIV/STI prevention conversations to occur between YMSM and their providers during a medical visit may be vital to promote HIV/STI testing, and to reinforce the importance of status awareness through routine HIV/STI screening. As part of this study, we examined the proportion of YMSM who had reported HIV and STI testing and investigated whether YMSM’s HIV/STI testing behaviors differed between those who had accessed a medical provider in the prior year and those who had not. We then examined whether comprehensive HIV/STI testing and other services were associated with YMSM’s comfort discussing sexual matters with a provider and prior HIV/STI prevention discussions with providers. We hypothesized that YMSM would be more likely to report recent use of HIV and STI testing services if they had seen a medical provider within the prior year, felt more comfortable discussing sexual matters with their providers, and had discussed HIV/STI prevention strategies with their providers.
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METHODS SAMPLE AND PROCEDURES Data for this article come from a cross-sectional observational study examining YMSM’s structural and psychosocial vulnerabilities to HIV/AIDS in the Detroit metropolitan area. To be eligible for participation, recruits had to be between the ages of 18 and 29; identify as male, transgender male, or transgender female; report currently residing in the Detroit metropolitan area (as verified by zip code and IP address), and report having had sex with men. Details on study procedures have been reported elsewhere (Bauermeister et al., 2014). We developed our web survey using best practices (Couper, 2008), including various iterations of pilot testing prior to data collection. Consented participants then answered a 30–45-minute survey. Participants were compensated with a $30 Visa e-gift card via e-mail upon completion of the questionnaire. We acquired a Certificate of Confidentiality from the U.S. Department of Health and Human Services to protect study data. The University of Michigan Institutional Review Board approved all study procedures. For this article , we have excluded trans-identified participants from our analyses (N = 32). Though testing among trans-identified youth is important to consider, we acknowledge that there may be distinct barriers faced by gender minority youth (e.g., transphobia) that are absent among cisgender-identified youth in accessing medical care and sexual health screenings. Similarly, our analyses excluded HIVpositive participants (N = 41) because given their status, these participants were not asked the items regarding HIV susceptibility.
MEASURES Testing/Service Utilization Categories. Participants were provided with a list of sexual health services and were asked to mark the services they had previously utilized. These services included: HIV testing; STI testing for syphilis, gonorrhea, or chlamydia; anal Pap smear; and vaccination for hepatitis A, hepatitis B, and human papillomavirus (HPV). Due to the low reported frequency of past utilization of some of these sexual health services (see Table 1), participants were collapsed into three categories: Never Testers, which included participants who reported never having tested for HIV or other STIs; HIV Only, which included participants who reported having tested for HIV but never testing for other STIs; and HIV and Other, which included participants who reported having previously tested for HIV as well as at least one other STI. HIV Testing Accessibility. A dichotomous item (0 = No; 1 = Yes) was included in the survey in order to capture whether a participant knew where to receive a confidential HIV test. Healthcare Access. Participants were asked to report the number of times in the past 12 months that they had visited a medical provider for a routine physical or check-up. This item was assessed on a 6-point scale (0, 1, 2, 3, 4, or 5+ times). For analytical purposes, this item was dichotomized into Never and At least one visit. Provider Discussions. Participants were asked whether a doctor had ever talked to them about HIV/STI prevention, a dichotomous item (0 = No; 1 = Yes). Addition-
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MEANLEY ET AL. TABLE 1. Comprehensive Sexual Health Components, N = 304 N (%)
Sexual Health Screening/Vaccine HIV Test
250 (82.2)
STI Test (Syphilis, Chlamydia, and Gonorrhea)
175 (57.6)
Anal Pap Smear
12 (3.9)
Hepatitis A Vaccine
64 (21.1)
Hepatitis B Vaccine
76 (25.0)
HPV Vaccine
16 (5.3)
ally, participants reported the extent to which they felt comfortable discussing their sexual behaviors with a medical provider using a 4-point Likert scale (1 = Strongly Disagree; 4 = Strongly Agree). Perceived HIV Susceptibility. To ascertain participants’ perceived susceptibility to acquiring HIV, participants were asked how likely they thought it was that they would become HIV-positive in the future using a 4-point Likert scale (1 = Very Likely; 4 = Very Unlikely). A second item asked participants to rate their perceived likelihood of acquiring HIV in the next ten years when compared to others of their same gender, age, and sexual orientation (1 = Much More Likely; 4 = Much Less Likely). Both items were combined to create a composite perceived HIV susceptibility score (Cronbach’s α = .70). Demographic Information. Standard measures were utilized to collect demographic information on age, race/ethnicity, level of educational attainment, sexual identity, housing status, and insurance status. Due to the low frequencies of some categories, race/ethnicity and sexual identity were collapsed into four (Black, White, Latino, and Other Race) and three (Gay, Bisexual, and Other Sexual Identity) categories, respectively. Housing status was dichotomized into participants who had versus had not spent one night homeless, transient, or in unstable housing in the prior 30 days. Lastly, insurance status was categorized to compare participants without insurance with those who had some insurance coverage.
DATA ANALYTIC STRATEGY We first conducted c2 and ANOVA tests to examine whether there were any differences in testing categories by demographic and psychosocial variables (see Table 2). We then conducted a logistic regression model to examine what psychosocial predictors were associated with having seen a medical provider for a routine physical or check-up in the prior year. In our analyses, we included sociodemographic variables (e.g., age, race/ethnicity, education, sexual identity), structural variables (e.g., housing instability and insurance coverage), and provider characteristics (e.g., comfort discussing sexual matters with provider, HIV/STI testing provider recommendations). We also adjusted for YMSM’s perceived susceptibility to HIV and knowledge about where to test, as they could confound the observed relationships with HIV/STI testing categories. Finally, among YMSM who reported accessing a medical provider in the prior year, we conducted another logistic regression to examine whether comfort discussing sexual behaviors with a provider and testing groups was associated with provider discussions regarding HIV/STI prevention. We attempted to repeat
PROVIDER INTERACTIONS 19 TABLE 2. Testing Categories by Sociodemographic and Psychosocial Variables, N = 304 Non-Testers
Age, M (SD)
HIV Only
HIV/STI Tester
(N = 54)
(N = 57)
(N = 193)
22.43 (2.88)
23.00 (3.03)
22.96 (2.82)
Race/Ethnicity, N (%) Black/African American
17 (12.1)
30 (21.3)
94 (66.7)
White/Caucasian
21 (23.9)
15 (17.0)
52 (59.1)
13 (27.1)
11 (22.9)
24 (50.0)
Other Race/Ethnicity
3 (11.1)
1 (3.7)
23 (85.2)
Sexual Identity, N (%)
6.65
Gay/Homosexual
50 (19.3)
51 (19.7)
Bisexual
4 (15.4)
3 (11.5)
19 (73.1)
Other Sexual Identity
0 (0.0)
3 (6.3)
29 (84.2)
158 (61.0)
HIV Status, N (%)
207.13***
Negative
15 (5.7)
57 (21.5)
Unknown
39 (100.0)
0 (0.0)
0 (0.0)
3.19 (1.36)
3.21 (1.35)
3.59 (1.28)
193 (72.8)
Housing Instability, N (%) No Nights Homeless/Transient
46 (17.7)
51 (19.6)
163 (62.7)
8 (18.2)
6 (13.6)
30 (68.2)
23 (19.5)
26 (22.0)
69 (61.2)
Insurance Coverage, N (%)
Some Coverage Perceived HIV Susceptibility, M (SD)
2.20
31 (16.7)
31 (16.7)
124 (66.7)
6.67 (1.47)
6.40 (1.66)
6.89 (1.26)
Testing Location Knowledge, N (%)
11.04 50.18***
No
22 (59.5)
3 (8.1)
12 (32.4)
Yes
32 (12.0)
54 (20.2)
181 (67.8)
Not in Prior Year
38 (26.2)
35 (24.1)
72 (49.7)
In Prior Year
16 (10.1)
22 (13.8)
121 (52.3)
2.72 (1.00)
2.96 (.89)
3.03 (.83)
Routine Medical Visit, N (%)
Provider Comfort, M (SD)
3.10* .90
1+Nights Homeless/Transient
No Coverage
.80 15.64*
Latino
Education Level, M (SD)
F/X2 Test Statistic
23.77***
Provider Prevention Discussions, N (%)
2.65 63.97***
No
44 (38.6)
26 (22.8)
44 (38.6)
Yes
10 (5.3)
31 (16.3)
1149 (78.4)
*p < .05. **p < .01. ***p < .001.
