Reframing the Context of Preventive Health Care Services and Prevention of HIV and Other Sexually Transmitted Infections for Young Men: New Opportunities to Reduce Racial/Ethnic Sexual Health Disparities

Abstract

Young Black males, aged 13 to 29 years, have the highest annual rates of HIV infections in the United States. Young Black men who have sex with men (MSM) are the only subgroup with significant increases in HIV incident infections in recent years. Black men, particularly MSM, are also disproportionately affected by other sexually transmitted infections (STIs). Therefore, we must strengthen HIV and STI prevention opportunities during routine, preventive health care visits and at other, nontraditional venues accessed by young men of color, with inclusive, nonjudgmental approaches. The Affordable Care Act and National HIV/AIDS Strategy present new opportunities to reframe and strengthen sexual health promotion and HIV and STI prevention efforts with young men of color.

Periodic, preventive assessments are considered prime opportunities to provide screening, evaluation, and counseling for many health conditions, including HIV and other sexually transmitted infections (STIs).^1,2 Evidence is strong in support of periodic, preventive health visits for children of both sexes through age 12 years, girls and women aged 13 years and older, and men aged 40 years and older, during which time routine screenings and immunizations may occur.^3–9 For young women, these preventive health visits are culturally accepted and provide important opportunities for sexual health discussions and screenings, usually during annual gynecological visits.^1,5,6 Initial reproductive health visits and discussions are formally recommended by the American College of Obstetricians and Gynecologists to begin with young women aged between 13 and 15 years.^1,5

For young men, however, formal recommendations for routine, preventive sexual health visits do not yet exist. Yet, young men in this age group, especially young men who have sex with men (MSM), are disproportionately affected by preventable diseases, including HIV and other STIs.^10–14 For young men of color, particularly Black and Hispanic men, the burden of HIV and STIs is especially high compared with that of their White male peers.^10–14

The absence of consistent, structured, timed, and provider-enforced national guidelines for preventive reproductive health care visits for young men aged 13 to 39 years decreases opportunities for screenings, evaluations, and counseling in support of HIV and STI prevention and improved sexual health. This remains a gap in our public health approach to improve sexual health and decrease our national burden of HIV and other STIs, particularly among young MSM. As adolescence and young adulthood can be times of sexual exploration and lack of disclosure regarding sexual identity and sexual behaviors,¹⁵ preventive sexual health discussions and services for young men should be sensitive and inclusive to ensure appropriate prevention coverage. We discuss the importance of increasing efforts to help define an optimal preventive sexual health care process for young men, and describe strategies to strengthen and improve sexual health access for young men that are also inclusive of and culturally appropriate for young MSM.

HIV AND OTHER SEXUALLY TRANSMITTED INFECTIONS AMONG YOUNG BLACK MEN

In the United States, an estimated 1.2 million men and women are living with HIV infection¹⁴; Blacks are disproportionately affected.^11,13 Although constituting only 13% of the total US population,¹⁶ Blacks represent 52% of new diagnoses of HIV infection and the burden of disease rests most heavily on Black men, particularly MSM.^10,11,14 An estimated 1 in 16 Black males will be diagnosed with HIV infection during his lifetime.¹⁷ Black men also rank first in number of new HIV diagnoses^11,14; the primary transmission route is sexual transmission with more than 80% of incident HIV infections attributable to MSM, especially among men younger than 40 years.^10,11,14 Among male adolescents, aged 15 to 19 years, a group at disproportionate risk for incident HIV infections, 3.6% to 4.6% report ever having had oral or anal sexual intercourse, or both, with a male partner.^14,18

Blacks are also disproportionately affected by other STIs and account for 71% of all reported cases of gonorrhea and nearly half of all reported cases of chlamydia and syphilis.¹² By gender, women have higher reported rates of both chlamydia and gonorrhea,¹² but gender-based routine reproductive examinations and screening recommendations have long been recognized by providers for young, sexually active women and not men.^12,18,19 When HIV and STI data for young men aged 13 to 39 years are reviewed by race, wide racial/ethnic disparities exist; rates are 9 to 20 times higher among Black young men compared with their White male peers (Table 1).^10–13 Infectious syphilis disparities among men are largely accounted for by disproportionately affected Black and Hispanic MSM (compared with White MSM) and young MSM aged 20 to 29 years.²⁰

