Abstract
Adolescent sexual minority males have low rates of HIV testing despite increased risk for HIV acquisition. The purpose of this study is to examine adolescent sexual minority males’ (a) HIV testing behaviors and intentions, and (b) associations with disclosure to healthcare providers of male-male attraction. Sexual minority males were recruited using online social media sites to obtain a national sample. Participants (N = 207) were 14-to-17-year-old cisgender males (i.e., assigned male sex at birth and reporting male gender identity) living in the United States who (1) self-identified as gay or bisexual, (2) reported sexual attraction to males, and/or (3) reported voluntary sexual contact with a male in the past year. Only 14% of participants reported they had been tested for HIV, even though 20% reported a history of condomless anal intercourse with male partners. Three-quarters (77%) planned to get tested for HIV in the future, but only 48% planned to do so annually (i.e., the current CDC recommendation). Only 20% of participants had disclosed male-male attraction to their healthcare provider. Adolescents who disclosed to their health care provider had almost six times the odds of testing for HIV (AOR = 5.40, 95% CI [2.13, 13.84]). Rates of HIV testing and disclosure of male-male interests to a healthcare provider are low among adolescent sexual minority males. Given the association between disclosure and HIV testing, creating trusting and non-judgmental health care settings and optimizing patient-provider communication are likely to improve uptake of HIV testing by at-risk youth.
Keywords: sexual minority, adolescents, HIV testing, healthcare
Introduction
Although adolescent sexual minority males (ASMM; reporting male-male sexual attraction, behavior, or non-heterosexual identity) carry a disproportionate burden of new HIV infections in the United States (CDC, 2017), only 17% have tested for HIV (Kann et al., 2016). HIV testing is essential for prevention given that most HIV-infected young men who have sex with men (MSM) are unaware of their infection (Balaji et al., 2013). Thus, the CDC recommends opt-out HIV testing for all adolescents and annual screening for gay, bisexual, and other MSM (Branson et al., 2006; DiNenno et al., 2017). Despite these recommendations, little is known about HIV testing among ASMM.
One factor that may influence HIV testing is the infrequency with which ASMM disclose sexual behaviors to health care providers (HCPs) (Alexander et al., 2014). The only study examining HCP disclosure among sexually-active ASMM found that those who disclosed were more likely to have been tested (Fisher, Fried, Macapagal, & Mustanski, 2018). However, it is also important to target adolescents who are not yet sexually active to encourage healthy testing behaviors prior to sexual initiation.
To explore factors related to HIV testing, we assessed 14–17-year-old ASMMs’ behavioral intentions to pursue HIV testing, disclosure of male-male interest to HCPs, and testing behaviors. We also assessed associations between HCP disclosure and HIV testing.
Methods
Study Design
Data for this study were drawn from a cross-sectional online survey assessing ASMM’s sexual health needs. Participants (N = 207) were recruited online utilizing advertisements and posts on social media sites (Nelson, Carey, & Fisher, 2018). Participation was restricted to 14–17-year old, cisgender males (i.e., assigned male sex at birth and identifying as male) living in the United States who qualified as sexual minority via self-identification, sexual attraction to males, and/or past-year voluntary sexual contact with a male (Austin et al., 2007). Procedures and a waiver of guardian permission were approved by the Miriam Hospital Institutional Review Board.
Procedures
Participants completed consent and survey procedures on a secure website using REDCap (Harris et al., 2009). To limit multiple entries, participants were emailed a unique survey link, and responses were cross-referenced using birthdate, location, sexual activity, and email address. Following survey completion, participants received a $15 Amazon.com code.
Measures
Demographics.
Participants reported age, race/ethnicity (White, Black/African-American, Latino, Asian, American Indian/Alaska Native, Native Hawaiian or other Pacific Islander, mixed race/other), and state of residence.
Sexual behavior.
Participants reported whether they had voluntary sexual contact (e.g., kissing, oral sex) with male partners. Participants reported on whether they used condoms during anal intercourse. A dichotomous variable capturing any condomless anal intercourse (CAI) was created using this information (yes, no).
