Gay Neighborhoods: Can They Be Identified in a Systematic Way Using Latent Class Analysis?

Identifying gay neighborhoods could help in targeting HIV prevention efforts for men who have sex with men. This study's purpose was to identify gay neighborhoods using latent class analysis (LCA). Data at the ZIP code level were drawn from the American Community Survey, website lists of gay bars and neighborhoods, and the Florida Department of Health HIV surveillance system. A two-class model was selected based on fit. About 9% of the ZIP code data was in class two, which was designated as gay neighborhoods. Cohen's kappa coefficient was used to examine agreement between the classification of ZIP codes from LCA and websites. Fair agreement was found (0.2501). Gay neighborhoods could serve as a place to disseminate information about pre-exposure prophylaxis and other methods for HIV prevention. Improved measures, such as the planned question about same-sex spouses for the 2020 US Census, are needed to identify gay neighborhoods in population-level surveys.

Social disorganization and new HIV diagnoses, 2013-2017, Florida: Rural-urban differences.

PURPOSE: To compare the role of neighborhood social disorganization factors on human immunodeficiency virus (HIV) diagnosis rates in urban and rural areas in Florida, we conducted an ecologic study of HIV diagnosis rates during 2013-2017 and social disorganization components, including concentrated disadvantage, ethnic heterogeneity, and residential instability. METHODS: Indices of social disorganization components were obtained from principal component analyses of American Community Survey variables for 910 postal codes. Rural/urban classification was based on the United States Department of Agriculture Rural Urban Commuting Area codes. Using multivariable linear regression, the relationship between social disorganization indices and HIV diagnosis rates was assessed. FINDINGS: The only social disorganization index that was significantly higher in rural than urban areas was concentrated disadvantage. In rural areas, the concentrated disadvantage index was significantly associated with HIV diagnosis rates (P = .007) when controlling for the other social disorganization factors but was no longer significant after additionally controlling for prevalence of people with an HIV diagnosis who were not virally suppressed. In urban areas, even after controlling for prevalence of people with HIV who were not virally suppressed, lower male-to-female population ratios and higher scores of residential instability, concentrated disadvantage, and LatinX/immigrant density indices were associated with higher HIV diagnosis rates (all P < .01). CONCLUSIONS: In addition to improving community levels of viral suppression, the community contextual environment, including the rurality of the environment, needs to be considered in strategies to end the HIV epidemic in the United States.

Examining the Psychometrics of the National HIV Behavioral Surveillance Measure for Community HIV-Related Stigma.

The research tested the psychometrics of the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance (NHBS) community HIV-related stigma scale. Data was from men who have sex with men (MSM) NHBS cycles conducted 2011-2017 in Miami-Dade, Florida among n = 1455 participants. MSM were cis-gender male, 18+ years old, reported lifetime oral/anal sex with a male, and lived in Miami-Dade County. We assessed reliability using Cronbach's alpha and McDonald's omega, determined factors using principal factor analysis, and assessed construct validity using five a priori hypotheses. The scale was unidimensional, had questionable internal reliability (α = 0.68, ω = 0.69), and met four of five a priori hypotheses in the expected direction. Correlations were medium-weak in strength and only one was consistently met. Future iterations of the NHBS survey should consider replacing the 4-item community HIV-related stigma scale with an instrument that has superior internal reliability, measures multiple HIV-related stigma dimensions, and demonstrates stronger evidence of validity.

RESUMEN: La investigación evaluó la psicometrías de la escala comunitaria de estigma relacionada con el VIH de La Vigilancia del Comportamiento Nacional del VIH de los Centros de Control y la Prevención de Enfermedades (National HIV Behavioral Surveillance, NHBS por sus siglas en Ingles). Los datos fueron de hombres que tienen sexo con hombres (HSH) ciclos NHBS realizados 2011­2027 en Miami-Dade, Florida entre n = 1455 participantes. Los HSH eran hombres cisgénero, mayores de 18 años, reportando haber tenido sexo oral/anal de toda la vida con un hombre y vivían en el condado de Miami-Dale. Evaluamos la confiabilidad usando el alfa de Cronbach y el omega de McDonald, determinamos los factores usando el análisis de factores principales y evaluamos la validez de constructo usando cinco hipótesis a priori. La escala era unidimensional, tenía una fiabilidad interna cuestionable (α = 0.68, ω = 0.69), y cumplía cuatro de cinco hipótesis a priori en la dirección esperada. Las correlaciones fueron de intensidad media-débil y solo una se cumplió de manera consistente. Las iteraciones futuras de la encuesta NHBS debería considerar reemplazar la escala comunitaria de estigma relacionada con el VIH de 4 ítems por un instrumento que tenga una confiabilidad interna superior, mida múltiples dimensiones del estigma relacionado con el VIH y demuestre una evidencia mas solida de validez.

