Recruitment approaches to identifying newly diagnosed HIV infection among African American men who have sex with men

Abstract

Summary

To determine effectiveness of alternate venue testing (AVT), social network strategy (SNS) and provider referral (PR) for identifying previously undiagnosed HIV-infected 18–64-year-old African American men who have sex with men (AA MSM) by a health department. For AVT, staff used a mobile clinic to conduct HIV testing. For PR, staff solicited contact information from HIV-infected AA MSM, located contacts and offered HIV testing. For SNS, HIV-positive AA MSM recruited network associates for HIV testing. Two hundred and eighteen self-identified AA MSM were tested through AVT (25.2% HIV positivity) of whom 20 were newly identified HIV-positive. Fourteen HIV-positive men participated in SNS; 22 AA MSM contacts were recruited through SNS, eight (36.4%) were HIV positive and none were new positives. Two HIV-infected men participated in the PR strategy, yielding two AA MSM sex partners (one previously positive). The results suggest the need for health departments to consider using several complimentary strategies for identifying previously undiagnosed HIV infections in AA MSM in urban environments such as Baltimore.

Keywords

HIV men who have sex with men MSM African American diagnosis alternate venue testing social network strategy provider referral undiagnosed case finding

INTRODUCTION

The US Centers for Disease Control (CDC) and Prevention estimates that approximately 1.2 million individuals are living with HIV in the United States and about 50,000 new infections occur each year.¹ African Americans (AA) are the most severely impacted by race. An estimated 44% of the 48,100 new infections that occurred in 2009 were among African Americans, who comprise only 14% of the US population. Within this subpopulation, gay, bisexual and other men who have sex with men (MSM) have particularly high rates of infection. While rates of new infections are stable or dropping in most groups, rates are actually increasing among AA MSM. Between 2006 and 2009, the estimated number of new infections among 13–29-year-old AA MSM increased 48% from 4500 cases in 2006 to 6500 cases in 2009.² Reasons for these disparities are multifaceted and include both individual risk behaviours and the social and contextual environment in which risk behaviours occur.³

A major goal of the National HIV/AIDS Strategy for the US is addressing disparities in HIV rates among disproportionately impacted populations by targeting resources to undetected infection.⁴ One key strategy for addressing unrecognized infection and reducing disparities in HIV rates is to increase the number of individuals who are aware of their status and link infected persons to appropriate treatment and follow-up. The public health challenge is finding the most cost-effective ways of identifying these individuals.

One way to identify HIV-positive individuals who are unaware of their status is to provide HIV counselling and testing services (CTS) to the partners of HIV-positive individuals. At the start of this project, the standard health department strategy for providing CTS to partners of HIV-positive individuals was partner counselling and referral services, now known as provider referral (PR).⁵ The definition of PR adopted for this project was as follows: PR is a public health strategy that involves health department staff identifying, locating and interviewing HIV-infected persons (index patients) to elicit names and locating information of partners, health department staff notifying the partners of their exposure to HIV, and providing HIV counselling, testing and referral services to those partners. Health departments have used PR to interrupt the transmission of infectious diseases like syphilis. However, existing PR practices may be limited in reaching hidden, high-risk populations such as MSM because of the high frequency of anonymous sex partners and mistrust in government institutions and health departments.^6,7

Sex partner meeting venues are increasingly found to play a role in creating the sexual networks that contribute to disease transmission. The role of such venues in enabling sexually transmitted infection (STI) transmission has been recognized for several decades.^8,9 Alternative venues (e.g. clubs, street corners and bookstores) serve as a geographical entry into a cohesive network of men.¹⁰ Public health officials have exploited this property of the networks through alternate venue testing (AVT), hoping to tap into previously hard-to-find networks of MSM to generate estimates of infection rates and behavioural risk.

The social network strategy (SNS) is another means to tap into social networks. Unlike traditional PR, this method uses a referral system in which respondents are responsible for recruiting their own social and sexual contacts.¹¹ Other differences include the fact that SNS does not make respondents differentiate between sexual and social contacts, permits the respondent to pick and choose whom they recruit and offers small incentives to respondents for each contact they refer for testing. These differences may make SNS more effective than PR in identifying undiagnosed HIV-positive persons. SNS may also have advantages over AVT in that it is not limited to the subgroup of contacts accessible at venues, but extends to all potential members of their social networks.

The purpose of this study was to compare the relative effectiveness of AVT, SNS and PR for identifying previously undiagnosed HIV-infected AA MSM 18–64-year-olds. This study is unique in that it examined the comparative effectiveness of these strategies as conducted by a health department – the Baltimore City Health Department (BCHD). While there are considerable administrative, cultural and personnel-related challenges to implementing such operational research within a health department, it is important that we study these strategies in this context for several reasons. Health departments receive significant public support from for HIV testing. Health departments are already engaged in case finding and control activities for other STIs so there are synergies that can be found among work on different STIs. In addition, health departments maintain surveillance databases that can be used to guide and evaluate programmes. Finally, health departments operate under public health authority that allows them to contact HIV-infected persons without prior consent.