these analytic procedures using Hepatitis and HPV vaccines as outcomes, yet the limited number of cases for each vaccine in our sample made it impossible to test. For brevity, only statistically significant findings (p ≤ .05) are discussed.
RESULTS Our sample (N = 304) had a mean age of 22.9 (SD = 2.87). The racial/ethnic distribution of our sample was predominantly Black/African American (N = 190; 51.2%), followed by non-Latino/Hispanic White/Caucasian (N = 92; 24.8%), Latino (N = 55; 14.8%), and Other Race (N = 34; 9.2%). The vast majority of participants self-
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identified as gay or homosexual (N = 259; 85.2%). Bisexual participants made up 8.6% of our sample (N = 26) and all others were grouped into a single Other Sexual Identity category (e.g., participants wrote-in identities such as same gender loving, queer; N = 19; 6.3%). Nearly two thirds of our sample (N = 193; 63.5%) reported having tested for HIV and at least one other STI (categorized into the HIV and STI Testing group), with smaller minorities who had never tested for HIV or other STIs (the Never Testers category; N = 62; 16.7%) and who had tested for HIV, but not tested for or been vaccinated against any other STIs (the HIV Only category; N = 66; 17.8%). We found that a lower percentage (18.5%) of those in the Never Testers category reported having had HIV/STI prevention discussions with a medical provider, and that participants in the HIV and STI Testing category reported a higher percentage of discussions with providers (77.2%; c2(2) = 89.75; p < .001). No significant differences between testing categories were observed by age, race/ethnicity, sexual orientation identity, education, insurance status, housing status, perceptions of HIV susceptibility, or comfort discussing sexual behaviors with a medical provider. Over half of our sample (N = 159; 52.3%) had accessed a medical provider in the prior year for a routine physical or check-up. Participants who had accessed a medical provider exhibited an average lower age (M = 22.38, SD = 2.74) compared to those who had not seen a medical provider (M = 23.41, SD = 2.92) for a routine check-up in the prior year (t(302) = 3.15; p < .01). Latino participants reported a significantly lower percentage (33.3%) of medical care access whereas participants in the Other Race/Ethnicity category reported a higher percentage (66.7%); c2(3) =10.29; p < .05. Those who had accessed care reported a higher percentage of insurance coverage (N = 121; 76.1%) than participants who reported not having seen a medical provider in the past year (N = 65; 34.9%); c2(1) = 31.23; p < .001. Lastly, we observed that visits with a medical provider in the previous year were associated with having HIV/STI prevention discussions with a doctor (c2(1) = 12.03; p = .001). No differences in medical provider access were observed by sexual identity, education, housing status, or perceived susceptibility to HIV.
MULTIVARIATE MODELS Access to a Medical Provider. Using a multiple logistic regression (see Table 3), we first conducted an exploratory analysis to determine the demographic and psychosocial characteristics associated with accessing a medical provider in the past year. Visiting a medical provider in the previous 12 months was associated with greater comfort discussing sexual behaviors with a provider (OR = 1.56; 95% CI [1.14, 2.13], p < .01). Participants in the HIV and STI Testing category were more likely to have seen a medical provider in the past 12 months compared to participants in the Never Testers category (OR = 3.99; 95% CI [1.68, 9.49], p < .01). We found no association with provider visits in the HIV Only category. Insurance coverage was associated with greater likelihood of accessing a medical provider in the prior 12 months (OR = 4.44; 95% CI [2.43, 8.12], p < .001). Age was negatively associated with the odds of having seen a provider (OR = .84; 95% CI [.76, .94], p < .01). We observed no relationship between medical access and perceived susceptibility, HIV testing location knowledge, and prior prevention discussions with providers (see Table 3).
PROVIDER INTERACTIONS 21 TABLE 3. Logistic Regression—Medical Provider Visit/Routine Check-Up Prior Year, N = 304 AOR Constant
95% CI
.91
Age
.84**
.76, .94
Race/Ethnicitya
1.43
.76, 2.67
Education Level
.95
.74, 1.22
Housing Instability
1.04
.48, 2.27
Insurance Coverage
4.44***
2.43, 8.12
Perceived HIV Susceptibility
1.05
.87, 1.28
HIV Testing Location Knowledge
1.06
.42, 2.68
1.56**
1.14, 2.13
Provider Comfort Discussing Sexual Behaviors Test Categoryb HIV Test Only HIV & STI Testing Prior Provider Prevention Discussions
1.60
.62, 4.18
3.99**
1.68, 9.49
1.50
.82, 2.74
Notes. aAdjusted Odds Ratio (AOR) compares non-Hispanic Whites to non-Hispanic White counterparts. bNonTesters serve as referent category. **p < .01. ***p < .001 .
Testing Categories. Among participants who had accessed a medical provider for a check-up or routine care, those in the HIV and STI Testing group were more likely than Never Testers to have had discussions with a provider regarding HIV/STI prevention (OR = 9.78, 95% CI [2.67, 35.85], p < .01). We found no difference on patient discussions between Never Testers and those in the HIV Only testing category. No differences in demographic and psychosocial variables of interest were observed.
DISCUSSION Comprehensive sexual health screening and care services are necessary to reduce the HIV/STI disparities faced by YMSM. Although HIV testing was relatively high in our sample (82%), a smaller proportion of YMSM reported having one or more STI tests (58%) or being vaccinated against Hepatitis A (21%) or B (25%) or HPV (5%). Our study elucidates the urgency of improving access to and awareness of preventive vaccinations within the contexts of comprehensive sexual health service provision. Compared to heterosexual counterparts, MSM are at increased risk for Hepatitis A and Hepatitis B, with estimated new cases around 10 and 20 percent, respectively, among adults (U.S. Centers for Disease Control and Prevention, 2010). With the same referent group, MSM are at increased risk for HPV-related conditions such as anal cancer (Gilbert, Brewer, Reiter, Ng, & Smith, 2011). Gilbert et al. (2011) showed that compared to heterosexual men, gay and bisexual men have higher acceptability to HPV vaccination as well as higher anticipated regret when considering how it would feel to decline vaccination and subsequently be diagnosed with a HPV-related condition. Because our results revealed that prevention discussions with a medical provider are an associated marker of comprehensive sexual health access, we suggest that medical providers are an integral part of discussing the importance of sexual health care (e.g., screenings and vaccinations) among YMSM.