TABLE 1—

Estimated Numbers of Cases and Rates for HIV and Sexually Transmitted Infections for Young Men by Race and Black–White Rate Ratio Disparities: United States, 2012

	Non-Hispanic Black Young Men		Non-Hispanic White Young Men
Variable	Cases, No.	Ratea	Cases, No.	Ratea	Black–White Rate Ratio
Diagnoses of HIV infectionb	13 555	82.9	7132	9.7	8.5
Gonorrheac	73 151	946.0	15 168	46.5	20.3
Chlamydial infectionc	134 202	1706.4	64 323	194.7	8.7
Primary and secondary syphilisc	4172	56.3	2005	6.3	8.9

^aRate per 100 000 population.

^bHIV/AIDS Surveillance Report¹⁰; data reported for ages 13–39 years.

^cData reported from the Sexually Transmitted Diseases Surveillance Report,¹² for ages 15–39 years.

Social determinants, which include fewer jobs, increased poverty, disproportionate incarceration, fewer educational opportunities, stigma, homophobia, and concurrent sexual networks in some Black communities, provide a context for higher community burden of HIV and STIs and persistent racial/ethnic disparities; increasing routine HIV and STI screening and treatment efforts with young men, particularly young MSM, may have a great impact on these gaps.^21,22 Still, barriers remain for young men to access preventive health care services and ensure HIV and STI screenings once accessed.^23,24

CHALLENGES TO ACCESSING HEALTH CARE SERVICES FOR YOUNG MEN

Adolescence and young adulthood are high-risk periods for sexual health challenges, such as HIV, STIs, and unintended pregnancy, as well as for being uninsured and lacking access to health care compared with older adults^{10–15,25–28}; this underscores the importance of health care access and sexual health care service provision for young people of both sexes.^27,29

Lack of health insurance, not having a usual source of medical care, and lacking a doctor visit in the past year all disproportionately affect young men compared with young women,^29–33 and among men, Black and Hispanic young men are more likely to be uninsured compared with White male peers.^34–36 Factors that contribute to men’s poor health-seeking behaviors and underutilization of health services include socially constructed notions of masculinity, homophobia, stigma regarding open discussions of sexuality and sexual health with health care providers, increasing preferences for accessing information online, and economic factors.^37–43 Among those who do access services, discussion of reproductive health topics and HIV and STI screening by providers in clinical settings are as low as 14% among young men aged 18 years and older with a doctor’s visit in the past year.^24,44,45

Other policies contribute to the discrepant rates of preventive health screenings among men and women. Young women have longstanding recommendations for routine reproductive health visits,^1,5–7 and these clinical visits often include preventive services such as sexual health discussions and HIV and STI testing. No equivalently enforced reproductive health visit recommendation exists for men.^33,45 Strategies to shift the sexual health context for men should include at least 2 approaches: (1) adding sexual health prevention and screenings to existing recommendations for routine preventive health visits, and (2) identifying innovative, nontraditional approaches to offer sexual health discussions and HIV and STI screening to young men, especially young Black MSM who are disproportionately affected by HIV and other STIs and often difficult to access through traditional health care systems.³⁸

CURRENT RECOMMENDATIONS FOR ROUTINE PREVENTIVE HEALTH SCREENINGS

For young men, expert panels have made recommendations on the basis of available data or expert opinion; selected recommendations for men and nonpregnant women aged 13 to 39 years are summarized in Table 2 and grouped separately on the basis of recommendations for sexual health and chronic health conditions. The US Preventive Services Task Force (USPSTF) provides a highly referenced and respected set of clinical guidelines for preventive health services.⁶ The Centers for Disease Control and Prevention (CDC), American College of Physicians, and American College of Obstetricians and Gynecologists (women only) also offer evidence-based recommendations for preventive clinical services for adults and adolescents.^1,46–48 The American Academy of Pediatrics’ Bright Futures Initiative recommends routine STI screening for all sexually active adolescents aged 11 to 21 years, although reports of routine STI screening among young men in this age group remain low.⁴⁹ In addition, the American Medical Association provides a set of recommendations for adolescents, aged 11 to 21 years (Guidelines for Adolescent Preventive Services), but some of these recommendations have limited supporting scientific evidence and are not widely implemented by providers.^50,51

