Abstract
Black adolescents in the U.S. are disproportionately impacted by HIV and sexually transmitted infections (STIs), with gender differences in testing behaviors. This study examined predictors of HIV and STI testing among sexually active Black adolescents using data from the 2021 Youth Risk Behavioral Surveillance System. Weighted regression models assessed the odds of lifetime HIV and STI testing, with predictors including substance use before sex, condom use, forced intercourse, and current use of e-cigarettes, alcohol, and cannabis, adjusting for sex and age. The sample included 394 sexually active Black adolescents; mean age 16 years, 55% male. Results showed higher testing for those with more sexual partners and current substance users, with substance type influencing testing behaviors. Males had significantly higher odds of testing than females. E-cigarette use emerged as a novel factor influencing testing indicating how nicotine consumption trends may impact preventative health measures and risk assessment among youth.
Keywords: HIV testing, STI testing, Black adolescents, substance use, adolescent health, sexual health
Introduction
In the United States (U.S.), adolescents are being diagnosed with human immunodeficiency virus (HIV) and sexually transmitted infections (STIs) at an elevated rate. From 2018 to 2021, adolescents comprised of 20% of new HIV diagnoses (Outlaw et al., 2022; Prevention, 2023; Ryan et al., 2024). Furthermore, sexually active adolescents have been reported to be disproportionately affected by HIV and STIs (Cuffe et al., 2016; Pleasure et al., 2022; Prevention). Increases in HIV and STI rates may stem from adolescents partaking in risky behaviors, such as condomless sex, multiple sexual partners, early initiation into sex, and drug and alcohol use (Adebayo & Gonzalez-Guarda, 2017; Mahat & Kelly, 2023; Outlaw et al., 2022; Sharma et al., 2022).
Among adolescents, Black adolescents are diagnosed with HIV and STIs at a higher rate compared to Hispanic/Latinx and White adolescents; with one study finding Black adolescent males diagnosed with HIV at a 2.5 times higher rate than Hispanic/Latinx and 3.3 times higher rate than White adolescent males (Brawner et al., 2019). The same study found Black female adolescents to be diagnosed with HIV at a 4 times higher rate than Hispanic/Latinx and White adolescent females (Brawner et al., 2019). Another study identified African American/Black adolescents to receive 45% of new HIV diagnoses though they only represent 12% of the population, noting a severe imbalance in HIV diagnoses among Black adolescents in the U.S. (Lardier et al., 2019). In addition, Black adolescents are more likely to be diagnosed with STIs compared to White adolescents, with Black adolescent females at increased risk in certain regions of the U.S. (Evans et al., 2020; Walden et al., 2024).
Although Black adolescents are, in general, more likely to get tested (and diagnosed) than adolescents of other races (Decker et al., 2015), testing rates among adolescents overall, and specifically Black adolescents, remain low. One study used Youth Risk Behavior Surveillance System (YRBSS) data from 2019 to 2021 and discovered that lifetime HIV testing decreased from 9% to 6% among high school students and STI testing in the 12-months prior to survey administration decreased from 20% to 15% (Szucs et al., 2023). In a sample of 990 Black adolescents, 71 percent of sexually active Black adolescents had never been tested for HIV (Swenson et al., 2009). Several individual and contextual-level factors influence HIV/STI testing utilization and disparities among Black adolescents. Older age, less religious service attendance, testing-related partner communication, past STI testing history and diagnosis, and knowledge about STIs are associated with more HIV testing in this population (Swenson et al., 2009). In addition, experiences of racial discrimination are associated with less likelihood of STI testing (Alarcon et al., 2020). Socio-environmental factors compound these barriers. Black adolescents are less likely to receive HIV education compared to White adolescents (Phillips et al., 2020) and more likely to receive health care from emergency department settings (Douglas et al., 2024), which are considered suboptimal contexts for STI testing and treatment (Bergquist et al., 2019).
Several studies indicate gender disparities in HIV testing among Black adolescent and young adult populations (Arrington-Sanders & Ellen, 2008; Talib et al., 2013). Male students attending historically Black colleges and universities (HBCUs) are less likely to get tested while reporting more sex partners (McElrath et al., 2017) and Black female adolescents are 2.7 more likely to get testing compared to male adolescents. For Black female adolescents, testing often occurs as part of routine (e.g., Pap smear) and pregnancy-related gynecological exams (Arrington-Sanders & Ellen, 2008; Payne et al., 2006). Indeed, Arrington-Sanders and colleagues found no gender differences in HIV testing between Black male and female adolescents with no history of pregnancy, indicating that gender disparities in testing and diagnosis among Black adolescents may be attributable to pregnancy-related health service utilization.