Disclosure of male-male attraction.
Participants were asked about disclosure of male-male attraction to guardians (“Have you told [primary/secondary guardian] that you are sexually attracted to other boys/males?”) and their guardians’ acceptance of their male-male attraction; we assessed both actual (“How accepting is [guardian] of your sexual attraction to other boys/males?) and perceived (“How accepting do you believe [guardian] would be if they learned about your sexual attraction to boys/males?”) acceptance. These variables were collapsed to reflect whether participants: (1) were out to (i.e., had told) a guardian (dichotomous); (2) experienced a guardian as rejecting (dichotomous).
Participants were also asked about disclosure to their HCP (“I have spoken to my doctor about my interest in sex with male partners.” Yes; No).
Behavioral intentions for testing.
Participants reported their behavioral intentions for testing, including whether they planned to test (“Do you plan to get HIV tested in the future?” Yes; No; I don’t know) and how frequently (Every three months; every six months; yearly; less than once a year; only when I think I have done something that puts me at risk; I don’t know). Testing intention frequency was recoded to reflect CDC recommendations (at least annually; less than annually). Those who reported they did not know or would only pursue risk-based testing were considered less than annually.
HIV testing.
Participants self-reported whether they had ever tested for HIV (yes, no) and whether any test results indicated they tested HIV-seropositive.
Statistical Analysis
Chi-square analyses determined whether demographic variables, HIV testing behavior and intentions, and rates of disclosure to HCPs differed as a function of CAI engagement.
Exact logistic regression models examined associations between HIV testing and demographic variables (age; race/ethnicity), sexual behavior with male partners, disclosure of male-male interest to a guardian, and disclosure to HCP. Factors associated with HIV testing in univariate analyses were included in multivariable exact logistic regression models. Separate models were fitted for anal sex and CAI, as CAI was dependent upon having anal sex.
Results
Study Demographics (Table 1)
Table 1.
Demographic Characteristics of Adolescent Sexual Minority Males in the United States (N = 207)
| Condomless Anal Intercourse | ||||
|---|---|---|---|---|
| Total (N = 207) | No (n = 166) | Yes (n = 41) | χ2 | |
| Age: 14 | 30 (15%) | 26 (16%) | 4 (10%) | 4.07a |
| 15 | 52 (25%) | 45 (27%) | 7 (17%) | |
| 16 | 68 (33%) | 52 (32%) | 15 (37%) | |
| 17 | 57 (28%) | 41 (25%) | 15 (37%) | |
| Race: White | 107 (52%) | 89 (55%) | 16 (39%) | 3.32 |
| Racial or ethnic minority | 98 (48%) | 73 (45%) | 25 (61%) | |
| U.S. Census Region: | ||||
| Northeast | 34 (17%) | 29 (18%) | 5 (13%) | 3.44 |
| Midwest | 41 (20%) | 33 (21%) | 7 (18%) | |
| South | 58 (29%) | 41 (25%) | 16 (40%) | |
| West | 70 (34%) | 58 (36%) | 12 (30%) | |
| Sexual orientation disclosure | ||||
| Told at least one parent/guardian about same-sex attraction | 109 (53%) | 83 (50%) | 26 (63%) | 2.26 |
| Told HCP about interest in sex with male partners | 41 (20%) | 30 (18%) | 11 (27%) | 1.49 |
| Received lifetime HIV testing | 30 (14%) | 18 (11%) | 12 (29%) | 8.79** |
| HIV results among 30 ASMM who received testing | ||||
| Negative | 27 (90%) | 16 (88%) | 11 (92%) | |
| Positive | 1 (3%) | 1 (6%) | 0 (0%) | |
| Prefer not to answer | 2 (7%) | 1 (6%) | 1 (8%) | |
| Behavioral intentions for future HIV testing | ||||
| No plan to test | 12 (6%) | 9 (6%) | 3 (7%) | 0.31a |
| Plan to test | 159 (77%) | 125 (77%) | 32 (78%) | |
| “I don’t know” | 34 (17%) | 28 (17%) | 6 (15%) | |
| Frequency of behavioral intentions for HIV testing (CDC recommendations) | ||||
| Less than annually | 105 (52%) | 79 (49%) | 26 (63%) | 2.81 |
| Annually or more | 98 (48%) | 83 (51%) | 15 (37%) | |
| Frequency of behavioral intentions for HIV testing | ||||
| No plan to test | 12 (6%) | 9 (6%) | 3 (7%) | 8.34a |
| “I don’t know” | 32 (16%) | 25 (15%) | 7 (17%) | |
| “Only when I think I have done something that puts me at risk” | 56 (28%) | 40 (25%) | 16 (39%) | |
| “Less than once a year” | 5 (2%) | 5 (3%) | 0 (0%) | |
| “Yearly” | 27 (13%) | 24 (15%) | 3 (7%) | |
| “Every six months” | 45 (22%) | 40 (25%) | 5 (12%) | |
| “Every three months” | 26 (13%) | 19 (12%) | 7 (17%) | |
Note.
