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. Author manuscript; available in PMC: 2022 Jul 1.
Published in final edited form as: Am J Prev Med. 2021 May 6;61(1):20–27. doi: 10.1016/j.amepre.2021.01.039

Factors Associated With HIV Testing Among High-School Girls in the U.S., 2015–2017

Alissa C Cyrus 1, Richard Dunville 2, Athena P Kourtis 3, Karen W Hoover 3, Pattie Tucker 1
PMCID: PMC8312734  NIHMSID: NIHMS1706395  PMID: 33965266

Abstract

Introduction:

Few studies have examined the factors associated with HIV testing, specifically among U.S. high-school girls.

Methods:

Investigators analyzed 2015 and 2017 Youth Risk Behavior Survey data to calculate the prevalence ratios and the corresponding 95% CIs for the association of HIV-related risk behaviors and other factors with HIV testing. Analyses were completed in March 2020.

Results:

Approximately 1 in 10 high-school girls reported ever having had an HIV test. Ever having had an HIV test was most common among girls who had ≥4 lifetime sexual partners and those who had ever injected illegal drugs.

Conclusions:

High-school girls who engage in behaviors or experience other factors that put them at higher risk for HIV are more likely to have ever gotten tested. However, the prevalence of having ever had an HIV test remains relatively low, indicating that continued efforts may be warranted to reduce risk behaviors and increase testing among high-school girls.

INTRODUCTION

The overall rate of HIV diagnoses in the U.S. decreased from 13.1 to 11.8 per 100,000 population from 2012 through 2017.1 Adolescent girls are at increased risk of HIV owing to social and biological factors2; in 2016, nearly 270 girls aged 13–19 years in the U.S. received an HIV diagnosis.3 The Centers for Disease Control and Prevention (CDC) recommends that healthcare providers offer routine HIV screening for everyone aged 13–64 years and annually for high-risk individuals.4 Many young people are unaware of their HIV status; estimates indicate that more than half of individuals aged 13–24 years living with HIV in the U.S. are undiagnosed5 and that the lowest proportion of lifetime HIV testing is among those aged 15–17 years.6 In 2017, only about 1 in 10 high-school students reported ever having an HIV test.7

Testing for HIV is more common among high-school students who are female, who are Black/African American, who are in higher grade levels (i.e., 11th or 12th grade), or who engage in behaviors that increase HIV risk.7–9 Risk behaviors include illegal drug use, having multiple sexual partners, not using a condom during sex, and using alcohol or drugs before sex.10–13 In 2017, <1% of high-school girls reported lifetime illegal injection drug use, nearly 15% reported lifetime prescription pain medicine misuse, and almost 8% reported having ≥4 lifetime sexual partners.7 Among sexually active girls, about half did not use a condom, and about 15% used alcohol or drugs the last time they had sex.7

Other factors potentially associated with HIV risk pertinent to high-school girls include sexual violence victimization (e.g., forced sexual intercourse, sexual dating violence) and mental health factors, including general psychological distress and suicidal thoughts or attempts.9,10,14 Although associations between sexual violence victimization and sexually transmitted disease (STD)/HIV risk behaviors15–17 among adolescent girls have been well established, the relationship between sexual violence victimization and HIV testing in the U.S. is less clear. Decker et al.14 found that adolescent girls who experienced dating violence were more likely to get tested for STDs/HIV; however, this study used data, which are now 20 years old, from 1 state. Mental health factors may lead to poor judgment and decision making or lack of agency in relationships, which in turn may lead to riskier behavior.18 Whether mental health factors are associated with HIV testing has not been as well studied. These factors are particularly important for high-school girls because of the large affected proportion: >40% report persistent feelings of sadness or hopelessness; approximately 10% have been forced to have sexual intercourse; and of those who dated someone in the past year, 1 in 10 experienced sexual dating violence.7

Previous studies of HIV-related risk behaviors and HIV testing have reported on adolescents and young adults overall8–10 or stratified by sex.11,12,19–21 The few studies focused on adolescent girls have used either clinic-based17,22 or state-based14,23 samples, results of which are not generalizable to all U.S. high-school girls. To the authors’ knowledge, no studies have used nationally representative data to describe factors related to HIV testing concentrating on high-school girls. This study uses national Youth Risk Behavior Survey (YRBS) data to examine the factors associated with HIV testing among high-school girls in the U.S.

