Characteristics Associated with Trust in and Disclosure of Sexual Behavior to Primary Care Providers Among Gay,Bisexual,and Other Men Who Have Sex with Men in the United States

Abstract

Purpose:

Characteristics associated with having a primary care provider (PCP), patient–provider trust, and sexual behavior disclosure were examined among men who have sex with men (MSM).

Methods:

MSM (N = 4239) were surveyed regarding demographic, behavioral, and medical characteristics. Multivariable logistic regression analyses were used.

Results:

Among 86.3% of MSM with a PCP, characteristics associated with lower patient–provider trust included younger age, Asian, bisexual, HIV-negative-not-on-pre-exposure prophylaxis, HIV-unknown, and lower medical literacy; with nondisclosure: Asian, bisexual, straight, HIV-negative, HIV-unknown, fewer partners, recruitment source, lower medical literacy, and lower patient–provider trust.

Conclusion:

Medical literacy and patient–provider trust are promising points of intervention to improve health outcomes among MSM.

Introduction

Gay, bisexual, and other men who have sex with men (MSM) in the United States are disproportionately affected by health problems, including HIV and other sexually transmitted infections (STIs).^1–3 Regular engagement with primary care services may help to reduce these health disparities among MSM.⁴ However, less is known about the factors associated with primary care engagement among MSM. Certain factors identified in studies of other populations may be related to engagement in primary care among MSM. For example, studies have found that lower medical literacy is related to lower utilization of primary care services and poor health outcomes, and that higher trust in primary care providers (PCPs) is associated with increased engagement in primary care services and improved outcomes in non-MSM samples.^5–10

Providers' knowledge of their MSM patients' sexual identities^11,12 and behavior^13–15 is critical to informing appropriate care provision and counseling. Among MSM with a PCP, there is a limited but growing literature regarding the disclosure of sexual behavior to providers—a process critical to optimizing primary care engagement and, in turn, improving health outcomes among MSM.^13–15 Although some studies have examined sociodemographic characteristics in relation to disclosure of same-sex sexual behavior to PCPs among MSM,^12,15 few studies have examined the role of patient–provider trust, indicating a key gap in the extant literature. Indeed, a recent systematic review also found that most previous studies have been qualitative in nature and have used samples comprised of mostly White, well-educated, and middle-aged people.¹¹ One relevant study found that lack of disclosure was associated with mistrust in providers among younger African American MSM.¹⁶ However, additional research is needed among larger and more diverse groups of MSM to better elucidate the relationship between patient–provider trust and disclosure of sexual behavior to PCPs. We, therefore, sought to examine characteristics associated with having a PCP and with trust in and disclosure of same-sex sexual behavior to PCPs in a diverse national sample of gay, bisexual, and other MSM, hereafter collectively referred to as MSM, in the United States.

Methods

Participants and data collection

A full description of this study's methods has been published previously.¹⁷ In brief, between May 2016 and March 2017, participants from across the United States were recruited online using advertisements on sexual networking (i.e., hookup) and pornographic websites, a geo-social hookup app, and Facebook, and in-person in gay neighborhood settings or in HIV/STI clinics in New York City (NYC). Eligibility criteria included being age ≥18 years, cisgender male, and reporting same-sex sexual behavior in the past 5 years. All participants completed the survey using an anonymous self-administered online survey platform (Qualtrics, Provo, UT). Electronic informed consent was obtained through Qualtrics. Participants recruited online were entered into a drawing to win one of fifty $20 gift cards and participants recruited in-person were given a movie theater gift card. This study was approved by the institutional review boards of the City University of New York and the Albert Einstein College of Medicine.

Measures

We assessed three outcomes: (1) whether participants currently had a PCP, and among those with a PCP, (2) trust in their PCP, and (3) disclosure of same-sex sexual behavior to their PCP. Patient–provider trust was measured using the Wake Forest Physician Trust scale, which contains five Likert-type items that assess how strongly participants agree with statements about their physician (e.g., “My doctor is extremely thorough and careful.”).¹⁸ The items were summed and then dichotomized at the mean. Disclosure of same-sex sexual behavior was assessed using a single dichotomous item (“Does your primary care doctor know that you have sex with men?”).¹⁵

Medical literacy was assessed using a single Likert-type item (“How confident are you in filling out medical forms by yourself?”), which was dichotomized into low (“not at all” through “somewhat”) and high (“quite a bit” and “extremely”) medical literacy.¹⁹ The survey also collected self-reported information on sociodemographic characteristics (age, race/ethnicity, zip code, sexual identity, and education), HIV status (HIV+, HIV− and on pre-exposure prophylaxis [PrEP], HIV− and not on PrEP, and unknown HIV status), the number of sex partners in the past 3 months, recruitment source, and current relationship status.

