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Self-testing is a new form of HIV testing introduced to the UK in 2015. A key aim of self-testing is to expand access to testing through reducing barriers for individuals at risk of HIV infection. Self-testing has been shown to be highly acceptable to the key populations at risk of HIV in the UK, namely, Black African men and women, and men who have sex with men (MSM). The vast majority of evidence within the self-testing field relates to the acceptability of self-testing for key populations. As the availability of self-testing increases globally it is important to have a psychological understanding of the pre- and post-self-test experiences of individuals who test positive from this form of testing. This study investigated the key psychological processes involved with self-testing in people testing positive for HIV, for example, choosing to self-test, testing positive from a self-test, linking to HIV care, HIV disclosure, adjustment, coping, and adapting to any relationship changes. The aim of this Grounded Theory (Charmaz, 2014) study was to explore, and create a model of, the experience of individuals who had received a positive self-test result, and a diagnosis of HIV. Seven MSM aged between 25-53 years were recruited via a nationwide charity pilot project which was designed to send out free self-tests, and was advertised via Grindr, Facebook and the charity website. Five theoretical codes were identified from the semi-structured interviews and subsequent analysis, and are presented in a theoretical model of the experience of individuals who test positive from a self-test: 1. Self-testing as a purposeful choice; 2. Reflecting on the self-testing experience; 3. Feeling shock and disbelief; 4. Coping with HIV; 5. Attempting to move forwards as a sexual person. The findings are discussed with regards to future research and the clinical implications for self-testing, and personal reflections are offered.

There is evidence that some sub-Saharan African individuals suspect that they are HIV positive before diagnosis but delay being tested for HIV. This increases the likelihood of being diagnosed late (with a severely compromised immune system), a phenomenon that has been observed in sub-Saharan Africans diagnosed in the UK. Late diagnosis has negative personal and public health consequences. There is a lack of understanding of the psychological processes associated with delayed HIV-testing. This study used a Grounded Theory methodology. It aimed to produce a theoretical model to explain the psychological processes associated with delayed HIV testing in sub-Saharan Africans in the UK but also how these processes changed over time and contributed to the decision to test. Seven HIV-positive sub-Saharan African individuals from a London HIV clinic and one from a HIV charity were interviewed about their experiences. Analysis led to the development of a theoretical model of delayed HIV testing. This model consisted of three theoretical codes: moving in and out of uncertainty about HIV infection; preferring not to know HIV status; and making the decision to test for HIV. Participants' HIV risk perception fluctuated and was characterised by uncertainty. This, in combination with a preference to not know their HIV status due to a number of feared consequences of being HIV-positive, deterred them from testing. Participants' thoughts and feelings about knowing their HIV status changed over time. These changes were that they: wanted certainty, had hope of being HIV-negative and/or a hope for treatment and life and preparing for and accepting a potentially positive result. The findings can inform interventions to reduce delayed testing and suggest: a) intervening with ambivalence on an individual level and b) promoting awareness of HIV c) promoting the benefits of testing/costs of not testing at a population level. The findings are discussed in relation to existing research and theory. Strengths and limitations of the study are discussed, as are clinical implications and suggestions for future research.

HIV testing is essential to HIV prevention at the individual and population level. Knowledge of HIV status is a prerequisite for the adoption of behavioural and biomedical HIV prevention strategies, including HIV pre-exposure prophylaxis. Among populations at increased risk of HIV infection, such as gay and other men who have sex with men (GMSM), frequent HIV testing is necessary for the early detection of HIV infection, enabling the initiation of HIV treatment, leading to viral suppression, reduced mortality and morbidity, and the prevention of secondary transmissions. High uptake of HIV testing is required to reach the UNAIDS goal to eliminate HIV transmission by 2030. I examined rapid HIV testing as a safe method to increase HIV testing among GMSM in New South Wales (NSW), Australia, and assessed its impact on HIV testing frequency. As the goal of HIV testing is to reduce the prevalence of undiagnosed HIV infection, I also conducted two studies to estimate the proportion of people living with HIV in NSW who are undiagnosed: I developed an HIV diagnosis and care cascade, and I conducted a study to directly measure the undiagnosed proportion among HIV-positive GMSM. Project 1 assessed the performance of a rapid HIV test among GMSM: without parallel laboratory serology with rapid HIV tests many acute HIV infections would not be detected. Project 2 assessed the impact of rapid HIV testing on HIV testing frequency among GBM: Among men who had at least one rapid test, the mean number of tests was significantly higher than among men who did not have rapid tests. Project 3 estimated the HIV diagnosis and care cascade for NSW in 2016 and described methods to improve cascade data quality: In 2016 New South Wales surpassed the UNAIDS 90-90-90 targets. Project 4 measured the prevalence of undiagnosed HIV infection among GMSM in Sydney, NSW in repeated bio-behavioural surveillance studies (2014 and 2018): Low prevalence of undiagnosed HIV infections was sustained, coincident with increased HIV testing and use of PrEP. When implemented safely, making rapid HIV testing routinely available is an effective strategy to increase HIV testing frequency among GMSM.