METHODS

Study Sample

Data from the national YRBS were analyzed.24 Conducted every 2 years, the YRBS collects self-reported data on health-related topics, including unintentional injuries, violence, tobacco use, alcohol and other drug use, sexual behaviors, dietary behaviors, physical activity, and overweight and obesity. The YRBS uses a 3-stage, cluster sample design to obtain a nationally representative sample of 9th–12th-grade students in public and private high schools in the 50 states and the District of Columbia. Data were weighted to adjust for nonresponse and oversampling of Black and Hispanic students.25 CDC’s IRB approved the national YRBS. Weighted data from the 2015 and 2017 YRBS were combined to ensure adequate sample size for analyses, following CDC-recommended procedures.26

Measures

Demographic characteristics included race/ethnicity (non-Hispanic White, non-Hispanic Black or African American, Hispanic or Latina; because sample sizes were too small for meaningful analysis, other racial/ethnic groups were collapsed into a non-Hispanic other or multiple-races category), high school grade level (9th, 10th, 11th, 12th), grades in school (mostly C’s, D’s, and F’s; mostly A’s and B’s), sexual identity (heterosexual; gay, lesbian, or bisexual; not sure), and sex of sexual contacts (male contacts only, female contacts only or both male and female contacts, or no sexual contact).

Included HIV-related risk behaviors were the number of lifetime sexual partners (≥4, <4, never had sexual intercourse), condom use at last sexual intercourse (yes, no, never had sexual intercourse), alcohol or drug use before last sexual intercourse (yes, no, never had sexual intercourse), ever misused prescription drugs (yes, no),a and ever injected illegal drugs (yes, no).

Other factors included were ever forced to have sexual intercourse (yes, no), experienced sexual dating violence in the past 12 months (i.e., someone they went out with or were dating forced them to do sexual things they did not want to do [yes, no, did not date anyone in past 12 months]), and persistent feelings of sadness or hopelessness (i.e., felt so sad or hopeless almost every day for ≥2 weeks in a row that they stopped performing some usual activities [yes, no]).

One HIV testing measure, ever having had an HIV test, was assessed. Respondents were considered to have ever had an HIV test if they responded yes to: Have you ever been tested for HIV, the virus that causes AIDS? (Do not count tests done if you donated blood).

Statistical Analysis

Prevalence estimates and corresponding 95% CIs of selected demographic characteristics, HIV-related risk behaviors, and other factors overall and stratified by ever or never having an HIV test were calculated. Nonoverlapping CIs were used to identify significant differences between those who ever and those who never had an HIV test. Logistic regression was performed to calculate the prevalence ratios (PRs) and the corresponding 95% CIs for the association of HIV-related risk behaviors and other factors with HIV testing, adjusted for high school grade level, race or ethnicity, grades in school, and sex of sexual contacts. Analyses were completed in March 2020 using SUDAAN, version 11.0.1.

A total of 30,389 high-school students participated in the combined 2015 and 2017 YRBS. The sample was limited to female students (n=15,283); further excluded were respondents missing on variables of interest (n=4,667): demographic characteristics (n=3,408), HIV-related risk behaviors (n=639), other factors (n=588), and HIV testing (n=32). The final analytic sample comprised 10,616 female high-school students with complete information, which scaled to 11,067 after weights were applied.

RESULTS

Overall, most high-school girls were non-Hispanic White (57.1%). Approximately one quarter were in each grade level (ranged from 23.9% [11th grade] to 26.1% [10th grade]), and >80% received mostly A’s and B’s. Most girls identified as heterosexual (83.1%), and nearly half had not had sexual contact with either males or females (49.3%). Slightly fewer than 1 in 10 girls reported having ≥4 lifetime sexual partners (8.3%), and 17.9% did not use a condom the last time they had sex. Approximately 6% reported using alcohol or drugs before they last had sex, nearly 15% ever misused prescription drugs, and only 0.5% ever injected illegal drugs. Almost 1 in 10 girls reported having been forced to have sexual intercourse and having experienced sexual dating violence (9.9% and 9.2%, respectively). In total, 40% of girls reported persistent feelings of sadness or hopelessness. Approximately 1 in 10 girls (10.3%) had ever had an HIV test (Table 1).

Table 1.