Analysis

We used descriptive statistics to characterize the overall sample. We then used logistic regression to identify factors independently associated with each of the three outcomes: having a PCP, trust in PCP, and disclosure of same-sex sexual behavior to PCP. We included all significant variables (p < 0.05) from the bivariable analyses in the multivariable logistic regression models. We also report the unadjusted and adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for each outcome in Table 1. SPSS Version 25 (IBM Corp., Armonk, NY) was used for all analyses.

Table 1.

Characteristics Associated with Having a Primary Care Provider (Model 1), and Trust in (Model 2) and Disclosure of Same-Sex Sexual Behavior (Model 3) to Primary Care Providers Among a National Sample of Gay, Bisexual, and Other Men Who Have Sex with Men in the United States

	Total (N = 4239), n (%)	Model 1: has PCP (N = 4239)		Model 2: trust in PCP (n = 3658)		Model 3: disclosure (n = 3658)
	Total (N = 4239), n (%)	UOR (95% CI)	AOR (95% CI)	UOR (95% CI)	AOR (95% CI)	UOR (95% CI)	AOR (95% CI)
Age, years
18–26	1034 (24.4)	0.08^** (0.03–0.25)	0.09^** (0.03–0.29)	0.53^** (0.36–0.78)	0.61^** (0.40–0.93)	1.11 (0.75–1.65)	0.94 (0.56–1.59)
27–34	957 (22.6)	0.11^** (0.04–0.35)	0.09^** (0.03–0.30)	0.67^* (045–0.99)	0.61^** (0.40–0.93)	1.85^** (1.24–2.78)	1.19 (0.70–2.00)
35–44	796 (18.8)	0.20^** (0.06–0.65)	0.18^** (0.06–0.60)	0.75 (0.51–1.12)	0.67 (0.44–1.01)	1.94^** (1.28–2.92)	1.35 (0.81–2.27)
45–64	1325 (31.3)	0.37 (0.11–1.18)	0.34 (0.10–1.09)	0.82 (0.56–1.20)	0.72 (0.48–1.07)	1.58^** (1.07–2.34)	1.21 (0.74–1.97)
65+	127 (3.0)	1.00	1.00	1.00	1.00	1.00	1.00
Race/ethnicity^a
Black	454 (10.7)	0.93 (0.70–1.25)	0.81 (0.58–1.13)	1.31^* (1.05–1.64)	1.13 (0.88–1.45)	1.34 (1.03–1.73)	0.82 (0.58–1.17)
Latino	790 (18.6)	0.86 (0.68–1.08)	1.06 (0.82–1.39)	0.93 (0.78–1.11)	1.00 (0.82–1.23)	1.20 (0.98–1.47)	1.18 (0.90–1.55)
White	2527 (59.6)	1.00	1.00	1.00	1.00	1.00	1.00
Native American, Alaskan, Hawaiian, Pacific Islander	54 (1.3)	0.97 (0.44–2.17)	1.36 (0.50–3.67)	1.92^* (1.02–3.60)	1.92 (0.99–3.75)	1.21 (0.61–2.39)	1.27 (0.52–3.07)
Asian	148 (3.5)	0.68 (0.44–1.06)	1.06 (0.65–1.72)	0.55^** (0.38–0.79)	0.67^* (0.45–1.00)	0.73 (0.50–1.07)	0.53^** (0.33–0.85)
