Implementing bathhouse-based voluntary counselling and testing has no adverse effect on bathhouse patronage among men who have sex with men

INTRODUCTION

Diagnosing unidentified HIV infections is a cornerstone of the international approach to HIV prevention. ¹ To achieve this, routine HIV screening in health-care settings is increasingly recommended, together with provision of voluntary counselling and testing (VCT) outside medical settings in locations frequented by high-risk individuals who are willing to test. ^1,2 A large proportion of men who have sex with men (MSM) who report recent unprotected anal intercourse also indicate that they frequent bathhouses or sex clubs. ^3,4 Research documents that bathhouse-based VCT using both standard and rapid testing technologies is a feasible strategy for reaching high-risk men who are recently untested, and VCT in this setting often returns a higher proportion of HIV-positive cases among MSM than other testing locations. ^5–9 Despite the promise of bathhouse-based VCT, distribution of testing programmes to these venues is incomplete. A recent study of bathhouses and sex clubs in North America revealed that 32% do not offer any kind of testing programme on site. ¹⁰ One concern venue managers have in collaborating with public health officials to offer VCT is that testing will adversely affect business, as patrons might be put off by reminders of HIV and sexually transmitted infections (STIs). ¹¹ This study examined whether offering VCT on the premises of a bathhouse changed patterns of patron visits.

METHODS

A collaborating bathhouse provided anonymized electronic records of every entrance and exit to their establishment from their entire population of patrons. Data were analysed for consecutive three-month periods (end of October through end of January) in each of three years. A VCT programme was implemented in the bathhouse with different frequencies during various segments of time.

Details of the testing programme have been reported elsewhere. ^12,13 All testing was done anonymously, using oral testing technologies. Both standard and rapid tests were offered at different times. To advertise services, an outreach worker actively recruited patrons to test as they passed through the area of the club where the programme was set up, fliers announcing the testing were posted around the club and periodic announcements were made over the public address system. During 2001–02, testing occurred once weekly on Saturdays for six hours. During 2002–03 and 2003–04 testing was added for another three hours on Wednesday evenings. Additionally, for five weeks during 2002–03 an intensive ‘test-a-thon’ provided testing five days per week for three to six hours per day. This variability allowed us to examine two potential impacts of testing: (a) that increasing frequency of testing within a club creates an overall pall on patronage, evidenced by fewer entrances to the club during phases when testing is offered more regularly, and (b) that any specific testing session creates an isolated effect on patronage, evidenced by either decreased entrances or increased exits to the club during an isolated testing session, relative to comparable days/times when testing is not offered.

We carved each day into 48 half-hour periods, and calculated the number of entrances to and exits from the club within each period. This yielded a total of 13,821 half-hour periods for analysis. Periods were coded to indicate whether a specific testing session overlapped with the period, and whether the period fell during a larger phase when testing was offered once, twice or five times weekly.

RESULTS

To examine whether implementing a specific testing shift had an isolated impact on patronage during the shift, we first selected only the 1567 half-hour periods that overlapped with a day and time when testing might have been offered during certain months. We then modelled the number of club entrances and exits as a function of whether testing was actually being offered during that specific half-hour time. Relative to day- and time-matched half hours without testing, during half-hour periods when testing was occurring, there was no decrease in the number of entrances to the club or increase in exits from the club.

DISCUSSION

Implementing bathhouse-based VCT did not have any demonstrable impact on patronage. Bathhouse entrances remained stable, regardless of whether VCT was being offered once, twice or five times weekly. Moreover, men did not enter the bathhouse with less frequency or exit more rapidly during times when specific testing shifts were occurring. Thus, concerns about the financial impact of testing on bathhouse business appear to be unfounded.

These findings must be qualified by two limitations. Because testing was operating within the bathhouse at least one day/week throughout our observation period, we cannot be certain that having absolutely no testing programme on site might not improve patronage. Additionally, although we observed little effect of one specific model of testing, we cannot rule out the possibility that testing programmes using other methods (e.g. more aggressive outreach, less sensitive staff) might impact patronage.

These data provide further support for the feasibility of collaborating with bathhouses to implement VCT – sensitive programmes appear to have no negative impact on business. Moreover, they successfully attract high-risk men into testing and efficiently identify new HIV cases. ^5,7,8 Public health officials may find these results help alleviate club managers’ concerns about patron reactions to providing testing on site. Additionally, the approach of monitoring patron turnover can provide an objective basis for negotiating new or expanded public health programmes in these venues.