Prevalence of Selected Characteristics Among High-School Girls by HIV Testing Status—Youth Risk Behavior Survey, 2015–2017

Characteristics Overall (N=11,067)
% (95% CI)		 Ever had an HIV test (n=1,142)
% (95% CI)		 Never had an HIV test (n=9,925)
% (95% CI)
Overall N/A 10.3 (9.2, 11.5) 89.7 (88.5, 90.8)
Race or ethnicity
 White, non-Hispanic 57.1 (52.8, 61.3) 49.1 (43.0, 55.2) 58.1 (53.8, 62.2)
 Black or African American, non-Hispanic 11.6 (10.1, 13.3) 17.5 (13.6, 22.1) 10.9 (9.5, 12.5)
 Hispanic or Latina 21.4 (18.6, 24.6) 22.3 (18.5, 26.7) 21.3 (18.5, 24.5)
 Other or multiple, non-Hispanic 9.8 (8.2, 11.6) 11.1 (8.5, 14.4) 9.7 (8.1, 11.5)
Grade level
 9th grade 25.6 (23.9, 27.3) 16.6 (13.7, 19.9) 26.6 (24.8, 28.5)
 10th grade 26.1 (24.7, 27.6) 22.6 (19.6, 25.8) 26.5 (25.0, 28.1)
 11th grade 23.9 (22.9, 25.0) 24.8 (21.4, 28.5) 23.8 (22.7, 25.0)
 12th grade 24.4 (23.3, 25.5) 36.1 (32.8, 39.5) 23.0 (22.0, 24.2)
Grades in school
 Mostly C’s, D’s, and F’s 18.5 (16.4, 20.8) 29.8 (25.8, 34.1) 17.2 (15.2, 19.4)
 Mostly A’s and B’s 81.5 (79.2, 83.6) 70.2 (65.9, 74.2) 82.8 (80.6, 84.8)
Sexual identity
 Heterosexual 83.1 (81.3, 84.9) 77.1 (73.8, 80.0) 83.8 (81.8, 85.7)
 Gay/lesbian/bisexual 13.0 (11.6, 14.6) 20.3 (17.4, 23.5) 12.2 (10.7, 13.9)
 Not sure 3.8 (3.3, 4.5) 2.7 (1.9, 3.7) 4.0 (3.4, 4.7)
Sex of sexual contacts
 Males only 41.6 (39.5, 43.7) 62.8 (59.1, 66.4) 39.1 (37.1, 41.2)
 Females only or both males and females 9.1 (8.0, 10.3) 20.0 (17.0, 23.3) 7.8 (6.8, 9.0)
 No sexual contact 49.3 (46.9, 51.7) 17.2 (14.1, 20.9) 53.0 (50.7, 55.4)
Number of lifetime sexual partners
 ≥4 8.3 (7.3, 9.5) 29.2 (26.2, 32.4) 5.9 (5.0, 7.0)
 <4 30.2 (28.3, 32.2) 48.8 (45.5, 52.2) 28.0 (26.0, 30.1)
 Never had sexual intercourse 61.5 (58.6, 64.3) 22.0 (18.6, 25.9) 66.1 (63.3, 68.7)
Used a condom at the last sexual intercourse
 No 17.9 (16.1, 19.7) 45.3 (41.8, 48.9) 14.7 (13.1, 16.5)
 Yes 20.6 (19.2, 22.1) 32.6 (29.7, 35.8) 19.2 (17.8, 20.8)
 Never had sexual intercourse 61.5 (58.6, 64.3) 22.0 (18.6, 25.9) 66.1 (63.3, 68.7)
Used alcohol or drugs before last sexual intercourse
 Yes 6.1 (5.3, 6.9) 16.5 (14.0, 19.3) 4.9 (4.2, 5.6)
 No 32.4 (30.1, 34.9) 61.5 (57.7, 65.2) 29.1 (26.7, 31.6)
 Never had sexual intercourse 61.5 (58.6, 64.3) 22.0 (18.6, 25.9) 66.1 (63.3, 68.7)
Ever misused prescription drugs
 Yes 14.7 (13.6, 16.0) 27.2 (23.6, 31.1) 13.3 (12.1, 14.5)
 No 85.3 (84.0, 86.4) 72.8 (68.9, 76.4) 86.7 (85.5, 87.9)
Ever injected illegal drugs
 Yes 0.5 (0.4, 0.8) 2.0 (1.2, 3.3) 0.4 (0.2, 0.6)
 No 99.5 (99.2, 99.6) 98.0 (96.7, 98.8) 99.6 (99.4, 99.8)
Ever forced to have sexual intercourse
 Yes 9.9 (8.7, 11.3) 24.0 (20.5, 27.8) 8.3 (7.3, 9.5)
 No 90.1 (88.7, 91.3) 76.0 (72.2, 79.5) 91.7 (90.5, 92.7)
Experienced sexual dating violence in the past 12 months
 Yes 9.2 (8.3, 10.1) 15.3 (12.5, 18.5) 8.5 (7.6, 9.4)
 No 60.5 (58.6, 62.5) 71.8 (67.9, 75.5) 59.2 (57.1, 61.3)
 Did not date anyone in the past 12 months 30.3 (28.1, 32.6) 12.9 (10.7, 15.5) 32.3 (30.0, 34.7)
Persistent feelings of sadness or hopelessness
 Yes 40.2 (37.9, 42.6) 54.8 (51.3, 58.3) 38.6 (36.2, 40.9)
 No 59.8 (57.4, 62.1) 45.2 (41.7, 48.7) 61.4 (59.1, 63.8)
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N/A, not applicable.

