Mystery Shopping Reveals Need for Higher-Quality HIV Testing, Counseling Services Among High-risk Group

CDC recommends that young men who have sex with men have an HIV test every 6 months.

Following almost 5 years of substantial declines, new HIV infections began to level off in 2013. The CDC estimates this is because effective HIV prevention and treatment methods are not adequately reaching those who could most benefit from them. One of these groups is young men who have sex with men (YMSM).

According to data from the CDC released in November of 2018. “Gay and bisexual men aged 13 to 34 made up 64% of new HIV diagnoses among all gay and bisexual men” in 2017. The University of Pennsylvania School of Nursing initiated a study to understand how adequate testing and counseling services are for this group and to recommend improvements where necessary. Their results will soon be published in the Journal of Acquired Immune Deficiency Syndromes.1

“While research indicates that YMSM may feel more willing to take part in HIV counseling, testing, and referral (CTR) services, there are no systematic assessments to evaluate the quality of agencies’ CTR services, nor an understanding of how YMSM clients perceive and react to the testing services delivered,” José A. Bauermeister, PhD, MPH, Penn Nursing’s Presidential Professor of Nursing and the study’s principal investigator, said in a statement.

As part of the National Institutes of Health’s Adolescent Medicine Trials Network for HIV/AIDS Interventions, mystery shoppers visited HIV testing sites in 3 cities—Philadelphia, Pennsylvania; Atlanta, Georgia; and Houston, Texas—that were chosen because of their high rates of new HIV infection. Each site was visited twice by 2 mystery shoppers, at different times and on different days. Inclusion criteria were that each site had to be “youth accessible.” They had to offer free, rapid HIV testing and walk-in appointments, which the study authors found using and Google. Methods to recruit the mystery shoppers included reaching out to former research participants who said they could be contacted for future studies, partnering with local LGBTQ groups and those that serve YMSM, and word-of-mouth. Lastly, sites were measured on length of visit, how prominent were LGBTQ symbols and printed materials, clinic environment, management of privacy and confidentiality, and discussions with providers on relationship status, testing and counseling, safer sex recommendations, and pre-exposure prophylaxis (PrEP).1

With the ultimate goal of improving HIV testing and prevention services for YMSM, the results were inconsistent. Scores were pooled to reduce potential bias and confounding and to account for variability. The 3 positives were that visits lasted an average of 30 minutes (SD, 25.5), the atmosphere was welcoming and friendly (70.9%), and most sites respected privacy and confidentiality (84.3%). A majority of feedback, however, was negative. There were discrepancies in what services were offered between websites and their brick-and-mortar counterparts, providers lacked skills in dealing with sexual minorities (63.4%), mystery shoppers felt uncomfortable during their visit (65.7%), neither risk-reduction counseling nor safer sex education were provided (56.8% and 24.3%, respectively), there was poor visibility of LGBT support/materials (49.6%) and these individuals were not included on medical forms (57.95%), discussions of YMSM’s relationship status (49.8%) were lacking, and PrEP info/counseling was only provided at just over half of the sites (58.85%).1

Study limitations include lack of a comprehensive review of all providers at each site, results are not generalizable across the United States, an incomplete picture of the full scope of testing facilities in each city because health systems were excluded, and lack of causal inferences due to the cross-sectional study design.

So, what can be done? Improve HIV testing services so they are “culturally and developmentally appropriate” for YMSM. Be more aware of their needs and experiences. Increase the availability of free, rapid, walk-in HIV testing. Strengthen the delivery of CTR services. Offer risk-reduction counseling. Create spaces that are welcoming to LGBT clients.1

The study authors believe their findings emphasize the importance of accounting for the influence of testing site characteristics and provider interactions at those sites. “Investment in system-level interventions and strategies will be necessary to optimize HIV prevention and care delivery for YMSM,” they noted in the statement.

To learn more about how HIV affects communities across the US, visit

For more on the NIH Adolescent Medicine Trials Network for HIV/AIDS Interventions, visit

To read about the experiences of real people with the HIV continuum of care, visit


1. Bauermeister JA, Golinkoff JM, Lin WY, et al. Testing the testers: are young men who have sex with men receiving adequate HIV testing and counseling services? J Acquir Immune Defic Syndr. 2019;82(suppl 2):S133-S141. doi: 10.1097/QAI.0000000000002173.

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