Multiracial	260 (6.1)	0.58^** (0.42–0.80)	0.70 (0.49–1.01)	1.04 (0.78–1.38)	1.01 (0.74–1.39)	1.23 (0.88–1.72)	1.07 (0.70–1.63)
Region^a
New England	175 (4.1)	0.96 (0.59–1.56)	1.17 (0.69–2.00)	0.93 (0.66–1.31)	1.09 (0.74–1.61)	0.81 (0.53–1.23)	1.39 (0.83–2.34)
Middle Atlantic	996 (23.5)	1.00	1.00	1.00	1.00	1.00	1.00
East North Central	564 (13.3)	0.77 (0.57–1.04)	0.99 (0.70–1.41)	0.85 (0.68–1.07)	0.95 (0.73–1.25)	0.55^** (0.42–0.71)	0.93 (0.66–1.31)
West North Central	238 (5.6)	0.73 (0.49–1.08)	0.94 (0.60–1.47)	1.05 (0.77–1.44)	1.18 (0.83–1.68)	0.42^** (0.30–0.59)	0.69 (0.44–1.07)
South Atlantic	726 (17.1)	0.89 (0.67–1.18)	1.07 (0.77–1.49)	0.88 (0.71–1.08)	0.95 (0.74–1.22)	0.60^** (0.47–0.77)	0.92 (0.66–1.28)
East South Central	173 (4.1)	0.75 (0.48–1.18)	0.93 (0.56–1.56)	0.84 (0.59–1.19)	0.88 (0.60–1.30)	0.52^** (0.35–0.77)	0.77 (0.47–1.25)
West South Central	429 (10.1)	0.72^* (0.52–0.99)	0.91 (0.63–1.33)	1.01 (0.79–1.29)	1.13 (0.84–1.51)	0.50^** (0.38–0.66)	0.71 (0.49–1.02)
Mountain	277 (6.5)	0.75 (0.52–1.10)	0.97 (0.63–1.50)	0.73^* (0.54–0.97)	0.78 (0.56–1.08)	0.49^** (0.35–0.68)	0.78 (0.51–1.19)
Pacific	645 (15.2)	1.05 (0.77–1.43)	1.31 (0.91–1.87)	0.83 (0.67–1.03)	0.89 (0.69–1.15)	0.91 (0.70–1.19)	1.25 (0.88–1.78)
Urbanicity^a
Large city	3724 (87.9)	1.00	1.00	1.00	—	1.00	1.00
Small city	244 (5.8)	1.02 (0.70–1.48)	—-	0.89 (0.67–1.18)	—	0.49^** (0.37–0.66)	0.70 (0.49–1.01)
Small town	78 (1.8)	0.97 (0.51–1.84)	—	1.02 (0.63–1.67)	—	0.45^** (0.27–0.73)	0.79 (0.43–1.46)
Rural	63 (1.5)	0.95 (0.47–1.94)	—	1.08 (0.63–1.86)	—	0.59 (0.34–1.04)	0.79 (0.41–1.52)
Sexual identity
Gay	3294 (77.7)	1.00	1.00	1.00	1.00	1.00	1.00
Bisexual	688 (16.2)	0.83 (0.66–1.04)	1.03 (0.80–1.32)	0.64^** (0.53–0.76)	0.69^** (0.57–0.84)	0.16^** (0.13–0.19)	0.20^** (0.16–0.25)
Straight	45 (1.1)	1.25 (0.49–3.18)	1.12 (0.42–2.99)	0.52 (0.27–1.01)	0.58 (0.29–1.17)	0.03^** (0.01–0.09)	0.05^** (0.02–0.14)
Other	212 (5.0)	0.42^** (0.23–0.75)	0.53 (0.27–1.03)	0.60 (0.33–1.11)	0.64 (0.34–1.21)	1.02 (0.47–2.21)	0.92 (0.37–2.26)
Education
High school	670 (15.8)	0.80 (0.59–1.09)	1.07 (0.75–1.52)	0.85 (0.68–1.06)	0.87 (0.67–1.11)	0.85 (0.67–1.09)	1.08 (0.77–1.51)
Some college	1590 (37.5)	0.74^* (0.57–0.96)	0.98 (0.73–1.31)	1.05 (0.88–1.27)	1.06 (0.87–1.30)	0.89 (0.72–1.10)	0.87 (0.67–1.14)