The distribution of demographic characteristics, HIV-related risk behaviors, and other factors differed between high-school girls who ever had an HIV test and those who never had. A higher proportion of girls who ever had an HIV test were non-Hispanic Black or African American (17.5% vs 10.9%); were in the 12th grade (36.1% vs 23.0%); got mostly C’s, D’s, and F’s (29.8% vs 17.2%); identified as gay, lesbian, or bisexual (20.3% vs 12.2%); had ever misused prescription drugs (27.2% vs 13.3%); ever injected illegal drugs (2.0% vs 0.4%); had been forced to have sexual intercourse (24.0% vs 8.3%); and had persistent feelings of sadness or hopelessness (54.8% vs 38.6%) than the proportion of those who never had an HIV test. A higher proportion of those who never had an HIV test had not had sexual contact with males or females (53.0% vs 17.2%), had never had sexual intercourse (66.1% vs 22.0%), and had not dated anyone in the past 12 months (32.3% vs 12.9%) (Table 1).

The prevalence of lifetime HIV testing varied by risk behaviors and other factors. Only 14.1% of high-school girls who had persistent feelings of sadness or hopelessness, 17.2% who experienced sexual dating violence, and 19.1% who ever misused prescription drugs ever had an HIV test. By contrast, 36.2% of girls who had ≥4 lifetime sexual partners and 37.5% of those who ever injected illegal drugs ever had an HIV test. In unadjusted logistic regression models, each of the assessed factors was a significant predictor of ever having an HIV test (PRs ranged from 1.40 [experienced sexual dating violence] to 3.69 [ever injected illegal drugs]). After adjustment for demographic characteristics, PRs were attenuated; however, all but having experienced sexual dating violence remained significant (adjusted PRs ranged from 1.31 [used alcohol or drugs before last sex] to 2.15 [ever injected illegal drugs]) (Table 2).

Table 2.

Prevalence and APRs for the Association of HIV-Related Risk Behaviors and Other Factors With HIV Testing—Youth Risk Behavior Survey, 2015–2017

Variables Prevalence of HIV testing
% (95% CI)		 Unadjusted
PR (95% CI)		 Adjusteda
APR (95% CI)
Had ≥4 lifetime sexual partners 36.2 (31.4, 41.3) 2.16 (1.85, 2.54) 1.99 (1.70, 2.32)
Did not use a condom at the last sexual intercourse 26.2 (23.5, 29.1) 1.60 (1.39, 1.84) 1.48 (1.30, 1.69)
Used alcohol or drugs before last sexual intercourse 28.1 (23.8, 32.9) 1.44 (1.21, 1.71) 1.34 (1.12, 1.60)
Ever misused prescription drugs 19.1 (16.1, 22.4) 2.16 (1.81, 2.58) 1.43 (1.20, 1.69)
Ever injected illegal drugs 37.5b (22.1, 55.9) 3.69 (2.31, 5.87) 2.15 (1.21, 3.82)
Ever forced to have sexual intercourse 24.9 (22.0, 28.0) 2.86 (2.43, 3.35) 1.71 (1.48, 1.98)
Experienced sexual dating violence in the past 12 months 17.2 (14.0, 20.9) 1.40 (1.12, 1.76) 1.23 (0.97, 1.54)
Persistent feelings of sadness or hopelessness 14.1 (12.5, 15.8) 1.80 (1.60, 2.03) 1.31 (1.16, 1.48)
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a