Denotes those tests using Fisher’s exact to determine significance.
p < .01.
Participants came from 40 states, representing all major geographic areas of the country (i.e., northeast, midwest, south, west).
Sexual behavior.
Most adolescents had engaged in voluntary sexual contact with males (n = 118; 57%); one-quarter (27%, n = 55) reported anal sex with a male partner, and one-fifth (n = 41; 75% of ASMM who had anal intercourse) reported CAI.
Behavioral intentions for testing.
The majority of adolescents (77%) planned to get tested for HIV. When asked about frequency, 28% reported they would do so only when they perceived risk exposure and half (48%) planned to test annually.
Disclosure to HCP.
Forty-one (20%) ASMM had disclosed interest in male-male sex to their HCP.
HIV testing rates.
Thirty (14%) of the participants reported testing for HIV. ASMM who had engaged in CAI were more likely to have been tested than ASMM who had not. One participant self-reported testing positive for HIV.
Factors Associated with HIV Testing (Table 2)
Table 2.
Associations between demographic, sexual behavior, identity, disclosure behaviors, and HIV Testing among adolescent sexual minority males in the United States (n = 207). Multivariate models presented in columns 3 and 4 present odds ratios adjusted for the other predictor.
| OR [95% CI] | AOR [95% CI] | AOR [95% CI] | |
|---|---|---|---|
| Demographics | |||
| Age | 1.31 [0.88, 1.96] | -- | -- |
| Race/ethnicity | 1.52 [0.70, 3.31] | -- | -- |
| Sexual Behavior | |||
| Had anal sex with men | 2.90 [1.31, 6.45] | 2.43 [0.95, 6.10] | -- |
| Had condomless anal sex with men | 3.36 [1.46, 7.71] | -- | 3.14 [1.17, 8.29] |
| Sexual Identity | |||
| Gay vs. other | 0.63 [0.29, 1.40] | -- | -- |
| Disclosure of Same-Sex Behavior | |||
| Out to guardian | 1.15 [0.53, 2.49] | -- | -- |
| Guardian(s) rejecting | 1.24 [0.44, 3.47] | -- | -- |
| HCP disclosure | 5.81 [2.54, 13.29] | 5.13 [2.04, 13.00] | 5.40 [2.13,13.84] |
Note. OR = Odds Ratio; AOR = Adjusted Odds Ratio; CI = Confidence Interval
Demographic variables, disclosure to guardian(s), and guardian(s) reactions to disclosure were not significantly associated with HIV testing. In contrast, ASMM who reported anal sex, CAI, or disclosed interest in male-male sex to HCPs were more likely to have tested for HIV compared to ASMM who had not.
In multivariable models, HCP disclosure remained a significant predictor of HIV testing controlling for history of anal sex or CAI with male partners. CAI remained a significant predictor but having anal sex did not.