Current HIV and STI testing guidelines for adolescents are that all people of both genders from ages 13 to 64 years should get tested for HIV at least once and all sexually active women younger than age 25 years should be tested for gonorrhea and chlamydia yearly (Prevention, 2024). While these guidelines are well established, low testing rates for both HIV and STIs persist among adolescent populations (Adebayo & Gonzalez-Guarda, 2017; Cuffe et al., 2016; Outlaw et al., 2022). Prior research demonstrates that HIV and STI testing share common predictors, though the literature focuses more on HIV testing and its predictors. HIV testing predictors include gender (more likely females), race (more likely Black adolescents), age (more likely as age increases), sexual orientation (more likely sexual minorities), sexual risk behavior status, substance use, and prior STI testing (Outlaw et al., 2022; Swenson et al., 2009). On the other hand, STI testing can be predicted by gender (more likely females), as national guidelines focus on females only (Cuffe et al., 2016).
Based on the testing rates and predictors for adolescents and unique experiences of Black adolescents discussed above, the purpose of this study was to investigate the associations between HIV and STI testing and their predictors among sexually active Black adolescents in the U.S. using 2021 YRBSS data, and to examine any gender differences. We hypothesized that sexually active Black adolescents reporting substance use and partaking in sexual risk behaviors would be more likely to report testing for HIV and STIs. We also hypothesized that gender would act as a moderator between predictors and HIV and STI testing.
Methods
Participants
National data from the Youth Risk Behavior Surveillance System (YRBSS) 2021 cycle was used for this analysis. The YRBSS is a system of biennial cross-sectional administered to high school students which captures data on six categories of health-related behaviors (e.g., behaviors that contribute to unintentional injuries and violence, sexual behaviors related to unintended pregnancy and sexually transmitted diseases [including HIV], substance use, unhealthy dietary behaviors, and physical activity) that contribute to the leading causes of death and disability among adolescents. The survey employs a sampling design that ensures national representation of demographic groups. Inclusion criteria for this study were adolescents who identified as Black or African American, were 14 years or older, and who reported having at least one sexual partner in the last 3 months (sexually active), resulting in a weighted analytic sample size of 394 adolescents (unweighted N=459). Data used for this secondary analysis are de-identified and publicly available, thus no protocol approval from an institutional review board was necessary. Details of the YRBSS methods can be found elsewhere (Mpofu et al., 2023).
Measures
Outcomes
HIV testing
The YRBS asked students “Have you ever been tested for HIV, the virus that causes AIDS? (Do not count tests done if you donated blood.)” Responding “yes” was considered ever having been tested for HIV; responding “no” was considered never having been tested. Respondents could also select “not sure”; however, these responses were excluded from the multivariate and interaction analyses.
STI testing
The YRBS asked students “During the past 12 months, have you been tested for a sexually transmitted disease (STD) other than HIV, such as chlamydia or gonorrhea?” Responding “yes” was considered ever having been tested for an STI; responding “no” was considered never having been tested. Respondents could also select “not sure”; however, these responses were excluded from the multivariate and interaction analyses.
Predictors
Use of alcohol or drugs before sex
The YRBS asked students “Did you drink alcohol or use drugs before you had sexual intercourse the last time?” Responding “yes” was considered use of drugs or alcohol before sex; responding “no” was considered no drugs/alcohol use before sex. Those who reported never had sex were not included in this analysis.
Use of condom during last sex
The YRBS asked students “The last time you had sexual intercourse, did you or your partner use a condom?” Students could respond with “I have never had sex,” “yes,” and “no.” Those who reported never had sex were not included in this analysis.
Number of sexual partners
The YRBS asked, “During your life, with how many people have you had sexual intercourse?” Students could respond with “I have never had sexual intercourse,” “1 partner,” “2 partners,” and so forth up to “6 or more people”. The use of this variable in the current analysis was treated as a continuous variable and did not include those who had never had sex.