Adjusted for high school grade level, race or ethnicity, grades in school, and sex of sexual contacts.

b

Estimate has a relative SE between 20 and 30 and should be interpreted with caution.

APR, adjusted prevalence ratio; PR, prevalence ratio.

DISCUSSION

Approximately 1 in 10 high-school girls reported ever having received an HIV test; it was most common among girls who had ≥4 lifetime sexual partners and those who had ever injected illegal drugs. Several factors associated with lifetime HIV testing were identified. It is encouraging that high-school girls who engage in behaviors or experience other factors that put them at higher risk for HIV are more likely to have been tested. However, the prevalence of ever having an HIV test is still relatively low, indicating that continued efforts may be warranted to reduce risk behaviors and increase testing among high-school girls.

Approximately 10% of high-school girls had ever received an HIV test, which was similar to a 2018 report.7 Other studies that included only sexually experienced adolescent girls found higher percentages, on the order of ≥20%.9,10,19 This study was not limited to sexually experienced high-school girls because some factors assessed may increase the risk for contracting HIV regardless of sexual experience (e.g., illegal injection drug use). In addition, girls who have been forced to have sexual intercourse may not consider themselves sexually experienced, and some girls may only consider vaginal intercourse when asked about sexual experience even if they have engaged in oral or anal sex; these girls would have been excluded were the study limited on the basis of sexual experience.

High-school girls who engaged in high-risk behaviors were more likely than those who did not to have ever received an HIV test, even after adjustment for demographic characteristics. Those who ever injected illegal drugs and those who had ≥4 lifetime sexual partners reported the highest prevalence of ever having an HIV test (37.5% and 36.2%, respectively) and were twice as likely to have had an HIV test as those who did not report these behaviors. Although smaller in magnitude, associations were also found between lack of condom use at last sex, use of alcohol or drugs before last sex, and ever having misused prescription drugs with HIV testing. With few exceptions, these results are similar to the findings of previous studies conducted among sexually experienced adolescents overall (i.e., boys and girls).8–10 Balaji and colleagues10 and Pampati et al.9 did not find an association between alcohol or drug use before last sex and prescription opioid misuse, respectively, and HIV testing. These differences may be due, in part, to the fact that these studies used a sample of only sexually experienced adolescents, who may be more similar in both risk behaviors and HIV testing than a sample of all adolescents. In addition, because adolescents may engage in multiple HIV-related risk behaviors, controlling for them as these studies did may attenuate some results.

The finding that girls who had ever been forced to have sexual intercourse were more likely to have had an HIV test but that those who had experienced sexual dating violence in the past 12 months were not aligns with the findings of Pampati and colleagues.9 Other studies also found an association between forced sexual intercourse and HIV testing,8–10 possibly because girls who have been forced to have sex perceive themselves at higher risk of contracting HIV and request HIV testing directly or are referred for HIV testing after seeking out sexual assault services.14,27 The relationship between sexual dating violence and HIV testing is murkier. A study using Massachusetts YRBS data found that high-school girls who experienced both physical and sexual dating violence were more likely to be tested for and diagnosed with STDs and HIV.14 However, a Boston area clinic-based study found that although 10% of adolescent girls sought care for testing or symptoms of HIV or STDs, there were no statistically significant associations with lifetime or current intimate partner violence.28 The finding that high-school girls who experience sexual dating violence are not more likely to get tested for HIV is concerning. Male adolescents and young adults who perpetrate physical or sexual dating violence are more likely to engage in sexual risk behaviors and to be diagnosed with STDs, thereby increasing their partners’ risk of contracting STDs or HIV.29–31 This is an important area that merits additional attention.

