Advertisement

Low Rates of Human Immunodeficiency Virus Testing Among Adolescent Gay, Bisexual, and Queer Men

      Abstract

      Purpose

      Adolescent gay and bisexual men (AGBM) are disproportionately affected by human immunodeficiency virus (HIV), but little is known about testing rates among men aged 18 years and under or about the barriers that they face when contemplating an HIV test. Therefore, we investigate here the testing behaviors and barriers among a diverse national sample of AGBM.

      Methods

      A total of 302 AGBM aged 14–18 years were recruited via Facebook ads to participate in an mHealth (text messaging-based) HIV prevention program. Recruitment was stratified to ensure approximately 50% were sexually inexperienced.

      Results

      Only 30% of sexually active participants had ever been tested for HIV, and nearly half of them did not know where they could go to get tested for HIV (42.9%). Based on exploratory factor analysis, nine questions assessing potential barriers to HIV testing factored into three subscales: external factors, fear, and feelings of invincibility. Among sexually active participants, those who had never tested for HIV had significantly greater scores on the external factors (odds ratio, 1.63; 95% confidence interval, 1.01–2.66) and fear (odds ratio, 1.88; 95% confidence interval, 1.11–3.19) subscale. Older (16–18 years old) youth were especially likely to be affected by external factor barriers, and fear was associated with never testing among gay-identified individuals.

      Conclusions

      HIV testing rates were low among AGBM. Several modifiable barriers emerged, especially a lack of knowledge about the closest testing site. Interventions and programs that target high school–age adolescents could address external barriers by introducing HIV testing services into high schools.

      Keywords

      Implications and Contribution
      Although adolescent gay and bisexual men are disproportionately affected by human immunodeficiency virus (HIV), little is known about their HIV testing rates. This study highlights low testing rates among 14- to 18-year-old sexual minority males and classifies testing barriers into three categories: external factors, fear, and feelings of invincibility.
      Adolescent gay and bisexual men (AGBM), along with other young men who have sex with men (YMSM) but who do not identify with these labels, are disproportionately affected by human immunodeficiency virus (HIV). In the United States, YMSM aged 13–24 years represent one of the only risk group in which the number of new HIV diagnoses has continued to increase from 2009 to 2013 [
      Centers for Disease Control and Prevention
      HIV surveillance—Men who have sex with men.
      ]. This also does not account for 63% of YMSM and 54% of racial/ethnic minority men who have sex with men (MSM) who are unaware of their HIV infection [

      Centers for Disease Control and Prevention. Prevalence and awareness of HIV infection among men who have sex with men—21 cities, United States, 2008. 2010:1201–1207.

