Mystery shopper exercise shows that HIV testing services for young gay men in the US need to be improved

A quality assurance exercise using 'mystery shoppers' in three US cities with high HIV incidence among young gay men showed that although most testing sites were perceived as welcoming, friendly and confidential, other problems were identified. Testing sites performed poorly on LGBTQ visibility, only a minority discussed relationship contexts or provided safer sex education, and information about PrEP was inconsistently provided. The study is published in the 1 December issue of the Journal of Acquired Immune Deficiency Syndromes.

“As an HIV test is often an individual’s first experience with HIV prevention services (eg PrEP), it is important that this event is a positive experience, as a negative experience may deter future testing or engagement with care,” comment the investigators. “This study’s systematic collection of young men who have sex with men’s experiences when seeking HIV testing and prevention services in 3 large metropolitan areas is an important step towards improving these services for youth.”

Increasing the rate of HIV testing among young gay men is essential if the US is to achieve its goal of ending the HIV epidemic by 2030. To date, research and interventions have focused on strengthening the uptake of testing. In contrast, less attention has been paid to ensuring that counselling, testing and referral services are welcoming, respectful and have been tailored to the needs of younger gay men. 

A team of investigators led by Dr José Bauermesiter of the University of Philadelphia therefore designed a study to assess the HIV testing experiences of young gay men using a mystery shopper methodology.

Young HIV-negative gay men aged between 18 and 24 years were recruited in Philadelphia, Atlanta and Houston (all cities with high rates of new HIV infections among young gay men). They received training about the HIV testing process, PrEP and were given information about what a high-quality testing experience would include.

Investigators identified sites offering free, rapid, walk-in HIV tests. They checked the testing sites’ opening times and services online and then telephoned the site to confirm that they were correct. Numerous discrepancies were noted. Sites were informed in writing about the study and its use of a mystery shopper methodology and asked if they consented to participating in the research. Only one location refused to join the study.

The young gay men were dispatched to these sites as mystery shoppers. Afterwards, they provided their impressions as to how welcoming and friendly they found the testing sites, confidentiality and privacy during the testing process, providers’ competencies dealing with sexual minorities, LGBTQ visibility, discussion of relationships, provision of risk-reduction counselling and safer sex and information on the availability of PrEP. 

Each of the testing sites was visited separately by two mystery shoppers. These visits took place at different times of the day and on different days of the week (weekdays vs weekends).

A total of 24 young gay men were recruited to the study. Twelve were black and nine were Latino. Nine men recruited in Philadelphia visited 30 testing sites; six participants in Atlanta visited 17 sites; and nine young gay men in Houston visited 17 testing locations.

The pooled results showed that visits averaged 30 minutes. The sites were perceived as welcoming and friendly (71%) and privacy and confidentiality was respected (84%).

However, on two-thirds of occasions, the young gay men noted that the sites lacked competencies when dealing with sexual minorities. Fewer than half of locations had LGBTQ material visible and in only 58% of instances did medical forms include information or questions that were inclusive for gay and other men who have sex with men. Most sites did not discuss the young gay men’s relationship contexts and only 57% provided risk reduction counselling. Safer sex information was provided by 24% of testing sites and only 59% provided PrEP information and counselling.

Sites were rated highly for some services while also showing room for improvement. For instance, testing sites in Atlanta did well for LGBTQ visibility (71%), inclusivity (76%) and confidentiality (87%) but scored poorly for safer sex education (16%).

"On two-thirds of occasions, the young gay men noted that the sites lacked competencies when dealing with sexual minorities."

Comments from the mystery shoppers highlighted variability in their experiences at different sites. In regard to privacy and confidentiality, one man noted: “There was sufficient privacy, because we were taken into the consulting room for extra privacy and I liked how everything was handled professionally.” In contrast, another participant told the investigators: “They need to update the confidential part of it because I got tested in a room with people.”

There was similar diversity of experience in respect to risk reduction counselling. “The lady was extremely nice and made me feel comfortable and explained a lot of safer choices for me,” said one man. However, another commented: “I was offered no risk reduction options or condoms.”

Some staff were appreciated: “I really liked it, (provider) was very nice and super helpful. I felt so comfortable with him and it felt like I could just tell him and ask anything knowing he would not judge me, he takes his job seriously and he is just so nice and caring.” However, at another location: "I feel like my experience here was the typical experience of going somewhere where they see a lot of gay people and even work with them but there is a lack of real understanding of a lot of what comes along with the lifestyle."

"Testing sites' variable performance underscores the importance of improving HIV testing services for young men who have sex with men," conclude Bauremeister and colleagues. They recommend strategies for testing sites to promote cultural sensitivity, including funding staff training, creating systems to assess adherence to testing guidelines and best practices, and implementing new service delivery models.


Bauermeister JA et al. Testing the testers: are young men who have sex with men receiving adequate HIV testing and counseling services? Journal of Acquired Immune Deficiency Syndromes, 82: S133-141,  2019.

doi: 10.1097/QAI.0000000000002173.