Lessons Learned from Use of Social Network Strategy in HIV Testing Programs Targeting African American Men Who Have Sex with Men.
Objectives: We report lessons derived from implementation of the Social Network Strategy (SNS) into existing HIV counseling, testing, and referral services targeting 18- to 64-year-old Black gay, bisexual, and other men who have sex with men (MSM). Methods: The SNS procedures used in this study were adapted from a Centers for Disease Control and Prevention-funded, 2-year demonstration project involving 9 community-based organizations (CBOs) in 7 cities. Under the SNS, HIV-positive and HIV-negative men at high risk for HIV (recruiters) were enlisted to identify and recruit persons from their social, sexual, or drug-using networks (network associates) for HIV testing. Sites maintained records of modified study protocols for ascertaining lessons learned. The study was conducted between April 2008 and May 2010 at CBOs in Washington, DC, and New York, New York, and at a health department in Baltimore, Maryland. Results: Several common lessons regarding development of the plan, staffing, training, and use of incentives were identified across the sites. Collectively, these lessons indicate use of SNS is resource-intensive, requiring a detailed plan, dedicated staff, and continual input from clients and staff for successful implementation. Conclusions: SNS may provide a strategy for identifying and targeting clusters of high-risk Black MSM for HIV testing. Given the resources needed to implement the strategy, additional studies using an experimental design are needed to determine the cost-effectiveness of SNS compared with other testing strategies.
Lessons Learned From Use of Social Network Strategy in
HIV Testing Programs Targeting African American Men
Who Have Sex With Men
Donna H. McCree, PhD, MPH, RPh, Gregorio Millett, MPH, Chanza Baytop, DrPH, MPH, Scott Royal, PhD, Jonathan Ellen, MD, MS, Perry N. Halkitis, PhD,
MS, Sandra A. Kupprat, MS, and Sara Gillen, MPH
Approximately 1.1 million people are living
with HIV in the United States and about
50 000 new infections occur each year.
bisexual, and other men who have sex with
men (MSM) remain the most affected subpop-
ulation. Although constituting approximately
2% of the US population,
MSM accounted for
63% of all new infections in 2010,
HIV diagnoses among men in 2010,
represent approximately 48% of people living
Among MSM, Black MSM are dispropor-
tionately affected. Young (aged 13---24 years)
Black MSM accounted for 55% of new in-
fections among young MSM in 2010.
are more new HIV infections among 13- to 24-
year-old Black MSM than among any other
subgroup by race/ethnicity, age, and gender in
the United States.
The available literature suggests that myriad
individual, social, and contextual factors con-
tribute to the HIV rates among young, Black
These factors include a higher back-
ground prevalence of HIV in the community
leading to a greater chance of exposure to an
infected partner despite less risky behavior
a higher prevalence of other sexually trans-
mitted infections, like syphilis and gonorrhea,
that might facilitate the acquisition and trans-
mission of HIV
; limited access to treatment
and health care
; stigma, homophobia, dis-
; partner characteristics and risk
; and lack of awareness of in-
dividual or partner’s HIV status.
Awareness of HIV status is a critical step in
addressing the HIV epidemic among young,
Black MSM. Centers for Disease Control and
Prevention (CDC) estimates that approximately
18% of the people living with HIV have not
Furthermore, of those living
with HIV in 2009, 66% are linked to care,
37% retained in care, and 25% have
a suppressed viral load.
consistently suppressed viral load experience
reduced HIV-related morbidity and mortality
and have a lower probability of transmitting
the virus to others.
Although Blacks are more
likely to have ever been tested for HIV than
other racial/ethnic groups in the United States,
2 in 5 have never been tested.
many test too late in the course of their in-
fection to receive maximum beneﬁts from
In 2008, more than one third of
Blacks who were diagnosed with HIV were also
diagnosed with AIDS within 1 year.