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MEANLEY ET AL. Table 4. Logistic Regression—Prior Provider Prevention Discussions, N = 304 AOR
Constant
95% CI
3.79
Age
.91
.78, 1.08
Race/Ethnicitya
.98
.40, 2.39
Education Level
1.07
.72, 1.58
Housing Instability
2.18
.55, 8.72
Insurance Coverage
.89
.32, 2.49
Perceived HIV Susceptibility
.94
.71, 1.24
HIV Testing Location Knowledge
1.00
.24, 4.16
Provider Comfort Discussing Sexual Behaviors
1.03
.66, 1.61
Test Categoryb HIV Test Only HIV & STI Testing
2.17
.50, 9.38
9.78**
2.67, 35.85
Notes. aAdjusted Odds Ratio (AOR) compares non-Hispanic Whites to non-Hispanic White counterparts. bNonTesters serve as referent category. **p < .01.
Participants in the HIV and STI Testing category reported a higher percentage of accessing routine medical care in the prior year, supporting the notion that primary care provides an effective platform for comprehensive sexual health care. Interestingly, there was a small but noteworthy proportion of our sample reporting an HIV-negative status even though they were represented in the Never Tester group. In the context of primary care, medical providers may be an effective route for discussing the importance of testing as a means of ensuring knowledge of one’s HIV status and decreasing the rates of those with unknown status. Participants who reported at least some health insurance coverage also reported higher odds of accessing a medical provider for a routine check-up in the prior year. This relationship speaks to the logical need to remove financial barriers to accessing care. The implementation of the Patient Protection and Affordable Care Act (ACA) will likely increase health insurance access for YMSM, as Medicaid eligibility for childless adults has broadened and youth may remain on parental insurance plans until the age of 26 years. Efforts should be made to increase awareness among uninsured YMSM of their health insurance options as well as the sexual health services covered by these plans. For those who remain uninsured, it would be important to increase community awareness of free and reduced cost clinics (e.g., clinics with sliding fees) that accept patients without health insurance.
COMPREHENSIVE SEXUAL HEALTH CARE An overwhelming majority of our population had tested for HIV because of ubiquitous messaging around HIV (risk and testing) targeting men who have sex with men as well as increased public health efforts to prioritize accessibility of free, rapid testing. Conversely, STI testing remains costly, necessitates a longer waiting period for results, and may have less visibility in public health campaigns. In fact, Mimiaga, Goldhammer, Belanoff, Tetu, and Mayer (2007) found that MSM were more likely to have been part of prevention strategies targeted toward HIV testing rather than STI testing. Thus, though HIV testing has been at the forefront of sexual health promotion, STI prevention strategies demand further attention, particularly with
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rising rates of syphilis, chlamydia, gonorrhea, and HIV co-infection in the MSM community (Purcell et al., 2012). Many YMSM’s lack of engagement with comprehensive sexual health care may be attributable to several key issues. As reflected by our results, having access to a medical provider who can help address sexual health needs speaks to the importance of routine medical care access. Secondly, our results elucidate the unique space in which providers can offer HIV and STI testing recommendations based on an individual’s specific needs. Because of the burden of STI infection among young people and the fact that STI infection greatly increases one’s risk of HIV infection (Fleming & Wasserheit, 1999), a push toward comprehensive sexual health screening for YMSM is an important aspect of controlling the HIV epidemic in this population. One important finding is that younger participants were more likely to have seen a medical provider compared to their older counterparts. One interpretation of this finding is that younger participants may be more likely to be subsumed under their parents’ current health insurance coverage or have access to clinics offering free or reduced costs to individuals under a specified age (e.g., under 21 years of age). With the implementation of the ACA, we expect this age difference to dissipate once older YMSM begin to use their ACA insurance to access routine medical care access. While the primary care clinic is a strategic setting in which to implement sexual health promotion initiatives for YMSM, we found that YMSM were most likely to report having tested for HIV and STIs if they had visited a medical provider visit in the prior year and felt comfortable discussing sexual behaviors with their providers. These findings are consistent with prior studies documenting how fear of judgment, condescension, and other expressions of condemnation may deter YMSM from accessing care (Rounds, McGrath, & Walsh, 2013). Further, YMSM who do not feel comfortable disclosing their sexual practices to a medical provider may feel less motivated to seek medical care if they feel that they must hide or otherwise disguise some part of their identity (Wall et al., 2010). Therefore, it is vital that primary care services include welcoming and culturally competent services for YMSM as they may signal a safe zone for YMSM to discuss sexuality-related topics. Interventions and structural initiatives that promote affirming environments may foster increased willingness to seek HIV/STI testing services and discuss sexuality-related health matters in primary care settings. Prevention discussions were reported by a higher percentage of YMSM in the HIV and STI Testers category, as compared to YMSM in the HIV Only and Never Testers categories. Trainings for providers that increase understanding of and sensitivity to issues surrounding sexuality and sexual behaviors, as well as give providers an opportunity to practice conversations about sexuality, sexual behaviors, and sexual health care may be key to improving patient-provider interactions. Furthermore, despite YMSM being labeled as a high-risk group for HIV, STIs, and HIV co-infection, we recommend medical providers be vigilant about framing risk and recommendations based on identity. Though understanding youths’ identities (e.g., gay, bisexual, straight, other) may assist in having effective conversations about sexual health, medical providers should focus on participants’ behaviors (e.g., use of condoms or PrEP, oral versus anal sex) when discussing comprehensive sexual health rather than attributing risk to sexual identity. The cultivation of an affirming environment in which YMSM can discuss their sexuality with their medical providers may yield useful insight in revealing additional salient factors that motivate or discourage access to comprehensive sexual health care. For example, a study conducted by Huebner, Davis, Nemeroff, and
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Aiken (2002) found a negative relationship between internalized homophobia and comprehensive sexual health care access. Specifically, individuals who scored higher in internalized homophobia were less likely to be aware of accessible preventive services and less likely to utilize services when aware; therefore, we suggest acquiring a comprehensive account of psychosocial barriers on motivations to get tested and working through these issues with patients in an effort to promote routine testing behaviors. Future research in this area is warranted in order to inform culturallysensitive programming for YMSM.