Current substance use
The YRBS asked, “During the past 30 days, on how many days did you have at least one drink of alcohol?” Students were identified as current alcohol users if they reported drinking alcohol on at least one day in the past 30 days; non-users reported zero days. To measure current cannabis use, students were asked “During the past 30 days, how many times did you use cannabis?” Students were identified as current cannabis users if they reported using cannabis at least once in the past 30 days; non-users reported zero days. To measure current e-cigarette use, “During the past 30 days, how many times did you use an electronic vapor product?” Students were identified as current e-cigarette users if they reported using e-cigarettes at least once in the past 30 days; non-users reported zero days.
Forced intercourse
The YRBS asked, “Have you ever been physically forced to have sexual intercourse when you did not want to?” Students could respond “yes” or “no.”
Demographics
Demographics include age, sex, and race/ethnicity. Age was assessed with the YRBS question, “How old are you?” Students could respond “12 years old,” “13 years old,” “14 years old,” “15 years old,” “16 years old,” “17 years old,” or “18 years old or older.” Students aged 13 years and younger were excluded from the analysis due to small sample size and limited exposure to HIV/STI testing (Aivadyan et al., 2023). Race/ethnicity was based on a variable created by the CDC in which responses were coded “non-Hispanic Black,” “non-Hispanic White,” “Hispanic,” or “Other.” For the present analyses, only the non-Hispanic Black adolescents subsample was used.
Procedures
Univariate analyses described the distribution of demographics, predictors, and HIV and STI testing. Bivariate tests (t-tests, chi-square) determined any statistical associations between testing and predictors and demographics. Multivariable logistic regression models determined odds of lifetime HIV and STI testing among sexually active non-Hispanic Black adolescents, with drugs and alcohol before sex, condom use during sex, forced intercourse, current e-cigarette use, current alcohol use, and current cannabis use as predictor variables, adjusting for sex and age. Separate models were run for each outcome. Collinearity was assessed using variance inflation factor (VIF). An interaction analysis explored the intersection of gender and HIV/STI testing among sexually active Black adolescents. Appropriate sampling weights were applied, and survey estimations were implemented to account for the sampling design (Mpofu et al., 2023). The weighting process adjusted for potential oversampling and non-response biases, giving greater or lesser influence to participants based on their probability of selection, thus allowing for more accurate generalizations from the sample to the broader adolescent population (Mpofu et al., 2023). Analyses were conducted using Stata statistical software version 17.0 (College Station, TX).
Results
The 2021 YRBSS sample of sexually active Black adolescents (weighted N=394; unweighted N=459) had a mean age of 16 years (linearized standard error [SE]: 0.09) and was 55% male. Eighteen percent (unweighted n=70) of the sample reported having tested for HIV at least once; 19% of the sample (unweighted n=66) reported having tested for an STI. The sample had a weighted mean of 3 sexual partners; 16% reported having been forced to have sexual intercourse (unweighted n=60). Around 20% (unweighted n=90) of the sample reported drinking alcohol or using drugs before last sexual intercourse, and 51% (unweighted n=251) reported not using a condom during last sexual intercourse. Around 31% of the sample reported using e-cigarettes at least once in the last 30 days; 30% reported alcohol use in the last 30 days, and 49% reported using cannabis in the last 30 days (Table 1).
Table 1.