These data underscore the need for strate-
gies to identify undiagnosed HIV positive,
young, Black MSM. This paper presents results
from a multisite study designed to evaluate the
relative effectiveness of 3 strategies—alternate
venue testing (AVT), the Social Network Strat-
egy (SNS), and partner counseling and referral
services (PCRS; now known as Partner Ser-
vices)—for reaching and motivating previously
undiagnosed, 18- to 64-year-old Black MSM
to be tested for HIV and linked to medical
care and prevention services. Applicants
were required to meet the following eligibility
criteria for funding: (1) conduct the study in
a city with an Black population of at least
100 000 based on 2000 US Census data; (2)
have an HIV counseling and testing program
(CTR) that had been in existence for at least
3 years (prior to 2006) and that historically
and currently provided services to Black men,
including MSM; and (3) conduct PCRS or have
Objectives. We report lessons derived from implementation of the Social
Network Strategy (SNS) into existing HIV counseling, testing, and referral
services targeting 18- to 64-year-old Black gay, bisexual, and other men who
have sex with men (MSM).
Methods. The SNS procedures used in this study were adapted from a Centers
for Disease Control and Prevention–funded, 2-year demonstration project in-
volving 9 community-based organizations (CBOs) in 7 cities. Under the SNS,
HIV-positive and HIV-negative men at high risk for HIV (recruiters) were enlisted
to identify and recruit persons from their social, sexual, or drug-using networks
(network associates) for HIV testing. Sites maintained records of modiﬁed study
protocols for ascertaining lessons learned. The study was conducted between
April 2008 and May 2010 at CBOs in Washington, DC, and New York, New York,
and at a health department in Baltimore, Maryland.
Results. Several common lessons regarding development of the plan, stafﬁng,
training, and use of incentives were identiﬁed across the sites. Collectively, these
lessons indicate use of SNS is resource-intensive, requiring a detailed plan,
dedicated staff, and continual input from clients and staff for successful
Conclusions. SNS may provide a strategy for identifying and targeting clusters
of high-risk Black MSM for HIV testing. Given the resources needed to implement
the strategy, additional studies using an experimental design are needed to
determine the cost-effectiveness of SNS compared with other testing strategies.
(Am J Public Health. Published online ahead of print August 15, 2013: e1–e6. doi:
RESEARCH AND PRACTICE
Published online ahead of print August 15, 2013 | American Journal of Public Health McCree et al. | Peer Reviewed | Research and Practice | e1
a written agreement with the local health
department to obtain aggregate PCRS data for
Black MSM. Each of the funded sites had
existing AVT programs that were expanded for
this study to focus on Black MSM. All of the
sites received SNS training and implemented
this strategy into their existing CTR programs.
The purpose of this article is to report common,
cross-site lessons learned from implementation
of SNS into existing HIV CTR services in
New York City, New York; Baltimore,
Maryland; and Washington, DC.
THE SOCIAL NETWORK STRATEGY
For purposes of this study, SNS was based
on the concept that individuals are linked
together to form large social networks, where
high-risk sex and drug-using behaviors are
and was patterned after
the SNS used in a CDC-funded, 2-year dem-
onstration project involving 9 community-
based organizations (CBOs) in 7 cities.
this strategy, HIV-positive and high risk HIV-
negative persons (recruiters) are enlisted to
identify and recruit persons from their social,
sexual, or drug-using networks (network asso-
ciates) for testing. As such, SNS involves work-
ing with those who test positive and negative
to identify network associates who might be at
high risk and unaware of their HIV status, as
well as social contacts in the identiﬁed networks
of these HIV-positive or negative recruiters.
Findings from the literature support the
beneﬁts of using SNS in HIV counseling, testing,
and referral programs. Results from the 2-year
CDC-funded demonstration project found an
approximate 6% prevalence of HIV infection
among network associates.
This rate is ap-
proximately 5 times the average prevalence
reported by publically funded CTR sites. Addi-
tionally, results from a community-based pilot
study conducted in Massachusetts on the po-
tential utility of SNS suggests that the use of
social networks can play a strong role in in-
creasing the volume of testing and targeting of
at-risk, heterosexually active populations with
undiagnosed HIV infection.
sults from studies on HIV prevention among
injection drug users
suggest the potential
power and utility of social networks and their
associated norms in reducing HIV risk behavior
within networks. Finally, testing results from
the New York site of the study reported in this
article showed that SNS identiﬁed more pre-
viously undiagnosed Black MSM than AVT or
Collectively, these data provide evidence
that SNS is valuable in identifying individuals
with undiagnosed HIV status; however, there
are no data on lessons learned from strategic
implementation into existing CTR programs
targeting Black MSM. This article contributes
to that extant literature.