Discussion
Despite their elevated risk for HIV acquisition and recommendations that adolescents receive HIV screening, only 14% of ASMM had tested for HIV. This rate is similar to previous reports (17%: Kann et al., 2016). The current results identified two modifiable predictors of testing (i.e., HIV risk knowledge and disclosure of same-sex interest to HCPs) that can be targeted to increase testing. This study represents an advance in that it: (1) focuses on 14–17-year-old ASMM, adding to the one published study of this group (Fisher et al., 2018), and (2) is the first to examine testing behaviors and intentions in a broader sample of ASMM.
Risk-based HIV testing requires that ASMM be able to identify when they have engaged in risk behavior and/or been exposed to the virus. Fewer than one-third of ASMM engaging in CAI had tested for HIV, and the majority (63%) reported either uncertainty about future testing or only risk-dependent testing intentions. Therefore, it appears that these youth, like adolescents generally (Facente, 2001) and adult MSM (Mackellar et al., 2011), find it challenging to judge risk. Targeting HIV knowledge and risk awareness might help to increase testing. Although interventions targeting young MSM improve knowledge (Mustanski, Garofalo, Monahan, Gratzer, & Andrews, 2013), it is unclear whether improved knowledge increases HIV testing rates. Until more research is conducted, alternative methods (e.g., opt-out testing) are more likely to increase testing rates.
A second modifiable factor in testing uptake is disclosure of interest in male-male sex to HCPs. Finding that disclosure to a HCP is associated with increased odds of HIV testing corroborates research with young adult (Stupiansky et al., 2017) and adolescent MSM (Fisher et al., 2018). However, also consistent with research, most ASMM had not disclosed to their HCP (Fisher et al., 2018). Training HCPs in sexual history taking (Lanier et al., 2014) increases HIV testing rates and is likely to facilitate more open communication regarding adolescents’ health and sexual behaviors. Technology might further improve adolescents’ engagement with and trust in HCPs (Holloway et al., 2017).
Limitations
First, the online survey required individuals have Internet access, perhaps limiting sample representativeness. Second, self-report is vulnerable to social (e.g., social desirability) and cognitive (e.g., memory) biases (Schroder, Carey, & Vanable, 2003). Third, the study was not powered to detect differences based on specific identities. Future work will be strengthened by addressing these limitations.
Conclusions
Few ASMM are testing for HIV and many do not plan to test regularly. The likelihood of testing increases when ASMM have disclosed male-male sexual interests to their HCP. As many doctors do not ask patients about sexual orientation (Dahan, Feldman, & Hermoni, 2008) and many sexual minority individuals fear discrimination from HCPs (Fisher et al., 2018), it is important for providers to foster non-judgmental communication about sexual health. In addition, health communication campaigns should target risk perceptions and the importance of routine testing for these youth to increase testing and ultimately decrease HIV transmission.
Acknowledgements:
All authors contributed to the interpretation of the findings and the writing of the manuscript. Drs. Nelson and Norris were responsible for the management of the data as well as data analysis.
Source of Funding: This work is supported by the National Institute of Mental Health (K23 MH10934; T32 MH078788). The content of this publication is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health.
Footnotes
Conflicts of Interest: None to declare.