Demographic characteristics of sexually active* Black adolescents in the 2021 YRBSS (weighted n=394; unweighted n=459)
| Unweighted n (weighted %) | |
|---|---|
| Age (years) (weighted mean (SE)) | 16.25 (0.09) |
| Sex | |
| Male | 249 (54.6) |
| Female | 207 (45.4) |
| Ever tested for HIV | |
| Yes | 70 (16.7) |
| No | 322 (75.9) |
| Not sure | 25 (7.8) |
| Ever tested for an STI | |
| Yes | 66 (18.6) |
| No | 263 (77.0) |
| Not sure | 13 (4.4) |
| Number of sexual partners in lifetime (weighted mean (SE)) | 2.5 (1.7) |
| Forced sexual intercourse (ever) | |
| Yes | 60 (16.4) |
| No | 318 (83.6) |
| Drank alcohol or used drugs before last sexual intercourse | |
| Yes | 90 (19.7) |
| No | 332 (80.3) |
| Used a condom during last sexual intercourse | |
| Yes | 202 (48.8) |
| No | 251 (51.2) |
| Used e-cigarettes in the past 30 days | |
| At least once | 135 (30.9) |
| Zero times | 246 (69.1) |
| Drank alcohol in the past 30 days | |
| At least once | 130 (29.6) |
| Zero times | 288 (70.4) |
| Used cannabis in the past 30 days | |
| At least once | 230 (48.5) |
| Zero times | 229 (51.5) |
at least one sexual partner in the last 3 months
There were no statistically significant differences in lifetime HIV testing by age, sex, drug or alcohol use before sex, or cannabis use in the last 30 days (p>0.05 for all). Lifetime HIV testing was associated with e-cigarette (p=0.027) and alcohol use (p<0.001) in the last 30 days. There were no statistically significant differences in past-year STI testing by age, sex, drugs or alcohol before sex, or e-cigarette use in the last 30 days (p>0.05 for all). Past-year STI testing was associated with alcohol use (p<0.001) and cannabis use (p=0.022) in the last 30 days and higher number of sexual partners (p<0.001) (Table 2).
Table 2.
Bivariate associations between HIV/STI testing and sexual risk and substance use correlates among sexually active* Black adolescents in the 2021 YRBSS.
| Weighted n (weighted %) | ||||||
|---|---|---|---|---|---|---|
| Ever tested for HIV | p | Ever tested for STI | p | |||
| Yes | No | Yes | No | |||
| Age (weighted mean (linearized SE)) | 16.4 (0.19) | 16.3 (0.09) | 0.533 | 16.6 (0.18) | 16.2 (0.09) | 0.063 |
| Sex | 0.531 | 0.841 | ||||
| Male | 35 (59.7) | 142 (53.1) | 33 (53.8) | 141 (55.3) | ||
| Female | 24 (40.3) | 125 (46.9) | 29 (46.2) | 113 (44.7) | ||
| Number of sexual partners in lifetime (rounded weighted mean) | 4 | 3 | 0.054 | 4 | 3 | <0.001 |
| Drank alcohol or used drugs before last sexual intercourse | 0.286 | 0.103 | ||||
| Yes | 16 (26.9) | 51 (18.8) | 18 (28.7) | 47 (18.7) | ||
| No | 43 (73.1) | 216 (81.2) | 44 (71.3) | 206 (81.3) | ||
| Used a condom during last sexual intercourse | 0.059 | 0.382 | ||||
| Yes | 19 (33.4) | 129 (48.6) | 26 (42.6) | 126 (50.0) | ||
| No | 39 (66.6) | 136 (51.4) | 35 (57.4) | 126 (50.0) | ||
| Forced sexual intercourse | 0.031 | 0.055 | ||||
| Yes | 17 (24.9) | 21 (11.0) | 16 (24.6) | 21 (11.0) | ||
| No | 52 (75.1) | 173 (89.0) | 49 (75.4) | 173 (89.0) | ||
| Used e-cigarettes in the past 30 days | 0.027 | 0.134 | ||||
| At least once | 20 (44.7) | 65 (29.8) | 20 (42.1) | 60 (29.2) | ||
| Zero times | 25 (55.3) | 153 (70.2) | 28 (57.9) | 145 (70.8) | ||
| Drank alcohol in the past 30 days | <0.001 | <0.001 | ||||
| At least once | 32 (55.1) | 63 (25.5) | 33 (55.6) | 57 (24.3) | ||
| Zero times | 26 (44.9) | 184 (74.5) | 26 (44.4) | 178 (75.7) | ||
| Used cannabis in the past 30 days | 0.144 | 0.022 | ||||
| At least once | 39 (66.9) | 123 (45.8) | 55 (51.6) | 110 (34.1) | ||
| Zero times | 20 (33.1) | 145 (54.2) | 19 (30.9) | 145 (56.9) | ||
At least one sexual partner in the last 3 months.