      ]. In one of the few epidemiologic studies of HIV prevalence among YMSM that included individuals aged <18 years, the Young Men's Study conducted between 1994 and 1998 found that 5.6% of YMSM between the ages of 15 and 19 years were HIV positive [
      • Valleroy L.A.
      • MacKellar D.A.
      • Karon J.M.
      HIV prevalence and associated risks in young men who have sex with men: Young Men's Survey Study Group.
      ].
      Despite the Centers for Disease Control and Prevention (CDC) recommendations that sexually active MSM get tested for HIV at least every 6 months [
      • Workowski K.A.
      • Berman S.
      Sexually transmitted diseases treatment guidelines, 2010.
      ], HIV testing rates of YMSM are suboptimal [
      • Finlayson T.J.
      • Le B.
      • Smith A.
      • et al.
      HIV risk, prevention, and testing behaviors among men who have sex with men—National HIV Behavioral Surveillance System, 21 U.S. cities, United States, 2008.
      ,
      • Sumartojo E.
      • Lyles C.
      • Choi K.
      • et al.
      Prevalence and correlates of HIV testing in a multi-site sample of young men who have sex with men.
      ,
      • Kann L.
      • Kinchen S.
      • Shanklin S.L.
      • et al.
      Youth risk behavior surveillance—United States, 2013.
      ,
      • Phillips 2nd, G.
      • Hightow-Weidman L.B.
      • Arya M.
      • et al.
      HIV testing behaviors of a cohort of HIV-positive racial/ethnic minority YMSM.
      ,
      • Leonard N.R.
      • Rajan S.
      • Gwadz M.V.
      • Aregbesola T.
      HIV testing patterns among urban YMSM of color.
      ]. In the National HIV Behavioral Surveillance System (NHBS), the lowest lifetime testing rate among MSM was in the youngest age group of 18- to 19-year-olds (75%), and only 64% had been tested in the past year [
      • Finlayson T.J.
      • Le B.
      • Smith A.
      • et al.
      HIV risk, prevention, and testing behaviors among men who have sex with men—National HIV Behavioral Surveillance System, 21 U.S. cities, United States, 2008.
      ]. In the Community Intervention Trial for Youth, conducted in 1999, researchers found that only 50% of YMSM aged 15–17 years had tested for HIV [
      • Sumartojo E.
      • Lyles C.
      • Choi K.
      • et al.
      Prevalence and correlates of HIV testing in a multi-site sample of young men who have sex with men.
      ]. Nearly fifteen years later, the 2013 Youth Risk Behavior Survey found that only 11% of high school males, across sexual identities, had ever been tested for HIV. This proportion was only slightly greater in later grades (13% each of 11th- and 12th-grade males) [
      • Kann L.
      • Kinchen S.
      • Shanklin S.L.
      • et al.
      Youth risk behavior surveillance—United States, 2013.
      ]. As HIV testing is the first step in the HIV continuum of care, it is vitally important to improve testing rates to decrease the HIV burden among AGBM.
      Research has also highlighted a lag time between the first sex and the first HIV test. For example, several studies have shown that black and Latino YMSM have their first HIV test an average of 2 years after sexual debut [
      • Phillips 2nd, G.
      • Hightow-Weidman L.B.
      • Arya M.
      • et al.
      HIV testing behaviors of a cohort of HIV-positive racial/ethnic minority YMSM.
      ,
      • Leonard N.R.
      • Rajan S.
      • Gwadz M.V.
      • Aregbesola T.
      HIV testing patterns among urban YMSM of color.
      ]. This delay in testing constitutes a significant period of time in which YMSM remain unaware of their HIV status and could be the reason why one study found that one-third of racial/ethnic minority YMSM tested positive on their first HIV test [
      • Phillips 2nd, G.
      • Hightow-Weidman L.B.
      • Arya M.
      • et al.
      HIV testing behaviors of a cohort of HIV-positive racial/ethnic minority YMSM.
      ]. In comparison, NHBS found that 16% of adult MSM tested HIV positive on their first HIV test [
      Centers for Disease Control and Prevention
      HIV testing among men who have sex with men—21 cities, United States, 2008.
      ]. We need to not only invigorate testing rates but also reduce the time between the first sex and the first HIV test.
      Investigating barriers and facilitators to HIV testing is vital in understanding the reason for low testing krates among AGBM. Frequently endorsed reasons for testing include wanting to know an HIV-negative status, concerns about potential HIV exposure, presence of social support, and exposure to HIV prevention information [
      • Sumartojo E.
      • Lyles C.
      • Choi K.
      • et al.
      Prevalence and correlates of HIV testing in a multi-site sample of young men who have sex with men.
      ,
      • Phillips 2nd, G.
      • Hightow-Weidman L.B.
      • Arya M.
      • et al.
      HIV testing behaviors of a cohort of HIV-positive racial/ethnic minority YMSM.
      ,
      • Leonard N.R.
      • Rajan S.
      • Gwadz M.V.
      • Aregbesola T.
      HIV testing patterns among urban YMSM of color.
      ]. However, not much is known about factors that hinder HIV testing, particularly those that relate to structural and psychological barriers, among young men. Therefore, we proposed to investigate the HIV testing behaviors and reported obstacles among a diverse national sample of AGBM aged 14–18 years.

      Methods

      Between June and November 2014, 302 gay, bisexual, or queer identified males aged 14–18 years from across the United States were enrolled into a randomized controlled trial testing, a text messaging–based HIV prevention program (Guy2Guy). The research protocol was reviewed and approved by both the Chesapeake Institutional Review Board and the Northwestern University Institutional Review Board. A waiver of parental permission was obtained to prevent youth from being required to disclose their sexual identity to their parents to participate in the study [
      • Mustanski B.
      Ethical and regulatory issues with conducting sexuality research with LGBT youth.
      ].

      Participants

      To take part in the study, respondents needed to self-identify as gay, bisexual, and/or queer; have a male sex assigned at birth; have a male gender identity; be between the ages of 14 and 18 years; speak English; report being the exclusive owner of a cell phone with an unlimited text messaging plan; have used text messaging for at least 6 months; intend to have the same number for the next 6 months; and provide informed assent/consent. Participants also completed an assessment of decisional capacity as part of the assent process [
      • Mustanski B.
      Ethical and regulatory issues with conducting sexuality research with LGBT adolescents: A call to action for a scientifically informed approach.
      ]. Regarding threats to external validity because of the requirement that participants have a cell phone and unlimited text messaging, recent national data show that 78% of teens have a cell phone [
      Pew Internet & American Life Project
      Teens and technology.
      ] and 63% exchange texts with people in their lives on a daily basis [
      Pew Internet & American Life Project
      Teens, smartphones & texting.
      ]. Of our screened participants, only three (.9%) were deemed ineligible because of lack of a cell phone; two of these individuals were still able to exchange text messages through their tablet computers.