The study was conducted at community-
based organizations (CBOs) located in the
District of Columbia and New York, and
a health department in Baltimore City. The
CBOs were Us Helping Us (UHU), People Into
Living, Inc. under collaboration with Abt As-
sociates, and Harlem United Community AIDS
Center in collaboration with New York Uni-
versity. UHU is one of the largest gay-identiﬁed
HIV and AIDS organizations providing services
speciﬁcally to the Black community in the
Washington metropolitan area. Harlem United
Community AIDS Center is a nonproﬁt AIDS
Service Organization in New York City that
provides health care, housing and HIV pre-
vention services for clients from East Harlem to
the Bronx. The Baltimore City Health Depart-
ment (BCHD) participated as a partnership with
Johns Hopkins Medicine. BCHD is the oldest,
continuously operating health department in
the United States.
We conducted the study between April
2008 and August 2010. Common eligibility
criteria across the sites were (1) 18 to 64 years
of age, (2) biologically male, (3) self-reported
race as being Black, and (4) self-reported oral
or anal sex with a man in the past year. Men
at the Washington, DC, site had to report oral
or anal sex with a man in the past 6 months.
The Social Network Strategy
Recruiters participated in initial coaching
sessions and boosters, led by SNS staff at each
of the sites, on how to elicit social contacts for
testing. The network associates (NAs) were
referred by recruiters to HIV counseling and
testing services at a designated site location.
NAs and recruiters were linked. Incentives
were provided to recruiters for NAs who were
tested; NAs received incentives for testing. The
amount of the incentives varied across the sites
based on usual and customary practices for
CTR programs and HIV research studies in the
areas. The incentive schedule utilized was as
follows: (1) Baltimore, $5 gift coupons to re-
cruiters for each NA that tested; (2) Washing-
ton, $20 visa gift card to recruiters and $20
visa gift card for each NA that tested; and (3)
New York, $4 Metrocard and $10 gift cards to
recruiters and $4 Metrocard and $20 gift
card to each NA that tested and completed the
intake form. Men found to be infected, or at
high risk for becoming infected based on
reported behavior, were referred to appropriate
medical care and prevention services per the
standard protocol in place at each of the sites.
Each of the sites used separate study pro-
tocols and elements of SNS were tailored to
each individual CTR program to ensure that
normal testing processes were not disrupted by
the research. Investigators from each site and
the CDC team worked in close collaboration
to develop, implement and monitor the study
protocols. Sites submitted targeted recruitment
numbers for each of the testing strategies,
including SNS, in advance of study implemen-
tation. Additionally, all sites were required to
maintain an SNS log that was completed by
designated SNS staff and included the following
information: how the client was referred, date
and time of the interview, speciﬁcs on what was
done during the interview, and successes or
problems reported. These data were collected
for the initial SNS interview and all follow-up
interviews conducted with each SNS client. Site
staff input all study data into a database de-
veloped by the CDC team. The de-identiﬁed
data were transferred from the sites via a Se-
cure Data Network to the CDC team. Successes
and challenges to implementing the strategy
and recruiting participants were monitored via
the database and discussed on monthly cross-
site conference calls and during annual face-to-
face meetings. Based on these discussions, study
protocols were amended with required IRB
approvals, and recruiting numbers were modi-
ﬁed as needed. The lessons learned discussed in
this manuscript are common from all 3 sites
identiﬁed during the study implementation and
discussed on the monthly conference calls and
RESEARCH AND PRACTICE
e2 | Research and Practice | Peer Reviewed | McCree et al. American Journal of Public Health | Published online ahead of print August 15, 2013
at face-to-face meetings. Figures 1 through 3
provides a schematic design of the SNS strategy
used at each of the sites. Additional site speciﬁc
data on the study are available elsewhere
(C. Baytop, unpublished data, 2013).