TABLE 2—

Selected Recommended Preventive Health Screenings for Men and Nonpregnant Women, Aged 13–39 Years: United States, 2012

	Men			Nonpregnant Women
Screening	USPSTF6	CDC46,47	ACP48	USPSTF6	CDC46,47	ACP48
Reproductive and sexual health screenings
HIV	Strongly recommends screening all adolescents and adults at increased risk for HIV infection. (July 2005)	Recommends routine screening in all health care settings for all patients aged 13–64 y as well as all patients initiating treatment of TB and STDs. Annual testing is recommended for all persons likely to be at high risk for HIV.a (Sept. 2006)	Recommends routine screening for all individuals and repeat screening conducted, on an individual basis, with high-risk individuals being tested more frequently. (Jan. 2009)	Strongly recommends screening all adolescents and adults at increased risk for HIV infection. (July 2005)	Recommends routine screening in all health care settings for all patients aged 13–64 y as well as all patients initiating treatment of TB and STDs. Annual testing is recommended for all persons likely to be at high risk for HIV.a (Sept. 2006)	Recommends routine screening for all individuals and repeat screening conducted, on an individual basis, with high-risk individuals being tested more frequently. (Jan. 2009)
Chlamydia	…	Recommends routine (at least annually) screening for all sexually active MSM; more frequent screening (i.e., at 3–6 mo intervals) is indicated for MSM who engage in certain behaviors.b (Dec. 2010)	…	Recommends screening for all sexually active nonpregnant young women aged 24 y and younger and for older nonpregnant women who are at increased risk. (June 2007)	Recommends annual screening of all sexually active women aged ≤ 25 y and screening of older women with risk factors (e.g., those who have a new sexual partner or multiple sexual partners). (Dec. 2010)	…
Gonorrhea	…	Recommends routine (at least annually) screening for all sexually active MSM; more frequent screening (i.e., at 3–6 mo intervals) is indicated for MSM who engage in certain behaviors.b (Dec. 2010)	…	Recommends screening all sexually active women for gonorrhea infection only if they are at increased risk for infection. (May 2005)	Recommends screening of young women (i.e., those aged < 25 y) at increased risk for infection. (Dec. 2010)
Syphilis	Strongly recommends that clinicians screen persons at increased risk for syphilis infection. (July 2004)	Recommends routine (annual) screening for all sexually active MSM; more frequent screening (i.e., at 3–6 mo intervals) is indicated for MSM who engage in certain behaviors.b (Dec. 2010)	…	Strongly recommends that clinicians screen persons at increased risk for syphilis infection. (July 2004)	…	…
STI counseling	Recommends high-intensity behavioral counseling to prevent STIs for all sexually active adolescents and for adults and increased risk for STIs. (Oct. 2008)	Encourages health care providers to routinely obtain sexual histories from all their patients as well as offer STD and HIV prevention counseling. (Dec. 2010)	Encourages clinicians to counsel patients to reduce risky behaviors when such counseling is feasible. (Jan. 2009)	Recommends high-intensity behavioral counseling to prevent STIs for all sexually active adolescents and for adults at increased risk for STIs. (Oct. 2008)	Encourages health care providers to routinely obtain sexual histories from all their patients as well as offer STD and HIV prevention counseling. (Dec. 2010)	Encourages clinicians to counsel patients to reduce risky behaviors when such counseling is feasible. (Jan. 2009)
Chronic medical condition screenings
Blood pressure	Recommends screening for adults aged 18 y and older. (Dec. 2007)	…	…	Recommends screening for adults aged ≥ 18 y. (Dec. 2007)	…	…
Lipid disorders	Strongly recommends screening men aged ≥ 35 y and recommends screening men aged 20–35 y if they are at increased risk for coronary heart disease. (June 2008)	…	…	Recommends screening women aged 20–45 y if they are at increased risk for coronary heart disease. (June 2008)	…	…
Type 2 diabetes mellitus	Recommends screening in asymptomatic adults with sustained blood pressure greater than 135/80 mm Hg. (June 2008)	…	…	Recommends screening in asymptomatic adults with sustained blood pressure greater than 135/80 mm Hg. (June 2008)	…	…

Note. ACP = American College of Physicians; CDC = Centers for Disease Control and Prevention; MSM = men who have sex with men; STD = sexually transmitted disease; STI = sexually transmitted infection; TB = tuberculosis; USPSTF = United States Preventive Services Task Force.