Routine HIV testing for adults 65 years and older is imperative for prevention and treatment efforts among the vulnerable population. To date, limited research exists that examines associations between sex in HIV testing, HIV risk perception, and HIV risk among adults who are 65 years and older. Certain risk behaviors can lead to missed testing opportunities for some Medicare beneficiaries aged 65 and older, increasing the likelihood of new HIV transmissions and late-stage diagnoses. A federal mandate requires that Medicare Part B (outpatient insurance) cover annual wellness visits, which allow providers and beneficiaries to develop personalized prevention plans of care. However, Medicare does not offer routine HIV testing to beneficiaries 65 years and older, unless they specifically ask for a test (risk perception) or considered at risk (actual risk). This quantitative, cross-sectional, causal-comparative research design was guided by the health belief model (HBM) and theory of gender and power (TGP). Chi-square tests analyzed secondary data from the 2018 National Health Interview Survey, Adult Sample file regarding HIV testing, HIV risk perception and HIV risk among non-institutionalized adults, 65 years and older. The significance of statistical tests was determined at the .05 alpha level. Study findings revealed a significant association between sex and HIV testing prevalence, with men (24.3%) testing more frequently than do women (20.1%). Findings also revealed a significant association between sex and HIV risk. Men (41%), when compared to women (22%), were almost twice as likely to have at least one factor increasing HIV risk. There was no significant association between sex and HIV risk perception. Findings revealed that both men (99.6%) and women (99.6%) equally lacked HIV risk perception.

Introduction:Cambodia has set a goal to test at least 95% of all pregnant women for HIV. Thanks to Cambodia’s “Boosted Linked Response” strategy, the HIV testing rate among pregnant women attending antenatal care (ANC) has gradually increased but plateaued out at approximately 90% for the past several years. Moreover, since 2012, the strategy has failed to test more than one-fourth of male partners of ANC-attending pregnant women. Therefore, we examined factors associated with HIV testing during ANC among pregnant women and their male partners. In addition, we also explored men’s barriers to attending ANC with their pregnant partners, and their perspectives on three HIV testing alternative strategies (home-based HIV testing, free-of-charge pregnant woman–delivered HIV self-testing, and out-of-pocket community pharmacy–delivered HIV self-testing.Methods: In Study 1, we pooled together three Cambodia Demographic Health Surveys (2005, 2010, and 2014) and adopted Anderson’s Behavioral Model of Health Services to guide our data analysis. The study population consisted of all Cambodian women aged 15–49 years with one or more live births in the three years preceding each survey who attended ANC for the most recent birth (weighted N=11,181). In Study 2, we conducted a Case-Control study. The study population consisted of men who attended ANC with their pregnant partners from September 2020 to December 2020. The outcome was defined as declining or accepting an HIV test as part of ANC. 132 cases and 264 controls were recruited from three government-run ANC health facilities in Phnom Penh (the National Maternal and Child Health Center, Chaktomuk Referral Hospital, and Posenchey Health Center). An Extended Theory of Planned Behavior (ETPB) was applied to guide our data analysis. In Study 3, a qualitative study was nested within the Case-Control study. The study population consisted of 30 men (10 HIV testing decliners, 10 acceptors, and 10 ANC non-attendees). All participants were recruited using consecutive sampling from ANC and postpartum departments of the National Maternal and Child Health Center.Results: In Study 1, HIV testing rates as part of ANC increased significantly by year (15.5% in 2005, 46.2% in 2010, and 77.4% in 2014, p

Background: Research in the United States has found that individuals who identify as SGM have poor health outcomes when compared to their heterosexual counterparts and participate in more risk behaviors that have been linked to poor health. There are few cross-sectional studies that have included questions regarding SGM status. Using national surveillance data from the 2016 BRFSS, risk behavior participation and poor mental health identification will be compared to SGM status, with particular attention paid to women who have sex with women (WSW) in order to provide a more widespread and complete image of healthcare concerns for all SGM individuals. Methods: Data from the 26 states that utilized the SGM questionnaire in the 2016 BRFSS was first analyzed using a chi-square analysis to determine initial levels of significance between demographics and risk factors with a known connection to poor health outcomes. A crude odds ratio was conducted to remove non-significant risk behaviors and followed by a multiple logistic regression analysis to determine an adjusted odds ratio and to account for confounding relationships between SGM status, significant demographics, and risk factors. Results: SGM respondents were at increased odds, when compared to their heterosexual counterparts, of identifying poor mental health, participating in high-risk situations, smoking status, and having been tested for HIV regardless of sex. WSW in particular, had a higher likelihood of having poor mental health (AOR=2.03, pConclusions: SGM identifying respondents were at an increased odds of participating in high-risk behaviors that have a known connection to poor health outcomes. Public health efforts should utilize a holistic approach to address risk behavior participation and disparities in overall health for SGM individuals.