HIV testing procedures were conducted in
accordance with standard CTR procedures at
each of the sites. Testing at the UHU and
Harlem United sites was conducted using the
OraQuick Advance Rapid HIV-1/2 Antibody
Test for screening (OraSure Technologies, Inc.,
Bethlehem, PA) and the OraSure (OraSure
Technologies, Inc.) for conﬁrmatory testing.
Clients who screened HIV-positive were given
an appointment to receive their conﬁrmatory
test results. Those conﬁrmed as HIV-positive
received appropriate counseling and follow-up
per standard procedures at the sites. Testing
at BCHD was conducted using conventional
testing, (ELISA and conﬁrmatory Western blot,
as well as HIV RNA testing), as per BCHD
standard diagnostic algorithm.
A total of 24 recruiters were identiﬁed and 149
men were tested through SNS at the UHU site in
Washington, DC. Almost half (49%) were 25 to
34 years of age, about two thirds (62%) reported
at least some college education, and more than
half (52%) identiﬁed as heterosexual, but reported
sex with a male partner in the past year. Addi-
tionally, more than two thirds (68%) reported that
they had never been tested for HIV. Of the
149 men tested, 30 tested HIV-positive. Of those,
16 (11%) were newly identiﬁed as HIV-positive.
A total of 70 recruiters were identiﬁed and
109 men received HIV testing through SNS
at the Harlem United site. The mean age of the
men in the New York sample was 25 years.
About one third reported having either a high
school education or some college or Associates
degree, and all reported their sexual orienta-
tion as either gay (59%) or bisexual (41%).
Almost 6% of the recruiters reported that they
CTR sta to
to CTR sta
CTR sta on
to ongoing risk-
on type of
Ongoing coaching for
SNS recruiters as
Note. CTR = counseling and training program; SNS = Social Network Strategy; UHU = Us Helping Us.
FIGURE 1—Schematic design of UHU Social Network Strategy: Washington, DC.
RESEARCH AND PRACTICE
Published online ahead of print August 15, 2013 | American Journal of Public Health McCree et al. | Peer Reviewed | Research and Practice | e3
had never been tested for HIV. Of the 109 men
tested, 21 (19%) tested HIV-positive. The
study protocol did not provide a mechanism to
reconcile whether men who tested positive had
ever received a prior HIV-positive diagnosis
with the New York City Department of Health.
For purpose of the study at the BCHD, all
Black men who tested positive for HIV for the
ﬁrst time, (according to BCHD records), from
alternate venue testing (AVT) or from BCHD’s
ﬁxed testing sites and reported engaging in sex
with a man within the last 6 months were
alternately assigned to SNS or partner services
(known as partner counseling and referral
services at the time of the study) based on the
order in which they received their results. As
such, 27 pr evious H IV-positive men a nd 9
newly identiﬁed HIV-positive men (n = 36)
were assigned as SNS recruiters. Twenty-two
declined and received standard partner ser-
vices per the BCHD protocol. Fourteen men
(10 previous positives and 4 new positives)
elected to participate as SNS recruiters. A
total of 22 men were tested. Eight (36%)
tested HIV-positive and none w ere newly
We learned several common lessons re-
garding development of the plan, stafﬁng,
training, and use of incentives.
The SNS Plan. Successful implementation
and use of the SNS strategy in an HIV CTR
program requires a detailed plan that is de-
veloped with input from clients and staff and
tailored for the existing testing program. The
plan may require several modiﬁcations. Regu-
larly scheduled check-in meetings between
supervisors and staff (at least monthly) to
discuss challenges and resolutions and modify
plans as needed are critical. The inclusion of
program staff in a regular review of the plan
will enable buy-in among all employees and
provide an opportunity to develop strategies
for addressing challenges and improving pro-
ductivity. This plan should include intake forms
that allow collection of data needed to link
persons to appropriate follow-up care.