Identifying patterns of retention in care and viral suppression using latent class analysis among women living with HIV in Florida 2015-2017.

The study objective was to classify women with newly diagnosed HIV into patterns of retention in care (≥2 HIV care visits ≥3 months apart) and viral suppression over time and identify factors associated with class membership. Florida HIV/AIDS surveillance data were used to conduct Latent Class Analysis to classify women into patterns, and multinomial regression was used to compare the prevalence of class membership by demographic and clinical factors. Four classes were selected based on model fit parameters: (Class 1) consistently retained and suppressed (>90% probability of being retained and suppressed), (Class 2) not consistently retained or suppressed (≤10% probability of being retained and suppressed), (Class 3) increasingly retained and suppressed, and (Class 4) decreasingly retained and suppressed. The proportion of women in each class was 48.6%, 24.9%, 14.3%, and 12.2%, respectively. Women aged 25-34 compared to 35-49 years old, injection drug use mode of exposure, US born, and not linked to care three months post-diagnosis had a lower prevalence of belonging to the consistently retained and suppressed class. Findings may be useful in tailoring and targeting interventions to increase the prevalence of women who are consistently retained in care and virally suppressed.

Estimating the size of HIV-negative MSM population that would benefit from pre-exposure prophylaxis in Florida.

PURPOSE: This study aimed to estimate the size of the population of men who have sex with men (MSM) in Florida with high-risk behaviors that would indicate eligibility for pre-exposure prophylaxis (PrEP) use. METHODS: Three methods were used to estimate the MSM population. Estimates from the three methods were averaged, and the number of MSM living with HIV in each zone improvement plan (ZIP) code was subtracted. RESULTS: The average MSM estimate was 1-2184 men (1.5-22.9%) by ZIP code. The size of the MSM population with indications for PrEP use was highest when using estimates of MSM with more than one sex partner in the past year obtained from the National HIV Behavioral Surveillance system and lowest when the MSM estimate was multiplied by 24.7% (percentage of MSM with PrEP indications from other studies). CONCLUSION: Areas with high numbers of MSM with PrEP indications could be targeted with information to reduce HIV acquisition.

Improving HIV Surveillance Data by Using the ATra Black Box System to Assist Regional Deduplication Activities.

BACKGROUND: Focused attention on Data to Care underlines the importance of high-quality HIV surveillance data. This study identified the number of total duplicate and exact duplicate HIV case records in 9 separate Enhanced HIV/AIDS Reporting System (eHARS) databases reported by 8 jurisdictions and compared this approach to traditional Routine Interstate Duplicate Review resolution. METHODS: This study used the ATra Black Box System and 6 eHARS variables for matching case records across jurisdictions: last name, first name, date of birth, sex assigned at birth (birth sex), social security number, and race/ethnicity, plus 4 system-calculated values (first name Soundex, last name Soundex, partial date of birth, and partial social security number). RESULTS: In approximately 11 hours, this study matched 290,482 cases from 799,326 uploaded records, including 55,460 exact case pairs. Top case pair overlaps were between NYC and NYS (51%), DC and MD (10%), and FL and NYC (6%), followed closely by FL and NYS (4%), FL and NC (3%), DC and VA (3%), and MD and VA (3%). Jurisdictions estimated that they realized a combined 135 labor hours in time efficiency by using this approach compared with manual methods previously used for interstate duplication resolution. DISCUSSION: This approach discovered exact matches that were not previously identified. It also decreased time spent resolving duplicated case records across jurisdictions while improving accuracy and completeness of HIV surveillance data in support of public health program policies. Future uses of this approach should consider standardized protocols for postprocessing eHARS data.

Changing demographic among Latino MSM diagnosed with HIV in Florida, 2007-2016.