College	1180 (27.8)	0.81 (0.61–1.06)	0.91 (0.68–1.23)	1.01 (0.83–1.22)	1.01 (0.82–1.24)	1.16 (0.93–1.46)	1.07 (0.81–1.25)
Graduate school	799 (18.8)	1.00	1.00	1.00	1.00	1.00	1.00
HIV status
HIV+	767 (18.1)	1.00	1.00	1.00	1.00	1.00	1.00
HIV− and on PrEP	502 (11.8)	0.28^** (0.14–0.57)	0.37^* (0.17–0.80)	0.69^** (0.54–0.88)	0.84 (0.64–1.10)	0.56^** (0.33–0.92)	0.54^* (0.30–0.98)
HIV− not on PrEP	2656 (62.7)	0.06^** (0.04–0.13)	0.08^** (0.04–0.15)	0.42^** (0.35–0.51)	0.49^** (0.41–0.60)	0.08^** (0.06–0.12)	0.09^** (0.06–0.14)
Unknown status	314 (7.4)	0.04^** (0.02–0.07)	0.05^** (0.03–0.10)	0.21^** (0.16–0.30)	0.29^** (0.21–0.41)	0.02^** (0.01–0.04)	0.02^** (0.01–0.04)
Number of sex partners in the past 3 months
>1 partner	2851 (67.3)	1.00	1.00	1.00	1.00	1.00	1.00
1 partner	850 (20.1)	1.01 (0.80–1.26)	0.91 (0.70–1.17)	1.11 (0.94–1.31)	1.07 (0.89–1.28)	1.28 (1.05–1.57)	1.11 (0.87–1.42)
0 partners	538 (12.7)	0.80 (0.62–1.03)	1.02 (0.76–1.35)	0.78^** (0.64–0.96)	0.83 (0.66–1.03)	0.61 (0.49–0.76)	0.61^** (0.47–0.80)
Recruitment source
Hookup site	938 (22.1)	0.38^** (0.19–0.76)	0.70 (0.14–3.44)	0.59^** (0.41–0.84)	1.22 (0.47–3.13)	0.17 (0.10–0.30)	0.13^* (0.02–0.78)
Facebook	462 (10.9)	1.00	1.00	0.55^** (0.37–0.81)	1.15 (0.45–3.00)	0.41 (0.23–0.74)	0.29 (0.05–1.74)
NYC gay neighborhood setting	305 (7.2)	0.45^* (0.22–0.95)	1.33 (0.26–6.70)	0.50^** (0.33–0.74)	1.03 (0.40–2.65)	0.68 (0.36–1.29)	0.46 (0.08–2.77)
Geo-social app	1903 (44.9)	0.53 (0.25–1.16)	1.91 (0.38–9.65)	0.44^** (0.31–0.62)	0.95 (0.37–2.43)	0.28 (0.16–0.48)	0.22 (0.04–1.27)
Adult websites	455 (10.7)	0.26^** (0.13–0.51)	0.84 (0.17–4.14)	0.57^** (0.39–0.84)	1.26 (0.48–3.26)	0.30 (0.17–0.53)	0.25 (0.04–1.51)
Clinic	176 (4.2)	0.43^* (0.21–0.89)	1.02 (0.20–5.13)	1.00	1.00	1.00	1.00
Relationship status
No	2635 (62.2)	1.00	1.00	1.00	—	1.00	—
Yes	1604 (37.8)	1.70^** (1.40–2.06)	1.47^** (1.17–1.85)	1.05 (0.92–1.20)	—	1.08 (0.93–1.26)	—
Medical literacy
Low	415 (9.8)	1.00	1.00	1.00	1.00	1.00	1.00
High	3794 (89.5)	2.06^** (1.61–2.65)	1.44^** (1.09–1.90)	2.55^** (2.00–3.25)	2.28^** (1.75–2.97)	2.14^** (1.69–2.71)	1.51^** (1.11–2.06)
Missing	30 (0.7)
Trust in PCP
Low	—	—	—	—	—	1.00	1.00
High	—	—	—	—	—	2.29^** (1.96–2.66)	1.71^** (1.42–2.07)