SNS Program Staff. SNS staff should possess
excellent interpersonal and project manage-
ment skills and include members of the target
population. Based on experiences at the 3 sites,
the best stafﬁng plan is to have 1 primary
counselor whose sole responsibility is to mon-
itor and manage all SNS activities. Ideally, all
counseling and testing staff should be trained
on SNS and be tasked with identifying potential
recruiters and referring those individuals to
the primary counselor that oversees SNS
activities. Th at primary counselor sho uld be
responsible for orienting and providing
coaching to recruiters, tracking NAs, and
making decisions about when to dismiss or
retire a r ecruiter. The primary counselor
should also network with and plan HIV testing
events for agencies, clubs, ch urche s, and
venues the target pop ulatio n is likely to fre-
quent. Additionally, high t urnover rates
should be anticipated among the staff. How-
ever, providing incentives (e.g., special recog-
nition awards or ﬁnancial compensa tion for
ach ievement of recruit ment goals) to staff
based on their productivity in identifying and
retaining recruiters keeps morale high and
Training. Based on results from this study,
all counseling and testing staff should receive
SNS training. The optimal approach is to have
staff attend trainings together to facilitate dis-
cussions and provide opportunities for staff to
interact on training scenarios. This training
should focus on the following: SNS theory;
strategies for identifying, creating rapport and
BCHD HIV TESTING SERVICES
Fixed facility testing:
Alternative venue testing
Pre-test counseling using standardized
Notication of results and post-
Partner counseling and
Social contacts oered SNI and
Identify more venues
for AVT (PLACES)
HIV+ and refuse SNI
Note. AVT = alternate venue testing; BCHD = Baltimore City Health Department; SNI = social network interview; STI = sexually
FIGURE 2—Schematic design of BCHD Social Network Strategy: Baltimore, MD.
RESEARCH AND PRACTICE
e4 | Research and Practice | Peer Reviewed | McCree et al. American Journal of Public Health | Published online ahead of print August 15, 2013
establishing partnerships with and coaching
recruiters; and processes needed to create
daily, weekly, and monthly goal setting for staff.
Additionally, booster sessions (i.e., ongoing
trainings) are needed to maintain momentum
and increase productivity. Sites in this study
included booster sessions in regular staff
Incentives. Use of incentives for testing was
customary at UHU and Harlem United prior to
implementation of this study. For this study, the
UHU and Harlem United sites provided in-
centives to both recruiters and NAs who tested;
the BCHD site provided incentives to recruiters
only. However, the incentive amounts at UHU
and Harlem United were increased based on
feedback received from study participants. As
a result, the participation rate increased at both
sites. These results suggest that use of incen-
tives increased participation in testing. The
type and amount should be determined by
community standards (e.g. be competitive
with incentives offered in other CTR or HIV
research-related activities conducted in the
area). Results also suggest that use of incentives
may result in a higher number of previous
HIV-positive persons testing through the pro-
gram. As such, it is critical to collaborate with
health departments in SNS testing initiatives
to verify true undiagnosed HIV-positives.
Testing History. It is important that sites have
mechanisms in place (e.g., relationships with
local health departments) to determine the
testing history of men tested via SNS. There are
multiple reasons why network associates may
report not being HIV positive at the time of
testing, particularly when incentives are provided
for testing. Mechanisms to verify testing history
that do not rely solely on self-report will allow
sites to more accurately determine the number
of new diagnoses identiﬁed by the strategy.
The focus of this article is to present
common, cross-site lessons learned from
implementation of the SNS into existing CTR
programs in New York, Baltimore, and Wash-
ington, DC. Our intent is to provide information
for HIV counseling and testing program sites
that may be interested in implementing SNS
into their programs that target Black MSM.
Based on the results, use of the SNS in HIV
counseling and testing programs may provide
a strategy for identifying and targeting clusters
of high-risk, previously undiagnosed, Black
MSM for HIV testing. Successful implementa-
tion of the strategy, however, is resource in-
tensive and requires a detailed plan, training,
a dedicated staff, support from the testing
agency, input from the target population, use
of appropriate incentives, and collaborations
with health departments. Future studies should
use an experimental design and common pro-
tocol to determine the effectiveness and cost
of implementing SNS into testing programs and
to identify the best combination of testing
strategies for identifying, reaching and moti-
vating previously undiagnosed HIV-positive
Black MSM to be tested for HIV and linked
to care and prevention services.