There has been a limited focus on HIV among men who purchase sex (MWPS) in many countries. Systematic information is lacking on the HIV prevalence in this population, and on interventions conducted to reduce HIV risk. Looking specifically to Indonesia, MWPS are understood to be at higher risk of HIV infection compared with men in the general population but there has been a relative lack of attention put towards identifying characteristics such as the rate of condom use and HIV testing in this population and developing appropriate interventions. Accordingly, the studies included in the thesis contribute to filling the knowledge gap for this population in regard to estimation of rate of condom use and HIV testing and evaluation of control strategies among MWPS in Indonesia. A range of research designs and analytical approaches was applied. The first study is a meta-analysis of the burden of HIV among MWPS in low- and middle-income countries (LMICs). We found that HIV prevalence was elevated compared to the population as a whole, and that there was a strong association (RR 1.95) between purchasing sex and HIV prevalence. The second study is a systematic review of HIV interventions conducted among MWPS, or groups often used as proxies for MWPS, in LMICs to reduce their risk of HIV infection. We observed that only a few studies had evaluated the impact of interventions on HIV testing rates. The third study is a survey in Bali, Indonesia, which identifies rates and predictors of condom use and HIV testing among MWPS in this setting. The study found a high condom use (88.5%), but low HIV testing rates (8.1%) among this group. The fourth study explores in more detail why such a low HIV testing phenomenon among MWPS occurs in this setting and the preferences for testing strategies. Men‘s preference for HIV self-testing over HIV testing at the clinic was expressed. The fifth study is a study piloting the HIV self-testing strategies to identify whether this method could improve HIV testing rates among this group. A pilot single-arm non-randomised trial study was conducted among men presenting at the brothels area and found high acceptability of this testing strategy to improve HIV testing rates among MWPS; HIV testing acceptance was 6-7 times higher than the HIV testing history of less than 8.1% found in the third study. Together, the five studies provide insight into estimation of the HIV burden and evaluation of control strategies among MWPS in Indonesia.

Men who have sex with men (MSM) remain at high risk of HIV infection globally. In Vietnam, HIV prevalence, understanding of risk factors, and barriers to testing and treatment among MSM are poorly understood. This thesis aimed to determine the prevalence of infectious syphilis, HIV, and HIV testing and associated factors among male sex workers (MSWs) and MSM, estimate the cascade of care, and identify barriers to treatment for HIV-positive MSM in Hanoi. Data from the first wave of baseline recruitment for the HIM-Hanoi study, and the Hanoi arm of the SHEATH study, together with in-depth interview with HIV-positive MSM were utilised. Syphilis prevalence (21.2%) among 316 MSWs was high and independently associated with recent STI testing, HIV positive status, longer duration of sex work, and recent oral sex with non-client male partners. Weighted HIV prevalence among 796 MSM was 10.9%, and independently associated with lifetime sex with male clients, recent condomless anal intercourse (CLAI) with non-commercial male partners, three or more recent non-commercial anal sex partners, recent group sex with party drugs, STI symptoms, syphilis infection, and past/current hepatitis B infection. HIV testing uptake was suboptimal, with 33.1% never tested, 11.7% tested >12 months ago, and 55.2% tested ≤ 12 months. Non-recent testers were older, less educated, and less likely to receive free condoms than recent testers. Never testers were less engaged with the MSM community, less likely to disclose their homosexuality and to have been diagnosed with an STI, but more likely to report recent CLAI with male clients. Among 79 HIV-positive MSM, 35.2% were aware of their status, 27.9% were on antiretroviral therapy (ART) and 17.1% were virally suppressed. Qualitative interviews revealed barriers to ART uptake including inadequate preparation for a positive diagnosis, dual stigmatisation of homosexuality and HIV, confusion about treatment access, failure to protect confidentiality, and providers’ reticence to discuss same-sex issues. Findings increase understanding of the epidemiology of HIV among MSM in Vietnam and potentially inform policy and practice. Programmatic responses are needed, including HIV pre-exposure prophylaxis, scaled-up HIV testing, integration of STI and HIV screening, and expanded access to timely, MSM-friendly treatment and care.

According to the Centers for Disease Control (CDC), in 2017 of the 27,000 new HIV diagnoses among the men who have sex with men (MSM) population, individuals between the ages of 13 to 34 made up 64% (17,194) of new HIV diagnoses. But, according to CDC's Atlas Plus data tool, the number of HIV diagnoses among MSM aged 13-24 years has been declining since 2014. The aim of this study was to assess changes over time in HIV testing among young MSM, as change in testing behavior is one potential reason for declining HIV diagnoses. Using survey data collected by the PRISM Health Research Team at the Emory University Rollins School of Public Health, HIV testing behaviors of young MSM between the ages of 15-29 from the years 2013 to 2018 were analyzed. The age group and year group was broken down into two groups of 15-24 and 25-29 year olds and 2013-2015 and 2016-2018. A logistic regression model was used to test whether covariates confounded on or had an effect modification on the exposure (year) and outcome (HIV test) of interest. The major finding was that testing behavior among 15-24 year olds remained unchanged across time, but an increase in past year testing was observed in the 25-29 year old group (p-value