LIMITATIONS We acknowledge that our study has several limitations. Our study explored the association of having discussed HIV and STI prevention and HIV/STI testing; therefore, we are unable to make causal assertions due to the cross-sectional nature of our study. Furthermore, participants in our study were not asked time-specific items regarding provider discussions or testing behaviors. Despite some having been to a provider in the prior year for a routine check-up or health screening, we are unaware if participants had these discussions within the context of a primary care provider and/or before their self-reported check-up. Specifically, some participants may have tested more than a year ago, yet discussed HIV/STI prevention within a routine check-up in the past year. Longitudinal studies examining the timing between provider discussions and HIV/STI behaviors are therefore warranted. Furthermore, our study did not include a large enough proportion of trans-identified individuals to be adequately represented in our statistical analyses. Nevertheless, we acknowledge that this population merits increased attention given the barriers that trans-identified individuals may face in addressing their sexual health needs. We also recommend further investigation into the multiple psychosocial factors associated with accessing medical care and testing behaviors among YMSM. At present, we do not know whether our finding that younger participants were more likely to see a medical provider is indicative of a generational effect or is simply consistent with our earlier speculation that YMSM’s access to medical care decreases with age. Future research examining changes in YMSM’s use of medical care and testing behaviors over time may clarify this relationship and shape future interventions designed to retain YMSM in care as they transition into adulthood. Lastly, generalizability may be compromised as our sample focused on YMSM living in the Detroit metropolitan area prior to the implementation of the ACA. Because Michigan has adopted Medicaid expansion through the Affordable Care Act, a reduction in financial barriers for YMSM or youth in general may alter the structural barriers hindering YMSM’s access to providers. As the ACA is implemented, more youth are expected to gain access to health insurance covering preventive sexual health services such as HIV screening, syphilis screening, and STI prevention counseling at free or reduced costs. Therefore, as these changes occur, the relationship between health insurance status and testing behaviors may warrant further observation.
CONCLUSION Through this study, we collected important data regarding access to comprehensive sexual health care among YMSM. Specifically, medical providers have the potential to play an important role in HIV and STI testing behaviors, particularly within
PROVIDER INTERACTIONS 25
primary care contexts. Receiving comprehensive sexual health care services is associated not only with accessing routine medical care, but also with some of the interpersonal aspects of the medical encounter, such as comfort discussing sexual behaviors and having discussions related to HIV and STI prevention. Trainings for medical providers that emphasize cultural competency, increase sensitivity around issues of sexuality and sexual practices, and increase knowledge of YMSM-specific health concerns may help allay any discomfort of discussing issues pertinent to receiving comprehensive sexual healthcare. Continued HIV and STI testing outreach for YMSM in the healthcare system, combined with efforts to increase insurance enrollment and ensure providers’ LGBT cultural competency, will ultimately ensure that YMSM can safely test, be linked to treatment as necessary, and maintain their right to enjoy sexual health and well-being.
REFERENCES Bauermeister, J. A., Meanley, S., Hickok, A., Pingel, E., Loveluck, J., & Van Hemert, W. (2014). Sexuality-related work discrimination and its association with the health of gay and bisexual emerging and young adults in the Detroit Metro Area. Sexuality Research & Social Policy, 11(1), 1–10. Bernstein, K. T., Liu, K., Begier, E. M., 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, 1458–1464. Corliss, H. L., Goodenow, C. S., Nichols, L., & Austin, S. B. (2011). High burden of homelessness among sexual-minority adolescents: Findings from a representative Massachusetts high school sample. American Journal of Public Health, 101(9), 1683– 1689. doi:10.2105/AJPH.2011.300155 Couper, M. P. (2008). Designing effective web surveys. New York, NY: Cambridge University Press. Dean, H. D. & Fenton, K. A. (2010). Addressing social determinants of health in the prevention and control of HIV/AIDS, viral hepatitis, sexually transmitted infections, and tuberculosis. Public Health Reports, 125, 1–5. Fleming, D. T., & Wasserheit, J. N. (1999). From epidemiological synergy to public health policy and practice: The contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sexually Transmitted Infections, 75, 3–17. Garofalo, R., Mustanski, B., Johnson, A., & Emerson, E. (2010). Exploring factors that underlie racial/ethnic disparities in HIV risk among young men who have sex with men. Journal of Urban Health, 87(2), 318–323.
Gilbert, P., Brewer, N. T., Reiter, P. L., Ng, T. W., & Smith J. S. (2011). HPV vaccine acceptability in heterosexual, gay, and bisexual men. American Journal of Men’s Health, 5, 297–305. Huebner, D. M., Davis, M. C., Nemeroff, C. J., & Aiken, L. S. (2002). The impact of internalized homophobia on HIV preventive interventions. American Journal of Community Psychology, 30, 327–348. Ickovics, J. R., & Meade, C. S. (2002). Adherence to HAART among patients with HIV: Breakthroughs and barriers. AIDS Care, 14, 309–318. Kipke, M. D., Weiss, G., & Wong, C. F. (2007). Residential status as a risk factor for drug use and HIV risk among young men who have sex with men. AIDS and Behavior, 11(6 Suppl), 56–69. doi:10.1007/s10461006-9204-5 Mimiaga, M., Goldhammer, H., Belanoff, C., Tetu, A., & Mayer, K. H. (2007). Men who have sex with men: Perceptions about sexual risk, HIV and sexually transmitted disease testing, and provider communication. Sexually Transmitted Diseases, 34, 113–119. Purcell, D. W., Johnson, C. H., Lansky, A., Prejean, J., Stein, R., Denning, P., et al. (2012). Estimating the population size of men who have sex with men in the United States to obtain HIV and syphilis rates. Open AIDS Journal, 6, 98–107. doi:10.2174/1874613601206010098 Rounds, K. E., McGrath, B. B., & Walsh, E. (2013). Perspectives on provider behaviors: A qualitative study of sexual and gender minorities regarding quality of care. Contemporary Nurse, 44, 99–110. Tai, E., Sanchez, T., Lansky, A., Mahle, K., Heffelfinger, J., & Workowski, K. (2008). Self-reported syphilis and gonorrhoea testing among men who have sex with men:
26 National behavioural surveillance system, 2003–5. Sexually Transmitted Infections, 84, 478–482. U.S. Centers for Disease Control and Prevention. (2010). CDC fact sheet: The role of STD prevention and treatment in HIV prevention. Retrieved March 16, 2014, from http://www.cdc.gov/std/hiv/stds-and-hivfact-sheet.pdf U.S. Centers for Disease Control and Prevention. (2011). STDs in men who have sex with men. Retrieved April 22, 2014, from http:// www.cdc.gov/std/stats10/msm.htm U.S. Centers for Disease Control and Prevention. (2012). HIV and young men who have sex with men. Retrieved May 16, 2014, from http://www.cdc.gov/healthyyouth/sexualbehaviors/pdf/hiv_factsheet_ymsm.pdf
MEANLEY ET AL. U.S. Centers for Disease Control and Prevention. (2014). HIV among gay, bisexual, and other men who have sex with men. Retrieved April 23, 2014, from http://www.cdc.gov/ hiv/risk/gender/msm/facts/index.html Wall, K. M., Khosropour, C. M., & Sullivan, P. S. (2010). Offering of HIV screening to men who have sex with men by their healthcare providers and associated factors. Journal of the International Association of Physicians in AIDS Care, 9, 284–288. Woods, E. R., Samples, C. L., Melchiono, M. W., & Harris, S. K. (2003). Boston HAPPENS Program: HIV-positive, homeless, and atrisk youth can access care through youthoriented HIV services. Seminars in Pediatric Infectious Diseases, 14(1), 43–53.