      Recruitment

      All participants were recruited through national advertisements placed on Facebook. These advertisements asked viewers to take part in a “text messaging-based healthy sexuality program” that was designed for “gay, bi, & queer teen guys like you!” To ensure a demographically representative sample of AGBM, targeted ads were also used to enroll individuals from particular subgroups with low response rates for this study (e.g., 14-year-olds, black males). Anyone who clicked on the link in the advertisement was directed to an online screener form. Based on their responses, individuals who appeared eligible were contacted sequentially, based on recruitment targets, to confirm eligibility; those who were ineligible were e-mailed HIV prevention resources. Recruitment targets included the following: sexual experience (50% experienced), race (65% white, 20% black, and 15% other), ethnicity (20% Hispanic), age (40% 14–15 years and 60% 16–18 years), and urban versus rural living situation determined by ZIP code (80% urban and 20% rural). These recruitment targets were developed through reviewing U.S. Census and American Community Survey data and oversampling minority populations (e.g., 13.2% of people living in the United States identified as black, so the target was increased to 20%) [
      United States Census Bureau
      Selected characteristics of the native and foreign-born populations. 2013 American community survey 1-year estimates.
      ]. Once eligibility was determined, the participant was provided with more details about the study, and verbal assent/consent was obtained. The participant was then sent a link to the online survey via text message and e-mail.
      An individual was not considered enrolled in the study until he completed the baseline survey and was randomized into one of the study arms. Of the 321 gay, bisexual, and/or queer males who were eligible and provided consent, all but 19 (5.9%) completed the baseline assessment and were enrolled in the study. There were no significant demographic differences between those who were enrolled and those who were not except for Hispanic ethnicity: those who did not complete the baseline survey were significantly more likely to identify as Hispanic than those who completed the survey (p = .02).

      Measures

      Baseline data were used in this article. Demographic characteristics assessed included age, race, ethnicity, and sexual identity. Participants could identify multiple sexual identities; to identify differences between bisexually identified and gay-identified youth, those who identified as both categories were excluded from analyses addressing sexual identity. There were no significant differences in characteristics between youth who identified as both gay and bisexual, and those who identified as only one of those sexual identities.

      Human immunodeficiency virus testing behaviors

      Participants were asked a series of questions regarding their HIV testing behaviors. Specifically, they were asked how many times they had ever been tested, if they had been tested in the prior 3 months, and their status on their most recent HIV test. Additional questions collected information on knowledge about where to get tested and distance to the closest HIV testing location. Finally, a series of items were included to assess components of the information-motivation-behavioral skills (IMB) model [
      • Misovich S.J.
      • Fisher W.A.
      • Fisher J.D.
      A measure of AIDS prevention information, motivation, behavioral skills, and behavior.
      ]. Related to this analysis, the item “Most people my age who have sex get tested for HIV” from the questionnaire was used.

      Human immunodeficiency virus testing barriers

      A nine-item scale to assess barriers to HIV testing was adapted from a 13-item scale developed by Awad et al. [
      • Awad G.H.
      • Sagrestano L.M.
      • Kittleson M.J.
      • Sarvela P.D.
      Development of a measure of barriers to HIV testing among individuals at high risk.
      ]. In this adaptation, items were revised to be more applicable to adolescent males (e.g., most adolescents would have difficulties responding to the item, “You are afraid of losing your health insurance,” and so it was dropped). Additionally, scoring was changed to three response options: “not important,” “somewhat important,” and “very important.” All participants were asked these questions regardless of their sexual experience or HIV testing history; however, the introductory text was altered based on whether they had ever tested and if they had tested in the prior 3 months.

      Consensual sexual experience

      Participants were classified as sexually experienced if they indicated at least one person in response to the question: “With how many people have you ever had anal sex (where a penis goes into someone's anus) or vaginal sex (where a penis goes into someone's vagina) when you wanted to (you were not forced)?”