Socio-ecological factors such as poverty and mobility have been linked to HIV transmission in East African fishing communities. Little however is known about the influence of these factors on access to and use of HIV testing, treatment and care. To address this gap, in-depth interviews were conducted with 42 HIV positive fisherfolk and 15 health care providers from two HIV clinics located in two fishing communities in Uganda to identify socio-ecological factors influencing access to and use of HIV testing, treatment and care. Bronfenbrenner’s (1979) ecological systems theory guided the analysis of the above interviews. Informational, instrumental, affiliative and emotional support emerging from micro and mesosystem contexts facilitated access to and use of HIV testing, treatment and care. However, HIV-related discrimination present in these same contexts left some participants less supported in accessing services. Exosystem factors, including partner notification initiatives, facilitated some participants’ access to HIV testing, while occasional disruptions in supplies to clinics constrained the availability of HIV-related care. Macrosystem cultural factors, such as beliefs in traditional healing systems, delayed some fisherfolk’s access to HIV testing, while factors linked to the economic context in fishing communities including fisherfolk’s geographic mobility and poor transport systems regularly constrained access to treatment and care. Despite these difficulties, health service organisational factors were to a large extent successful in facilitating fisherfolk’s access to HIV testing, treatment and care. The effects of enabling and constraining factors and processes operating at each of these levels are identified in the thesis which also includes a diachronic analysis – using selected case studies – of the manner in which individual health and illness trajectories are impacted upon by different combinations of factors over time. Overall, the thesis contributes to a more nuanced, socially located understanding of factors influencing access to and use of HIV testing, treatment and care in fishing communities in Uganda. It highlights the need for programmes and interventions to engage more seriously with structural and contextual factors influencing fisherfolk access to services and support.

Background: HIV continues to disproportionately affect young Black men (YBM) and efforts are needed to increase HIV testing in this population. The primary purpose of this dissertation was to develop and evaluate a theory driven social media marketing (SMM) campaign (based upon social learning theory) to increase HIV testing among young Black men attending a public university in Atlanta, GA. Methods: Three focus groups with YBM were conducted to develop a social media marketing campaign. The three month social media marketing campaign included targeted Facebook and Instagram advertisements as well as print advertising, campaign related events, a campaign website, and blog. Two hundred four students (n=106 for the baseline survey and n=98 for the post campaign survey) completed an online survey assessing sexual behaviors, attitudes toward HIV testing, stigma, testing barriers, exposure to HIV testing campaigns, social learning processes, and Integrated Behavior Model (IBM) constructs. Baseline data analyses involved a confirmatory factor analysis treating social learning as a latent variable and regressing IBM constructs on social learning. Evaluation of the campaign involved comparing pre and post differences in HIV testing frequency and mean scores for covariates as well as the association of the pre/post-grouping variable with HIV testing in a multivariable logistic regression model. A mediation analysis was conducted to assess a potential causal pathway through which the intervention affected HIV testing in bivariate models and in path analyses. Results: The latent variable of social learning was indirectly associated with HIV testing intentions through experiential attitudes (β=0.135, p=0.014) and directly associated with experiential attitudes (β=-0.248, p=0.010). There was a significant difference in HIV testing frequency pre and post campaign (62.2% vs. 39.6%; p=0.001) in unadjusted analyses. Differential association (the people who share normative patterns of behavior with YBM) was the only mediator to have a direct association with HIV testing (AOR= 1.418, p= 0.035) in the adjusted model. Conclusions: HIV testing was higher post campaign launch. Differential association for HIV testing may be the key to increase testing uptake among young Black men. Social learning may be extended to HIV testing behavior and may influence experiential attitudes toward HIV testing.

At the time this research commenced, there was limited operational or implementation research on the uptake and impact of new HIV testing service models or other service innovations on HIV testing in gay, bisexual and other men who have sex with men (GBM) in Australia. The primary aim of this thesis is to contribute to the evidence base required to support programmatic decisions on the implementation or expansion of innovative HIV testing models for GBM in Australia. The research presented in this thesis has contributed substantially to the knowledge base surrounding the use of innovative HIV testing models in GBM in Australia and internationally. This thesis describes the development, implementation and evaluation of the first community-based HIV testing services in Australia, a fast-track clinic-based testing service and an innovative patient registration system. According to my knowledge, the evaluation of the fast-track clinic-based service is the first study to demonstrate that attendance at such type of service was associated with increased HIV retesting in GBM. Also, the evaluation of the electronic self-registration system is the first study to demonstrate significant improvements in reception processing time and patient journey time, reducing barriers to testing experienced by GBM. The community-based testing service evaluations demonstrated the feasibility and success of such services in attracting untested and less frequently tested GBM, providing new information for Australia. This body of research has had significant influence on programmatic approaches to HIV testing in GBM in Australia. It is acknowledged, however, that there are other innovative testing alternatives, which need to be considered, piloted and rigorously evaluated to determine which ones facilitate more untested and less frequently tested men testing for HIV and which increase the testing frequency of GBM.

