Abstract
Objectives. We assessed awareness of and preferences for rapid HIV testing among young, urban men of color who have sex with men and are engaged in high-risk behaviors for HIV.
Methods. A cross-sectional survey was conducted in New York City among 177 young men who have sex with men (MSM).
Results. Among the 85% of the participants who had previously undergone HIV testing, 43% reported rapid testing at their most recent test. In terms of future tests, 64% would seek rapid testing, as compared with 36% who preferred traditional testing. Those who preferred rapid testing were significantly more likely to have attended at least some college, to have discussed HIV testing with a sexual partner, to be aware of rapid testing, and to have had a previous HIV test.
Conclusions. In general, young MSM of color seem aware of rapid testing. However, our results indicate the need to carefully consider the unique needs of those who are particularly disenfranchised or engaged in high-risk behaviors and who may need concerted efforts around HIV counseling and testing. Likewise, our findings point to a need for more effective education and social marketing strategies.
According to recent Centers for Disease Control and Prevention (CDC) surveillance data, HIV infection rates in the United States remain high among men who have sex with men (MSM). In 2005, MSM accounted for more than half (53%) of all HIV/AIDS diagnoses and 71% of reported adult male and adolescent HIV infections.1 Racial disparities have emerged within the MSM population as the AIDS epidemic has shifted increasingly toward minorities. Despite representing only 13% of the US population in 2000, Blacks accounted for 49% of cumulative HIV/AIDS diagnoses in 2005, with same-sex contact the primary mode of infection transmission.2
At the same time, young adult members of minority groups have also exhibited greater rates of HIV infection. In 2006, Black young adults accounted for 60% of HIV/AIDS diagnoses among adolescents and young adults aged 13 to 24 years. Although Black adolescents make up only 16% of the US adolescent population, they accounted for 69% of new AIDS cases reported for that age group in 2006.3
Research has shown that young minority MSM are at particular risk for infection, with consistent reports of risky sexual behaviors4 reflected in high rates of HIV prevalence, incidence, and undiagnosed infections.5–7 Nationally, 52% of new infections among Black MSM occur among those aged 13 to 29 years, as compared with 25% among their White MSM counterparts.8 A study analyzing data from the CDC's Young Men's Survey, a cross-sectional survey of MSM aged 15 to 22 years in Baltimore, Maryland, and New York City, New York, revealed HIV prevalence to be 10 times higher among Blacks (17.7%) than among Whites (1.7%).9
Although HIV incidence and prevalence are high among young minority MSM, many are unaware of their status2 and unknowingly expose their partners to HIV.7 CDC guidelines recommend at minimum annual HIV testing for sexually active MSM,5 especially younger MSM and those from minority groups.10 Despite these recommendations, however, testing frequency remains low. In a study assessing HIV testing behaviors among MSM, the CDC analyzed data from 5 cities participating in the National HIV Behavioral Surveillance System. Results showed that nearly half (48%) of those found to be HIV positive were unaware of their infections, with the proportions highest among MSM aged 18 to 30 years and minority MSM. In fact, 64% of those with unrecognized infections were Black, and 58% had not taken an HIV test in the preceding year.2
Another study analyzing data from the Young Men's Survey revealed similar results among participating MSM aged 15 to 29 years. The odds of having an unrecognized HIV infection were nearly 7 times greater among Black MSM than they were among White MSM. Fifty-five percent of those with unrecognized infections had not undergone an HIV test during the preceding year.7
To advance HIV prevention efforts in the United States, prevention programs must reduce unrecognized infection among young MSM by increasing the demand for and availability of HIV testing.7 In an effort to increase testing rates, the CDC announced in 2003 a set of new prevention strategies. A main component of this initiative is to expand HIV testing to increase the numbers of HIV-infected individuals who are aware of their status.11 New HIV testing technologies have made it possible to reach and test a larger, more diverse population in nontraditional venues. The OraQuick (Orasure Technologies, Bethlehem, PA) rapid HIV test, approved by the Food and Drug Administration, allows for presumptive diagnoses of HIV infection within 20 minutes, and the test can be performed outside clinical settings with either finger-stick whole blood or oral swabs.