^aPersons likely to be at high risk include injection drug users and their sexual partners, persons who exchange sexual intercourse for money or drugs, sexual partners of HIV-infected persons, and MSM or heterosexual persons who themselves or whose sexual partners have had > 1 sexual partner since their most recent HIV test.

^bMore frequent screening is indicated for MSM who have multiple or anonymous partners, who have sexual intercourse in conjunction with illicit drug use (particularly methamphetamine use), or whose sexual partners participate in these activities.

Several differences are noted in the specifics of the HIV and STI recommendations included in Table 2. Regarding HIV screening, CDC has the broadest recommendation.⁴⁶ However, the USPSTF strongly recommends HIV screening for adolescents and adults at increased risk for HIV infection, including MSM and men and women who have unprotected sexual intercourse with multiple partners (“A” recommendation), but evidence for the recommendations for routine, non–risk-based HIV testing is graded as a “C,” which has negative implications for HIV-screening reimbursement from health insurance providers.^6,52 Routine HIV testing, with prompt linkage to care and treatment of those who test positive, remains an effective yet underutilized tool to prevent the further spread of HIV.^53–55

For STIs, CDC encourages routine sexual histories from all patients and STI prevention counseling,⁴⁷ but lack of cultural and sexual competency, context, and comfort are barriers to open, effective provider–patient sexual history dialogue that can strengthen STI screening efforts.⁵⁶ Current CDC recommendations are for young, sexually active men who self-identify as MSM to have routine STI screening, which leaves a gap in routine STI screening for non–gay-identified men having same-sex behaviors who are also at increased risk (Table 2).^46,57 To combat racial/ethnic sexual health disparities for young men, it will be important to strengthen broad sexual health messages for all young men, including gay-identified and non–gay-identified MSM engaging in same-sex behaviors, as most STIs, including HIV, are asymptomatic and will be detected only by routine screening.

The recommendations for sexual health and chronic medical condition screenings summarized in Table 2 represent missed and underutilized opportunities because of infrequent health care visits by young men and low delivery rates of preventive screenings by providers.^18,29,58 Opportunities also exist to provide reproductive health services, including HIV and other STI screenings, during other pre-established, recommended health care visits (including preparticipation sports physicals, which currently lack a sexual health component).⁵⁹ For approximately 78% of high-school young men, preparticipation sports examinations serve as the only opportunity to receive a routine medical evaluation.^59,60 As such, preparticipation sports examinations may be an optimal time and important opportunity to offer sexual health evaluations and nonjudgmental preventive sexual health discussions for young men.^61,62 A pilot study among high-school athletes demonstrated the feasibility of urine-based STI screening during preparticipation sports physical examinations and that asymptomatic STIs were prevalent among both boys and girls.⁶¹

NEW OPPORTUNITIES TO INCREASE PREVENTION EFFORTS WITH YOUNG MEN

To turn the tide on HIV and STI disparities among young men, especially men of color and MSM, innovative, effective, nontraditional strategies must also be considered to increase opportunities for routine sexual health discussions and HIV and other STI screenings. Recently, there has been growing advocacy to implement routine, annual sexual health examinations for young men, and health promotion approaches to improve outcomes have been suggested.^33,63 Similar to the gynecological examination for women, this annual examination would assess men’s sexual and reproductive health and provide an opportunity for HIV and STI prevention and screening. Next steps should include more research to explore and validate the benefits of a periodic sexual health evaluation for the overall health of young men and their sexual partners. In addition, clear, congruent messages from family, communities, and providers with young men to break sexual silences and discuss preventive sexual health services and a timetable for the delivery of these services would be an important component of establishing a new culture of routine sexual health examinations and comfortable health dialogue for young men and their social networks. To support these efforts toward a normalized sexual health discussion for young men, federal, local, and professional organizations have crucial roles to play as part of a comprehensive, unified sexual public health effort that engages young men, including self-identified and nonidentified MSM of color.