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THE ROLE OF PROVIDER INTERACTIONS ON COMPREHENSIVE SEXUAL HEALTHCARE AMONG YOUNG MEN WHO HAVE SEX WITH MEN Steven Meanley, Alyssa Gale, Chelsea Harmell, Laura Jadwin-Cakmak, Emily Pingel, and José A. Bauermeister
Testing for both HIV and STIs is an essential component of comprehensive sexual healthcare for young men who have sex with men (YMSM). Using data collected from YMSM living in the Detroit metropolitan area (N = 304, ages 18–29; 51% Black, 25% White, 14% Latino), we examined YMSM’s access to a medical provider in the prior year and tested whether a provider’s conversation regarding HIV/STI prevention was associated with their type of testing behavior: Non-Testers, HIV-Only Testing, and HIV and STI Testing. Over half (56.7%) reported a routine provider visit in the previous year. Visits were associated with having insurance, provider comfort, and prior HIV and/or STI testing. Among YMSM who visited a doctor, our multinomial regression exhibited that those whose provider discussed HIV/ STI prevention were most likely to have tested for both HIV and STIs, as compared to the HIV Only and Never Tester categories. Patient-provider communication regarding HIV/STI prevention is critical to motivate comprehensive sexual healthcare access among YMSM. Strategies that enable providers to discuss HIV/STI prevention with YMSM in a sex-positive manner may help maximize comprehensive testing.
A third of all HIV infections are among adolescents and young adults aged 13–19 years, with 91% of these infections attributed to male-to-male sexual contact (U.S. Centers for Disease Control and Prevention, 2014). These numbers only continue to increase; between 2008 and 2010, the estimated number of new HIV infections among young men who have sex with men (YMSM) aged 13–24 rose by 22% (U.S. Centers for Disease Control and Prevention, 2012). Black and Latino YMSM carry Steven Meanley, M.P.H., Alyssa Gale, M.P.H., Chelsea Harmell, M.P.H., Laura Jadwin-Cakmak, M.P.H., Emily Pingel, M.P.H., and José A. Bauermeister, M.P.H., PhD, are affiliated with The Center for Sexuality & Health Disparities, University of Michigan School of Public Health, Ann Arbor, Michigan. The UHIP academic-community partnership included representatives from AIDS Partnership Michigan, the HIV/AIDS Resource Center, Detroit Latin@z, Ruth Ellis Center, and the University of Michigan’s Center for Sexuality & Health Disparities. This work was supported by the MAC AIDS Fund (PI: Bauermeister). Dr. Bauermeister was supported by a Career Development Award (K01-MH087242) from the National Institutes of Mental Health. The content is solely the responsibility of the authors and does not represent the official views of the funding agencies. Address correspondence to José A. Bauermeister, M.P.H., PhD, 300 North Ingalls St., 9th Floor, Wing D, Ann Arbor, MI 48109. E-mail: [email protected]
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MEANLEY ET AL.
the greatest burden of infection (U.S. Centers for Disease Control and Prevention, 2014), accounting for 63% and 18% of HIV positive youth aged 13–24 years, respectively. Given that STI infections may increase risks for HIV infection (Fleming & Wasserheit, 1999), there is an urgent need to encourage testing and other preventive measures (e.g., vaccinations) for HIV and STIs concurrently. Testing for HIV and other STIs can be an effective means of both primary and secondary prevention (Dean & Fenton, 2010). Routine STI testing is all the more pressing given the frequently asymptomatic nature of some of the most common STIs, including gonorrhea, syphilis, and chlamydia. Early detection of HIV and STIs through routine testing has proven a successful means of secondary prevention, facilitating better clinical outcomes through earlier entry into care (Ickovics & Meade, 2002). Although HIV testing may be accessible through community-based organizations and/or home kits, STI testing requires access to a medical setting and access to health insurance coverage (unlike HIV tests, STI testing is not free in most venues). These barriers may be particularly salient among the most socially vulnerable, including residentially unstable and homeless YMSM (Corliss, Goodenow, Nichols, & Austin, 2011; Kipke, Weiss, & Wong, 2007; Woods, Samples, Melchiono, & Harris, 2003). Taken together, these findings underscore the importance of examining how structural barriers may hinder YMSM’s ability to seek medical care and access comprehensive testing (e.g., HIV and STI tests) within these settings. Although access to care has been identified as a barrier to prevention services among YMSM (Garofalo, Mustanski, Johnson & Emerson, 2010), the implementation of the Affordable Care Act (ACA) is expected to aid in reducing barriers to comprehensive preventive care, including HIV and STI screening. Medical service providers may promote HIV/STI status awareness among YMSM by encouraging HIV/STI testing during routine medical visits. In order to be effective, however, patient-provider interactions must provide opportunities for patients to feel safe disclosing their sexuality and sexual behaviors. In prior research, patients’ comfort and willingness to disclose their sexual orientation to providers has been associated with health promotive behaviors (Bernstein et al., 2008). For example, patients who report greater comfort in disclosing their sexual orientation and/or behaviors to their physician are more likely to receive testing recommendations during their medical encounter (Wall, Khosropour, & Sullivan, 2010), and are also more likely to test for STIs (Tai et al., 2008). Therefore, creating opportunities for HIV/STI prevention conversations to occur between YMSM and their providers during a medical visit may be vital to promote HIV/STI testing, and to reinforce the importance of status awareness through routine HIV/STI screening. As part of this study, we examined the proportion of YMSM who had reported HIV and STI testing and investigated whether YMSM’s HIV/STI testing behaviors differed between those who had accessed a medical provider in the prior year and those who had not. We then examined whether comprehensive HIV/STI testing and other services were associated with YMSM’s comfort discussing sexual matters with a provider and prior HIV/STI prevention discussions with providers. We hypothesized that YMSM would be more likely to report recent use of HIV and STI testing services if they had seen a medical provider within the prior year, felt more comfortable discussing sexual matters with their providers, and had discussed HIV/STI prevention strategies with their providers.
PROVIDER INTERACTIONS 17
METHODS SAMPLE AND PROCEDURES Data for this article come from a cross-sectional observational study examining YMSM’s structural and psychosocial vulnerabilities to HIV/AIDS in the Detroit metropolitan area. To be eligible for participation, recruits had to be between the ages of 18 and 29; identify as male, transgender male, or transgender female; report currently residing in the Detroit metropolitan area (as verified by zip code and IP address), and report having had sex with men. Details on study procedures have been reported elsewhere (Bauermeister et al., 2014). We developed our web survey using best practices (Couper, 2008), including various iterations of pilot testing prior to data collection. Consented participants then answered a 30–45-minute survey. Participants were compensated with a $30 Visa e-gift card via e-mail upon completion of the questionnaire. We acquired a Certificate of Confidentiality from the U.S. Department of Health and Human Services to protect study data. The University of Michigan Institutional Review Board approved all study procedures. For this article , we have excluded trans-identified participants from our analyses (N = 32). Though testing among trans-identified youth is important to consider, we acknowledge that there may be distinct barriers faced by gender minority youth (e.g., transphobia) that are absent among cisgender-identified youth in accessing medical care and sexual health screenings. Similarly, our analyses excluded HIVpositive participants (N = 41) because given their status, these participants were not asked the items regarding HIV susceptibility.