Introduction HIV remains a severe global health problem. The Republic of Chad is moderately affected (1.3%), compared to Cameroon who suffers more of the burden of the HIV/AIDS (4.5%). We described the HIV risk factors in two neighboring Central African Republics, and compared the gaps in both countries. Methods This was a retrospective cross-sectional study; data was obtained from the Demographic and Health Survey. A stratified multi-stage cluster sample design was conducted. The sample size was 5248 in Chad and 7191 in Cameroon. We used SAS to fit a multilevel logistic model, and conducted a multivariate analysis. Results The median age of respondents was 30 (IQR, 20-40) years in Chad, and 28 (IQR, 20-40) in Cameroon. Only 12.45% reported had ever been tested for HIV in Chad, (41.77% in Cameroon). In Chad, 46.40% of participants did not know a place to get HIV test, (11.15% in Cameroon). The median number of lifetime sexual partners was 2 (IQR, 1-4) in Chad, and 6 (IQR, 3-15) in Cameroon. Among Chadian participants 31.63% had only one lifetime sexual partner, (10.76% in Cameroon). In Chad 86.95% of participants reported having no sex partner other than their spouse in the last 12 months; (57.3% in Cameroon). Conclusion Condom use and HIV testing rates were very low among Chadian men comparing to Cameroonian men; however, Cameroonian men were more likely to engage in multiple sexual partners and extra-marital relationship than Chadian men.

INTRODUCTION: In the United States, Blacks and Hispanics compared to Whites are disproportionately infected with HIV. Testing for HIV is critical to reduce HIV transmission, lower risk behaviors, and improve access to treatment among persons living with HIV. However, racial & ethnic minorities are tested at later stages of HIV. Previous studies that examined racial discrimination and HIV testing reported inconsistent findings and additional knowledge is needed to understand whether differential treatment based on race is an important barrier to HIV testing. AIM: We examined whether HIV testing is influenced by how an individual reacts to race-based treatment, rather than experiences of discrimination alone, among Whites, Blacks, and Hispanics; and we determined if this relationship was modified race and ethnicity. METHODS: We performed a cross-sectional analysis of the 2012 Behavioral Risk Factor Surveillance System’s (n=12,579) self-reported HIV testing data and Reaction to Race (RR) module, which captures experiences of differential treatment based on race and an individual’s reaction to racialized treatment. Multivariable logistic regression was used to assess the association between RR-based treatment and HIV testing. Statistical interaction between RR-based treatment and race was assessed. RESULTS: Approximately 21% participants reported ever being tested for HIV, and 19% of the participants had one or more experiences of RR-based treatment. Prevalence of HIV testing was higher among Blacks (62%) and Hispanics (33%) compared to Whites (32%). In an adjusted model, the odds of HIV testing among those who reported one experience of Reactions to Race based treatment was 1.37 (95% CI: 1.08-1.75) times the odds among those with no experiences of RR-based treatment. We did not detect statistical interaction between RR-based treatment and HIV testing by race. DISCUSSION: Our findings suggest that experiences of racial discrimination may be counter intuitively associated with increased HIV testing overall and within each racial and ethnic group. Additional research is needed to clarify settings in which experiences of race-based treatment and the associated reactions to the treatment can positively or negatively influence HIV testing behaviors.

HIV and incarceration represent two epidemics facing the African American community, specifically, but the larger American population, as well. Most of the existing literature focuses on the disadvantages incarceration creates with regard to employment, voting rights or disenfranchisement, health insurance and governmental benefits, economics, social relationships and disengagement, conditions of incarceration within prison walls, and other aspects of effective citizenship. While there is growing speculation that incarceration also has health-related spillover effects both inside and outside prison walls, there are only a few studies that empirically test this relationship. This study seeks to fill that void by directly examining the effects of incarceration on the health of the larger community outside of prison walls, with specific attention given to HIV. Results suggest that increases in incarceration may decrease community HIV cases, signaling that incarceration itself can serve as a possible public health intervention in the HIV epidemic. One of the suggested intervention mechanisms is the introduction of HIV testing within state prisons. Although current HIV data is relatively limited and future inquiry is definitely needed to further unpack the possibility of the intervention of prisons, this study introduces a much-needed conversation with regard to looking to criminal justice policy as public health policy, not just for those incarcerated but for the entire population. Since what happens in prison can spill over to the outside community, prison policy needs to be considered in conjunction with larger health strategies in areas such as infectious disease. More importantly, additional attention and caution should be taken in interpreting the results of this study so as to not construe them to mean that more incarceration is the solution to slowing the spread of HIV. Incarceration itself poses many societal injuries, and much attention is being drawn toward reducing prison rolls. Instead, studies like this one should be used as a starting point to explore how current structures can be used to address health problems, while future policies are devised to build alternative interventions that avoid the harm of incarceration.