In a 2007 literature review summarizing the available research on rapid HIV testing, Roberts et al. found considerable variation in clients' rates of acceptance of rapid testing, ranging from 14.1% to 98%.12 Several studies assessing acceptance rates for rapid testing technology have revealed rates upwards of 65%.13–15 Focus group data from Black adults showed that although the rapid test was preferred over traditional HIV testing as a result of the shorter turnaround time for results, concerns were raised about the test's accuracy.16
Another study conducted with MSM, injection drug users, and high-risk heterosexuals revealed that only 13% of the participants were aware of rapid HIV tests and that, among those who were aware, only 14% had actually been tested via this modality. Preference for the standard test was reported as a primary reason for not undergoing rapid testing.17 Studies with Black young adults aged 18 to 24 years have produced similar findings. Although a majority of respondents report a preference for receiving results in 1 session, many continue to express concern about the accuracy of the test.18,19
HIV testing preferences have been well-documented among older MSM, who have shown an inclination toward anonymous over confidential testing,20,21 as well as a preference for testing at sex clubs over clinic settings.22 Not being of minority race or ethnicity, having completed more years of schooling, and having access to testing services have been found to be factors associated with increased likelihood of testing among MSM.23 Reasons for avoiding or delaying HIV tests include fear of positive test results and concern that others might learn about the results.23
The need to increase rates of acceptance of HIV testing among populations of color is clear, particularly among young MSM. However, relatively little is known about the factors that influence their decision to test or the circumstances that prevent them from being tested. Although 1 recent study attempted to assess the correlates of HIV testing among young minority MSM,23 it did not explore preferences with respect to HIV testing method, which could potentially have a large impact on HIV testing rates. The researchers did find that awareness of a comfortable testing site and greater perceived social support concerning HIV were strongly associated with HIV testing among their sample.23
Given the high rates of unrecognized infection and the potential to reach greater numbers of affected individuals through rapid HIV testing, it is important to understand the awareness and acceptability of this testing modality among young minority MSM. We attempted to fill the gaps in the available literature by assessing awareness of and preferences for rapid HIV testing among a sample of young MSM of color engaged in high-risk behaviors for HIV.
A 41-item survey was developed aimed at assessing knowledge of and attitudes toward rapid HIV testing. In the survey, rapid testing was defined as an HIV test with results available in the same visit as the test, as opposed to a traditional HIV test with results available 1 to 2 weeks after the test. The questionnaire also gathered data on assessed demographic characteristics, involvement with risk-taking behaviors, and past experiences with HIV testing.
An expert panel of counselors from Gay Men of African Descent (GMAD), a community-based organization that provides social support services and HIV counseling and testing, assessed the questionnaire for content validity. The panelists collectively reviewed and then revised survey items to reflect the language used by the study target population. The questionnaire was subsequently pilot tested among a small number of young adult MSM of color seeking services at GMAD, and survey items were again revised on the basis of their feedback.
To recruit participants, counselors from GMAD approached young MSM of color at community outreach and social events in New York City during August and September of 2005 and invited them to complete the questionnaire at these offsite settings. Although GMAD provides rapid testing at its offices, counselors made no specific mention of this when recruiting survey participants in the field.
Prior to completing the questionnaire, participants were informed about the study and signed consent forms. After completing the questionnaire, participants were offered a $10 gift card in compensation for their time.
SAS version 9.1.3 (SAS Institute Inc, Cary, NC) was used in analyses evaluating knowledge of and attitudes toward elements of current HIV testing protocols and interest in rapid testing. Subgroup analyses were conducted to determine variations based on demographic characteristics or risk behaviors. The data were checked for outliers, and distributional properties were examined for all variables. Simple frequencies (sample size and percentages) were calculated for categorical variables, and means and standard deviations (SDs) were calculated for continuously scaled variables of interest. We conducted χ2 analyses (for discrete variables) and t tests (for continuous measures) comparing those who had and had not been previously tested with respect to demographic and other variables. Type I error was set at 5%, and, because of the exploratory and descriptive nature of this study, no adjustment was made for multiple comparisons.
A total of 177 men completed the survey. Respondents were aged between 18 and 24 years, with a mean age of 20.4 years (SD = 2.15). Sixty-four percent of the men self-identified as African American/Black, 24% as Latino, and 11% as mixed ethnicity. In regard to sexual orientation, 89% of respondents identified as gay, bisexual, or “down low” (i.e., men who have sex with men as well as women but do not self-identify as bisexual); 5% as straight; and 6% as other orientation. The vast majority of the sample (80%) reported having graduated high school or having received a general equivalency diploma. Table 1 presents detailed information on the characteristics of the sample.