MEASURES Testing/Service Utilization Categories. Participants were provided with a list of sexual health services and were asked to mark the services they had previously utilized. These services included: HIV testing; STI testing for syphilis, gonorrhea, or chlamydia; anal Pap smear; and vaccination for hepatitis A, hepatitis B, and human papillomavirus (HPV). Due to the low reported frequency of past utilization of some of these sexual health services (see Table 1), participants were collapsed into three categories: Never Testers, which included participants who reported never having tested for HIV or other STIs; HIV Only, which included participants who reported having tested for HIV but never testing for other STIs; and HIV and Other, which included participants who reported having previously tested for HIV as well as at least one other STI. HIV Testing Accessibility. A dichotomous item (0 = No; 1 = Yes) was included in the survey in order to capture whether a participant knew where to receive a confidential HIV test. Healthcare Access. Participants were asked to report the number of times in the past 12 months that they had visited a medical provider for a routine physical or check-up. This item was assessed on a 6-point scale (0, 1, 2, 3, 4, or 5+ times). For analytical purposes, this item was dichotomized into Never and At least one visit. Provider Discussions. Participants were asked whether a doctor had ever talked to them about HIV/STI prevention, a dichotomous item (0 = No; 1 = Yes). Addition-
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MEANLEY ET AL. TABLE 1. Comprehensive Sexual Health Components, N = 304 N (%)
Sexual Health Screening/Vaccine HIV Test
250 (82.2)
STI Test (Syphilis, Chlamydia, and Gonorrhea)
175 (57.6)
Anal Pap Smear
12 (3.9)
Hepatitis A Vaccine
64 (21.1)
Hepatitis B Vaccine
76 (25.0)
HPV Vaccine
16 (5.3)
ally, participants reported the extent to which they felt comfortable discussing their sexual behaviors with a medical provider using a 4-point Likert scale (1 = Strongly Disagree; 4 = Strongly Agree). Perceived HIV Susceptibility. To ascertain participants’ perceived susceptibility to acquiring HIV, participants were asked how likely they thought it was that they would become HIV-positive in the future using a 4-point Likert scale (1 = Very Likely; 4 = Very Unlikely). A second item asked participants to rate their perceived likelihood of acquiring HIV in the next ten years when compared to others of their same gender, age, and sexual orientation (1 = Much More Likely; 4 = Much Less Likely). Both items were combined to create a composite perceived HIV susceptibility score (Cronbach’s α = .70). Demographic Information. Standard measures were utilized to collect demographic information on age, race/ethnicity, level of educational attainment, sexual identity, housing status, and insurance status. Due to the low frequencies of some categories, race/ethnicity and sexual identity were collapsed into four (Black, White, Latino, and Other Race) and three (Gay, Bisexual, and Other Sexual Identity) categories, respectively. Housing status was dichotomized into participants who had versus had not spent one night homeless, transient, or in unstable housing in the prior 30 days. Lastly, insurance status was categorized to compare participants without insurance with those who had some insurance coverage.
DATA ANALYTIC STRATEGY We first conducted c2 and ANOVA tests to examine whether there were any differences in testing categories by demographic and psychosocial variables (see Table 2). We then conducted a logistic regression model to examine what psychosocial predictors were associated with having seen a medical provider for a routine physical or check-up in the prior year. In our analyses, we included sociodemographic variables (e.g., age, race/ethnicity, education, sexual identity), structural variables (e.g., housing instability and insurance coverage), and provider characteristics (e.g., comfort discussing sexual matters with provider, HIV/STI testing provider recommendations). We also adjusted for YMSM’s perceived susceptibility to HIV and knowledge about where to test, as they could confound the observed relationships with HIV/STI testing categories. Finally, among YMSM who reported accessing a medical provider in the prior year, we conducted another logistic regression to examine whether comfort discussing sexual behaviors with a provider and testing groups was associated with provider discussions regarding HIV/STI prevention. We attempted to repeat
PROVIDER INTERACTIONS 19 TABLE 2. Testing Categories by Sociodemographic and Psychosocial Variables, N = 304 Non-Testers
Age, M (SD)
HIV Only
HIV/STI Tester
(N = 54)
(N = 57)
(N = 193)
22.43 (2.88)
23.00 (3.03)
22.96 (2.82)
Race/Ethnicity, N (%) Black/African American
17 (12.1)
30 (21.3)
94 (66.7)
White/Caucasian
21 (23.9)
15 (17.0)
52 (59.1)
13 (27.1)
11 (22.9)
24 (50.0)
Other Race/Ethnicity
3 (11.1)
1 (3.7)
23 (85.2)
Sexual Identity, N (%)
6.65
Gay/Homosexual
50 (19.3)
51 (19.7)
Bisexual
4 (15.4)
3 (11.5)
19 (73.1)
Other Sexual Identity
0 (0.0)
3 (6.3)
29 (84.2)
158 (61.0)
HIV Status, N (%)
207.13***
Negative
15 (5.7)
57 (21.5)
Unknown
39 (100.0)
0 (0.0)
0 (0.0)
3.19 (1.36)
3.21 (1.35)
3.59 (1.28)
193 (72.8)
Housing Instability, N (%) No Nights Homeless/Transient
46 (17.7)
51 (19.6)
163 (62.7)
8 (18.2)
6 (13.6)
30 (68.2)
23 (19.5)
26 (22.0)
69 (61.2)
Insurance Coverage, N (%)
Some Coverage Perceived HIV Susceptibility, M (SD)
2.20
31 (16.7)
31 (16.7)
124 (66.7)
6.67 (1.47)
6.40 (1.66)
6.89 (1.26)
Testing Location Knowledge, N (%)
11.04 50.18***
No
22 (59.5)
3 (8.1)
12 (32.4)
Yes
32 (12.0)
54 (20.2)
181 (67.8)
Not in Prior Year
38 (26.2)
35 (24.1)
72 (49.7)
In Prior Year
16 (10.1)
22 (13.8)
121 (52.3)
2.72 (1.00)
2.96 (.89)
3.03 (.83)
Routine Medical Visit, N (%)
Provider Comfort, M (SD)
3.10* .90
1+Nights Homeless/Transient
No Coverage
.80 15.64*
Latino
Education Level, M (SD)
F/X2 Test Statistic
23.77***
Provider Prevention Discussions, N (%)
2.65 63.97***
No
44 (38.6)
26 (22.8)
44 (38.6)
Yes
10 (5.3)
31 (16.3)
1149 (78.4)
*p < .05. **p < .01. ***p < .001.
these analytic procedures using Hepatitis and HPV vaccines as outcomes, yet the limited number of cases for each vaccine in our sample made it impossible to test. For brevity, only statistically significant findings (p ≤ .05) are discussed.
