Introduction

High HIV infection rates among Black men who have sex with men (BMSM) in the United States (US) remain a major public health crisis. A 2008 surveillance study in 21 cities estimated HIV prevalence among BMSM to be 28 %, compared with 18 % among Latino men who have sex with men (MSM) and 16 % among non-Latino White MSM [1]. A more recent study of BMSM in six US cities reported an HIV prevalence of 21 % [2] and a yearly HIV incidence rate of 3.0 % [3]. While the generalizability of these results is limited, they underscore the severity of the epidemic among subpopulations of BMSM in highly populated urban areas. In 2010, an estimated 134,746 of BMSM in the US were living with diagnosed HIV infection, and BMSM accounted for more than 20 % of total new infections [4]. Rates of new infections among BMSM, aged 13–30, have been particularly alarming, with yearly incidence estimates ranging from 5.1 to 6.4 % [35]. Although rates of new HIV infections remained stable from 2006 to 2009 among other racial and ethnic groups of MSM aged 13–29, there was a 48 % increase in new HIV infections among young BMSM during this time period [1, 6].

Structural-level factors, which include the socio-economic and -cultural contexts of communities, have contributed to the high burden of HIV among BMSM. Based on the work of Latkin et al. [7], structural factors can be defined as forces that work outside the individual and beyond the individual’s control to foster or impede health or health behaviors, and they often distally impact health outcomes in diffuse and indefinite ways. Although a multiplicity of factors contribute to each individual’s risk of HIV infection, there is a growing body of literature recognizing that structural-level factors have served a primary role in shaping the epidemic [5, 723]. For example, Peterson and Jones [13] described the effects of structural factors—including stigma, racism, barriers to healthcare, and incarceration—on HIV risk among BMSM, and discussed the need for structural interventions to reduce HIV-related racial disparities. Mays et al. [16] provided recommendations to move the HIV prevention research agenda for BMSM toward a social/interpersonal focus that addresses social–structural barriers contributing to HIV infection. More recently, Millett et al. [12] discussed the inability to eliminate disparities in HIV infection among BMSM without addressing structural barriers such as low income, incarceration, unemployment, and low education.

Building on this formative research, Latkin et al. introduced a dynamic social systems theoretical model that provides a framework for better understanding the complex processes by which structural factors drive the elevated rates of HIV infection among BMSM. Emphasizing the social nature of structural factors within the scope of HIV prevention research, the authors’ model conceptualizes structural factors across three core dimensions encompassing: (1) resources, (2) social influence and control factors, and (3) contextual factors [7]. Resources involve economic, social, cultural, and infrastructural resources (e.g., staffing and equipment at HIV testing sites), and can also include scientific knowledge and technological innovations related to HIV prevention (e.g., research on rapid HIV testing technologies). Social influence and control factors include non-institutionally sanctioned social influence (e.g., social norms) as well as institutionally sanctioned social influence (e.g., decision rules to recommend HIV testing to certain individuals). Resources and social influence can be considered forms of power, and they operate through contextual factors, including the structure of social relationships (e.g., relationships between clients and staff at HIV testing sites) and geographic, spatial, or social boundaries (e.g., local availability of HIV testing sites) [7]. Each element in the model can influence and be influenced by other elements, reflecting the interdependent and dynamic nature of structural factors. Furthermore, each of the dimensions of structural factors can operate on macro (i.e., socio-political, economic, and cultural contexts and the social institutions that shape social organizations with the broadest reach), meso (i.e., systems within more immediate institutions in which individuals and groups are involved), and micro (i.e., immediate social and physical contexts in which interactions among individuals and small groups take place) levels of society [7]. Specific structural factors may function at a variety of levels, depending on the perspective and specific question of the observer [7]. Given that structural factors are correlates of HIV risk among BMSM [8, 12, 13], employing this model to conceptualize structural factors across these multi-level structural dimensions provides for a systematic and theoretically grounded approach to investigate the complex processes underlying their substantial contribution to the disproportionate HIV infection rates among BMSM. Since HIV prevention research examining the mechanisms by which structural factors impede prevention efforts for BMSM is understudied, a more comprehensive review rooted in this dynamic social systems model is warranted.