The study's objective was to assess temporal changes in birth country and age among newly diagnosed Latino men who have sex with men (MSM). We used records from Hispanics/Latinos (2007-2016) who were reported to the Florida HIV/AIDS surveillance system. We compared trends in birth country/region and age by year using a two-sided Cochran-Armitage Trend Test. Of 12,427 new diagnoses, 85.9% were among men. Of men, 79.5% were MSM. The proportion attributable to MSM increased from 70.0% in 2007-85.7% in 2016 (p-value < .0001). Compared with the trend in the proportion of MSM cases born in US-mainland, the proportion born in Cuba (20.0-29.9%; p-value < .0001) and South America (13.8% to 23.2%; p-value < .0001) increased significantly over time, and the proportion born in Central America (8.1% to 4.5%; p-value < .0001) decreased significantly over time. Compared with the trend in the proportion of MSM aged 35-49 years, the proportion aged 13-24 (15.4% to 20.6%; p-value < .0001) and 25-34 (25.0% to 35.6%; p-value < .0001) years increased significantly over time. In Florida, HIV prevention and screening strategies should be enhanced for Cuban and South American immigrants and young Latinos to address the increasing trend in new diagnoses among Latino MSM.

Racial/Ethnic Disparities in Failure to Initiate HIV Care: Role of HIV Testing Site, Individual Factors, and Neighborhood Factors, Florida, 2014-2015.

Delayed initiation of human immunodeficiency virus (HIV) care affects disease progression. To determine the role of HIV testing site and neighborhood- and individual-level factors in racial/ethnic disparities in initiation of care, we examined Florida population-based HIV/AIDS surveillance system records. We performed multilevel Poisson regression to calculate adjusted prevalence ratios (APR) for non-initiation of care by race/ethnicity adjusting for HIV testing site type and individual- and neighborhood-level characteristics. Of 8,913 people diagnosed with HIV during 2014-2015 in the final dataset, 18.3% were not in care within three months of diagnosis. The APR for non-initiation of care for non-Hispanic Blacks relative to non-Hispanic Whites was 1.57 (95% confidence interval [CI] 1.38-1.78) and for those tested in plasma/donation centers relative to outpatient clinics was 2.45 (95% CI 2.19-2.74). Testing site and individual variables contribute to racial/ethnic disparities in non-initiation of HIV care. Linkage procedures, particularly at plasma/blood donation centers, warrant improvement.

Role of Country of Birth, Testing Site, and Neighborhood Characteristics on Nonlinkage to HIV Care Among Latinos.

The objective of this study was to estimate disparities in linkage to human immunodeficiency virus (HIV) care among Latinos by country/region of birth, HIV testing site, and neighborhood characteristics. A retrospective study was conducted using Florida HIV surveillance records of Latinos/Hispanics aged ≥13 diagnosed during 2014-2015. Linkage to HIV care was defined as a laboratory test (HIV viral load or CD4) within 3 months of HIV diagnosis. Multi-level Poisson regression models were used to estimate adjusted prevalence ratios (aPR) for nonlinkage to care. Of 2659 Latinos, 18.8% were not linked to care within 3 months. Compared with Latinos born in mainland United States, those born in Cuba [aPR 0.60, 95% confidence interval (CI) 0.47-0.76] and Puerto Rico (aPR 0.61, 95% CI 0.41-0.90) had a decreased prevalence of nonlinkage. Latinos diagnosed at blood banks (aPR 2.34, 95% CI 1.75-3.12), HIV case management and screening facilities (aPR 1.76, 95% CI 1.46-2.14), and hospitals (aPR 1.42, 95% CI 1.03-1.96) had an increased prevalence of nonlinkage compared with outpatient general, infectious disease, and tuberculosis/sexually transmitted diseases/family planning clinics. Latinos who resided in the lowest (aPR 1.57, 95% CI 1.19-2.07) and third lowest (aPR 1.33, 95% CI 1.01-1.76) quartiles of neighborhood socioeconomic status compared with the highest quartile were at increased prevalence. Latinos who resided in neighborhoods with <25% Latinos also had increased prevalence of nonlinkage (aPR 1.23, 95% CI 1.01-1.51). Testing site at diagnosis may be an important determinant of HIV care linkage among Latinos due to neighborhood or individual-level resources that determine location of HIV testing.

Delayed Diagnosis of HIV among Non-Latino Black Caribbean Immigrants in Florida 2000-2014.

