to be at risk for hepatitis B (Vallabhaneni et al., 2004), and 44% of the inmates were not aware that HBV can be transmitted through unprotected sexual activity.

Several studies have found that knowledge about hepatitis B is low among men who have sex with men, another population at high risk for HBV infection (McCusker et al., 1990; Neighbors et al., 1999; Rhodes et al., 2000). A 1990 study found that 68% of men who have sex with men and are patients at a community health center reported that they were aware of the vaccine, and 25% of those who knew about it had been vaccinated (McCusker et al., 1990). Most of the participants who knew about the hepatitis B vaccine had learned about it from newspapers targeting the gay population (64%); a minority had learned about it from health-care providers (44%), friends (37%), and brochures from health-care facilities or gay organizations (36%). A 1999 study had similar findings: 33% of the participants were unaware of the hepatitis B vaccine, and 63% had not been tested for hepatitis B; of those who were aware of the vaccine, only 22% had received the full vaccine series (Neighbors et al., 1999). A similarly low level of hepatitis B knowledge was found among patrons of gay bars in Birmingham, Alabama, where 32% reported having no information about hepatitis, 96% reported engaging in high-risk sexual behavior, and those who had not been vaccinated against HBV (58% of respondents) had much poorer knowledge about hepatitis B prevention than those who had been vaccinated (Rhodes et al., 2000).

Stigma

For many people born outside the United States, a cultural stigma is attached to a diagnosis of chronic hepatitis B. For example, in China, there is pervasive discrimination against people who are chronically infected with hepatitis B, who are frequently expelled from schools, fired from jobs, and shunned by other community members despite the recent passage of national antidiscrimination laws (China Digital Times, 2009). In a 2007 survey covering 10 major cities in China, hepatitis B was cited as one of the top three reasons for job discrimination (China Daily, 2007). Given the deeply ingrained stigma of hepatitis B in some endemic countries, it is not surprising that many immigrants remain reluctant to undergo testing and seek medical attention for a positive test result even after moving to the United States. Because that cultural aversion to hepatitis B testing and management is due largely to a lack of knowledge about routes of HBV transmission and means of prevention, any effort to deliver viral-hepatitis services to the foreign-born population must include an educational component to dispel myths (for example, that HBV can be transmitted through



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