In addition, working with health care providers to reinforce the existing sexual health and chronic health recommendations can highlight their importance and strengthen the culture of routine health screenings for young men and their providers. Over time, providers would become more aware of the importance of routine sexual health so that they can do their part during clinical visits with young men, especially young men with same-sex behaviors, for improved HIV and other STI prevention efforts. Creating continuing education opportunities for physicians and nurses can serve as reminders of the importance of sexual health for young men. Establishing young men’s health report cards for clinics, hospitals, and community health centers is also an innovative approach for holding clinicians and professional organizations accountable in support of improved delivery of preventive sexual health services for young men.

New opportunities for reframing sexual health with young men also exist on the policy front in the context of health care reform. The Patient Protection and Affordable Care Act offers new possibilities for routine, preventive assessments for young people who may otherwise lack health care coverage or regular access to a health care provider.⁶⁴ By working toward goals of improving access to quality health care for all Americans, strengthening diversity and cultural competency among health care providers, and expanding the health care workforce in underserved communities, the Affordable Care Act will also help reduce health disparities, including racial/ethnic health disparities and disparities on the basis of sexual orientation and young age.⁶⁴ Under the new law, young adults will be allowed to stay on their parent’s plan until they turn age 26 years.⁶⁴ This increased access to health care services for young people will support opportunities to provide routine sexual health prevention and screening services in both clinical and nontraditional settings.

As providers increase their engagement in support of young men’s health, health care provider sensitivity would need to be strengthened, especially with young men who may engage in same-sex behaviors. New efforts to train health care providers on culturally competent sexual history approaches and routine HIV and STI screenings and prevention tools are warranted to help ensure that the workforce will be ready for the new way forward under health care reform. Medical, nursing, and allied health professional schools, professional organizations, and AIDS Education Training Centers can help serve these important increased sexual health training needs. Increasing sexual health education and HIV and STI screenings are important action steps that can be implemented in clinical and nonclinical settings and evaluated with performance measures over time. As electronic health records are increasingly utilized and confidential electronic health records procedures help to streamline patient intake processes in clinical settings, brief self-administered sexual histories can be added to intake screens,⁵⁶ completed by patients in the preclinical area, and reviewed to stimulate HIV and STI awareness and prevention discussions during the clinical portion of the provider visit.

In addition, the first-ever National HIV/AIDS Strategy (NHAS), with its national goals of reducing HIV incidence, increasing access to care and services for persons living with HIV, and reducing HIV-related heath disparities,⁶⁵ provides a platform for exploring new approaches and expanding current HIV testing and treatment efforts that address the sexual health needs of underserved populations, such as young Black MSM. Efforts of NHAS include increased opportunities to offer HIV screening, linkage to care, and access to appropriate treatment to more MSM, especially young MSM of color, and this is an opportunity to reduce HIV-related health disparities. Increasing the likelihood of providers offering HIV and STI screening once a young man has accessed services can also be supported by strengthening reimbursement procedures for routine screenings. Aligning evidence-based USPSTF ratings with recommendations for routine HIV testing will help support efforts to ensure insurance reimbursements, which can be a barrier for providers offering preventive care services.

Finally, school-based condom education efforts have been linked to decreased HIV and STI diagnoses and increased HIV and STI knowledge among young men in the United States,⁶⁶ and policy efforts that support school-based sexual education approaches are warranted with all young men, but especially young Black MSM, in support of NHAS efforts.

Because young men of color are disproportionately incarcerated in the United States,⁶⁷ improved sexual health efforts will also require new relationships with prison and jail systems to ensure increased, routine HIV and STI prevention and screening activities, while simultaneously supporting social and structural interventions in support of jobs, housing, improved education, and increased cultural sensitivity for law enforcement to decrease disproportionate incarceration and increase educational and work opportunities for young men of color.