RESULTS Our sample (N = 304) had a mean age of 22.9 (SD = 2.87). The racial/ethnic distribution of our sample was predominantly Black/African American (N = 190; 51.2%), followed by non-Latino/Hispanic White/Caucasian (N = 92; 24.8%), Latino (N = 55; 14.8%), and Other Race (N = 34; 9.2%). The vast majority of participants self-
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MEANLEY ET AL.
identified as gay or homosexual (N = 259; 85.2%). Bisexual participants made up 8.6% of our sample (N = 26) and all others were grouped into a single Other Sexual Identity category (e.g., participants wrote-in identities such as same gender loving, queer; N = 19; 6.3%). Nearly two thirds of our sample (N = 193; 63.5%) reported having tested for HIV and at least one other STI (categorized into the HIV and STI Testing group), with smaller minorities who had never tested for HIV or other STIs (the Never Testers category; N = 62; 16.7%) and who had tested for HIV, but not tested for or been vaccinated against any other STIs (the HIV Only category; N = 66; 17.8%). We found that a lower percentage (18.5%) of those in the Never Testers category reported having had HIV/STI prevention discussions with a medical provider, and that participants in the HIV and STI Testing category reported a higher percentage of discussions with providers (77.2%; c2(2) = 89.75; p < .001). No significant differences between testing categories were observed by age, race/ethnicity, sexual orientation identity, education, insurance status, housing status, perceptions of HIV susceptibility, or comfort discussing sexual behaviors with a medical provider. Over half of our sample (N = 159; 52.3%) had accessed a medical provider in the prior year for a routine physical or check-up. Participants who had accessed a medical provider exhibited an average lower age (M = 22.38, SD = 2.74) compared to those who had not seen a medical provider (M = 23.41, SD = 2.92) for a routine check-up in the prior year (t(302) = 3.15; p < .01). Latino participants reported a significantly lower percentage (33.3%) of medical care access whereas participants in the Other Race/Ethnicity category reported a higher percentage (66.7%); c2(3) =10.29; p < .05. Those who had accessed care reported a higher percentage of insurance coverage (N = 121; 76.1%) than participants who reported not having seen a medical provider in the past year (N = 65; 34.9%); c2(1) = 31.23; p < .001. Lastly, we observed that visits with a medical provider in the previous year were associated with having HIV/STI prevention discussions with a doctor (c2(1) = 12.03; p = .001). No differences in medical provider access were observed by sexual identity, education, housing status, or perceived susceptibility to HIV.
MULTIVARIATE MODELS Access to a Medical Provider. Using a multiple logistic regression (see Table 3), we first conducted an exploratory analysis to determine the demographic and psychosocial characteristics associated with accessing a medical provider in the past year. Visiting a medical provider in the previous 12 months was associated with greater comfort discussing sexual behaviors with a provider (OR = 1.56; 95% CI [1.14, 2.13], p < .01). Participants in the HIV and STI Testing category were more likely to have seen a medical provider in the past 12 months compared to participants in the Never Testers category (OR = 3.99; 95% CI [1.68, 9.49], p < .01). We found no association with provider visits in the HIV Only category. Insurance coverage was associated with greater likelihood of accessing a medical provider in the prior 12 months (OR = 4.44; 95% CI [2.43, 8.12], p < .001). Age was negatively associated with the odds of having seen a provider (OR = .84; 95% CI [.76, .94], p < .01). We observed no relationship between medical access and perceived susceptibility, HIV testing location knowledge, and prior prevention discussions with providers (see Table 3).
PROVIDER INTERACTIONS 21 TABLE 3. Logistic Regression—Medical Provider Visit/Routine Check-Up Prior Year, N = 304 AOR Constant
95% CI
.91
Age
.84**
.76, .94
Race/Ethnicitya
1.43
.76, 2.67
Education Level
.95
.74, 1.22
Housing Instability
1.04
.48, 2.27
Insurance Coverage
4.44***
2.43, 8.12
Perceived HIV Susceptibility
1.05
.87, 1.28
HIV Testing Location Knowledge
1.06
.42, 2.68
1.56**
1.14, 2.13
Provider Comfort Discussing Sexual Behaviors Test Categoryb HIV Test Only HIV & STI Testing Prior Provider Prevention Discussions
1.60
.62, 4.18
3.99**
1.68, 9.49
1.50
.82, 2.74
Notes. aAdjusted Odds Ratio (AOR) compares non-Hispanic Whites to non-Hispanic White counterparts. bNonTesters serve as referent category. **p < .01. ***p < .001 .
Testing Categories. Among participants who had accessed a medical provider for a check-up or routine care, those in the HIV and STI Testing group were more likely than Never Testers to have had discussions with a provider regarding HIV/STI prevention (OR = 9.78, 95% CI [2.67, 35.85], p < .01). We found no difference on patient discussions between Never Testers and those in the HIV Only testing category. No differences in demographic and psychosocial variables of interest were observed.
DISCUSSION Comprehensive sexual health screening and care services are necessary to reduce the HIV/STI disparities faced by YMSM. Although HIV testing was relatively high in our sample (82%), a smaller proportion of YMSM reported having one or more STI tests (58%) or being vaccinated against Hepatitis A (21%) or B (25%) or HPV (5%). Our study elucidates the urgency of improving access to and awareness of preventive vaccinations within the contexts of comprehensive sexual health service provision. Compared to heterosexual counterparts, MSM are at increased risk for Hepatitis A and Hepatitis B, with estimated new cases around 10 and 20 percent, respectively, among adults (U.S. Centers for Disease Control and Prevention, 2010). With the same referent group, MSM are at increased risk for HPV-related conditions such as anal cancer (Gilbert, Brewer, Reiter, Ng, & Smith, 2011). Gilbert et al. (2011) showed that compared to heterosexual men, gay and bisexual men have higher acceptability to HPV vaccination as well as higher anticipated regret when considering how it would feel to decline vaccination and subsequently be diagnosed with a HPV-related condition. Because our results revealed that prevention discussions with a medical provider are an associated marker of comprehensive sexual health access, we suggest that medical providers are an integral part of discussing the importance of sexual health care (e.g., screenings and vaccinations) among YMSM.
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MEANLEY ET AL. Table 4. Logistic Regression—Prior Provider Prevention Discussions, N = 304 AOR
Constant
95% CI
3.79
Age
.91
.78, 1.08
Race/Ethnicitya
.98
.40, 2.39
Education Level
1.07
.72, 1.58
Housing Instability
2.18
.55, 8.72
Insurance Coverage
.89
.32, 2.49
Perceived HIV Susceptibility
.94
.71, 1.24
HIV Testing Location Knowledge
1.00
.24, 4.16
Provider Comfort Discussing Sexual Behaviors
1.03
.66, 1.61
Test Categoryb HIV Test Only HIV & STI Testing
2.17
.50, 9.38
9.78**
2.67, 35.85
Notes. aAdjusted Odds Ratio (AOR) compares non-Hispanic Whites to non-Hispanic White counterparts. bNonTesters serve as referent category. **p < .01.
Participants in the HIV and STI Testing category reported a higher percentage of accessing routine medical care in the prior year, supporting the notion that primary care provides an effective platform for comprehensive sexual health care. Interestingly, there was a small but noteworthy proportion of our sample reporting an HIV-negative status even though they were represented in the Never Tester group. In the context of primary care, medical providers may be an effective route for discussing the importance of testing as a means of ensuring knowledge of one’s HIV status and decreasing the rates of those with unknown status. Participants who reported at least some health insurance coverage also reported higher odds of accessing a medical provider for a routine check-up in the prior year. This relationship speaks to the logical need to remove financial barriers to accessing care. The implementation of the Patient Protection and Affordable Care Act (ACA) will likely increase health insurance access for YMSM, as Medicaid eligibility for childless adults has broadened and youth may remain on parental insurance plans until the age of 26 years. Efforts should be made to increase awareness among uninsured YMSM of their health insurance options as well as the sexual health services covered by these plans. For those who remain uninsured, it would be important to increase community awareness of free and reduced cost clinics (e.g., clinics with sliding fees) that accept patients without health insurance.