The 1 assessed mental health measure, persistent feelings of sadness or hopelessness, was associated with ever having an HIV test. Mental health factors have previously been associated with HIV-related risk behaviors such as injection drug use and sexual risk behaviors.32,33 The relationship between mental health and risk behaviors could partially explain this association; however, a recent study found that persistent feelings of sadness or hopelessness were associated with lifetime HIV testing even after adjustment for sexual risk behaviors.9 Psychological distress in female adolescents has been associated with real and perceived barriers to negotiating condom use with their sex partners.33 Female adolescents who perceive barriers to condom use are more likely to worry about HIV infection34 and thus may be more likely to seek testing for HIV. Further investigation is warranted to disentangle the relationship among high-school girls’ mental health, risk behaviors, and receipt of HIV testing.

Barriers to HIV testing cited by adolescents (and young adults) include that they do not perceive themselves at risk, that a healthcare provider did not suggest it, that they feared getting tested, privacy concerns, and the stigma associated with getting an HIV test.35,36 A multifaceted approach is likely needed to address these barriers and increase HIV testing in this population. Possible strategies include providing HIV education in school, integrating HIV testing into routine and reproductive health services, and utilizing newer technologies such as mobile health (mHealth) interventions.2,37 Schools are invaluable for the dissemination of information; receipt of HIV/AIDS education in school has been linked to increased HIV testing and reduced drug use and sexual risk behaviors.2,21,23,38 Healthcare providers can incorporate HIV testing into routine and reproductive health visits; this can help normalize testing, and adolescents indicate that being offered HIV testing by their providers would help them remember to get tested.36 These visits also represent an opportunity to conduct comprehensive screening of risk behaviors, violence victimization, and mental health and then for referral to additional services and HIV testing when appropriate. Interventions through mHealth, mostly using text messaging, have shown some promise in increasing HIV testing.37 More research is needed to determine the effectiveness of large-scale adoption of mHealth interventions; however, they have the potential to deliver low-cost, confidential information and reminders about HIV testing.37

Limitations

These data are subject to several limitations. First, YRBS data are self-reported and thus subject to recall and social desirability bias, which may result in under-reporting of HIV-related risk behaviors and other risk factors and under- or over-reporting of HIV testing. Second, YRBS is conducted in public and private high schools in the U.S.; therefore, data are only representative of those who attend school. Out-of-school high school–aged adolescents are more likely to engage in risky behaviors than those in school39; thus, estimates of risk behaviors presented in this study may be lower than estimates among all adolescent girls. Third, in 2015 and 2017, YRBS did not ask questions about all HIV-related risk behaviors (e.g., anal sex), testing for STDs, diagnosis of HIV or STDs, or access to health care, so this study was unable to account for those factors. Fourth, data on geographic location were not available in the national YRBS; therefore, the authors were unable to assess whether factors such as neighborhood stress or living in an area with high HIV prevalence were associated with HIV testing. In addition, they were unable to assess all racial and ethnic groups individually; because not all groups are equally likely to receive an HIV test,8 this is an area warranting further study. Finally, these data are cross-sectional, so causality cannot be determined. Despite these limitations, this study is unique because it assesses the relationship of HIV-related risk behaviors, sexual violence victimization, and mental health factors with HIV testing among high-school girls.

CONCLUSIONS

High-school girls who engage in HIV-related risk behaviors or experience other factors that put them at higher risk for HIV are more likely to get tested for HIV, which is encouraging. However, the prevalence of lifetime HIV testing among high-school girls remains relatively low, indicating opportunities for improvement in HIV testing in this group. A multifaceted approach, including HIV education in school, integration of HIV testing into routine and reproductive health services, and the use of newer mHealth technologies, aimed at reducing sexual risk behaviors and increasing HIV testing is warranted for all high-school girls but particularly for those who engage in high-risk behaviors.

ACKNOWLEDGMENTS

The authors would like to thank Asia Asberry for her assistance in conducting and summarizing the literature review.

The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

No financial disclosures were reported by the authors of this paper.

Footnotes

a

In 2015, respondents were asked: During your life, how many times have you taken a prescription drug (such as OxyContin, Percocet, Vicodin, codeine, Adderall, Ritalin, or Xanax) without a doctor’s prescription? In 2017, they were asked: During your life, how many times have you taken prescription pain medicine without a doctor’s prescription or differently than how a doctor told you to use it? (Count drugs such as codeine, Vicodin, OxyContin, Hydrocodone, and Percocet).

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