Eing infected with the virus.75 Because most persons who are infected with HIV reduce risk behavior when diagnosed76 and because many also become less infectious with treatment,77,78 persons who are unaware that they are infected are more likely to transmit HIV than persons who have received an HIV-positive diagnosis.79 The FDA approved the first HIV Thonzonium (bromide) site testing technology in 1985. From 1985 to 2001, rates of HIV testing among the general population rose to a plateau of 40 .79 This plateau in HIV testing uptake occurred despite widespread efforts to promote HIV testing. Multiple structural factors influence HIV testing behavior and have contributed to this plateau.80 Figure 3 presents an analysis of these factors from a structural perspective. A major influence on HIV testing behavior is the physical location or setting where HIV tests are provided. Test settings affect HIV testing behavior by influencing two factors, access, or whether individuals can obtain an HIV test, and cognitive and affective processes including motivation and perceived norms. Persons may have more or less access to HIV tests, depending on whether a facility allocates resources to the provision of the tests, has tests available, and prioritizes the provision of HIV tests among other services (e.g., primary care, emergency care).79-81 Persons may be more or less willing to test for HIV (cognitive and affective processes) depending on whether they are offered the test in a setting where testing for HIV is private, normative, and does not disrupt alternative activities (e.g., socializing, seeking urgent care).81,82 Setting is not only limited to the micro-level space where HIV tests are provided. The community or neighborhood within which tests are provided can also influence individuals’ HIV testing access and willingness to test. Whether HIV tests are available in one’s neighborhood can influence whether one accesses HIV testing because the demand for preventive services is I-CBP112 chemical information sensitive to the cost associated with preventative care (e.g., travel, child care).83,84 The community or neighborhood setting can also influence whether an individual is motivated to test for HIV. Factors such as the HIV prevalence in a given neighborhood or the density of outreach activities and educational displays can increase perceived vulnerability to HIV, a motivational influence on HIV testing behavior.85,86 Importantly, the degree to which services are integrated and visible in a community setting may create positive social norms toward testing by reducing fears of stigma and discrimination, important deterrents of HIV testing.16,87 Finally, the macro setting, such as the state or nation, can influence HIV testing behavior. For example, political and demographic lines can demarcate resource allocation for HIV testing (e.g., greater allocation to urban vs. rural settings or differential allocation to zip codes with predominately minority populations).86 These lines can also demarcate formal rules about testing provision and reporting of results (e.g., policies about anonymous vs. confidential HIV testing, partner notification programs, mandatory reporting). Both resource allocation and formal rules delimit physical spaces where individuals and groups may find it more or less difficult to access services or feel more or less motivated to receive an HIV test.NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author ManuscriptAIDS Behav. Author manuscript; available in PMC 2011 December.Eing infected with the virus.75 Because most persons who are infected with HIV reduce risk behavior when diagnosed76 and because many also become less infectious with treatment,77,78 persons who are unaware that they are infected are more likely to transmit HIV than persons who have received an HIV-positive diagnosis.79 The FDA approved the first HIV testing technology in 1985. From 1985 to 2001, rates of HIV testing among the general population rose to a plateau of 40 .79 This plateau in HIV testing uptake occurred despite widespread efforts to promote HIV testing. Multiple structural factors influence HIV testing behavior and have contributed to this plateau.80 Figure 3 presents an analysis of these factors from a structural perspective. A major influence on HIV testing behavior is the physical location or setting where HIV tests are provided. Test settings affect HIV testing behavior by influencing two factors, access, or whether individuals can obtain an HIV test, and cognitive and affective processes including motivation and perceived norms. Persons may have more or less access to HIV tests, depending on whether a facility allocates resources to the provision of the tests, has tests available, and prioritizes the provision of HIV tests among other services (e.g., primary care, emergency care).79-81 Persons may be more or less willing to test for HIV (cognitive and affective processes) depending on whether they are offered the test in a setting where testing for HIV is private, normative, and does not disrupt alternative activities (e.g., socializing, seeking urgent care).81,82 Setting is not only limited to the micro-level space where HIV tests are provided. The community or neighborhood within which tests are provided can also influence individuals’ HIV testing access and willingness to test. Whether HIV tests are available in one’s neighborhood can influence whether one accesses HIV testing because the demand for preventive services is sensitive to the cost associated with preventative care (e.g., travel, child care).83,84 The community or neighborhood setting can also influence whether an individual is motivated to test for HIV. Factors such as the HIV prevalence in a given neighborhood or the density of outreach activities and educational displays can increase perceived vulnerability to HIV, a motivational influence on HIV testing behavior.85,86 Importantly, the degree to which services are integrated and visible in a community setting may create positive social norms toward testing by reducing fears of stigma and discrimination, important deterrents of HIV testing.16,87 Finally, the macro setting, such as the state or nation, can influence HIV testing behavior. For example, political and demographic lines can demarcate resource allocation for HIV testing (e.g., greater allocation to urban vs. rural settings or differential allocation to zip codes with predominately minority populations).86 These lines can also demarcate formal rules about testing provision and reporting of results (e.g., policies about anonymous vs. confidential HIV testing, partner notification programs, mandatory reporting). Both resource allocation and formal rules delimit physical spaces where individuals and groups may find it more or less difficult to access services or feel more or less motivated to receive an HIV test.NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author ManuscriptAIDS Behav. Author manuscript; available in PMC 2011 December.