Church attendance associated with late HIV diagnosis among US MSM

Church attendance is associated with late HIV diagnosis among men who have sex with men (MSM), according to US research published in the online edition of Clinical Infectious Diseases. The study was conducted in Alabama and showed that church-attending MSM were more than twice as likely to have a CD4 cell count below 200 cells/mm³ at the time of HIV diagnosis than MSM who did not attend church. There was also some evidence that church attendance was associated with less frequent HIV testing among MSM.

“We report an independent association between church attendance and sexual behaviour on timing of HIV diagnosis…and patterns of HIV testing,” write the authors. “HIV-infected MSM who reported current church attendance were more likely to present with advanced disease and less likely to report a history of HIV screening than non-church attending MSM.”

The investigators describe their findings as “provocative” and urge caution in their interpretation.

Several studies have shown a positive association between religious belief and practice and health outcomes. However, this research has focused on non-stigmatised illnesses. Much less is known about the relationship between participation in organised religion and outcomes among people with stigmatised health conditions, such as HIV.

Investigators at the 1917 Clinic in Birmingham, Alabama, therefore designed a cross-sectional study involving people newly diagnosed with HIV after 2007.

Participants completed a questionnaire about their HIV testing history and sexual behaviour. They were categorised as MSM, men who have sex with women (MSW) and women who have sex with men (WSM). Participants were also asked if they attended church.

A total of 508 patients were included in the investigators’ analyses. Approximately two thirds (62%) were African American. The authors note that religious belief and church attendance is especially important among this group.

The majority of participants (60%) were categorised as MSM, 21% as MSW and 18% as WSM. Church attendance was reported by most patients, including 53% of MSM, 59% of MSW and 64% of WSM.

A third (32%) of patients had a CD4 cell count below 200 cells/mm³ at the time of entry to HIV care and were therefore considered to have been diagnosed 'late'. There was a significant interaction between church attendance and late presentation to care (p = 0.02).

Church-attending MSM were significantly more likely to have a CD4 cell count below 200 cells/mm³ at the time of their diagnosis than non-church-attending MSM (32 vs 20%). After adjusting for other factors known to be associated with late presentation, the investigators found that church attendance was associated with a more than two-fold increase in the risk of late diagnosis among MSM (OR = 2.2; 95% CI, 1.2-4.0; p = 0.01).

For both MSW and WSM, there was no association between church attendance and late diagnosis.

Just under a third (29%) of participants reported never having had a previous HIV test before their diagnosis. There was a significant interaction between church attendance and sexual behaviour and testing history (p = 0.012).

Women who did not attend church were more likely to report no previous HIV test compared to women who were church attenders (59 vs 32%; OR = 0.3; 95% CI, 0.1-0.8; p = 0.01). In their initial analysis, the investigators also found that church-attending MSM were more likely to report no previous test compared to MSM who did not attend church (21 vs 12%; p = 0.041). But there was no significant association after controlling for potential confounders.

The investigators offer three possible explanations for the relationship between church attendance and late diagnosis among MSM:

• Stigmatising attitudes of some churches towards sex between men.

• Denial about HIV risk among church-attending MSM.

• Turning to organised religion because of illness.

“Although we attempted to adjust for potential confounders, we acknowledge that church attendance may merely associate with the actual causal factor(s), and work is underway to understand predictors of church attendance in our population,” comment the investigators.

Nevertheless, they conclude: “The modifying role of church attendance on late presentation for care in MSM is a novel and potentially important finding…some religious communities may need to explore reasons why their HIV-infected MSM members might present with more advanced disease than non-church-attending MSM.”