This case study reports (1) the total number of AA MSM tested by each strategy, (2) the risk behaviours reported for men tested by each strategy, and (3) the total number of previously undiagnosed HIV-positive men identified by each strategy.

METHODS

Study site

The study was conducted as a partnership between Johns Hopkins Medicine (JHM) and BCHD.

Study population

Data were collected between January 2009 and June 2010. Men were eligible to participate if they were 18–64 years old, self-reported as being a black/African American man, self-reported oral or anal sex with a man in the past six months, and were able to provide verbal consent. The study protocol was reviewed and approved by Human Subjects Review Boards for the CDC and JHM.

Measures

Data were collected via a cross-sectional survey that was incorporated into the day-to-day data collection systems used by BCHD. Core questions focused on HIV-testing strategy, sociodemographic information (age, gender, race, ethnicity, sexual orientation and educational attainment), self-reported HIV testing history and sexual and drug-use behaviours. Conventional testing (ELISA and confirmatory Western blot, as well as HIV RNA testing) was used to determine participants’ HIV status as per BCHD standard of care. In addition, men were also tested for syphilis. Results were available within 14 days of the test date.

Training of study staff

All key study personnel have extensive experience and are well trained in providing CTS and PR to African American men, including MSM, in a culturally sensitive manner. All completed the CDC's Disease Intervention Specialist (DIS) training and the BCHD outreach safety training. Further, all staff received additional training on the study protocol at the onset of the study and mid-way through the project. Finally, SNS staff participated in two SNS trainings in Atlanta conducted by CDC.

Recruitment strategies

Alternate venue testing

We adapted a version of the PLACE methodology ¹² to identify new and important venues for conducting AVT. For the purposes of this study, potential venues were any location where AA MSM socialize and meet new sex partners, including bars, clubs, shopping malls, parks and street corners. We used three approaches to identify AA MSM venues: (1) case-based venue surveillance (individuals diagnosed with HIV in the STI clinics were asked where they met their sex partner); (2) targeting known high-risk meeting venues (identified by members of local community-based organizations and institutions that provide services to MSM, e.g. churches, drug rehabilitation programmes, social service providers, clubs that cater to MSM, law enforcement personnel and health department DIS who provided names and locations of such venues on an ongoing basis); and (3) targeting high-transmission census block groups. Examples of the types of venues visited include: bars, parks, street corners, and clubs.

BCHD staff visited a site with one of two mobile clinics available to the city. Pre-test counselling, consent for testing mandated by Maryland state law and testing procedures were conducted according to BCHD standard procedures. Field staff collected demographic and behavioural data using paper and pencil as part of standard BCHD procedure. Participants were tested using a conventional HIV test per BCHD standard procedure.

All persons tested by BCHD field-workers received a card with the phone number for the results line. They were instructed to call the results line two weeks after the testing date. Individuals who tested negative through AVT were informed of their results when they called the results line established by BCHD for all outreach testing. As per BCHD protocol, any individual with positive results was assigned to a DIS who contacted them before they called in for their results to ensure that results and post-test counselling were received in person. A positive test was considered to indicate a newly diagnosed infection if there was no record of the individual previously testing positive in BCHD's public health surveillance records.

PCRS and the SNS

Conducting PR with new HIV-positive clients is the current standard of care for BCHD. For the purposes of this study (see Figure 1), all African American men who tested positive for HIV for the first time (according to BCHD records) from AVT or from BCHD's fixed testing sites and reported engaging in sex with a man within the last six months were alternately assigned to SNS or standard PR. In addition, all individuals tested through AVT who tested positive and who had a record of a previous positive test (‘previous positives’), were assigned to SNS. In Baltimore, few HIV-infected men are identified in the STD or other BCHD fixed testing sites clinics thus most individuals offered SNS and PR originated from the AVT. Clients co-infected with syphilis were excluded from the current study.

Figure 1

Recruitment and testing outcomes for individuals participating in alternate venue testing, social network strategy and provider referral

For PR, staff solicited the names and contact information for recent sex and needle-sharing partners. The staff then located the infected man's named sex partners and offered standard CTS.

For SNS, HIV-positive AA MSM (‘recruiters’) were encouraged to recruit no more than six social contacts or ‘network associates’ for HIV testing. Network associates who participated in testing received a $5 coupon as reimbursement for travel and time spent. Recruiters received a $10 coupon for each network associate that participated in testing. In addition, all network associates who tested positive were offered the opportunity to become a social network recruiter.

Linkage to care

As standard BCHD practice, a DIS case finder introduced all HIV-positive persons receiving post-test counselling to a designated health-care facilities where primary medical services could be received. BCHD has a Memorandum of Understanding with 10 primary care providers. The client had the right to refuse assistance at any time, and the case was automatically closed. DIS followed up with providers to assess linkage to care. If the client was not linked with care, the case was referred to the BCHD linkage to care coordinator for additional follow-up.