Moreover, a major limitation of the growing body of HIV prevention research investigating structural factors among BMSM involves the lack of focus on barriers to accessing HIV testing and HIV prevention services [24]. BMSM report irregular HIV testing patterns [10, 25] despite recommendations issued by the CDC that sexually active MSM should be tested at least once annually and that high-risk MSM be tested every 3–6 months [26]. Only 67 % of HIV-negative BMSM in one study were tested for HIV in the last 2 years [27] and only 52 % in another study were tested in the last year [28]. Other findings highlight the heterogeneity of HIV testing patterns among BMSM [29]. HIV-infected BMSM are also less likely than other HIV-infected MSM to be aware of their positive serostatus [10, 3032]. One study reported that 59 % of HIV-infected BMSM in 21 cities were unaware of their positive serostatus [1], and another study reported that 14.5 % of BMSM who had been tested for HIV in the past 12 months were unaware that they were HIV-positive, compared with 6.7 % of Latino MSM and 3.0 % of non-Latino White MSM [32]. Being unaware of one’s own positive HIV status increases the likelihood of HIV transmission risk behaviors [33], which may partially explain the higher HIV prevalence among sexual networks of BMSM [13, 19, 30, 3436]. Compared to HIV-infected non-Latino White MSM, HIV-infected BMSM are also less likely to attain viral suppression and a high CD4 count [12] and more likely to have sexually transmitted co-infections [1012, 37], both of which increase the risk of HIV transmission [38, 39]. Since limited healthcare access and other structural factors are associated with HIV infection risk among BMSM [8, 12, 13], these findings point to a potential relationship between structural factors and the use of HIV testing and prevention services [i.e., HIV counseling, HIV education, and the provision of pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP)]. For instance, BMSM who are unable to access optimal healthcare services in their communities may experience barriers to getting tested, learning their HIV status, receiving pre- and post-test HIV counseling, and consequently altering behaviors to prevent HIV acquisition or transmission. While formative research has investigated the risk of HIV infection associated with healthcare access, racism, homophobia, stigma, incarceration, low income, unemployment, and low education [8, 12, 13, 16], the roles of these structural factors as barriers to HIV testing and prevention services among BMSM are unclear.

Building on previous scholarly work and incorporating a dynamic social systems conceptual framework, we conducted a review of the literature on structural barriers to accessing HIV testing and prevention services among BMSM across the domains of healthcare, stigma and discrimination, incarceration, and poverty. Notwithstanding varied or unclear definitions of structural factors across the body of literature pertaining to BMSM, this paper utilizes the definition and conceptual framework developed by Latkin et al. in reviewing articles, regardless of how authors defined or conceptualized structural factors. Furthermore, while structural factors may also act as facilitators to accessing HIV testing and prevention services—particularly as related to resiliency factors (e.g., social support, spirituality) [4042]—for the scope of this paper we only assessed their roles as barriers to services. Given the strong focus of HIV prevention research among BMSM on structural factors as barriers to services, this review attempts to draw on the available literature to identify strategic points of intervention to provide BMSM with core skills to overcome barriers to services. Though literature on resiliency factors among BMSM is more limited, this is also a crucial area of future investigation. Through critical examination of articles using this conceptual framework, this review aims to describe the roles of healthcare, stigma and discrimination, incarceration, and poverty as structural barriers to HIV testing and prevention services among BMSM.