Men who have sex with men (MSM) are disproportionately affected by the HIV epidemic in Australia, accounting for two-thirds of newly diagnosed infections annually. Rates of HIV infection in MSM have been increasing over the last ten years; however, only a minority of men test for HIV at the recommended frequency. Frequent testing is essential for early diagnosis and initiation of HIV treatment as prevention; and implementing point-of-care HIV testing has been proposed as a method to make testing quicker and more convenient. When this research commenced in 2011, no point-of-care HIV tests had been approved for clinical use in Australia and there had been very limited research into this approach. Hence, the aim of this research was to provide new information to inform policy development on HIV testing, and service provision, for MSM in Australia. This thesis is based on the Sydney Rapid HIV Test Study, which evaluated the use of the new fourth generation Alere Determine HIV Ag/Ab Combo rapid test for screening MSM at four sexual health clinics. A review of the relevant literature is followed by four published journal articles arising from this study; providing new information on barriers to HIV testing among MSM, and the acceptability of point-of-care testing to patients and clinic staff. Psychological and structural barriers to testing were common among clinic-based MSM; with most men reporting that they preferred point-of-care testing to conventional laboratory testing for their next HIV test, and would test more often if point-of-care testing was available. Staff reported high acceptance of point-of-care testing at baseline, which increased with experience of point-of-care testing. Finally, compared with laboratory fourth generation HIV immunoassays, the Determine Combo rapid test performed well in cases of established HIV infection, but was less sensitive in early infection (missing one-third of these cases). These findings support implementation of point-of-care HIV testing in Australian sexual health clinics, demonstrating that its use for screening MSM is feasible and acceptable to patients and staff in this setting. However, point-of-care testing should be performed with parallel laboratory testing in this population of MSM to avoid early HIV infections being missed.

By the end of 2015, over half of all HIV/AIDS cases will be in adults aged 50 and older. One of the fastest growing older adult sub groups afflicted by the HIV epidemic is older African American women. At present, no studies have explored the unique experiences of older African American women who have received an HIV diagnosis at the age 50 and older. A descriptive qualitative study employing constructivist grounded theory methodology was used to gain insights into the experience of African American women diagnosed with HIV at age 50 and older. In taking the constructivist approach, analysis stemmed from shared experiences and relationships with participants. Semi-structured interviews were conducted, audio-recorded and transcribed. A total of 16 interviews were used. Open-ended, non-leading questions and probes were developed from a literature review and community members’ suggestions. Coding, mapping, analytic strategy usage, and memoing all assisted in creation of the grounded theory. The results of this study demonstrated how older African American women utilized various strategies to repurpose a legacy, after an HIV diagnosis. The strategies used by the women included re-evaluating perceptions of HIV risk, learning lessons from tumultuous times, and reconciling past and present events. The women’s lack of HIV risk perceptions and their provider’s failure to assess risky behaviors resulted in delayed HIV testing. After being tested, the women embarked on a journey to resolve newfound issues, and in the process, learned various life lessons. This process allowed the women to make meaning of their HIV diagnosis and set out on a path to self-discovery. The results of this study can shape forthcoming research on the HIV trajectory of older African American women living with HIV/AIDS and at risk for HIV/AIDS.

Using a logistic regression model, this dissertation employed a macro level Gateway Provider Model to explore eight factors that may influence community health center HIV testing approach. The logistic regression model indicated that three variables related to community health center HIV testing approach. First, all else equal, the odds of offering routine HIV testing for community health centers that perceived their patients and community to be at average risk for HIV were 3.676 times the odds for those centers that perceived their patients and community to be at low or no risk for HIV. Further, the odds of offering routine HIV testing for community health centers that perceived their patients and community to be at high risk for HIV were 4.693 times the odds for those centers that perceived the community to be at low or no HIV risk. Second, all else equal, the odds of offering routine HIV testing for community health centers in which an HIV testing policy exists were 2.202 times the odds for those centers in which an HIV testing policy does not exist. Third, all else equal, the odds of offering routine HIV testing for community health centers that received funding specifically for HIV testing were 2.938 times the odds for those centers that did not receive such funding. No other individual predictor variables in the model were related to community health center HIV testing approach.