Prompt HIV diagnosis decreases the risk of HIV transmission and improves health outcomes. The study objective was to examine rates of delayed HIV diagnosis among non-Latino Black Caribbean immigrants in Florida. The sample included 39,008 Black HIV-positive individuals, aged 13 or older from the Caribbean and the mainland U.S. Delayed HIV diagnosis was defined as AIDS diagnosis within three months of HIV diagnosis. After adjusting for demographic factors, year of HIV diagnosis, transmission mode, neighborhood level socioeconomic status, and rural-urban residence, a disparity persisted for Caribbean-born Blacks in the Bahamas and Haiti compared with U.S.-born Blacks. Male Jamaican-Bahamian-Haitian-born Blacks were more likely to have delayed diagnosis (aOR 2.17, 95% confidence interval [CI] 1.53-3.03; aOR 1.88, 95% CI 1.01-3.44; aOR 1.58, 95%CI 1.58). Findings suggest the need for targeted, culturally relevant interventions to reduce delayed diagnosis incidence among specific Caribbean-born Blacks.

Role of Gay Neighborhood Status and Other Neighborhood Factors in Racial/Ethnic Disparities in Retention in Care and Viral Load Suppression Among Men Who Have Sex with Men, Florida, 2015.

This study's objective was to examine the role of gay neighborhood residence and other neighborhood factors in racial/ethnic disparities in retention in HIV care and viral load suppression during 2015. Florida residents diagnosed 2000-2014 with HIV infection and with transmission mode of men who have sex with men (MSM) were included in multi-level logistic regression models. Of 29,156 MSM, 29.4% were not retained and 34.2% were not virally suppressed. Non-Hispanic Blacks (NHB) had a higher likelihood of not being retained (adjusted prevalence ratio [aPR] 1.31, 95% confidence interval [CI] 1.24-1.38, p value < 0.0001) and not being virally suppressed (aPR 1.82, 95% CI 1.67-1.98, p value < 0.0001) compared with non-Hispanic Whites. Among NHBs, rural residence was protective for both outcomes. Although gay neighborhood residence was not associated with either outcome, the role of other neighborhood factors suggests that individual and neighborhood barriers to HIV care and treatment should be addressed among MSM.

Deaths Due to Screenable Cancers Among People Living With HIV Infection, Florida, 2000-2014.

INTRODUCTION: Because of antiretroviral therapy, people living with HIV infection are surviving longer and are at higher risk for chronic diseases. This study's objective was to assess the magnitude of deaths due to cancers for which there are screening recommendations for people living with HIV in Florida. METHODS: Florida Department of Health Enhanced HIV/AIDS Reporting System data were matched with Department of Health Vital Records and the National Death Index to identify deaths and their causes through 2014. The sex-specific and cause-specific mortality rates and indirect standardized mortality ratios (SMRs, using U.S. mortality rates as a standard) were calculated during 2016 for people reported with HIV infection 2000-2014. RESULTS: Despite the competing risk of HIV mortality, among the 25,678 females, there was a higher risk of cervical (SMR=6.32, 95% CI=4.63, 8.44), colorectal (SMR=2.05, 95% CI=1.44, 2.83), liver (SMR=8.96, 95% CI=5.39, 14.03), and lung (SMR=5.82, 95% CI=4.80, 6.96) cancer mortality and lower risk of breast cancer mortality (SMR=0.57, 95% CI=0.42, 0.76). Among 63,493 males, there was a higher risk of liver (SMR=5.50, 95% CI=4.47, 6.70) and lung (4.63, 95% CI=4.11, 5.19) cancer mortality. Among males, the lung cancer SMR significantly declined 2000-2014 (p<0.05), but was still high in 2012-2014 (SMR=3.59, 95% CI=2.87, 4.43). CONCLUSIONS: These results indicate the importance of primary and secondary cancer prevention during primary care for people living with HIV infection.

Retention in HIV Care and Viral Suppression: Individual- and Neighborhood-Level Predictors of Racial/Ethnic Differences, Florida, 2015.

