1. THE ROLE OF RELATIONSHIP STATUS ON HIV TESTING AMONG AFRICAN AMERICANS Alexandra Marshall, PhD, MPH, CPH, CHES Duston Morris, PhD, MS, CHES

2. Acknowledgement  Student: LaToya Zeigler  Performed the study presented today to complete her thesis for the MS in Health Sciences degree program  Completed Spring 2013  Dr. Morris acted as her research advisor

3. Objectives  Identify HIV incidence among African Americans.  Identify how relationship status influences HIV testing among African Americans.  Discuss the relationship between the Theory of Planned Behavior and HIV testing among African Americans.

4. Background  HIV/AIDS disproportionately affects African Americans in the U.S.  In 2010, African Americans made up 44% of all new cases of HIV.  Despite being only 14% of the U.S. population

5. Background (continued)  Men who have sex with men (MSM) remain the group most heavily affected by HIV in the United States.  CDC estimates that MSM represent approximately 4% of the male population in the United States  male-to-male sex accounted for more than 3/4 (78%) of new HIV infections among men and nearly 2/3 (63%) of all new infections in 2010 (29,800)

6. Background (continued)  Heterosexuals accounted for 25% of estimated new HIV infections in 2010 (12,100).  2/3 (66%) of those infected through heterosexual sex were women.  The number of new HIV infections among females attributed to heterosexual contact decreased from 9,800 in 2008 to 8,000 in 2010 largely because of a drop in infections among black heterosexual women overall.

7. AIDS incidenceHIV incidenceHIV/AIDS incidence YearNumberPercentNumberPercentNumberPercent 199343183.7%8416.3%515100.0% 199429368.1%13731.9%430100.0% 199525563.6%14636.4%401100.0% 199621669.7%9430.3%310100.0% 199719863.7%11336.3%311100.0% 199820463.8%11636.3%320100.0% 199918865.3%10034.7%288100.0% 200015957.2%11942.8%278100.0% 200117062.0%10438.0%274100.0% 200217460.4%11439.6%288100.0% 200312352.1%11347.9%236100.0% 200416153.5%14046.5%301100.0% 200518656.7%14243.3%328100.0% 200616753.9%14346.1%310100.0% 200715451.2%14748.8%301100.0% 20089235.1%17064.9%262100.0% 200913945.4%16754.6%306100.0% 201010937.1%18562.9%294100.0% 20118331.8%17868.2%261100.0% 20127631.1%16868.9%244100.0% 201311433.5%22666.5%340100.0% HIV/AIDS incidence 1993-2013 in Arkansas

8. AIDS incidence, Jan-Dec 2013 HIV incidence Jan-Dec 2013 HIV/AIDS incidence Jan- Dec 2013 GenderNumberPercentNumberPercentNumberPercent Female2521.9%4319.0%6820.0% Male8978.1%18381.0%27280.0% Total114100.0%226100.0%340100.0% Race/EthnicityNumberPercentNumberPercentNumberPercent White, Non-Hispanic4136.0%8738.5%12837.6% Black, Non-Hispanic5750.0%12454.9%18153.2% Am Ind/AK Nat, Non- Hispanic 00.0%0 0 Asian/HI/PI, Non- Hispanic 10.9%00.0%10.3% Hispanic97.9%125.3%216.2% Other, Non-Hispanic65.3%31.3%92.6% Total114100.0%226100.0%340100.0% HIV/AIDS by Gender & Race in Arkansas 2013

9. AIDS incidence, Jan-Dec 2013 HIV incidence Jan-Dec 2013 HIV/AIDS incidence Jan-Dec 2013 Age at DiagnosisNumberPercentNumberPercentNumberPercent <1300.0%10.4%10.3% 13-1400.0%0 0 15-241815.8%7935.0%9728.5% 25-343026.3%6729.6%9728.5% 35-443328.9%4519.9%7822.9% 45-542219.3%2310.2%4513.2% 55-6487.0%104.4%185.3% 65+32.6%10.4%41.2% Total114100.0%226100.0%340100.0% Exposure CategoryNumberPercentNumberPercentNumberPercent Male Sex w/ Male (MSM) 5951.8%13961.5%19858.2% Injection Drug Use (IDU) 43.5%52.2%92.6% MSM & IDU32.6%52.2%82.4% High Risk Heterosexual 119.6%198.4%308.8% No Identified/Reported Risk 3732.5%5825.7%9527.9% Total114100.0%226100.0%340100.0% HIV/AIDS incidence by Age & Exposure in Arkansas 2013

10. Top 10 States (including District of Columbia and Six Dependent Territories) for Newly Diagnosed HIV Infections, 2012

11. All Persons Living with HIV Infection as of 12/31/2013 in North Carolina by Selected Demographics

12. Adult/Adolescent Newly Diagnosed HIV Infection Cases by Hierarchical Risk of HIV Exposure in North Carolina, 2013

13. New HIV Diagnoses among Adolescent (13-24 years) by Gender and Race/Ethnicity in North Carolina, 2013

14. Hierarchical Risk of HIV Exposure among Adolescent (13-24 years) HIV Infection Cases Diagnosed (Unknown Risk Redistributed) in North Carolina, 2013

15. HIV testing  Testing is the first step in controlling the spread of HIV.  Relationship status has been shown to influence HIV testing among minority MSM.