In this study, I use data from the 2002 Kenya Behavioral Surveillance Surveys to examine the factors associated with having been tested for HIV and the acquisition of test results for female sex workers, low-income women, men in worksites, and policemen. With so many of the HIV/AIDS cases residing in sub-Saharan Africa, testing and counseling should be at the forefront of policies. But broad cultural norms surrounding gender and stigma affect the HIV testing and diagnosis-seeking behaviors of members of at-risk marginalized populations. Patriarchal ideologies support differential treatment and differential access to resources between women and men, and these differences are accentuated for men and women who are part of stigmatized, high risk populations. The current project contributes to scientific research on the demographic, cultural, and social-psychological factors that condition at-risk populations’ receptivity toward and pursuit of HIV testing and serostatus (HIV status) diagnosis.In the present study, I address two related questions concerning the research gap on HIV testing among at-risk populations. First, what factors influence the decision to be tested for HIV? Second, conditional on HIV testing having occurred, which factors influence the acquisition of test results for female sex workers and men in worksites? I explore these processes with rich data on vulnerable populations with unusually high HIV infection and transmission rates, using the gendered power perspective (Connell 1987; Wingood & DiClemente 2000) and Health Belief Model (Becker 1979; Strecher & Rosenstock 1997). For the first research question – predicting having been tested for HIV – five components of the Health Belief Model and several gendered culture variables are used. Two components of the Health Belief Model are significantly associated with having been tested for female sex workers and low-income women: perceived barriers (holding a high level of myths negatively predicts having been tested for HIV) and cues-to-action (having participated in HIV education programs is positively associated with having been tested for HIV). For men in worksites, two components of the Health Belief Model are significantly associated with having been tested for HIV: perceived barriers (believing that confidential testing is not available is negatively associated with having been tested for HIV) and cues-to-action (having participated in HIV education programs is positively associated with having been tested for HIV). None of the components of Health Belief Model is significantly associated with having been bested for HIV for policemen. For all four populations, none of the gendered culture variables is significantly related to having been tested for HIV. Results point to the importance of barriers and cues-to-action for having been tested for HIV. This underscores the need for accurate education on the transmission of HIV.For the second research question – predicting having acquired HIV test results, conditional on having been previously tested – five components of the Health Belief Model and several gendered culture variables are used. Only one component of the Health Belief Model is significantly associated with having acquired the HIV test results for female sex workers: perceived barriers (believing that no confidential testing is available and having been required to be tested for HIV are negatively related to having acquired HIV test results). For men in worksites, only one component of the Health Belief Model is significantly associated with having acquired the HIV test results: perceived barriers (having been required to be tested for HIV are negatively related to having acquired HIV test results). None of the gendered culture variables are significantly associated with having acquired HIV test results for female sex workers and men in worksites. Results point to the importance of decreasing barriers to confidential testing facilities, which in turn could increase voluntary testing.

This dissertation considers how Western health interventions are incorporated in non-Western societies. It focuses specifically on ‘HIV Testing,’ a key strategy that emerged to fight the spread of HIV in the West and was later institutionalized globally and exported to other, very different parts of the world. The empirical object of study is the “3Cs,” the cluster of Western norms and ideals upon which global testing policy rests: (1) that it includes counseling, (2) that it be conducted with informed consent, and (3) that the test results be confidential. Employing several methods of field research, this project investigates how the rationalities and motivations of various actors at national and local levels affect the implementation of a key global AIDS intervention in Malawi, a high HIV prevalence, rural African setting. Fundamental differences between the West and sub-Saharan Africa form the basis of this inquiry as to how imported models fare when implemented outside of their context of origin. Towards that end, this study considers how three strata of social and institutional actors who inform the HIV Testing encounter in Malawi interpret, and put into practice, the same ideas: the Counseling and Testing Establishment (CTE), HIV Counselors, and rural Malawians. For the CTE, its proponents, the “3Cs” are Western, human rights imports that are worth defending formally, but not necessarily worth prioritizing in practice. For HIV Counselors, its implementers, knowledge of the “3Cs” as Western biomedical jargon distinguishes them from villagers, but places them in situations where the ethics of testing conflict with moral concerns they have for those whom they were trained to help; thus they adapt them in practice. And for rural Malawians, its beneficiaries, the “3Cs” have little inherent value, and are perceived largely as doing harm rather than good in their communities. Thus, the net contribution of this study is that the “3Cs” have no single meaning as a normative testing regime, but rather acquire (differential) meaning (and import) during their implementation. Indeed, unless policy makers and analysts know something about this, interventions developed from afar are unlikely to have their intended effects on the ground.

Few studies exist on the types of characteristics associated with service utilization (e.g., shelters, food programs) among homeless youth in the U.S. Services are important, however, because without food and shelter, numerous homeless youth resort to trading sex in order to meet their daily survival needs. Access to physical and mental health services gives homeless youth more of an opportunity to integrate into mainstream society than they would otherwise have. To address this gap in our understanding, my study examines what traits (e.g. age, race, abuse history) correlate with the use of shelters, food programs, street outreach, counseling, STD/STI testing, and HIV testing among homeless youth. The Theory of Reasoned Action is used as an ideological framework in conjunction with theoretical constructs of risk, need, and prior service exposure. Data were obtained from the Social Network and Homeless Youth Project (SNHYP), a sample of 249 Midwestern homeless youth ages 14 to 21, which used trained interviewers to conduct structured interviews with youth. Respondents were interviewed in both shelters and on the street over a period of approximately one year. My findings revealed that homeless youth’s service usage varied across gender, sexual orientation, age, having recently held a job, and having ever been physically or sexually abused, in addition to other characteristics. Conversely, service use was not associated with social network size or subjective norms (i.e. attitudes of peers, such as acceptance of condom use) of youths’ social networks. By examining these areas, my study builds on previous research on homeless youth and lays the framework for future research on service utilization by homeless youth.

