Studying HIV and STI Testing Preferences in Men Who Have Sex With Men

Ellen Eaton, M.D. (right), and Kelsie Dodson.
University of Alabama-Birmingham

While many in the field of infectious disease research and medicine have noted the decline in new investigators and practitioners entering the workforce, the HIV Medicine Association and the Infectious Diseases Society of America Foundation have teamed up to do something about it. Over the summer, they announced a program to fund 15 medical students in the U.S. for clinical learning and research projects, each to be paired with an experienced mentor to support the student's research area of interest.

We spoke with Ellen Eaton, M.D., assistant professor of medicine, Division of Infectious Diseases at the University of Alabama at Birmingham, and her mentee, Kelsie Dodson, a third-year medical student at the University of Alabama at Birmingham, about their joint interest in learning the preferences of men who have sex with men with regard to sexually transmitted infection (STI) and HIV testing in order to provide patient-centered care.

Jeanine Barone: In terms of reducing HIV transmission, why is it so important for men who have sex with men (MSM) to be tested for STIs?

Ellen Eaton: Through a variety of mechanisms, bacterial STIs can increase the chances that an HIV-negative person will acquire HIV and the chances that an HIV-positive person will spread HIV to their sexual partners.

JB: How do you classify patient-centered testing options?

EE: "Patient-centered" refers to tests or interventions that put the patient's preferences and values first. Patient input is considered in conjunction with that of the clinician and health system and in keeping with relevant policies and procedures. Patient-centered testing may include a comfortable exam room; friendly, non-judgmental staff; and electronic options, such as text notification of lab results and medication prescription orders.

JB: Is any patient-centered testing option better than any non–patient-centered option, or is it more relevant for it to be customized by the patient?

EE: The best option is one that is accessible, acceptable, and used by patients. Even if a lab test is 100% accurate, it is useless if patients are unwilling to be tested due to stigma associated with a clinic or difficulty paying co-pays and laboratory bills. And yes, what is acceptable may need to be customized to certain patients, depending on their preferences. We found that it is important to have options when providing STI testing.

JB: Are patient-centered testing options more relevant for MSM who are at increased risk, as opposed to other high-risk demographics, such as women, with regard to HIV?

EE: We know that young women seek medical care more than young men, often due to reproductive health issues, and minorities have additional barriers to care. For that reason, we need to lower any barriers that may prevent young, black men from receiving appropriate STI and HIV testing and treatment. However, there is room to improve patient-centered care for patients of any age, race/ethnicity, and gender.

JB: What is the best evidence that patient-centered testing options make a difference in this population?

EE: The Dean Street clinic in the United Kingdom was able to dramatically increase the number of clients served and STI and HIV cases diagnosed by offering an attractive, anonymous, yet welcoming venue for sexual health care.

JB: Since you're located in Alabama, where the incidence of certain STIs is high compared with the rest of the country, do you think patient-centered testing might be more relevant in this state and others with similar statistics?

EE: Alabama and the Deep South, in general, have high rates of gonorrhea and chlamydia (in addition to HIV), which makes frequent STI testing critical. We see young, minority patients bearing the brunt of these conditions, and it is likely that we are only diagnosing the symptomatic infections (i.e., patients with discharge). This is just the tip of the iceberg; many of their sexual partners without symptoms are unknowingly spreading these silent infections through Deep South communities.

JB: Why did you decide to work with Dr. Eaton on this topic?

Kelsie Dodson: I met Dr. Eaton during one of my first weeks of medical school, when she was my preceptor for an introductory class called "Patient, Doctor, and Society." When I asked her about her ongoing projects, she sent me a New York Times article highlighting the burden of HIV in the Deep South to provide more context to her work, and I found the statistics particularly disturbing. I loved that this research project had the potential to directly inform patient care in my community.

JB: Did this topic interest you from the perspective of public health, HIV, or infectious diseases in general?

KD: All of the above. My favorite undergraduate course was virology, and infectious diseases has always been on my radar. I became specifically interested in HIV during my time after college as a high school biology teacher. My students' final project was to organize an information fair for their peers for National Youth HIV/AIDS Awareness Day. Though my goal had been for them to learn about viral replication and stigma in health care, I realized how little I actually knew about HIV. I was shocked by some of the statistics they shared, especially regarding HIV in minority adolescents.

JB: With regard to the focus groups you're participating in, can you discuss your findings?

KD: Recruitment for focus group participants was challenging. More participants were recruited by trusted individuals (health care staff or peers) than by flyers in public places or by a young male recruiter at community events. We realized how hard it is to recruit young racial and sexual minorities and how recruitment strategies impact results. When it comes to STI testing, the focus group participants prioritized trust, privacy, and choices. Some thought self-tests in non-traditional settings (the patient's home, public events, private businesses) would be convenient, though many participants preferred a clinical setting with medical professionals. Participants considered normalizing HIV testing as a means to combat stigma. Stigma is unfortunately still a barrier to testing for many.

JB: What role do you think your findings might have in the HIV field?

KD: Regarding recruitment, we still do not know enough about the health care preferences of young, black MSM in the Deep South. We also suspect that there are "hidden populations" of young, black MSM who are not represented in HIV research. Discussing our recruitment strategies may allow other researchers to more efficiently recruit young, black MSM for their projects and access men who have been traditionally excluded from research. Regarding STI/HIV testing, ultimately, learning the STI testing preferences of young, black MSM may impact how we allocate STI testing resources. Our findings indicate that home testing may be favorable for some young, black MSM, but many still prefer testing at clinical sites with appropriate physician follow-up. This highlights how patient preferences may vary greatly by individual and region. I also think this is extremely valuable information for primary care and urgent care providers, who are in a powerful position to offer testing to those at risk. Patient-centered care may mean providing affordable home-testing options, but it may also mean improving access to pre-existing clinical locations for young, black MSM.

Jeanine Barone is a scientist and journalist with an eclectic background. She's a nutritionist and exercise physiologist who regularly writes about travel, health, fitness, and food for numerous top-tier publications. Jeanine enjoys active travel, especially long-distance cycling and cross-country skiing.