Table 3 displays the results of the multivariate logistic regressions for HIV and STIs. After adjusting for sex and age, sexually active Black adolescents had 1.3 greater odds of testing for HIV if they had more sexual partners in their lifetime (Adjusted Odds Ratio [aOR]: 1.27; 95% Confidence Interval [CI]: 1.03, 1.56). Current e-cigarette users had 2 times greater odds of ever testing for HIV (aOR: 1.99, 95% CI: 1.11, 3.57) and 4.4 times greater odds if they were current alcohol users (aOR: 4.40, 95% CI: 2.10, 9.23). Those who experienced forced sexual intercourse had almost 4 times greater odds of HIV testing (aOR: 3.87, 95% CI: 1.53, 9.80). Associations between lifetime HIV testing and drug/alcohol use before last sex, condom use during last sex, and cannabis use were not statistically significant.
Table 3.
Weighted logistic regression estimating odds of HIV and STI testing by sexual risk and substance use correlates among sexually active* Black adolescents in the 2021 YRBSS.
| Weighted Odds Ratio (OR) | Weighted Confidence Interval (CI) | Weighted Odds Ratio (OR) | Weighted Confidence Interval (CI) | |
|---|---|---|---|---|
| Ever tested for HIV | Ever tested for STI | |||
|
| ||||
| Number of sexual partners in lifetime | 1.27 | 1.03, 1.56 | 1.54 | 1.27, 1.87 |
|
| ||||
| Drank alcohol or used drugs before last sexual intercourse | ||||
| Yes | 1.65 | 0.68, 4.00 | 1.84 | 0.86, 3.93 |
| No | Ref. | - | Ref. | - |
|
| ||||
| Used a condom during last sexual intercourse | ||||
| Yes | 0.50 | 0.24, 1.06 | 0.75 | 0.37, 1.50 |
| No | Ref. | - | ||
|
| ||||
| Forced sexual intercourse | ||||
| Yes | 3.87 | 1.53, 9.80 | 2.77 | 0.98, 7.78 |
| No | Ref. | - | Ref. | - |
|
| ||||
| Used e-cigarettes in the past 30 days | ||||
| At least once | 1.99 | 1.11, 3.57 | 1.70 | 0.80, 3.57 |
| Zero times | Ref. | - | Ref. | - |
|
| ||||
| Drank alcohol in the past 30 days | ||||
| At least once | 4.40 | 2.10, 9.23 | 4.64 | 2.15, 10.03 |
| Zero times | Ref. | - | Ref. | - |
|
| ||||
| Used cannabis in the past 30 days | ||||
| At least once | 2.64 | 0.75, 9.33 | 2.91 | 1.06, 8.01 |
| Zero times | Ref. | - | Ref. | - |
At least one sexual partner in the last 3 months
Notes: separate models ran for each correlate; models adjusted for age and sex.
After adjusting for sex and age, sexually active Black adolescents had 1.5 times greater odds of testing for an STI if they had more sexual partners in their lifetime (aOR: 1.54; 95% CI: 1.27. 1.87), 4.6 times greater odds of testing for an STI in the past year if they were current alcohol users (aOR: 4.64, 95% CI: 2.15, 10.03), and 3 times greater odds if they were current cannabis users (aOR: 2.91, 95% CI: 1.06, 8.01). Associations between past-year STI testing and drug/alcohol use before last sex, condom use during last sex, forced sexual intercourse, and e-cigarette use were not statistically significant.
Table 4 shows the results of the interaction analysis looking at the intersection of gender and HIV/STI testing among sexually active Black adolescents. We observed almost twice greater odds of HIV testing among Black males if they had more sexual partners in their lifetime (aOR: 1.53, 95% CI; 1.25, 1.99), and approximately 8 times greater odds if they experienced forced sexual intercourse (aOR: 8.35, 95% CI: 1.46, 47.80). Black male alcohol users had approximately 8 times greater odds of STI testing compared to female non-users (alcohol; aOR: 8.34, 95% CI: 2.60, 26.86). Sexually active Black males had almost twice greater odds of STI testing if they had more sexual partners in their lifetime (aOR: 1.94, 95% CI: 1.59, 2.37).
Table 4.