TABLE 1 Characteristics of the Study Sample: Harlem, NY, 2005
| Characteristic | No. (%) |
| Gender | |
| Male | 170 (96.0) |
| Transgender (male-to-female) | 7 (4.0) |
| Race/ethnicity | |
| African American/Black | 112 (64.4) |
| Hispanic or Latino | 42 (24.1) |
| Mixed | 20 (11.5) |
| Educational attainment | |
| Some high school | 34 (19.7) |
| High school or GED | 75 (43.3) |
| Some college or more | 64 (37.0) |
| Health insurance coverage | 131 (79.9) |
| Sexual identity | |
| Bisexual | 45 (26.0) |
| Down lowa | 6 (3.5) |
| Gay | 103 (59.5) |
| Straight | 9 (5.2) |
| Other | 10 (5.9) |
| Ever had oral, anal, or vaginal sex | 170 (97.7) |
| Risky behaviors | |
| History of unprotected oral sex | 123 (73.7) |
| History of unprotected anal sex | 71 (45.2) |
| History of unprotected vaginal sex | 31 (19.6) |
| Unprotected sex with HIV-positive partner | 14 (8.6) |
| Unprotected sex while high | 27 (16.5) |
| Shared needles or “works” | 0 |
| Piercing/tattoo by unlicensed person | 7 (4.3) |
| No. of different sex partners | |
| 1–5 | 62 (36.9) |
| 6–10 | 42 (25.0) |
| ≥ 11 | 64 (38.1) |
| Clinically high riskb | 103 (64.4) |
| Frequency of condom use: insertive anal sex (n = 134) | |
| Never | 6 (4.5) |
| Less than half of the time | 13 (9.7) |
| More than half of the time | 37 (27.6) |
| Always | 78 (58.2) |
| Frequency of condom use: receptive anal sex (n = 119) | |
| Never | 12 (10.1) |
| Less than half of the time | 16 (13.5) |
| More than half of the time | 24 (20.2) |
| Always | 67 (56.3) |
| Frequency of condom use: vaginal sex (n = 87) | |
| Never | 13 (14.9) |
| Less than half of the time | 4 (4.6) |
| More than half of the time | 9 (10.3) |
| Always | 61 (70.1) |
Note. GED = general equivalency diploma.
aMen who have sex with men as well as women but do not self-identify as bisexual.
bDefined as a history of 1 or more of the following: more than 10 lifetime sex partners, unprotected anal or vaginal sex, unprotected sex with HIV-positive partner, unprotected sex while high, sharing of needles or “works,” tattoo or piercing by an unlicensed person.
Several questions were asked to assess respondents' clinical risk status, defined as one or more activities that would place a person at increased risk for acquiring HIV (e.g., unprotected anal or vaginal sex, unprotected sex with someone who is HIV positive, unprotected sex while high, sharing of needles or “works”). On the basis of responses to the questionnaire, 64.4% of respondents were defined as high risk. However, when asked to rate their personal risk for contracting HIV, from no risk to high risk, the majority of respondents rated themselves as being at no or low risk (76%; Table 2). This result held across all sexual orientations and within separate risk behaviors, with respondents' perceived risk level lower than that indicated by their actual behavioral risk factors.