RESULTS

Alternative venue testing

A total of 218 self-identified African American men who reported having had anal sex with a man in the six months prior to study initiation were tested through AVT. As shown in Table 1, 55 HIV-positive AA MSM (25.2% HIV positivity) were identified of whom 20 were newly identified HIV positive. The mean age of the men tested was 30.6 years. Only 156 (71.6%) self-identified as homosexual and the mean number of male sex partners in the past six months was 2.6. Their mean number of female sex partners in the past six months was 1.2.

Table 1

HIV positivity, demographics and behavioural characteristics of African American men tested through three social network recruitment strategies

	AVT index	SNS partners	PCR partners
	(N = 218)	(N = 22)	(N = 2)
HIV positivity (%)	25.2	36.4	50
New HIV positivity	9.2% (10.9%)*	0%	0%
Age; mean (SD), range	30.6 (11.6), 15–63	47.6 (8.7), 25–61	37 (19.8), 23–51
<25 year old, HIV %	18.1% (N = 93)	0% (N = 0)	0% (N = 1)
≥25 years old, HIV %	33.0% (N = 115)	36.4% (N = 22)	50% (N = 1)
Homosexual (%)	71.6	33.3	100
IDU (%)	3.7	15.8	0
# Men anal sex past 6 months; mean (SD), range	2.6 (2.7), 1–18	0.3 (0.8), 0–3	1 (NA), NA
# Men unprotected sex past 6 months; mean (SD), range	1.2 (1.7), 0–12	2.0 (1.0), 1–3	1 (NA), NA
# Women vaginal/anal sex past 6 months; mean (SD), range	1.0 (2.5), 0–20	2.1 (4.4), 0–20	0 (NA), NA
# Women unprotected sex past 6 months; mean (SD), range	1.2 (1.5), 0–7	1.6 (2.6), 0–10	NA

*New positive/previously negative

Assignment to SNS and PR

Of the 55 HIV-positive AA MSM identified through AVT, 27 previous positives and nine new positives were initially assigned to SNS. Seven of the HIV-infected men identified through AVT (all new positives) and two new positives from an affiliated clinic were initially assigned to PR. Men who were co-infected with syphilis were excluded from study. In addition, men who could not be found for notification, and those who refused interview were also excluded.

Social network interviews (SNS)

Fourteen HIV-positive AA MSM participated in SNS (10 previous positives and 4 new positives). Twenty-two African American MSM social or sexual contacts were recruited, eight (36.4%) were HIV positive and none were newly identified as HIV positive. The mean age of the network associates who were positive was 47.6 years. Only 33% self-identified as homosexual and the mean number of male sex partners reported in the past six months was less than one (0.3). Their mean number of female sex partners in the past six months was 2.1.

Partner counselling and referral services (PR)

Only two HIV-infected men participated in the PR strategy that yielded two African American MSM sex partners. One previous HIV-positive man was identified.

DISCUSSION

Study results suggests that for BCHD AVT is an effective approach for reaching and engaging AA MSM into testing as indicated by the high number of men tested through AVT. For BCHD, a possible explanation for the relatively low numbers of AA MSM tested by SNS or PR compared with AVT, besides the study design, is that SNS and PR rely on notification and cooperation of HIV-infected individuals, which from our own study and that of others is a challenge.¹³

As for identification of previously undiagnosed HIV-positive AA MSM, AVT also seems to be the important approach. BCHD is able to identify a high number of previously undiagnosed HIV-positive men through AVT. The prevalence rate of newly diagnosed positives BCHD identified through AVT is consistent with other AVT studies.^14,15 However, BCHD's failure to find newly diagnosed positives through SNS stands in contrast to the conclusions of other SNS studies.^16–18 For example, Halkitis et al. found an HIV preliminary positive test prevalence of 19.3%. While we found a 36.4% preliminary positivity test prevalence among all associates, when we excluded those with a public health department record (in contrast to self-report used by other studies) of a previous positive test result, our positivity dropped to zero. These contrasting findings suggest that the men who consented to participate in the BCHD's SNS process may have different types of contacts than the men who do not consent or that the contacts who were recruited by BCHD are not representative of those recruited by non-health department third party staff.

We speculate that AVT may be effective in identifying newly diagnosed positives because individuals recruited from venues are part of place-based sex networks that are conducive to ongoing transmission and incident infection.^10,19 As we know personal behaviours alone are insufficient to explain acquisition of HIV among MSM. It is probably necessary that there be a multiplicity of individual and contextual factors that come together to create transmission and thus acquisition. The nexus of these factors may occur only at certain places.

This study has several limitations. Most significantly, the small sample size of individuals in the SNS and PR arms of the study preclude making any solid inferences from these data. In addition, the fact that the study was conducted in one health department in one city limits the generalizability to other health departments, though the study was conducted in such a way to mimic existing health department practice that limited types of data collected. Finally, since we did not offer SNS to previous positives from the clinics, we must be cautious in interpreting our results regarding effectiveness of SNS.

While the small sample size does not permit strong conclusions, our results combined with previous studies of SNS and PR suggest the need for health departments to consider using several complimentary strategies for identifying previously undiagnosed HIV infections in AA MSM in urban environments such as Baltimore.

Footnotes

ACKNOWLEDGEMENTS

The contents of this article are solely the responsibility of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

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