Methods

We searched two online databases (PubMed and Scopus) for peer-reviewed literature on structural barriers to HIV testing and prevention services among BMSM. We conducted the search in several stages using a comprehensive set of relevant key words and Medical Subject Heading, MeSH terms (“Appendix 1” section). First, we searched for articles pertaining to Black populations and cross-referenced those with articles pertaining to sexual identity or behavior applicable to MSM. Next, we cross-referenced these results with articles obtained from five additional searches. Four of the additional searches obtained articles related to each of four domains corresponding with structural factors that have been researched in the literature: (1) healthcare, (2) stigma and discrimination, (3) incarceration, and (4) poverty. The remaining, additional search cross-referenced articles on HIV and those related to structural factors in general. Excluding duplicates, the search returned a total of 1,019 articles. We used the following criteria to determine which articles would be included in this review: (1) articles written in English, (2) articles published before 7 June 2013, (3) articles that reported quantitative or qualitative data collected from a sample or subsample of BMSM in the US, and (4) articles that reported data on exposures or outcomes related to structural factors. We also reviewed articles meeting inclusion criteria that were cited as references within these articles. In total, we reviewed 98 articles and extracted information across each of the four aforementioned domains.

Results

Healthcare

Access to Healthcare Services

There is insufficient evidence to determine the extent to which economic and infrastructural resources affect access to healthcare services among BMSM. One study that assessed types of insurance coverage among BMSM, which operates as a structural factor across macro and meso levels of economic resources (Table 1), found that 79.2 % reported coverage by public insurance, 20.8 % reported coverage by private insurance, and 4.6 % reported no insurance coverage [27]. However, these results have limited generalizability due to the use of a modified respondent-driven sampling method. By contrast, 19.0 % of Blacks in the US, compared with 11.1 % of non-Latino Whites, reported not having health insurance coverage in 2012 [43]. Demonstrating that HIV-positive BMSM face particular challenges to acquiring health insurance, two studies found that HIV-positive BMSM were less likely than HIV-positive MSM of other races/ethnicities to report having health insurance [12] and less likely than HIV-negative BMSM to report having health insurance or a primary healthcare provider [44]. Furthermore, a qualitative study conducted among different subgroups of Black men—which included a focus group consisting of solely BMSM—provides some evidence that BMSM have experienced barriers to accessing healthcare services related to meso-level economic resources required for visits and inadequate micro-level infrastructural resources of healthcare facilities [45] (Table 1). All groups identified high perceived costs and low perceived benefits of healthcare visits as reasons for accessing healthcare more frequently for urgent health concerns as opposed to preventive care [45]. Primary healthcare may be viewed by some as optional, except in cases of urgent medical need, due to the high expense of quality medical care combined with the expense of taking time from work for visits [45]. However, while further research is needed that focuses on the relationship between resources available to BMSM and their use of services, access to general healthcare services does not necessarily yield receipt of HIV testing and prevention services [46, 47]. One study among BMSM found a positive association between having health insurance and being unaware of one’s HIV-positive status, suggesting that other factors such as stigma, fear of diagnosis, and perceived quality of services may serve more significant roles as barriers to learning one’s status [48] (Table 2).

Table 1 Structural barriers to HIV testing and prevention services among BMSM
Table 2 Studies of healthcare and HIV services in BMSM

Cultural Competency of Healthcare Services

BMSM experience barriers to accessing HIV testing and prevention services within micro-level informal and formal social influence dimensions related to the inadequate provision of culturally competent healthcare services (Table 1). Supportive social norms surrounding male-to-male sexual behavior as well as formal cultural competency of healthcare providers are critical for fostering positive relationships between providers and BMSM that facilitate access to HIV testing and prevention services at healthcare visits. Homophobia among physicians has decreased in recent years; however, research has shown that many physicians still express negative attitudes toward MSM [49, 50]. Many healthcare providers lack awareness of sexual identities and behaviors, and fail to recognize the importance of discussing sexual health with patients as a routine component of medical care [5154]. Having expressed concerns pertaining to issues of confidentiality, discrimination, comfort, distrust, and conspiracy beliefs [5560], BMSM are less likely than other MSM to disclose their sexual behavior or identity to healthcare providers [53, 61, 62]. Demonstrating the importance of an open and supportive patient-provider relationship for facilitating access to HIV testing and prevention services, MSM who disclosed their sexual behavior to their healthcare provider were more likely to discuss HIV, disclose their HIV status, accurately report unprotected anal intercourse (UAI), and obtain testing [44, 53, 62]. BMSM whose healthcare provider recommended HIV testing were more likely to have been tested in the last 2 years [63]. However, BMSM who disclose their sexual behavior to their healthcare providers may still fail to receive HIV prevention services. Among MSM in one study who had healthcare providers who were aware of their sexual behavior, only 59 % had received recommendations for HIV testing [53]. Moreover, among the 71.4 % of MSM who reported that their primary care provider was aware of their sexual orientation, 70.1 % reported having disclosed their sexual orientation without being asked, 13.8 % disclosed after the primary care provider asked, and 13.9 % believed their primary care provider correctly assumed their sexual orientation [53]. Those who are less comfortable discussing their sexual behavior may not disclose unless their healthcare provider actively inquires [53] (Table 2).

Access to PrEP and PEP

While no studies were identified that investigated barriers to access of antiretroviral therapy (ART) medications as PrEP or PEP to prevent HIV infection among BMSM, research that investigates how structural factors may limit access to PrEP or PEP is needed. PrEP has been found to be partially efficacious among MSM [64], and based on results from an online survey in 2010, BMSM were more willing than non-Latino White MSM to use PrEP for HIV prevention purposes [65]. A meta-analysis also found that BMSM were more likely than non-Latino White MSM to use PEP or PrEP [12], though the analysis included results from studies conducted prior to approval of ART as PrEP by the US Food and Drug Administration. There are challenges to PrEP implementation among MSM, however, related to the limited willingness of physicians to prescribe PrEP, inadequate effectiveness and cultural competency of messages about PrEP, and high costs to individuals [66]. In addition, psychosocial issues (e.g., substance use, housing/shelter, intimate partner violence) can impede successful PrEP adherence among BMSM [67]. To better understand these complexities, future studies should examine how structural factors affect access and adherence to PrEP and PEP among BMSM.

Treatment as Prevention

There are also barriers to treatment and care services among HIV-positive BMSM. While these are distinct from barriers to prevention services, they increase the virulence among sexual networks of BMSM and consequently increase the likelihood of HIV transmission [38], indirectly serving as a barrier to HIV prevention among this population. Since BMSM are more likely to have sexual partners who are Black, more effective treatment and care services may help decrease HIV transmission among the sexual networks of Black communities [30]. Similar to barriers to services experienced by HIV-negative BMSM, self-reported barriers to ART adherence and retention in care among HIV-positive BMSM include medical miscommunication, low levels of healthcare provider cultural competency, mistrust, embarrassment, racism, and sexual prejudice [60, 6871], encompassing informal and formal social influence structural dimensions on micro-level structures of society (Table 1). Research has found that HIV-positive BMSM were more likely than other HIV-positive MSM to be delayed testers [72, 73], and in an HIV testing program that used respondent-driven sampling to recruit BMSM, only 27 % of newly diagnosed men returned to receive their confirmatory test results and discuss referrals to care [74]. While it is possible that men already had a healthcare provider that they chose to go to for follow-up, the authors hypothesized that they may have been psychologically unready to receive confirmation of their HIV-positive status, serving as a barrier in linkage to care [74]. Consistent with such challenges, studies have found that BMSM were less likely to be retained in HIV care compared to non-Latino White MSM [7577] and less likely than other MSM to be virally suppressed 1 year after diagnosis [78]. However, there is inconsistent evidence that HIV-positive BMSM have lower ART adherence than other HIV-positive MSM. Four studies found lower adherence among BMSM compared to other MSM [7982], yet two other studies found no differences by race/ethnicity among MSM [83, 84] (Table 2).

Stigma and Discrimination

Based on interconnected social inequalities that exist on meso and micro structural levels of society, experiences of stigma and discrimination due to race [15, 17, 8597] and sexual orientation [15, 22, 86, 92, 96, 98104] among BMSM are significant barriers to HIV testing and prevention services within the structural dimension of informal social influence and control (Table 1). Consistent with studies that have found that stigma and discrimination are correlates of HIV risk among BMSM [105108] (Table 3), there is strong evidence that experiences of stigma and discrimination due to race and sexual orientation—operating through social interactions at healthcare visits and within social networks—negatively affect access to HIV testing and prevention services among this population [14, 22, 58, 60, 109112]. Such experiences may involve overt forms of discrimination as well as micro-aggressions, which are defined as brief, commonplace, often unintentional, daily verbal, behavioral, and environmental affronts directed at people of color and other disenfranchised groups [113]. BMSM across multiple studies have indicated perceptions of racism and homophobia during visits to healthcare providers and were less likely to use HIV prevention services if they were unable to access nonjudgmental, comfortable healthcare environments [14, 22, 109]. Voluntary HIV testing and use of HIV prevention services often involve the disclosure of stigmatized sexual behavior, such as having same-sex, anonymous, or multiple sexual partners [114116], which can also impede BMSM from using these services [58, 110]. If BMSM are HIV-positive or perceived to be HIV-positive, they may also experience stigma due to HIV status [101, 117121], sometimes leading to a fear of diagnosis and further hindering the use of prevention services [58]. Additionally, Blacks are more disapproving of homosexuality than Whites, even after controlling for religious and educational differences, which promotes internalized homophobia and may inhibit BMSM from adopting HIV testing behaviors [122124]. Experiences of stigma and discrimination among BMSM have consistently been associated with negative mental health outcomes, including depression and lower self-esteem [90, 96, 101, 112, 125, 126], and studies have found that poor mental health—which is associated with HIV infection [127132]—can contribute to the inadequate use of HIV testing and prevention services among this population [60, 90, 111, 112]. One study found that experiences of homophobia and racism in Black and LGBT communities, respectively, may lead to a psychological displacement that decreases the use of services and negatively affects open communication with healthcare providers [60]. Two studies found that racism and homophobia hindered the motivation of BMSM to access HIV prevention information [111, 112], and another study found that those who had a less positive self-identification of being Black and gay reported lower HIV prevention self-efficacy [90] (Table 3). In order to expand access to HIV testing and prevention services among BMSM, it is critical to address stigma and discrimination due to race, sexual orientation, and perceived HIV status on a structural level.

Table 3 Studies of stigma or discrimination and HIV risk in BMSM

Incarceration

Incarceration acts as a major structural barrier to HIV testing and prevention services for BMSM across meso-level dimensions of resources and social influence and control factors (Table 1). The rates of incarceration among Black men [133, 134] and BMSM [12, 61, 110, 135138] are highly disproportionate compared to rates among men and MSM, respectively, both of other races/ethnicities. Additionally, the HIV prevalence is approximately five times higher in prisons than in the general population [139, 140]. Despite research indicating that high HIV prevalence rates in correctional institutions may result primarily from transmission occurring prior to incarceration [141] and limited evidence of an association between incarceration and increased HIV risk among BMSM [20, 61, 81, 110, 142144] (Table 4), incarcerated settings are an important venue for the provision of comprehensive HIV testing, prevention, and education services. Previously incarcerated individuals often return to communities lacking preventive health information and skills, appropriate medical services, and other necessary forms of support [145]. There is also some evidence that HIV prevention case management and peer education programs have decreased risk behaviors and increased HIV knowledge among participants, though research on HIV prevention interventions in correctional settings is scarce [145, 146]. Despite the high HIV prevalence in prisons, only 20 states test all inmates for HIV at admission or while in prison, and only three states test them upon release [147]. In one state, only 31 % of male prisoners received a voluntary HIV test upon admission and many inmates were unaware of their status [148]. Prisons in certain states do offer services including instructor-led educational modules, peer education programs, and HIV prevention case management, but they are inconsistent [146, 149, 150]. Prisoners also experience a lack of condom availability [151], as only two state prison systems and five city/county jail systems in the US make condoms available to male inmates [152, 153]. Among Black men in one study who reported having anal intercourse while incarcerated, 90 % reported never using a condom during anal sex while incarcerated compared with 42 % who reported never using a condom during anal sex while not incarcerated [143]. Taken together, these studies demonstrate that improving the completeness and consistency of HIV testing and prevention services in correctional facilities represents a salient structural-level opportunity to expand services to more BMSM.

Table 4 Studies of incarceration and HIV risk in BMSM

Poverty

The effect of poverty on access to HIV testing and prevention services among BMSM is complex and not well understood. The unbalanced geographic distribution of services can act as a structural barrier to services within the meso-level dimension of settings (Table 1), as one study found that areas of a city where young BMSM lived and reported the highest rates of UAI also had the lowest densities of HIV prevention services [154]. While services were located primarily in areas most affected by HIV in the earlier years of the epidemic, there was a deficiency of services in Black communities despite a higher HIV prevalence in those areas of the city [154]. There is a void in research examining the potential relationship between socioeconomic status (SES) and access to HIV testing and prevention services among BMSM. Given that BMSM face economic and social challenges related to the unequal geographic allocation of resources, high levels of unemployment, the spatial concentration of violent crime, and disproportionate placement in the lowest-performing schools [155157], this is a particularly critical area of investigation. Although no articles were identified that discussed the relationship between SES and access to HIV prevention services among BMSM, studies among BMSM have found inconsistent evidence that poverty is associated with a greater risk of HIV infection [44, 48, 74, 105, 110, 158] (Table 5). However, their analyses have generally used arbitrary categorizations of self-reported income that have differed across studies and may account for some of the disparate results. A positive association between low income and HIV risk was reported by two studies [158, 159], one of which found that having an income less than $15,000 was one of the best predictors of UAI [159]. Others found non-significant associations between low income and HIV infection [44], financial hardship and UAI [105], and unemployment and UAI [110]. More rigorous research aiming to better understand the effects of poverty—and those of its intersectional nature with race, gender, and sexuality [160]—on access to services and risk of HIV infection among BMSM is needed. As the impact of poverty on access to HIV testing and prevention services among BMSM is complex, future research should consider specific mechanisms by which low SES may impede access to services, potentially involving the locations of HIV prevention service providers, convenience of available forms of transportation, physical layout of facilities, and exposure to community violence.

Table 5 Studies of poverty and HIV risk in BMSM

Discussion

The overarching objective of this research based on a critical review of the literature was to better understand how structural factors act as barriers to accessing HIV testing and prevention services among BMSM. The findings from this review provide compelling evidence that a novel approach to designing HIV prevention interventions that reflects the structural contexts in which BMSM access services is needed. Our analysis provides relevant findings pertaining to the complex processes by which structural factors are, in fact, related to individual testing behaviors and use of prevention services. In addition to aiming to reduce sexual risk behaviors, interventions for BMSM on a structural level ought to focus on the development and implementation of culturally congruent strategies that would eliminate barriers to accessing HIV testing and prevention services and equip BMSM with the knowledge, skills, and tools to navigate complex systems that may not meet their needs. Structural interventions that have been developed for other populations [161165] can also be adopted for implementation with BMSM.

In using the dynamic social systems model developed by Latkin et al. [7] to conceptualize the roles of structural factors as barriers to HIV testing and prevention services, three major themes emerged that underscore the strong social nature of structural barriers to services among BMSM. First, non-supportive relationships with healthcare providers within micro-level informal and formal social influence and control dimensions can impede access to services, as experiences of racism and homophobia during visits with healthcare providers limit the receipt of comprehensive HIV testing and prevention services [14, 109, 112]. Positive patient–provider relationships are critical for the provision of HIV prevention services by healthcare providers, which has been found to decrease risk behaviors [166, 167], increase HIV testing [51, 52, 62, 168], increase condom use, increase frequency of asking a sexual partner’s HIV status, and decrease the number of sexual partners [28]. Many healthcare providers lack cultural competency for working with patients of diverse sexual identities, and fail to recognize the importance of discussing sexual health with patients as a routine component of medical care [5154]. More comprehensive training of healthcare providers that encourages a proactive, client-centered, and nonjudgmental approach to HIV counseling and screening regardless of how patients identify or present themselves is needed to facilitate a better understanding of how HIV prevention fits into patients’ life priorities [53, 62, 169]. In 2013, the US Preventive Services Task Force updated its 2005 recommendation statement on screening for HIV to include all adolescents and adults aged 15–65—not only those who are known to be at increased risk for HIV infection—which may contribute to an increase in HIV testing among BMSM at healthcare visits [170].

Second, non-supportive relationships with members of social networks within micro-level informal social influence structures can also impede BMSM from accessing services. A lack of social support—often associated with experiences of stigma and discrimination from family, friends, and other community members due to sexual orientation, race, and/or perceived HIV status—can lead to negative mental health outcomes that hinder BMSM from accessing services [60, 90, 111, 112]. Experiences of stigma and discrimination diminish the motivation of BMSM to access HIV prevention information [111, 112] and lower their HIV prevention self-efficacy [90]. Testing for HIV is also stigmatized among social networks of BMSM, which can inhibit men from using these services [58, 110].

Third, many BMSM lack access to healthcare services due to insufficient economic and infrastructural resources. While the percentage of BMSM who lack health insurance coverage is unclear, it may be similar to the 19.0 % of Blacks in the US that reported not having health insurance coverage in 2012 [43]. With the full implementation of the Patient Protection and Affordable Care Act in January 2014, however, expanded and enhanced health insurance coverage may increase access to HIV prevention and care services among BMSM. As a result of this law, preventive care including HIV screening and counseling must be covered by insurance premiums and most insurance plans are unable to increase costs or refuse coverage to an individual as a result of a pre-existing health condition, including HIV infection [171]. Regardless of insurance status, there is some evidence that BMSM have reported high perceived costs and low perceived benefits of healthcare visits as barriers to accessing services [45]. While HIV clinics and community-based testing (e.g., mobile HIV testing vans) offer alternative options for accessing HIV testing and prevention services, no studies were identified that assessed the use of such services by BMSM. Additionally, a disproportionate number of BMSM have recurring contact with the prison system, where men experience a lack of condom availability [151] and incomplete and inconsistent access to HIV prevention services [146, 149, 150]. Improving services in correctional facilities represents a salient structural-level opportunity to expand testing and prevention to this population. Innovative ways to make HIV testing more accessible to BMSM in clinical, non-clinical, and outreach venues are needed [44].

This review should be interpreted in the context of several limitations. Many of the studies reviewed were cross-sectional, so temporality and causality could not be determined. However, this limitation is most relevant to studies that assessed the risk of HIV infection associated with various structural factors. Studies that provided findings most pertinent to understanding the roles of structural factors as barriers to HIV testing and prevention services were generally qualitative studies, meta-analyses, and other studies that offered descriptive statistics. In addition, many of the studies collected data using self-reporting methods and their results may have been affected by misclassification and/or social desirability bias. There was also significant variability in geographic location and sampling schemes across study populations; thus, the generalizability of findings is limited. We hope that this review may lead to a more complete and rigorous investigation of the roles of structural factors as barriers to HIV testing and prevention services. While most quantitative findings were based on multivariable analyses, some analyses did not adjust for all possible correlates and some findings were based on bivariate analyses. Moreover, our findings may have been influenced by publication bias in that we relied on two core databases for our literature search and this review was limited by the available literature. However, the literature search returned a large quantity of results, and to minimize the number of pertinent articles that could be neglected, we also reviewed relevant articles that were cited as references within all papers that met inclusion criteria. Our search included limited search terms, though they were of a broad scope and we did not limit our review to articles that focused solely on HIV.

Despite these limitations, our findings provide critical implications for future HIV prevention research and the development of innovative and culturally grounded structural interventions focusing on improving access to HIV testing and prevention services for BMSM. To our knowledge, this is the first paper to fully consider the role of structural factors as barriers to HIV testing and prevention services among BMSM, and our findings underscore the significant need for future studies to conduct more rigorous investigation into the roles of structural factors as barriers to services. These findings are also a call for the development of targeted interventions at the structural level that will reduce barriers to HIV testing and prevention services and provide BMSM with the knowledge, skills, and tools to more readily and consistently access available services in their communities.