TABLE 2 Respondents' HIV Testing Attitudes and Experiences: Harlem, NY, 2005
| No. (%) | |
| Ever asked by partner about past HIV testing | 127 (73.8) |
| Ever asked partner about partner's past HIV testing | 127 (73.8) |
| Close friend or family member who has HIV/AIDS | 99 (56.9) |
| Perceived risk for acquiring HIV | |
| No or low risk | 132 (75.9) |
| Medium or high risk | 42 (24.1) |
| Previously aware of rapid HIV testing | 139 (81.3) |
| Friends or family members have taken rapid HIV test | 91 (53.5) |
| Preferred timing for receipt of HIV test results | |
| 1–2 wk | 59 (36.2) |
| Same visit | 104 (63.8) |
| Reason for 1–2–wk preference (n = 59) | |
| Need time to prepare myself | 40 (66.7) |
| Want friend or family member with me | 7 (11.7) |
| Too scared/embarrassed | 2 (3.3) |
| Other | 11 (18.3) |
| Reason for same-visit preference (n = 89)a | |
| Want test results as soon as possible | 80 (89.9) |
| Too nervous to wait for results | 6 (6.7) |
| Might not return later | 2 (2.3) |
| Other | 1 (1.1) |
| Perception of accuracy of rapid blood test vs traditional HIV blood test | |
| More accurate or same accuracy | 143 (90.5) |
| Less accurate | 15 (9.5) |
| Perception of accuracy of rapid oral test vs traditional HIV blood test | |
| More accurate or same accuracy | 135 (88.2) |
| Less accurate | 18 (11.8) |
| Perception of accuracy of traditional oral test vs traditional HIV blood test | |
| More accurate or same accuracy | 146 (91.3) |
| Less accurate | 14 (8.7) |
| HIV pretest counseling type preferred | |
| Face-to-face session with counselor | 142 (87.7) |
| Counseling through written materials | 9 (5.6) |
| Telephone counseling | 4 (2.5) |
| Interactive computer presentation or video | 6 (3.7) |
| Other | 1 (0.6) |
| Preference for location of HIV test | |
| Clinic | 58 (43.9) |
| Private physician | 36 (27.3) |
| Hospital emergency room | 9 (6.8) |
| Mobile unit/van | 9 (6.8) |
| School | 8 (6.1) |
| Community-based organization | 7 (5.3) |
| Community event or festival | 2 (1.5) |
| Other | 3 (2.3) |
| Ever taken an HIV test | 150 (84.8) |
| No. of lifetime HIV tests | |
| 1–5 | 102 (69.8) |
| 6–10 | 30 (20.6) |
| ≥ 11 | 14 (9.6) |
| No. of HIV tests in past yearb | |
| 0 | 13 (8.8) |
| 1–5 | 129 (87.2) |
| 6–10 | 5 (3.4) |
| ≥ 11 | 1 (0.7) |
| Method of most recent testc | |
| Oral swab | 66 (50.8) |
| Finger-stick | 24 (18.5) |
| Blood draw from arm | 40 (30.8) |
| Location of most recent test | |
| School | 6 (4.5) |
| Clinic | 76 (57.1) |
| Hospital emergency room | 5 (3.8) |
| Private physician | 11 (8.3) |
| Mobile unit/van | 17 (12.8) |
| Jail/juvenile detention | 1 (0.8) |
| Community-based organization | 15 (11.3) |
| Community event or festival | 2 (1.5) |
| Returned for results | 146 (97.3) |
| Point at which results were available | |
| 1–2 wk | 79 (57.3) |
| During same visit | 59 (42.8) |
| Test results | |
| Negative | 130 (93.5) |
| Positive | 9 (6.5) |
aData were missing for 15 cases.
bOverall mean = 1.94; SD = 1.67.
cData were missing in 20 cases.
Table 2 presents an overview of HIV testing attitudes and experiences. Overall, in regard to HIV testing, 57% (n = 99) of the sample indicated knowing someone, such as a close friend or family member, with HIV. The vast majority of respondents (85%; n = 150) reported having been tested previously for HIV; 20% had undergone a single HIV test in their lifetime, and 73% had taken 2 or more tests. Those who had not yet been tested for HIV (15%; n = 27) cited issues related to time, confidentiality, fear, discomfort with talking with a counselor, and simply “forgetting.” Potentially motivating factors mentioned that might encourage future HIV testing included the perception that one's partner might have HIV or another sexually transmitted infection, a “condom accident,” feeling “sick,” and a partner undergoing testing.
As can be seen in Table 3, those who had not undergone testing were significantly less likely than were those who had been tested to have attended college (P = .004), to have a close friend or family member with HIV/AIDS (P < .001), and to have asked a partner or been asked by a partner about past HIV tests (P < .001). However, interestingly, those who had not been tested were significantly more likely to report unprotected anal intercourse (P = .003), and they were significantly less likely to be aware of rapid HIV testing (P = .001), to have had a friend or family member who had taken a rapid test (P < .001), and to report a preference for rapid testing in the future (P = .025).
TABLE 3 Distinguishing Characteristics Between Respondents With and Without a History of HIV Testing: Harlem, NY, 2005
| Characteristic | % Previously Tested (n = 150) | % Not Previously Tested (n = 27) | P |
| Educational attainment | .004 | ||
| Some high school, high school diploma, or GED | 58.5 | 88.5 | |
| Some college or college degree | 41.5 | 11.5 | |
| Unprotected anal sex | 40.2 | 72.0 | .003 |
| Ever asked by partner about HIV testing | 83.5 | 22.2 | <.001 |
| Ever asked partner about partner's HIV testing | 82.8 | 25.9 | <.001 |
| Close friend or family member with HIV/AIDS | 64.0 | 18.5 | <.001 |
| Previously aware of rapid HIV testing | 85.4 | 59.3 | .001 |
| Friends or family members have taken rapid HIV test | 60.1 | 18.5 | <.001 |
| Preference for receipt of test results at same visit as testing (i.e., rapid testing) | 67.4 | 44.0 | .025 |
Note. GED = general equivalency diploma.
With respect to experiences with rapid testing, 81% of the sample reported that they had previously heard about the rapid HIV test, and more than half (53.5%) reported having friends or a family member who had taken the test. Of the 150 respondents with previous HIV testing experiences, 43% indicated that their most recent test results were available during the same visit as their test (i.e., they had taken the rapid HIV test). Of those reporting that their results were available 1 to 2 weeks after the test, almost all indicated that they returned for their results. Respondents who had not returned for results clarified on the survey that they had recently been tested, were in the 2-week waiting period, and were scheduled to return for results over the upcoming weeks.
Sixty-four percent (n = 104) of the respondents reported that they would seek rapid HIV testing in the future. The reasons cited by these respondents included wanting the results as soon as possible (90%), feeling too nervous to wait for results (7%), and feeling that they might not return for results (2%). Of those who reported a preference for traditional testing procedures (n = 59; 36%), two thirds (n = 40) indicated that they would need time to prepare themselves, 12% (n = 7) wanted to have a friend or family member with them, and 3% (n = 2) indicated that they were too scared or embarrassed to get their results immediately. Twelve percent (n = 7) indicated some other reason for wanting to wait for their test results, including several who expressed a belief that the rapid test would not be as accurate as the traditional test.
Those who preferred same-day test results were significantly more likely than were those who preferred delayed results to have attended at least some college (P = .006), to have asked a sex partner or been asked by a sex partner about past HIV testing (P = .028 and P = .019, respectively), and to have a close family member or friend with HIV (P = .02; Table 4 ). Likewise, those preferring rapid testing were more likely to have a friend or family member who had taken a rapid test (P < .001) and to be aware of rapid testing (P = .004); they were also more likely to have been tested in the past (P = .025) and to have taken a rapid test previously (P < .001). Finally, when asked about beliefs regarding the accuracy of various types of HIV tests relative to a traditional HIV blood test, respondents who expressed a preference for delayed test results were significantly more likely to perceive the rapid blood test and the rapid oral test to be less accurate (P < .01 and P = .012, respectively).
TABLE 4 Distinguishing Sociodemographic and Behavioral Risk Factors Between Respondents Preferring Delayed Results vs Same-Day Results: Harlem, NY, 2005
| Characteristic | % Prefer Delayed Results (n = 59) | % Prefer Same-Visit Results (n = 104) | P |
| Educational attainment | .006 | ||
| Some high school | 21.4 | 58.6 | |
| High school or GED | 48.5 | 51.5 | |
| Some college | 22.2 | 77.8 | |
| College degree | 18.2 | 81.8 | |
| Unprotected sex while high | 7.6 | 21.7 | .027 |
| Ever asked by partner about HIV testing | 63.2 | 79.2 | .028 |
| Ever asked partner about partner's HIV testing | 63.2 | 80.2 | .019 |
| Close friend or family member with HIV/AIDS | 44.8 | 63.7 | .02 |
| Ever taken HIV test | 76.3 | 89.4 | .025 |
| Timing of receipt of past HIV test results | <.001 | ||
| 1–2 wk | 88.4 | 41.9 | |
| Same visit | 11.6 | 58.1 | |
| Previously aware of rapid HIV testing | 68.4 | 87.1 | .004 |
| Friends or family members have taken rapid HIV test | 33.9 | 65.4 | <.001 |
| Believes that rapid blood test is less accurate than traditional blood draw | 17.5 | 5.0 | <.01 |
| Believes that rapid oral test is less accurate than traditional blood draw | 20.8 | 7.0 | .012 |
| Believes that traditional oral test is less accurate than traditional blood draw | 8.6 | 8.8 | .965 |
Note. GED = general equivalency diploma.
A major benefit of rapid HIV testing is the potential to provide clients with their test results in a single session, thereby dramatically reducing the number of individuals who are unaware of their status because of failure to return for results. Provision of a positive test result, if linked to timely referrals for evaluation and treatment, can prove instrumental in reducing further transmission of the disease. In addition, morbidity and mortality rates could be further reduced through early intervention.
Contrary to other studies, the prevalence of HIV testing experiences among the surveyed population of MSM of color was quite high, at 85%. The rate of return for results among those with traditional HIV testing experiences was also greater than has been noted in other studies. However, given the high degree of risk taking reported by respondents, those who reported never having been tested (15%) are of particular concern.
Respondents seemed aware of rapid testing procedures and, similar to surveys with adult populations, appeared to embrace the ease and convenience of learning their status quickly. Of note, however, is that a substantial percentage of young adults (36%) indicated their preference for undergoing traditional tests in the future for reasons stemming from their need to have appropriate psychosocial preparation and support, as well as concerns about the accuracy of the test methodology itself. This percentage is higher than that reported in several studies conducted among adults, in which more than 80% expressed a preference for rapid testing modalities,13,16 and it could indicate the need to carefully consider the unique needs of young people.
Our findings suggest that public health approaches to alert young MSM of color about HIV and the importance of regular testing have been partially effective in reaching a subsample of the population. However, those young MSM of color who are particularly disenfranchised (e.g., lacking formal education) and who are at high risk of engaging in health-compromising behaviors may need additional and more concerted efforts at raising awareness about HIV testing and engagement in HIV counseling and testing opportunities.
Although rapid testing appears to be an important modality to enhance awareness of HIV status and potential linkage to care, a substantial percentage of our sample, as mentioned, preferred more traditional methods. Such preferences may change over time as rapid HIV testing becomes a more routine offering in both community and clinical settings. Our study indicates that respondents who had a friend or family member screened via rapid HIV testing methods were more likely to be screened in this manner themselves, suggesting the importance of social influences.
Nonetheless, care must be taken to examine and address additional reasons for reluctance to use this HIV testing modality. Given our participants' reported concerns about accuracy, there seems to be a need for more effective education and marketing strategies.
This pilot study involved several limitations. For example, use of self-reported information led to the possibility of recall bias or socially desirable responses. The sample was also relatively small and limited to data from a single urban community over a narrow time frame; therefore, our results are limited in regard to their generalizability to other individuals, places, or times.
We did not find, from our review of the current literature, any instruments that measure level of awareness of and preferences toward rapid HIV testing among young, urban MSM of color. Thus, we did not use a theory-driven approach in constructing our survey items, and these items had not been previously used with members of the population under study. However, as a means of reflecting the language commonly used and understood by the population of interest, a panel of experts who work closely with young, urban MSM of color was assembled to inform survey development. In addition, a group of individuals from the sample population provided substantial feedback that was used to further refine and finalize survey items.
Finally, because GMAD offers rapid testing at its offices, results may have been skewed in favor of rapid testing technologies. However, GMAD counselors did not recruit participants seeking HIV testing at their offices; rather, they recruited from community outreach and social events and made no specific mention of the types of HIV testing services offered at their organization. Despite the limitations just described, we believe that our findings provide important initial insight into testing preferences among young adult MSM in an urban minority community.
More attention should be focused on the perceived psychosocial needs of young adults undergoing HIV testing, in that several respondents noted the importance of having time to mentally prepare and acquire an appropriate support system to help them cope with a potentially life-changing diagnosis. Testing locations should be prepared to identify which young adults may be in need of support services and should be able to provide support to socially vulnerable HIV-positive individuals.14,15 Finally, testing sites engaging young MSM of color may want to consider continuing to offer a range of screening options for HIV to accommodate these young men's preferences and enhance their likelihood of testing.
Acknowledgments
Funding for this study was provided by Mark Kaplan and Abbott Laboratories.
We acknowledge the support of Tokes Osubu, executive director of Gay Men of African Descent (GMAD), as well as Columbus Gaskins, HIV health educator. Likewise, Borris Powell and Donald Powell of GMAD assisted with creation of the instrument and oversight of community data collection efforts.
Human Participant Protection
This study was approved by the Columbia University institutional review board. Participants provided written informed consent.