References
- Alexander SC, Fortenberry JD, Pollak KI, Bravender T, Østbye T, & Shields CG (2014). Physicians use of inclusive sexual orientation language during teenage annual visits. LGBT Health, 1, 283–291. [DOI] [PubMed] [Google Scholar]
- Austin SB, Conron KJ, & Freedner N (2007). Making sense of sexual orientation measures: Findings from a cognitive processing study with adolescents on health survey questions. Journal of LGBT Health Research, 3, 55–66. doi: 10.1300/J463v03n01 [DOI] [PubMed] [Google Scholar]
- Balaji AB, Bowles KE, Le BC, Paz-Bailey G, & Oster AM (2013). High HIV incidence and prevalence and associated factors among young MSM, 2008. AIDS, 27, 269–278. doi: 10.1097/QAD.0b013e32835ad489 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, & Clark JE (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. Morbidity and Mortality Weekly Report, 55, 1–17. [PubMed] [Google Scholar]
- Centers for Disease Control and Prevention (2017). CDC fact sheet: HIV among gay and bisexual men Retrieved from https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/cdc-msm-508.pdf
- Dahan R, Feldman R, & Hermoni D (2008). Is patients’ sexual orientation a blind spot of family physicians? Journal of Homosexuality, 55, 524–532. doi: 10.1080/00918360802345321 [DOI] [PubMed] [Google Scholar]
- DiNenno EA, Prejean J, Irwin K, Delaney KP, Bowles K, Martin T, & Lansky A (2017). Recommendations for HIV screening of gay, bisexual, and other men who have sex with men — United States, 2017. Morbidity and Mortality Weekly Report, 66, 830–832. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Facente AC (2001). Adolescents and HIV: Knowledge, behaviors, influences, and risk perceptions. The Journal of School Nursing, 17, 198–203. doi: 10.1177/10598405010170040501 [DOI] [PubMed] [Google Scholar]
- Fisher CB, Fried AL, Macapagal K, & Mustanski B (2018). Patient–provider communication barriers and facilitators to HIV and STI preventive services for adolescent MSM. AIDS and Behavior Advance online publication. doi: 10.1007/s10461-018-2081-x. [DOI] [PMC free article] [PubMed]
- Harris PA, Taylor R, Thielke R, Payne J, Gonzalez NCS, & Conde JG (2009). Research Electronic Data Capture (REDCap): A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42, 377–81. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Holloway IW, Winder TJ, Lea CH III, Tan D, Boyd D, & Novak D (2017). Technology use and preferences for mobile phone–based HIV prevention and treatment among black young men who have sex with men: Exploratory research. JMIR MHealth and UHealth, 5, e46. doi: 10.2196/mhealth.6436 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Kann L, Olsen EO, McManus T, Harris WA, Shanklin SL, Flint KH, …Zaza S (2016). Sexual identity, sex of sexual contacts, and health-related behaviors among students in grades 9–12 — United States and selected sites, 2015. Morbidity and Mortality Weekly Report, 65, 1–202. [DOI] [PubMed] [Google Scholar]
- Lanier Y, Castellanos T, Barrow RY, Jordan WC, Caine V, & Sutton MY (2014). Brief sexual histories and routine HIV/STD testing by medical providers. AIDS Patient Care and STDs, 28, 113–120. doi: 10.1089/apc.2013.0328 [DOI] [PMC free article] [PubMed] [Google Scholar]
- MacKellar DA, Hou SI, Whalen CC, Samuelsen K, Sanchez T, Smith A, … Sullivan P (2011). Reasons for not HIV testing, testing intentions, and potential use of an over-the-counter rapid HIV test in an internet sample of men who have sex with men who have never tested for HIV. Sexually Transmitted Diseases, 38, 419–428. doi: 10.1097/OLQ.0b013e31820369dd [DOI] [PubMed] [Google Scholar]
- Mustanski B, Garofalo R, Monahan C, Gratzer B, & Andrews R (2013). Feasibility, acceptability, and preliminary efficacy of an online HIV prevention program for diverse young men who have sex with men: The Keep It Up! intervention. AIDS and Behavior, 17, 2999–3012. doi: 10.1007/s10461-013-0507-z [DOI] [PMC free article] [PubMed] [Google Scholar]
- Nelson KM, Carey MP, & Fisher CB (2018). Is guardian permission a barrier to online sexual health research among adolescent males interested in sex with males? Journal of Sex Research Advance online publication. doi: 10.1080/00224499.2018.1481920 [DOI] [PMC free article] [PubMed]
- Schroder KEE, Carey MP, & Vanable PA (2003). Methodological challenges in research on sexual risk behavior: II. Accuracy of self-reports. Annals of Behavioral Medicine, 26, 104–123. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Stupiansky NW, Liau A, Rosenberger J, Rosenthal SL, Tu W, Xiao S, … Zimet GD (2017). Young men’s disclosure of same sex behaviors to healthcare providers and the impact on health: Results from a US national sample of young men who have sex with men. AIDS Patient Care and STDs, 31, 342–347. [DOI] [PubMed] [Google Scholar]
- U.S. Census Bureau (2010). 2010 census regions and divisions of the United States Retrieved from: https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf