摘要：Objectives. More than one quarter of HIV-infected people are undiagnosed and therefore unaware of their HIV-positive status. Blacks are disproportionately infected. Although perceived racism influences their attitudes toward HIV prevention, how racism influences their behaviors is unknown. We sought to determine whether perceiving everyday racism and racial segregation influence Black HIV testing behavior. Methods. This was a clinic-based, multilevel study in a North Carolina city. Eligibility was limited to Blacks (N = 373) seeking sexually transmitted disease diagnosis or screening. We collected survey data, block group characteristics, and lab-confirmed HIV testing behavior. We estimated associations using logistic regression with generalized estimating equations. Results. More than 90% of the sample perceived racism, which was associated with higher odds of HIV testing (odds ratio = 1.64; 95% confidence interval = 1.07, 2.52), after control for residential segregation, and other covariates. Neither patient satisfaction nor mechanisms for coping with stress explained the association. Conclusions. Perceiving everyday racism is not inherently detrimental. Perceived racism may improve odds of early detection of HIV infection in this high-risk population. How segregation influences HIV testing behavior warrants further research. Despite decreases in mortality because of AIDS, the prevalence of HIV infection in the United States remains high overall, and the proportion of diagnoses among Blacks is increasing. 1 Although Blacks represent less than 13% of the US population, they account for 42% of prevalent HIV infections and 54% of annual diagnoses. 1 An estimated one fourth of all HIV-infected US residents have not been diagnosed. 2 HIV-positive Blacks delay seeking care more, progress to AIDS faster, and die from AIDS sooner than do Whites, underscoring the need to improve HIV screening in this population. 3 , 4 Sexually transmitted disease (STD) clinics are an important setting for reaching people at elevated risk of sexual transmission, the primary mode by which infection occurs. 5 These clinics provide testing regardless of an individual's ability to pay. The prevalence of undiagnosed HIV infection is higher in STD-clinic populations than in the general population, and people engaging in STD risk behaviors are by definition at risk for HIV transmission. Furthermore, although not every exposure to HIV results in seropositivity, epidemiologic synergy between HIV and classic STDs such as gonorrhea renders STD-infected people more susceptible to HIV infection upon exposure to the virus. 6 Population-based surveys suggest that Blacks obtain HIV testing at higher rates than do other racial/ethnic groups 7 ; however, self-reports may overestimate actual testing behavior. In one nationally representative study, 25% of Blacks reporting prior HIV tests had assumed they were tested during some clinical visit in which they had neither requested nor consented to a test. 8 Among STD-clinic patients, Blacks may actually be less likely to test. 9 For Blacks, negative attitudes toward HIV prevention are linked to racism. 10 Racism has been defined as “an organized system, rooted in an ideology of inferiority that categorizes, ranks, and differentially allocates societal resources to human population groups.”11(p76) Racism is a multilevel construct fundamentally influenced by macrolevel factors such as residential segregation. 12 – 14 Research suggests that perceiving or experiencing racial discrimination contributes to hypertension, 15 – 17 preterm birth, 18 mental health outcomes, 19 , 20 and unhealthful coping behaviors (e.g., cigarette smoking and alcohol use). 21 Exactly how individuals respond to perceived racism also is important. In the CARDIA (Coronary Artery Risk Development in Young Adults) study, for instance, people who perceived and challenged racism on the job had lower systolic blood pressures (i.e., better outcomes) than did those whom investigators described as internalizing it. 16 For some Blacks, however, overachieving in response to racism may adversely affect health, a phenomenon described as “John Henryism.” 22 Racism can be thought of as an element in the social environment; perceived racism is the extent to which individuals are aware of that element. Perceived everyday racism reflects individuals' assessments of potentially negative routine interactions (e.g., being followed while shopping in a store) as resulting from racism rather than other causes (e.g., coincidence). 23 In some contexts, perceiving racism is detrimental, whereas in others it is self-protective. 24 Most racism-related HIV-prevention research examines extreme forms of racism rather than everyday racism. These studies indicate that awareness of the US Public Health Services' study of untreated syphilis among Black men and beliefs that “the government is … using AIDS as a way of killing off minority groups” 25 are prevalent and associated with negative attitudes about HIV prevention. 26 – 29 Few studies have examined perceived racism's association with HIV preventive behaviors, and these primarily assess self-reports of behavior. A national phone survey 28 of Blacks (N = 500) and a Houston-based survey 30 of a multiracial sample (N = 1494) found negative associations between conspiracy beliefs and self-reported condom use for Black men. 28 , 30 One study 31 found perceived everyday racism was positively associated with condom use. These studies did not account for residential context. Perceptions about racism are influenced by interracial interactions. More integrated Blacks perceive more racism. 32 Outside the workplace, residential areas are the most likely arenas for interactions; often, however, residential areas are racially segregated. The systematic residential isolation of Blacks from Whites through de facto segregation is a fundamental cause of disparities, differentially influencing access to health care, socioeconomic status, and quality of services. 13 , 33 , 34 Segregation historically has affected communities in the US South. The most widely assessed dimension of segregation is unevenness. Calculated via the dissimilarity index, D, it indicates an area's relative proportions of minority and majority populations. 35 Studies using census geographies, such as block groups, permit monitoring of area socioeconomic and demographic trends across time and place; census designations are well-defined units of analysis, and the socioeconomic data are systematically collected. 36 Block groups, which average 1500 residents, are the smallest geographic units for which the US Census Bureau provides sample data. 37 Although many studies operationalize neighborhoods as tracts or zip code regions, block groups may be more appropriate units when studying smaller cities or regions in which neighborhood boundaries change rapidly. The purpose of our study was to examine perceived everyday racism's association with routine HIV testing among at-risk Blacks while accounting for racialized residential contexts.