Responses missing due to nonresponse or refusal.

p < 0.05; ^**p < 0.01.

—, not included in model; AOR, adjusted odds ratio; CI, confidence interval; HIV, human immunodeficiency virus; NYC, New York City; PCP, primary care provider; PrEP, pre-exposure prophylaxis; UOR, unadjusted odds ratio.

Results

Participant characteristics and having a PCP

A total of N = 4239 participants completed the survey and were included in these analyses. Participants were from all 50 states, Puerto Rico, and the District of Columbia. See Table 1 for additional details about the composition of the sample. The majority of participants (n = 3658; 86.3%) reported having a PCP. In the multivariable model (Table 1), younger men were less likely to have a PCP than men ≥65 years (age 18–26, AOR = 0.09, 95% CI = 0.03–0.29; age 27–34, AOR = 0.09, 95% CI = 0.03–0.30; age 35–44, AOR = 0.18, 95% CI = 0.06–0.60). Men with HIV-negative and unknown serostatus were less likely to have a PCP than men living with HIV (AOR = 0.37, 95% CI = 0.17–0.80; AOR = 0.08, 95% CI = 0.04–0.15; AOR = 0.05, 95% CI = 0.03–0.10, respectively). Men in a current relationship were more likely to have a PCP than single men (AOR = 1.47, 95% CI = 1.17–1.85), and men with higher medical literacy were more likely to have a PCP than those with lower medical literacy (AOR = 1.44, 95% CI = 1.09–1.90).

Trust in PCP

Among respondents with a PCP, 54.7% (n = 2002) reported higher trust in their PCP. In the multivariable model (Table 1), younger men reported lower trust in their PCP than did men ≥65 years (age 18–26, AOR = 0.61, 95% CI = 0.40–0.93; age 27–34, AOR = 0.61, 95% CI = 0.40–0.93). Asian men reported lower trust than White men (AOR = 0.67, 95% CI = 0.45–1.00) and bisexual men reported lower trust than gay men (AOR = 0.69, 95% CI = 0.57–0.84). Men with HIV-negative serostatus not-taking-PrEP and those with unknown serostatus reported lower trust than men living with HIV (AOR = 0.49, 95% CI = 0.41–0.60; AOR = 0.29, 95% CI = 0.21–0.41), and men with higher medical literacy reported higher trust than men with lower medical literacy (AOR = 2.28, 95% CI = 1.75–2.97).

Disclosure to PCP

Among men with a PCP, 74.3% (n = 2718) reported disclosing same-sex sexual behavior to their provider. In the multivariable model (Table 1), Asian men were less likely to disclose their behavior than White men (AOR = 0.53, 95% CI = 0.33–0.85) and bisexual and straight-identified men were less likely to disclose their behavior than gay men (AOR = 0.20, 95% CI = 0.16–0.25; AOR = 0.05, 95% CI = 0.02–0.14). Men with HIV-negative and those with unknown serostatus were less likely to disclose their behavior than men living with HIV (AOR = 0.54, 95% CI = 0.30–0.98; AOR = 0.09, 95% CI = 0.06–0.14; AOR = 0.02, 95% CI = 0.01–0.04); men with zero recent sexual partners were less likely to disclose their behavior than men with more than one partner (AOR = 0.61, 95% CI = 0.47–0.80); and men who were recruited from hookup websites were less likely to disclose their behavior than men who were recruited from clinics (AOR = 0.13, 95% CI = 0.02–0.78). Men with higher medical literacy were more likely to disclose their behavior than those with lower medical literacy (AOR = 1.51, 95% CI = 1.11–2.06), and men with higher trust in their PCP were more likely to disclose their behavior than those with lower trust (AOR = 1.71, 95% CI = 1.42–2.07).

Discussion

Among the 86.3% of MSM with a PCP, lower patient–provider trust was associated with younger age, Asian race/ethnicity, bisexual identification, HIV-negative-not-on-PrEP and unknown serostatus, and lower medical literacy. Nondisclosure of same-sex sexual behavior was associated with Asian race/ethnicity, bisexual and straight identification, HIV-negative and unknown serostatus, fewer sex partners in the past 3 months, recruitment source, lower medical literacy, and lower patient–provider trust. These findings have several implications for the health of MSM. First, we found that certain subgroups of MSM (e.g., younger, unknown serostatus) were less likely to have a PCP than other men. It is hypothesized that if MSM have a PCP, they will be more likely to receive appropriate medical care, leading to improved health outcomes. Thus, greater outreach efforts should be made to engage MSM in primary care.