Weighted logistic regression estimating odds of HIV and STI testing by sexual risk and substance use correlates among sexually active* Black adolescents in the 2021 YRBSS: interaction model with sex.
| Weighted Odds Ratio (OR) | Weighted Confidence Interval (CI) | Weighted Odds Ratio (OR) | Weighted Confidence Interval (CI) | |
|---|---|---|---|---|
| Ever tested for HIV | Ever tested for STI | |||
| Number of sexual partners | ||||
| p for the interaction term<0.0001 | p for the interaction term<0.0001 | |||
| Females | 0.78 | 0.52, 1.19 | 1.17 | 0.91, 1.50 |
| Males | 1.58 | 1.25, 1.99 | 1.94 | 1.59, 2.37 |
|
| ||||
| Forced sexual intercourse | ||||
| p for the interaction term=0.0189 | ||||
| Females | ||||
| Yes | 2.67 | 0.83, 8.66 | ||
| No | Ref. | - | ||
| Males | ||||
| Yes | 8.35 | 1.46, 47.80 | ||
| No | Ref. | - | ||
|
| ||||
| Drank alcohol in the past 30 days | ||||
| p for the interaction term=0.0019 | p for the interaction term=0.0013 | |||
| Females | ||||
| At least once | 2.56 | 2.51 | 0.99, 6.31 | |
| Zero times | Ref. | - | Ref. | - |
| Males | ||||
| At least once | 6.74 | 2.37, 19.13 | 8.34 | 2.60, 26.86 |
| Zero times | Ref. | - | Ref. | - |
|
| ||||
| Used cannabis in the past 30 days | ||||
| p for the interaction term=0.0423 | ||||
| Females | ||||
| At least once | 2.35 | 0.73, 7.56 | ||
| Zero times | Ref. | - | ||
| Males | ||||
| At least once | 3.40 | 0.47, 24.79 | ||
| Zero times | Ref. | - | ||
At least one partner in the last 3 months
Notes: separate models ran for each correlate; interaction models adjusted for age. Only results for models with significant interaction terms presented.
Discussion
This study examined associations between sexual behaviors, substance use behaviors and HIV/STI testing among Black adolescents and gender differences. Key findings in this study include higher number of sexual partners, forced sexual intercourse, and substance use were positively associated with HIV and STI testing. To authors knowledge, this study is one of the first to identify e-cigarette use as a novel factor influencing STI testing behaviors and differing testing behaviors depending on substance used. The relationship found between number of sexual partners and HIV and STI testing aligns with previous literature (Coeytaux et al., 2014; Cuffe et al., 2016). Among Black male adolescents, a higher number of sexual partners was associated with a history of HIV testing (Swenson et al., 2009). The association between forced sexual intercourse and HIV testing corroborates existing literature on HIV testing among high school students in the United States (Coeytaux et al., 2014). Similar to previous research, our findings indicate a positive relationship between substance use and HIV and STI testing. Adolescents engaging in alcohol and cannabis use have higher odds of testing for HIV, however no studies have investigated the associations between e-cigarettes and HIV and STI testing (Mahat & Kelly, 2023; Outlaw et al., 2022). Our work is novel in identifying a positive association between e-cigarette use and HIV and STI testing among Black adolescents and adds to the broader discussion on e-cigarette use among adolescents. Additionally, our work highlights the positive statistical associations between sexual risk behaviors and substance use and HIV and STI testing. This is crucial for developing HIV and STI testing-focused interventions for Black adolescents that consider their lived experiences and context to ensure buy-in for the intervention (Evans et al., 2020).
Findings from our analysis underscore that while the use of substances among Black adolescents remains prevalent and associated with greater odds of ever testing for HIV and STIs, it is essential for HIV/STI testing to be made available to adolescents who may not be engaging in substances but are at risk of HIV/STI through sexual behaviors. Since HIV and STI risk co-occur with substance use behaviors, we suspect adolescents engaging in these behaviors are more likely to be knowledgeable of these risks and may have greater engagement with healthcare that offers HIV and STI tests (Pampati et al., 2019). In fact, we found that sexually active Black adolescents were at greater odds of ever testing for HIV and STI varied based on the type of substance used. Sexually active Black adolescents who reported current e-cigarettes use reported greater odds of testing for HIV but not STIs. This could signify a shift in how nicotine and cannabis use trends may be impacting preventative health measures for youth, such as testing. On the contrary, sexually active Black adolescents who reported current cannabis use were at greater odds of ever testing for STIs but not HIV. However, Black adolescents who reported current alcohol use were associated with greater odds of testing for both HIV and STIs. Further research should continue to elucidate these substance-specific patterns found in order to better tailor HIV and STI testing promotion interventions. That said, our findings are promising given that adolescents engaging in substance use behaviors are being tested for HIV and STIs as recommended by HIV and STI testing guidelines (Adolescence et al., 2014; Emmanuel et al., 2011).