16. History of State-Sponsored HIV Testing in North Carolina  The North Carolina State Laboratory of Public Health (North Carolina SLPH) has been processing blood samples for HIV testing since 1987  Effective in May 1997, anonymous testing in North Carolina was eliminated through a ruling made by the North Carolina Commission of Health Services.  North Carolina implemented procedures to increase access to HIV testing by making testing available in nontraditional testing sites.

17. History of State-Sponsored HIV Testing in North Carolina  Changes in policy, HIV testing technology, and funding have enabled North Carolina to expand the number of people tested for HIV over time.  In 2006, the CDC published revised HIV testing guidelines  North Carolina changed the state administrative code on November 1, 2007.  This rule change stated that for tests done in clinical settings, a written HIV consent form and pre-test counseling were no longer required, thereby removing some of the barriers to routine HIV testing.

18. North Carolina HIV Testing Positivity Rates by Setting and Gender, 2013

19. Study Purpose  To determine the role that relationships play in influencing HIV testing behavior among African American males and females in North Carolina.

20. Theoretical Framework  Survey items assessed the Theory of Planned Behavior (TPB) constructs:  subjective norms regarding HIV testing  attitudes toward HIV testing  perceived behavioral control over HIV testing  And the intention to get tested for HIV Intention to act is thought to be the greatest predictor of behavior.

21. Theory of Planned Behavior BehaviorIntention to act Attitude toward behavior Behavioral beliefs Evaluation of outcomes Subjective norm Normative beliefs Motivation to comply Perceived behavioral control Control beliefs Perceived power

22. Hypotheses 1. Presence of a significant other would significantly influence HIV testing among African Americans. 2. Significant others’ beliefs about testing would significantly influence HIV testing among African Americans. 3. Friends’ and family’s beliefs about testing would significantly influence HIV testing among African Americans.

23. Methods  A convenience sample of participants (N=100) were recruited from a community-based facility in Durham, NC.  Healing with CAARE, Inc.  http://caareinc.org/ http://caareinc.org/  Participants completed a 20-item survey that addressed self-reporting subjective norms related to HIV testing, attitudes toward HIV testing, perceived behavioral control over HIV testing, and behavioral intentions to get tested for HIV.

24. HIV Testing Inventory on African Americans  Selected demographic items

25.  Selected Attitude items HIV Testing Inventory on African Americans

26.  Selected Social Norms items HIV Testing Inventory on African Americans

27.  Selected Perceived Behavioral Control items

28. HIV Testing Inventory on African Americans  Selected Behavioral Intention items

29. Results  Results of the chi-square analyses revealed that there was no significant association between gender and intentions to test for HIV with a significant other X 2 (df=2, N=100) =.164, p=.26, phi=.164.

30. Results  There was no significant association between gender and being tested for HIV despite significant other not wanting to be tested X 2 (df=2, N=100) =.198, p=.14, phi=.198.

31. Results  There was no significant association between gender and getting tested despite disapproval from family or close friends for testing X 2 (df=2, N=100) =.106, p=.57, phi=.106.

32. Conclusions  Having a significant other did not influence HIV testing behaviors among African American participants in the study.  In addition, disapproval of HIV testing from family or close friends did not influence participants’ intention to get tested.

33. Discussion  Given the survey results, participants have a strong intention to get tested for HIV.  Clearly the health promotion messages advocating for HIV testing are effectively delivered in North Carolina particularly in this community.

34. Implication for Practice  The TPB may guide an understanding of HIV testing behaviors.  However, since intentions to get tested for HIV seem strong despite the influence of a significant relationship, other research may explore the “perceived severity” or “perceived susceptibility” constructs of the Health Belief Model or other theoretical models to help explain the strength of this association between intentions and behaviors.

35. Health Belief Model Likelihood of engaging in healthy behavior Perceived Benefits vs. perceived barriers Modifying variables (KAB) Perceived threat Perceived seriousness Perceived susceptibility Self-efficacy Cues to action

36. Discussion Questions  What similarities or differences did you notice between Arkansas and North Carolina regarding the data on HIV incidence presented?  What do you think would be worth exploring here in Arkansas?  What else stood out to you today?

37. References  Arkansas Department of Health STI/HIV/Hepatitis C/TB Section (2014). HIV Surveillance Report Arkansas, 2013. Arkansas Department of Health, Little Rock, Arkansas.  CDC. Estimated HIV incidence among adults and adolescents in the United States, 2007–2010. HIV Surveillance Supplemental Report 2012;17(No. 4). http://www.cdc.gov/hiv/topics/surveillance/resources/reports/#suppleme ntal. Published December 2012.  North Carolina HIV/STD Surveillance Unit. (2015). 2013 North Carolina HIV/STD Epidemiologic Profile. North Carolina Department of Health and Human Services, Raleigh, North Carolina.  Purcell D et al. Estimating the population size of men who have sex with men in the United States to obtain HIV and syphilis rates. The Open AIDS Journal 2012; 6(Suppl 1: M6): 114–123.

38. Alex Marshall @AMarshallTweets smarshall@uams.edu Duston Morris dustonm@uca.edu Thank you for your attention!