About the Authors
Donna H. McCree is with the Division of HIV/AIDS
Prevention, National Center for HIV, Viral Hepatitis, STD
and TB Prevention, Centers for Disease Control and Pre-
vention, Atlanta, Georgia. Gregorio Millett is with Centers
for Disease Control and Prevention, Washington, DC.
Chanza Baytop and Scott Royal are with Abt Associates,
Bethesda, MD. Jonathan Ellen is with the Department of
Pediatrics, Johns Hopkins University School of Medicine,
Baltimore, MD. Perry N. Halkitis and Sandra A. Kupprat
are with the Center for Health, Identity, Behavior and
Prevention Studies, Steinhardt School of Culture and
Human Development, New York University, New York, NY.
Sara Gillen is with Community Health Services, Harlem
United, New York, NY.
Correspondence should be sent to Donna Hubbard
McCree, PhD, MPH, RPh, Associate Director for Health
Equity, Division of HIV/AIDS Prevention, National
Center for HIV, Viral Hepatitis, STD and TB Prevention,
Centers for Disease Control and Prevention, 1600 Clifton
Road NE MS D-21, Atlanta, Georgia 30333 (e-mail:
email@example.com). Reprints can be ordered at http://www.
ajph.org by clicking the “Reprints” link.
This article was accepted January 21, 2013.
FIGURE 3—Schematic design of Harlem United Social Network Strategy: New York, NY.
RESEARCH AND PRACTICE
Published online ahead of print August 15, 2013 | American Journal of Public Health McCree et al. | Peer Reviewed | Research and Practice | e5
D. H. McCree provided scientiﬁc and administrative
oversight to the entire project, participated in the design
of the study, wrote the ﬁrst draft of the article, and
participated in revising all drafts of the article. G. Millett
assisted in leading the scientiﬁc and administrative
oversight of the entire project, participated in the design
of the study, and participated in revisions of the drafts.
C. Baytop, S. Royal, J. Ellen, P. N. Halkitis, and S. Gillen
served as principal investigator or coprincipal investiga-
tor at their individual sites, participated in the design of
the study, participated in recruitment and data collection,
and participated in revising all drafts of the article. S. A.
Kupprat served as project coordinator at the New York
site, participated in the design of the study, participated
in recruitment and data collection, and participated in
revising all drafts of the article.
This work was funded by Cooperative Agreements to Abt
Associates (1 UR6 PS000330), the Baltimore City Health
Department (5UR6PS000329), and Harlem United
Center for AIDS Research (5UR6PS000368) from the
US Centers for Disease Control and Prevention (CDC).
The authors wish to acknowledge the counseling and
testing staff at each of the participating sites and other
members of the CDC Study Team, Kenneth Jones, Holly
Fisher, and Sekhar Thadiparthi for their outstanding
contributions to this study. We also thank the study
participants for making this effort possible.
Note. The contents of this article are solely the
responsibility of the authors and do not necessarily
represent the views of CDC.
Human Participant Protectio n
All study protocols were approved by the CDC Human
Subjects Review Board and the institutional review
boards at each of the participating sites. All participants
provided informed consent for partici pation in the Social
1. Centers for Disease Control and Prevention. Mon-
itoring selected national HIV prevention and care objec-
tives by using HIV surveillance data—United States and 6
US dependent areas—2010. 2012. Available at: http://
August 13, 2013.
2. Purcell DW, Johnson C, Lansky A, et al. Estimating
the population size of men who have sex with men in the
United States to obtain HIV and syphilis rates. Open
AIDS. 2012;6:(suppl 1: M6);98---107.
3. Centers for Disease Control and Prevention. Esti-
mated HIV incidence among adults and adolescents in
the United States, 2007-2010. HIV Surveill Suppl Rep.
4. Centers for Disease Control and Prevention.
Diagnoses of HIV infection and AIDS in the United
States and dependent areas, 2010. HIV Surveill Rep.