COMPREHENSIVE SEXUAL HEALTH CARE An overwhelming majority of our population had tested for HIV because of ubiquitous messaging around HIV (risk and testing) targeting men who have sex with men as well as increased public health efforts to prioritize accessibility of free, rapid testing. Conversely, STI testing remains costly, necessitates a longer waiting period for results, and may have less visibility in public health campaigns. In fact, Mimiaga, Goldhammer, Belanoff, Tetu, and Mayer (2007) found that MSM were more likely to have been part of prevention strategies targeted toward HIV testing rather than STI testing. Thus, though HIV testing has been at the forefront of sexual health promotion, STI prevention strategies demand further attention, particularly with
PROVIDER INTERACTIONS 23
rising rates of syphilis, chlamydia, gonorrhea, and HIV co-infection in the MSM community (Purcell et al., 2012). Many YMSM’s lack of engagement with comprehensive sexual health care may be attributable to several key issues. As reflected by our results, having access to a medical provider who can help address sexual health needs speaks to the importance of routine medical care access. Secondly, our results elucidate the unique space in which providers can offer HIV and STI testing recommendations based on an individual’s specific needs. Because of the burden of STI infection among young people and the fact that STI infection greatly increases one’s risk of HIV infection (Fleming & Wasserheit, 1999), a push toward comprehensive sexual health screening for YMSM is an important aspect of controlling the HIV epidemic in this population. One important finding is that younger participants were more likely to have seen a medical provider compared to their older counterparts. One interpretation of this finding is that younger participants may be more likely to be subsumed under their parents’ current health insurance coverage or have access to clinics offering free or reduced costs to individuals under a specified age (e.g., under 21 years of age). With the implementation of the ACA, we expect this age difference to dissipate once older YMSM begin to use their ACA insurance to access routine medical care access. While the primary care clinic is a strategic setting in which to implement sexual health promotion initiatives for YMSM, we found that YMSM were most likely to report having tested for HIV and STIs if they had visited a medical provider visit in the prior year and felt comfortable discussing sexual behaviors with their providers. These findings are consistent with prior studies documenting how fear of judgment, condescension, and other expressions of condemnation may deter YMSM from accessing care (Rounds, McGrath, & Walsh, 2013). Further, YMSM who do not feel comfortable disclosing their sexual practices to a medical provider may feel less motivated to seek medical care if they feel that they must hide or otherwise disguise some part of their identity (Wall et al., 2010). Therefore, it is vital that primary care services include welcoming and culturally competent services for YMSM as they may signal a safe zone for YMSM to discuss sexuality-related topics. Interventions and structural initiatives that promote affirming environments may foster increased willingness to seek HIV/STI testing services and discuss sexuality-related health matters in primary care settings. Prevention discussions were reported by a higher percentage of YMSM in the HIV and STI Testers category, as compared to YMSM in the HIV Only and Never Testers categories. Trainings for providers that increase understanding of and sensitivity to issues surrounding sexuality and sexual behaviors, as well as give providers an opportunity to practice conversations about sexuality, sexual behaviors, and sexual health care may be key to improving patient-provider interactions. Furthermore, despite YMSM being labeled as a high-risk group for HIV, STIs, and HIV co-infection, we recommend medical providers be vigilant about framing risk and recommendations based on identity. Though understanding youths’ identities (e.g., gay, bisexual, straight, other) may assist in having effective conversations about sexual health, medical providers should focus on participants’ behaviors (e.g., use of condoms or PrEP, oral versus anal sex) when discussing comprehensive sexual health rather than attributing risk to sexual identity. The cultivation of an affirming environment in which YMSM can discuss their sexuality with their medical providers may yield useful insight in revealing additional salient factors that motivate or discourage access to comprehensive sexual health care. For example, a study conducted by Huebner, Davis, Nemeroff, and
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Aiken (2002) found a negative relationship between internalized homophobia and comprehensive sexual health care access. Specifically, individuals who scored higher in internalized homophobia were less likely to be aware of accessible preventive services and less likely to utilize services when aware; therefore, we suggest acquiring a comprehensive account of psychosocial barriers on motivations to get tested and working through these issues with patients in an effort to promote routine testing behaviors. Future research in this area is warranted in order to inform culturallysensitive programming for YMSM.
LIMITATIONS We acknowledge that our study has several limitations. Our study explored the association of having discussed HIV and STI prevention and HIV/STI testing; therefore, we are unable to make causal assertions due to the cross-sectional nature of our study. Furthermore, participants in our study were not asked time-specific items regarding provider discussions or testing behaviors. Despite some having been to a provider in the prior year for a routine check-up or health screening, we are unaware if participants had these discussions within the context of a primary care provider and/or before their self-reported check-up. Specifically, some participants may have tested more than a year ago, yet discussed HIV/STI prevention within a routine check-up in the past year. Longitudinal studies examining the timing between provider discussions and HIV/STI behaviors are therefore warranted. Furthermore, our study did not include a large enough proportion of trans-identified individuals to be adequately represented in our statistical analyses. Nevertheless, we acknowledge that this population merits increased attention given the barriers that trans-identified individuals may face in addressing their sexual health needs. We also recommend further investigation into the multiple psychosocial factors associated with accessing medical care and testing behaviors among YMSM. At present, we do not know whether our finding that younger participants were more likely to see a medical provider is indicative of a generational effect or is simply consistent with our earlier speculation that YMSM’s access to medical care decreases with age. Future research examining changes in YMSM’s use of medical care and testing behaviors over time may clarify this relationship and shape future interventions designed to retain YMSM in care as they transition into adulthood. Lastly, generalizability may be compromised as our sample focused on YMSM living in the Detroit metropolitan area prior to the implementation of the ACA. Because Michigan has adopted Medicaid expansion through the Affordable Care Act, a reduction in financial barriers for YMSM or youth in general may alter the structural barriers hindering YMSM’s access to providers. As the ACA is implemented, more youth are expected to gain access to health insurance covering preventive sexual health services such as HIV screening, syphilis screening, and STI prevention counseling at free or reduced costs. Therefore, as these changes occur, the relationship between health insurance status and testing behaviors may warrant further observation.
CONCLUSION Through this study, we collected important data regarding access to comprehensive sexual health care among YMSM. Specifically, medical providers have the potential to play an important role in HIV and STI testing behaviors, particularly within
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primary care contexts. Receiving comprehensive sexual health care services is associated not only with accessing routine medical care, but also with some of the interpersonal aspects of the medical encounter, such as comfort discussing sexual behaviors and having discussions related to HIV and STI prevention. Trainings for medical providers that emphasize cultural competency, increase sensitivity around issues of sexuality and sexual practices, and increase knowledge of YMSM-specific health concerns may help allay any discomfort of discussing issues pertinent to receiving comprehensive sexual healthcare. Continued HIV and STI testing outreach for YMSM in the healthcare system, combined with efforts to increase insurance enrollment and ensure providers’ LGBT cultural competency, will ultimately ensure that YMSM can safely test, be linked to treatment as necessary, and maintain their right to enjoy sexual health and well-being.
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