Notable gender disparities in testing among Black adolescents were captured. Particularly, Black males were more likely to test for HIV and STIs compared to Black females. These gender differences in testing behaviors may have implications for gender-responsive intervention and care. In our interaction analysis we observed almost twice greater odds of HIV testing and higher odds of STI testing among Black males if they had more sexual partners in their lifetime. While sexual orientation was not included in the present analysis, given the prevalence of HIV among Black men who have sex with men (MSM), sexual orientation should be explored in a future analysis. Additionally, Black male adolescents had greater likelihood of HIV testing if they experienced forced sexual intercourse. Black male adolescents in this sample may have an increased perceived risk of HIV, and thus are more likely to get tested (Evangeli et al., 2016). Greater odds of HIV testing among Black male adolescents who experienced forced sexual intercourse may be attributed to increased recognition and efforts to decrease stigma for males who experience forced sexual intercourse (Brooks et al., 2005). Our results also showed that Black male adolescents who used alcohol had significantly higher odds of STI testing compared to female non-users highlighting how future research should continue to examine these gender and substance use interaction patterns to better tailor HIV and STI testing promotion interventions. For example, gender-specific counseling services that address unique barriers, such as addressing stigma around sexual health among young women or challenging social and gendered norms that may deter health-seeking in young men, can promote engagement.
Another factor to consider in the landscape of HIV and STI testing among Black adolescents is stigma which plays an important role in accessing testing services for vulnerable populations. Higher levels of stigma are consistently associated with less HIV and STI testing (Morris et al., 2014). There is evidence indicating a difference between HIV- and other STI-related stigma, as research has found adolescents perceive HIV to be more damaging to one’s reputation (Neal et al., 2010). This is consistent with Black males receiving STI testing during general medical exams but opting out of HIV testing due to concerns about confidentiality and potential positive results (Doshi et al., 2013). Black female adolescents endorse less HIV-related stigma, greater self-efficacy related to HIV risk reduction behaviors, and more factual HIV/STI knowledge compared to boys. Black males, particularly those of lower socio-economic status, face significant barriers in accessing testing, such as difficulty accessing regular healthcare, mistrust in the healthcare system, perceived low quality of care in community-based clinics, concerns about confidentiality, and feelings of stigma associated with being recognized in testing centers (Doshi et al., 2013). The YRBSS did not enquire about stigma associated with testing behaviors, therefore more research is needed to elucidate whether stigma differentially impacts STI and HIV testing among Black adolescents.
Limitations
Findings must be considered within the context of several limitations. The cross-sectional nature of the data prohibits causal inference from being drawn. National YRBSS data are representative of public and private school students in grades 9–12 in the 50 states and the District of Columbia. Thus, results are not generalizable to adolescents who may be truant or in areas where there are high absentee rates and may face even greater barriers to HIV and STI testing than their peers. The YRBS collects limited information, precluding adjustment for other socioeconomic and structural factors that may influence HIV and STI testing (e.g., health insurance). Alcohol, cannabis, and e-cigarette use were assessed in the past 30 days, potentially excluding adolescents who previously but not recently engaged in the use of these substances. Drug/alcohol use and condom use were assessed with single items for last sexual intercourse only, potentially excluding adolescents who have ever but more previously engaged in these behaviors. Finally, it is essential to recognize the ethical complexities of working with adolescent data due to the sensitive nature of the data collected.
Conclusions
This study showed that among Black adolescents, sexual behaviors and substance use are linked to higher rates of HIV and STI testing. This study is among the first to highlight e-cigarette use as a novel factor influencing STI testing behaviors and to reveal variations in testing behaviors based on the type of substance used. The observed gender disparities and impact of trauma exposure on testing highlight a need for targeted, gender-specific interventions to increase testing uptake among Black adolescents. Future research should explore how diverse gender identities and sexual orientation impact the relation between sexual behaviors, substance use, and testing behaviors to improve HIV and STI prevention and testing initiatives for Black adolescents, as these insights could inform targeted public health programs and policy initiatives aimed at reducing barriers to care and promoting healthier behaviors within this population.
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