Missteps, misunderstandings, and missed opportunities: HIV testing among young African Americans

In 2006, more HIV infections occurred among young people under 30 (aged 13–29) than any other age group (34%, or 19,200).¹ Prevention of primary and secondary transmission is paramount to effective control of continuing spread of the virus. Unfortunately, vaccines as a reliable mechanism for prevention have remained elusive, underscoring the importance of public health, behavioral, and biomedical components of multi-modality prevention strategies. Identification and counseling of positives and subsequent secondary prevention strategies with partners are critical components of any multi-modal program.

In this issue of Sexually Transmitted Disease², Swenson et al. report low rates of HIV testing among a sample of sexually active African American adolescents; a group who has disproportionately high rates of HIV/AIDS, relative to the proportion of the US population they comprise. Of the estimated 18,849 people under the age of 25 whose diagnosis of HIV/AIDS was made during 2001–2004 in the 33 states with long-term confidential name-based HIV reporting, 11,554 (61%) were black.³ The authors found that among the adolescents sampled, only 29% reported having been tested for HIV infection. Notably, testing was found to be associated with sexual healthcare, partner communication, risk-reduction self-efficacy, sexually transmitted infection (STI) knowledge, and less religiosity. The strongest predictor of HIV testing for both African American girls and boys was having at least one STI test

While the testing percentages reported in the current study are low, they are actually an improvement over other studies that have examined rates of HIV testing among adolescents. The Youth Risk Behavior Survey (YRBS), a nationally representative sample of youth, found that in 2007 while 35% of students were currently sexually active, only 13% of 9^th–12^th grade students had ever been tested for HIV (22% among African Americans, 13% among Hispanics and 11% among white students).⁴ While the YRBS demonstrates a prevalence of HIV testing among African Americans higher than other racial and ethnic groups in the US, given the high endemic levels of infection within the wider African American community (both among adolescents and adults), concerted efforts need to be made to increase the uptake of HIV testing.

While it is useful to know the correlates associated with testing as presented in this study, to truly uncover undiagnosed HIV infection, we must understand and then increase testing among those individuals that have not tested or do not test often. Of the estimated 1.1 million people living with HIV in the US, approximately one quarter are unaware of their status⁵ and the rates may be even higher among youth.⁶ Adolescents with undiagnosed, asymptomatic HIV are at risk for unknowingly transmitting HIV to their offspring and sexual partners; are at increased risk for advanced disease at first presentation; and will miss critical opportunities for linkage to medical care, psychosocial services, and behavioral risk reduction programs. Consequently, there is a need to identify the “hidden population” of HIV infected youth and link them to counseling, testing, and referral services.^{6, 7}

Barriers to HIV testing for African American adolescents stem from a variety of sources, including personal and cultural beliefs, access to services, and concerns about need for parental consent. The Centers for Disease Control and Prevention (CDC) has identified HIV testing in adolescents as an area of high priority. Recommendations regarding de-linking testing from written consent and pre-test counseling are intended to help routininize HIV testing in healthcare settings and overcome some of the infrastructural and other barriers that providers, clinics, and agencies have had in implementing testing in the past.⁸ More than one-third of the African American youth in this study had had a prior STI exam however, even among the youth who had received STI services, nearly 26% had not been tested for HIV. Offering HIV testing during these exams presents a vital opportunity to teach—or remind—people how they can protect themselves and others from HIV/AIDS and other STIs

However, we must be mindful that not all youth seek routine care. National data show that adolescents have the lowest rates of outpatient visits among all age groups, with particularly low rates among boys and ethnic minorities.⁹ Public health clinics that offer free testing may not be accessible to youth due to limited hours of operation (e.g., when adolescents are attending school) or other transportation limitations. For universal testing policies to be successful we need to better understand access to health care and barriers to testing —both from patient and provider perspectives, and simple, cost-effective ways of integrating HIV testing into clinical care more effectively.

In any discussion focused on the importance of and plans for increasing testing among African American adolescents, we must not overlook the most vulnerable groups in need of additional programs and resources, such as young men who have sex with men (YMSM), as well as transgendered and homeless youth. In the 33 states with name-based reporting during 2001–2004, 62% of the 17,824 adolescents between the ages of 13–24 who were given either an HIV or AIDS diagnosis were male, of which 74% were YMSM.¹⁶ Overall, YMSM comprise the largest proportion of new HIV infections with a 15% increase in HIV infection rates per year. African American YMSM are disproportionately affected.¹⁷ From 2001 to 2006, the number of HIV/AIDS cases among black MSM aged 13–24 years increased 93%.¹⁸ Areas of further investigation to increase HIV testing among at-risk and minority youth include examining strategies for further streamlining the HIV counseling process, scaling-up rapid HIV testing and examining barriers to the opt-out approach in HIV testing among adolescents. Training of physicians that treat adolescents in HIV case finding, assisting youth community health providers in developing a strategic plan for routine HIV screening of their adolescent clients at all points of contact, including in school-based health clinics, and enhancing partner notification among adolescents could all increase the proportion of youth who are aware of their HIV status. If our true goal is to end this epidemic, then anything less than having 100% of sexually active adolescents screened for HIV is unacceptable. Moreover, it is not enough to simply increase testing. We are compelled to provide our HIV-negative youth with the tools to remain negative and to link our HIV-positive youth into quality medical care.