The objective of this study was to estimate racial/ethnic differences in retention in HIV care and viral suppression and to identify related individual and neighborhood determinants. Florida HIV surveillance records of cases aged ≥13 years diagnosed during the years 2000-2014 were analyzed. Retention in care was defined as evidence of ≥2 or more laboratory tests, receipts of prescription, or clinical visits at least 3 months apart during 2015. Viral load suppression was defined as a viral load of <200 copies/mL for the last test in 2015. Multi-level logistic regressions were used to estimate adjusted odds ratios (AORs). Of 65,735 cases, 33.3% were not retained in care, and 40.1% were not virally suppressed. After controlling for individual and neighborhood factors, blacks were at increased odds of nonretention in HIV care [AOR 1.29, 95% confidence interval (CI) 1.23-1.35] and nonviral suppression (AOR 1.55, 95% CI 1.48-1.63) compared with whites. Black and Latino males compared with their female counterparts had higher odds of nonretention and nonviral suppression. Compared with their US-born counterparts, foreign-born blacks and whites, but not Latinos, had higher odds of nonretention and nonviral suppression. Blacks and whites in urban compared with rural areas had higher odds of both outcomes. Disparities in retention in care and viral suppression persist and are not accounted for by differences in age, sex, transmission mode, AIDS diagnosis, neighborhood socioeconomic status, rural/urban residence, or neighborhood racial composition. Further, predictors of poor retention in care and viral suppression appear to differ by race/ethnicity.

Disparity in Retention in Care and Viral Suppression for Black Caribbean-Born Immigrants Living with HIV in Florida.

(1) The study aim was to assess disparities in non-retention in HIV care and non-viral suppression among non-Hispanic Black Caribbean immigrants living with HIV in Florida. (2) We analyzed cases involving individuals, aged ≥13, who met CDC HIV case definition during 2000-2014. Chi square test was used to evaluate differences in non-retention and non-viral suppression by country of origin/race/ethnicity. Multilevel logistic regressions with three referent groups [US-born Blacks, Hispanics, and non-Hispanic Whites (NHWs)] were used to estimate adjusted odds ratios (aOR). (3) Caribbean-born Blacks were less likely to be retained in care or be virally suppressed than US-born Blacks, Hispanics, and NHWs. Bahamians, Haitians, and Trinidadians and Tobagonians had increased odds of non-retention (aOR 3.13, 95% confidence interval [CI] 2.40 -4.10; aOR 1.52, 95% CI 1.40-1.66; aOR 2.30, 95% CI 1.38-3.83), and non-viral suppression (aOR 3.23, 95% CI 2.48-4.21; aOR 1.82, 95% CI 1.68-1.98; aOR 1.76, 95% CI 1.06-2.90) compared with NHWs. (4) Caribbean-born Blacks living with HIV infection are less likely than other racial/ethnic groups to be retained in care and/or achieve viral suppression. Further research is urgently needed to determine social, cultural, and biological factors that contribute to this disparity.

Missed Opportunities for Preventing Perinatal Transmission of Human Immunodeficiency Virus, Florida, 2007-2014.

OBJECTIVES: Despite declining numbers of perinatally exposed infants, an increase in perinatal human immunodeficiency virus (HIV) infections from 2011 to 2013 prompted this study to identify missed perinatal HIV prevention opportunities. METHODS: Deidentified records of children born from 2007 through 2014, exposed to HIV perinatally, and reported to the Florida Department of Health were obtained. Crude relative risks (RRs) and 95% confidence intervals (CIs) for factors associated with perinatal transmission, nondiagnosis of maternal HIV infection, and nonreceipt of antiretroviral medication were calculated. RESULTS: Of the 4337 known singleton births exposed to maternal HIV infection, 70 (1.6%) were perinatally infected. Among perinatal transmission cases, more than one-third of mothers used illegal drugs or acquired a sexually transmitted infection during pregnancy. Perinatal transmission was most strongly associated with maternal HIV diagnosis during labor and delivery (RR 5.66, 95% CI 2.31-13.91) or after birth (RR 26.50, 95% CI 15.44-45.49) compared with antenatally or prenatally. Among the 29 women whose infection was not known before pregnancy and whose child was perinatally infected, 18 were not diagnosed during pregnancy; 12 had evidence of an acute HIV infection, and 6 had no prenatal care. CONCLUSIONS: Late diagnosis of maternal HIV infection appeared to be primarily the result of acute maternal infections and inadequate prenatal care. In Florida, effective programs to improve utilization of prenatal care and detection and primary prevention of prenatal acute infection are needed.