In addition to the aforementioned demographic differences, men with lower medical literacy were also less likely to have a PCP. This suggests that MSM may benefit from increased medical literacy and that efforts toward this goal may translate to improvements in health outcomes among this population (e.g., public awareness campaigns about the importance of preventive care and/or the relevance of disclosing sexual behavior to providers). These findings are of particular importance in the context of past research that has documented associations between lower medical literacy and poor health outcomes in non-MSM samples.⁵

Second, these data indicate that, among MSM with a PCP, some subgroups of MSM (e.g., bisexual men) report less trust in their PCPs than other men. This suggests that providers and health systems could do more to create safer environments and to build trust with their MSM patients. Indeed, previous studies have found that environmental and provider-specific factors play an important role in facilitating or impeding the disclosure of sexual minority identities.¹¹ To enhance patient–provider trust, physicians should display comforting and caring behavior, demonstrate competency, encourage and answer patient questions, and explain procedures thoroughly.²⁰ Physicians should also ask their patients about their sexual identity, gender identity, and sexual behavior, as this line of proactive inquiry has been shown to lead to increased trust in providers among MSM.²¹ Furthermore, routine monitoring of patient experiences by health care providers and systems may inform efforts to improve the care of MSM and other historically marginalized patients.²¹

Third, our results show that MSM who were HIV-negative and not on PrEP and those with unknown serostatus were least likely to have disclosed their sexual behavior to their PCP, indicating likely missed opportunities for HIV/STI screening and HIV prevention interventions. Creating an affirming care environment, and asking patients about their sexual behaviors and identities using inclusive and nonjudgmental language, can improve disclosure, leading to optimal care.^11,22,23 Our results also indicate that HIV-negative serostatus MSM who were using PrEP were less likely than men living with HIV to have disclosed their sexual behavior to their PCP, indicating that some MSM are accessing PrEP in other settings. This lack of disclosure among those obtaining a primary HIV-prevention tool suggests additional missed opportunities in primary care settings and possible fragmentation of care, potentially leading to suboptimal care.²²

Finally, although these results reveal a pattern of demographic differences among MSM with respect to PCP-related outcomes, they extend the existing literature by revealing the strong associations between medical literacy and patient–provider trust and disclosure of same-sex sexual behavior to PCPs.^11–15 Interventions to help improve patient–provider trust, particularly among MSM, may help to improve the disclosure of sexual behavior and ensure the provision of appropriate clinical care.^7,8,14 Furthermore, public health programs and educational systems need to continue interventions designed to increase patients' medical literacy, as this may contribute to improved health outcomes overall.⁵

Limitations

This study's findings should be considered in light of its limitations. First, given the cross-sectional nature of this study, temporality cannot be inferred between outcomes and independent variables. Second, although participants in our sample were demographically and geographically diverse, the majority of participants were recruited through websites and mobile apps, and thus these findings may not generalize to all MSM in the United States. Third, our single-item measure of medical literacy may not fully capture all aspects of health literacy. However, this item has been widely used in other studies across diverse populations in the United States.¹⁹ Fourth, given the need for brevity in cross-sectional surveys, we did not assess trust in prior providers among those without a current PCP, nor did we assess lifetime or current medical insurance status. Fifth, due to limited resources, we were only able to conduct in-person recruitment in NYC. Sixth, the different participant incentives used in online versus in-person settings could have impacted response rates. Finally, these data were collected using a self-administered survey method. As such, there may be some error in the data due to participants' misunderstanding of questions or resulting from difficulties in using online or mobile platforms.

Conclusions

PCPs need to know about their patients' sexual behavior to optimize care. Given that trust in one's PCP is an important factor in the disclosure of sexual behavior to PCPs among MSM, further research is needed to inform and evaluate interventions designed to improve patient–provider trust. Furthermore, medical providers and systems need to create environments that encourage the disclosure of sexual behavior among MSM, thus leading to improved primary care engagement and health outcomes.

Footnotes

Disclaimer

Preliminary results from the project leading to this article were presented at the International Convention of Psychological Science in Paris, France, on March 9, 2019, by Christopher Stults. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

Support for this article was provided by the Centers for Disease Control and Prevention-funded New York University–City University of New York (CUNY) Prevention Research Center (U48DP005008) Special Interest Project (SIP 15-009: Christian Grov/Simona Kwon—multiple principal investigators). Drs. Kelvin, Anastos, and Patel were supported by the Einstein-Rockefeller-CUNY Center for AIDS Research (P30-AI-124414), which is supported by the following National Institutes of Health co-funding and participating institutes and centers: National Institute of Allergy and Infectious Diseases, National Cancer Institute, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Heart, Lung, and Blood Institute, National Institute on Drug Abuse, National Institute of Mental Health (NIMH), National Institute on Aging, Fogarty International Center, and Office of AIDS Research. Dr. Patel was also supported by a Career Development Award from the NIMH (K23-MH102118; Viraj V. Patel, principal investigator).

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