MSM are at increased risk of HIV, and they account for the majority of the HIV infections among adolescents in the United States [1]. Although there is a body of evidence on HIV-related risk behaviors and testing among adolescent MSM, most of the studies have included those aged 18 years and older [2,3]. In 2018, the US Food and Drug Administration approved preexposure prophylaxis for HIV for adolescents who weigh at least 35 kg [4], based on a trial that demonstrated its safety and tolerance among adolescent MSM aged 15–17 years [5]. Given the recent approval, a critical look at this specific age group and their vulnerability to HIV has become important. In this study, we assessed HIV-related risk behaviors and HIV testing among adolescent gay and bisexual younger than 18 years in the United States.
This study was a secondary data analysis of the 2015 and 2017 cycles of the Youth Risk Behavior Survey (YRBS). The YRBS is a nationally representative survey conducted to track health behaviors among high school students in the United States. More detailed information on the sampling design can be found at (https://www.cdc.gov/healthyyouth/data/yrbs/index.htm). In 2015, for the first time, the national survey included a question about sexual identity of the respondents. Our study population was adolescent boys (younger than 18 years) who self-identified as sexually active gay or bisexual. In this study, HIV testing referred to any previous test for HIV (excluding tests done during blood donation). We assessed the following HIV-related risk behaviors:
- Condom use: use of condom by the respondent or their partner at last sexual intercourse.
- Sexual partner: number of sexual partners in the last 3 months prior to the survey.
- Inject drug use: number of times respondents had used a needle to inject any illegal drug into their bodies in their lifetime.
- Substance abuse before sex: drinking of alcohol or use of drugs before last sexual intercourse.
We classified respondents as having high-risk behaviors if they had any of the following: no condom use, more than one sexual partner, injection drug use at least once, or used substance before sex. We conducted weighted descriptive statistics and logistic regression analysis to determine factors associated with HIV testing. We considered P value less than 0.05 as statistically significant. All data analyses were performed with SAS software Version 9.4; SAS Institute Inc., Cary, North Carolina, USA, using the procedures for complex survey. The study was deemed exempt by the institutional review board of the University of Nevada, Las Vegas, USA.
Out of the 12 840 adolescent boys younger than 18 years, 189 (1.5%) self-identified as sexually active gay or bisexual. The majority of the sexually active gay and bisexual boys (81%) were between 15 and 17 years of age. Approximately 43% of them were in the 10th grade, and 55% were of the white race/ethnicity. Forty-nine percent [95% confidence interval (CI) = 39.3–58.7] of them reported not using condom in their last anal sexual intercourse. About 65% (95% CI = 54.5–74.5) of them engaged in high-risk behaviors, and only 22% (95% CI = 13.8–29.3) had tested for HIV. In the logistic regression analyses, Hispanic/Latino adolescent gay and bisexual boys had nearly four times the odds for testing for HIV as white adolescent gay and bisexual boys (odds ratio = 3.5, 95% CI = 1.1–11.1) (Table 1).
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Table 1: Binary logistic regression results with HIV testing as the dependent variable.
Our results show that nearly seven in 10 sexually active adolescent MSM younger than 18 years in high school engage in high-risk behaviors. Low condom use in the study population maybe as a result of perceived lower sexual pleasure with condom and partner disapproval [6]. Our findings also show poor uptake of HIV testing. But, there was no enough evidence to suggest an association between HIV-related risk behaviors and HIV testing in our analysis. The variation in race/ethnicity in HIV testing was contrary to our expectations of higher HIV testing among black adolescent MSM given the disproportionate burden of HIV among them [7]. Low-risk perception, not knowing where to receive HIV tests, and concerns about confidentiality are some of the barriers that may be limiting HIV testing among adolescent gay and bisexual boys [8]. Laws preventing minors to consenting to HIV services may also be a structural barrier in some states. However, Nelson et al.[9] did not find legal capacity to consent for HIV testing to be significantly associated with HIV testing among adolescent sexual minority males.
In conclusion, as the United States has renewed its goal of ending the HIV epidemic [10], our findings indicate that there is a need to intensify HIV prevention interventions targeting adolescent gay and bisexual boys younger than 18 years.
Acknowledgements
Conflicts of interest
There are no conflicts of interest.
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