Because young men of color have historically been difficult to access through traditional health care venues, exploring existing nontraditional models of success is an important component of reframing the context of preventive health services and HIV and STI prevention with young Black men. Successful programs can serve as potential models for a broader approach with this at-risk and difficult-to-reach population. One example is The Young Men’s Clinic in New York City, which targets low-income, minority males, and has been shown to effectively operate as an interdisciplinary program combining research with service by integrating public health into clinical care, and including routine reproductive health assessments that actively engage and support the young men for continued care.⁶⁸ This clinic has been sustained by providing male-friendly, empowering, and health-promoting environments for young men and collaborations with government, nonprofit, and community-based organizations to leverage resources and provide comprehensive services.⁶⁸

Nontraditional, community-based approaches with Black men and trusted community opinion leaders also warrant consideration to access young men for reproductive health discussions and services. The Black-owned barber shop has historically been considered a safe and trusted haven for Black men to gather and discuss issues important to them, and many barbers are considered trusted opinion leaders in the communities in which they live and work.^69,70 A recent randomized clinical trial of a barber-based intervention showed significant improvement in blood pressure for Black male barber shop patrons with hypertension, which was likely because of the trusted, community barbers engaging with the study participants as health educators and promoters of physician follow-up.⁷⁰ Other effective community-based, nontraditional efforts describe using a mix of art, hip-hop, and role-playing as avenues to more effectively engage young men as early as middle school and promote prevention of HIV, STIs, and unplanned pregnancy; healthy decision-making; and self-esteem building among young Black men.^71,72 For young MSM of color, house and ball community networks often offer trusted support mechanisms that can also facilitate HIV prevention and sexual health efforts.⁷³ Local faith leaders also have a role to play by continuing to become more engaged in community HIV- and STI-prevention efforts with faith messages that are encouraging, nonstigmatizing, nonhomophobic, and welcoming for church members and their families, regardless of a person’s sexual orientation.⁷⁴

Mobilization at a community level is also an important component of engaging young Black men in a broader dialogue about preventive health services. Engaging young men through intergenerational dialogue, such as parent–child communication interventions, school-based efforts, college fraternities, respected civic organizations, and popular community venues, with consistent preventive health-seeking and sexual health messages will help provide broad support for young men to access trusted, nonjudgmental, and culturally relevant sexual health services. Media radio shows popular in some Black communities have successfully promoted taking a “loved one” to the doctor to encourage preventive health checks,⁷⁵ and young men of color have been engaged in some of these local efforts. It is also increasingly important to engage social media, Internet, and texting-based communication innovations,⁷⁶ which have been shown to be a vital means of delivering health-related information and to connect with young Black men, especially MSM, who are increasingly using the Internet for seeking sexual intercourse and often have the additional barriers of homophobia and stigma within their communities and during health-seeking efforts.⁷⁶ Public–private partnerships can help stimulate innovative strategies, ensure motivation and enthusiasm, increase financial support, decrease homophobia and stigma, and maintain community-level engagement as relevant and culturally tailored activities are developed in support of young men’s health.

CONCLUSIONS

To date, there has been no comprehensive, preventive, public health infrastructure that normalizes the routine reproductive and sexual health education and prevention needs of young men, especially young MSM. The absence of this foundation for young men has contributed to the disproportionate impact of HIV and other STIs, particularly incident HIV infections, in many Black communities, and warrants that we explore new approaches to normalize routine, preventive health visits, including sexual health discussions and screenings, for young men as an important aspect of HIV and STI prevention and control in the United States.

With the introduction of health reform in the United States, there is a new opportunity to set the stage for routine, preventive health checks for young men that should include routine HIV and STI screening and nonjudgmental sexual health discussions that include HIV- and STI-prevention messages that are inclusive of same-sex behaviors. When one also considers that there is a first-ever NHAS that is targeting a reduction in racial/ethnic disparities in HIV disease, the US public health workforce is historically poised to reframe the context of HIV and STI vulnerabilities and shift clinical and public health outcomes by establishing and supporting collaborations at the federal, state, and community level in support of broad sexual health prevention efforts with young men. The large racial/ethnic HIV and STI disparity that disproportionately affects young Black men, especially MSM, requires that we seize this moment and act on these unique opportunities now in an effort to reduce overall sexual health disparities in the United States.