The objective of this study was to determine factors that were associated with anonymous HIV testing at a community-based HIV testing site in Columbus, OH. Individuals had the choice of anonymous or confidential HIV testing. Data from HIV tests conducted between March 1, 2008 and February 28, 2009 (N = 1,022) were analyzed using logistic regression with anonymous testing as the outcome. Increasing age was associated with increased odds of anonymous testing (odds ratio [OR] = 1.028; 95% confidence interval [CI]: 1.011, 1.046), as was a greater frequency of alcohol and/or non-injection drug use (often/occasionally vs. rarely/never: OR = 1.77; 95% CI: 1.27, 2.49). Factors associated with reduced odds of anonymous testing included having had sex with an HIV-positive partner (OR = 0.45; 95% CI: 0.28, 0.72) and inconsistent condom use during receptive anal intercourse in the previous 12 months (often/rarely/never vs. always: OR = 0.44; 95% CI: 0.25, 0.77).

Objective: To determine factors associated with adolescent HIV testing and preferences for different testing methods.Methods: Sexually active 13-22 year-olds (N=200) completed a theory-based survey and were offered HIV testing. Those who agreed chose one of three HIV tests. Chi-square and logistic regression were performed to determine factors associated with testing.Results: Half of participants (49.5%) agreed to HIV testing: 51% chose rapid oral, 30% venipuncture, and 19% rapid fingerstick. Male gender (OR 3.52; 95% CI 1.35-9.21), parental completion of high school (OR 2.69; 95% CI 1.15-6.31), intention to test for HIV if offered by clinician (OR 6.78; 95% CI 2.01-22.92), and higher perceived likelihood of current HIV infection (OR 10.0; 95% CI 2.9-33.3) were independently associated with testing. Conclusions: Intention to test if offered by a clinician and perceived likelihood of current HIV infection appear to be important factors in decision to test.

HIV is a significant health concern and millions of people are tested for it each year. Many persons undergoing testing experience substantial psychological distress. This psychological distress may be influenced by information seeking strategies. Information seeking can vary along two dimensions: Monitoring and blunting. Monitoring refers to a strategy wherein a person seeks out information and blunting refers to a strategy wherein a person avoids information concerning threatening events. The ability to achieve cognitive structure (AACS) may play a moderating role in the relationship between monitoring and psychological distress. The present study examined the association among information seeking style and the ability to achieve cognitive structure on psychological distress associated with HIV testing. Results suggested that for individuals undergoing HIV testing, the AACS may be a better predictor of psychological distress than the level of monitoring. Limitations of the study, clinical implications, and suggestions for future research are also discussed.

Recent advances in HIV antiretroviral therapy and the availability of prophylaxis for opportunistic infections, combined with the opportunity to prevent perinatal HIV infection, underscores the value of early diagnosis of HIV infection. HIV antibody home test kits offer individuals the opportunity to collect a blood sample, send it anonymously to a laboratory, and receive counseling and referral over the phone. Home HIV testing may reduce barriers to testing that have precluded individuals from learning their HIV serostatus, and if seropositive, from taking advantage of efficacious therapeutic and preventive regimens. This study employed a randomized-controlled prospective field trial design to determine if the availability of home testing increased HIV testing relative to traditional counseling and testing among injecting drug users in three HIV prevention/drug treatment contexts; methadone maintenance, hospital-based detoxification, and syringe exchange. Theoretical correlates to HIV testing were also evaluated. Multivariate analyses demonstrated that participants randomized to home testing were 2.2 times more likely than those randomized to traditional counseling and testing to test for HIV antibodies in this study after controlling for demographic, HIV risk, and theoretical variables. No differences were observed between testing methods with regard to obtaining HIV test results. The relationship between HIV testing and test type was moderated by drug treatment context and history of homeless, with home testing resulting in increased testing among methadone participants and persons without a history of homelessness. Analyses of theoretical variables suggested that prevention education stressing the benefits of HIV testing, personal risk of HIV infection, and efficacy of available treatments could increase HIV testing among injecting drug users. Participants randomized to home testing were more satisfied with testing and telephone-based counseling than were those receiving traditional testing and face-to-face counseling. Home testing was associated with increased testing perhaps due to reduced barriers to testing. To further reduce barriers to testing and to increase testing among injecting drug users, consideration should be given to incorporating oral fluid testing and rapid result capability in home test kits. Counseling could be made available as needed, delivered by telephone, and contingent upon the volitional control of the testing consumer.