Black-White and Country of Birth Disparities in Retention in HIV Care and Viral Suppression among Latinos with HIV in Florida, 2015.

The study's purpose was to identify HIV, Black-White race, and birth country disparities in retention in HIV care and HIV viral load (VL) suppression among Latinos, in 2015. Florida's surveillance data for Latinos diagnosed with HIV (2000-2014) were merged with American Community Survey data. Multi-level (random effects) models were used to estimate adjusted odds ratios (aOR) for non-retention in care and non-viral load suppression. Blacks and Whites experienced similar odds of non-retention in care. Racial differences in VL suppression disappeared after controlling for neighborhood factors. Compared to U.S.-born Latinos, those born in Mexico (retention aOR 2.00, 95% CI 1.70-2.36; VL 1.85, 95% CI 1.57-2.17) and Central America (retention aOR 1.33, 95% CI 1.16-1.53; VL 1.28, 95% CI 1.12-2.47) were at an increased risk after controlling for individual and neighborhood factors. Among Central Americans, those born in Guatemala (retention aOR 2.39, 95% CI 1.80-3.18; VL 2.20, 95% CI 1.66-2.92) and Honduras (retention aOR 1.39, 95% CI 1.13-1.72; VL 1.42, 95% CI 1.16-1.74) experienced the largest disparities, when compared to U.S.-born Latinos. Disparities in care and treatment exist within the Latino population. Cultural and other factors, unique to Latino Black-White racial and birth country subgroups, should be further studied and considered for intervention.

Individual and Neighborhood Determinants of Late HIV Diagnosis Among Latinos, Florida, 2007-2011.

The objective of this study was to examine individual and neighborhood determinants of late HIV diagnosis by gender and birthplace among Latinos. Florida HIV surveillance data for 2007-2011 were merged with American Community Survey data to estimate the odds of late HIV diagnosis (AIDS within 3 months of HIV diagnosis). Of 5522 HIV-positive Latinos, 26.5 % were diagnosed late. The odds ratio (OR) for late diagnosis was 1.39 times higher for males than females [95 % confidence interval (CI) 1.14-1.69]. Neighborhood-level factors associated with late diagnosis included residing in the 3 highest quartiles of neighborhood unemployment for males. The OR was 1.22 times higher for foreign- than US-born Latinos (95 % CI 1.07-1.40). Among foreign-born, residing in areas in the 2nd and 3rd quartiles of unemployment, in rural areas, and areas with <25 % Hispanic/Latino population were associated with late diagnosis. Population-based HIV testing campaigns may require tailoring to ensure that they effectively reach male Latinos in areas with high unemployment and foreign-born Latinos in rural and predominantly non-Latino areas.

Racial/ethnic disparities in delayed HIV diagnosis among men who have sex with men, Florida, 2000-2014.

Only about 85% of men who have sex with men (MSM) with human immunodeficiency virus (HIV) have been tested for and diagnosed with HIV. Racial/ethnic disparities in HIV risk and HIV care outcomes exist within MSM. We examined racial/ethnic disparities in delayed HIV diagnosis among MSM. Males aged ≥13 reported to the Florida Enhanced HIV/AIDS Reporting System 2000-2014 with a reported HIV transmission mode of MSM were analyzed. We defined delayed HIV diagnosis as an AIDS diagnosis within three months of the HIV diagnosis. Multilevel logistic regressions were used to estimate adjusted odds ratios (aOR). Of 39,301 MSM, 27% were diagnosed late. After controlling for individual factors, neighborhood socioeconomic status, and rural-urban residence, non-Latino Black MSM had higher odds of delayed diagnosis compared with non-Latino White MSM (aOR 1.15, 95% confidence interval [CI] 1.08-1.23). Foreign birth compared with US birth was a risk factor for Black MSM (aOR 1.27, 95% CI 1.12-1.44), but a protective factor for White MSM (aOR 0.77, 95% CI 0.68-0.87). Rural residence was a risk for Black MSM (aOR 1.79, 95% CI 1.36-2.35) and Latino MSM (aOR 1.87, 95% CI 1.24-2.84), but not for White MSM (aOR 1.26, 95% CI 0.99-1.60). HIV testing barriers particularly affect non-Latino Black MSM. Social and/or structural barriers to testing in rural communities may be significantly contributing to delayed HIV diagnosis among minority MSM.