5. Oster AM, Wiegand RE, Sionen C, et al. Understanding
disparities in HIV infection between Black and White MSM
in the United States. AIDS. 2011;25:1103---1112.
6. Millett GA, Peterson JL, Wolitski RJ, Stall R. Greater
risk for HIV infection of Black men who have sex with
men: a critical literature review. Am J Public Health.
7. Berry M, Raymond HF, McFarland W. Same race
and older partner selection may explain higher HIV
prevalence among Black men who have sex with men.
8. Millett GA, Flores SA, Person JL, Bakeman R.
Explaining disparities in HIV infection among Black and
White men who have sex with men: a meta-analysis of
HIV risk behaviors. AIDS. 2007;21:2083---2091.
9. Flores SA, Bakeman R, Millett GA, Peter son JL. HIV
risk among bisexually and homosexually acti ve racially
diverse young men. Sex Transm Dis 2009; 36-325---329.
10. Harawa NT, Greenland S, Bingham TA, et al.
Associations of race/ethnicity with HIV prevalence and
HIR-related behaviors among young men who have sex
with men in 7 urban centers in the United States. J Acquir
Immune Deﬁc Syndr. 2004;35:526---536.
11. Marks G, Crepaz N, Senterﬁtt JW, Janseen RS. Meta-
analysis of high-risk behavior in persons aware and
unaware they are infected with HIV in the United States:
implications for HIV prevention programs. J Acquir
Immune Deﬁc Syndr. 2005;39:446---453.
12. Jeffries WL, Marks G, Lauby J, Murrill CS, Millett
GA. Homophobia is associated with sexual behavior that
increases risk of acquiring and transmitting HIV infection
among Black men who have sex with men. AIDS Behav.
13. Centers for Disease Control and Prevention. HIV
testing among men who have sex with men—21 cities,
United States, 2008. MMWR Morb Mortal Wkly Rep.
14. Hall I, Frazier EL, Rhodes P, et al. Differences in
human immunodeﬁciency virus care and treatment
among subpopulations in the United States. JAMA Intern
15. Centers for Disease Control and Prevention. HIV
surveillance---United States, 1981---2008. MMWR Morb
Mortal Wkly Rep. 2011;60(21):689---693.
16. Jordan WC, Tolbert L, Smith R. Partner notiﬁcation
and focused intervention as a means of identifying HIV-
positive patients. JNatlMedAssoc
17. Vargo S, Agronic k G, O’Donnell L, Stueve A. Using
peer recruitment and OraSure to increase HIV testing.
Am J Public Health. 2004;94(1):29---31.
18. Kimbrough LW, Fisher HE, Jones KT, Johnson W,
Thadiparthi S, Dooley S. Accessing social networks with
high rates of undiagnosed HIV infection: The social
networks demonstration project. Am J Public Health.
19. Knowlton A, Hua W, Latkin C. Social support
among HIV positive injection drug users: implications to
integrated intervention for HIV positives. AIDS Behav.
20. Knowlton AR, Hua W, Latkin C. Social support
networks and medical service use among HIV-positive
injection drug users: implications to intervention. AIDS
21. Latkin CA, Sherman S, Knowlton AR. HIV Pre-
vention among drug users: outcome of a network-
oriented peer outreach intervention. Health Psychol.
22. Latkin CA, Knowlton AR. Micro-social structural
approaches to HIV prevention: a social ecological per-
spective. AIDS Care. 2005;17:S102---S113.
23. Halkitis PN, Kupprat SA, McCree DH, et al. Evalu-
ation of the relative effectiveness of three HIV testing
strategies targeting African American men who have sex
with men (MSM) in New York City. Ann Behav Med.
24. Ellen JE, McCree DH, Muvva R, et al. Recruitment
approach for identifying newly diagnosed HIV infection
among African American men who have sex with men
(MSM): a case study at the Baltimore City Health De-
partment, 2007---2010. In J STDS AIDS. E-pub ahead of
print April 24, 2013.
RESEARCH AND PRACTICE
e6 | Research and Practice | Peer Reviewed | McCree et al. American Journal of Public Health | Published online ahead of print August 15, 2013