      Statistical analysis

      Univariate analyses were conducted to determine the distribution of participant responses to each of the HIV testing behavior and barrier questions. Odds ratios (ORs) and χ2 test statistics were calculated to assess significant associations between sexual experience, demographic characteristics, and HIV testing behaviors and barriers.
      An exploratory factor analysis (EFA) using maximum likelihood estimation and varimax rotation was conducted to identify the factor structure of the nine HIV testing barriers items using PROC FACTOR. Hypothesis testing was conducted to determine if there were any common factors and the optimal number of factors. Model fit was assessed using root mean square error of approximation [
      • Steiger J.H.
      Structural model evaluation and modification—an interval estimation approach.
      ] and the Tucker-Lewis index [
      • Tucker L.R.
      • Lewis C.
      The reliability coefficient for maximum likelihood factor analysis.
      ]. Variables that loaded onto a particular factor were determined by extracting all items with loadings >.30, and reviewing this complement of variables to ensure that they comprised a meaningful factor. Cronbach's α was calculated for each factor to assess internal consistency.
      Logistic regression modeling was used to identify significant associations between having tested for HIV and these subscales. Bivariate and multivariate analyses using factor scores were limited to sexually experienced participants. Stratified analyses were conducted to explore potential associations between testing for HIV and factor scores within three demographics believed to experience differential barriers—age, sexual identity, and race. All analyses were conducted using SAS version 9.4 (SAS Institute, Cary, NC).

      Results

      Because of purposeful sampling, most of the 302 AGBM participants were identified as white (67.6%), followed by 14.2% black, and 18.2% other race (Table 1). Nearly one-quarter (22.5%) identified their ethnicity as Hispanic. Approximately one third (38.4%) were aged 14–15 years, and a similar proportion (32.3%) identified as bisexual. Study participants came from geographically diverse areas, representing 43 states.
      Table 1Bivariable associations with ever testing for HIV among sexually experienced and inexperienced adolescent gay and bisexual men (n = 302)
      Total, n (column %)Tested, n (row %)Never tested, n (row %)OR (95% CI)
      Sexually experienced
       Yes152 (50.3)46 (30.3)106 (69.7)3.91 (2.07–7.38)
       No150 (49.7)15 (10.0)135 (90.0)1.00 (—)
      Age (years)
       14–15116 (38.4)19 (16.4)97 (83.6)1.00 (—)
       16–18186 (61.6)42 (22.6)144 (77.4)1.49 (.82–2.71)
      Race
       Black43 (14.2)6 (14.0)37 (86.1).61 (.24–1.53)
       Other55 (18.2)12 (21.8)43 (78.2)1.05 (.51–2.15)
       White204 (67.6)43 (21.1)161 (78.9)1.00 (—)
      Hispanic ethnicity
       Yes61 (20.2)12 (17.7)56 (82.4).81 (.40–1.63)
       No241 (79.8)49 (20.9)185 (79.1)1.00 (—)
      Type of community
       Urban area101 (34.0)16 (15.8)85 (84.2).69 (.33–1.45)
       Suburban area107 (36.0)23 (21.5)84 (78.5)1.01 (.51–2.00)
       Rural area89 (30.0)19 (21.4)70 (78.7)1.00 (—)
      Family income
       Lower than average72 (24.7)13 (18.1)59 (81.9).80 (.35–1.87)
       Average154 (52.9)33 (21.4)121 (78.6).99 (.49–2.01)
       Higher than average65 (22.3)14 (21.5)51 (78.5)1.00 (—)
      Sexual identity
      Excludes 19 who identified as both gay and bisexual and one who only identified as queer.
       Gay191 (67.7)37 (19.4)154 (80.6).97 (.52–1.83)
       Bisexual91 (32.3)18 (19.8)73 (80.2)1.00 (—)
      Sexual behaviors—ever (yes vs. no)n (column %)n (column %)
      Vaginal sex46 (15.2)18 (29.5)28 (11.6)3.18 (1.62–6.27)
      Receptive anal sex123 (40.7)39 (63.9)84 (34.9)3.31 (1.84–5.95)
      Insertive anal sex114 (37.8)36 (59.0)78 (32.4)3.01 (1.67–5.36)
      CI = confidence interval; HIV = human immunodeficiency virus; OR = odds ratio.
      a Excludes 19 who identified as both gay and bisexual and one who only identified as queer.

      Human immunodeficiency virus testing behaviors

      One fifth of all participants had ever tested for HIV (20.2%), and less than half of those had been tested within the prior 3 months (42.6%). AGBM, including sexually experienced and inexperienced youth, reported a mean of .4 lifetime HIV tests (standard deviation = 1.15). Nearly half of all participants did not know where they could go to get tested for HIV (42.9%). Not surprisingly, knowing where to get tested was significantly associated with having ever been tested (OR, 9.38; 95% confidence interval [CI], 3.89–22.6). Of those participants who were aware of a testing location, 36.1% said the nearest HIV testing place was <15 minutes away, 51.2% said it was between 15 and 30 minutes away, and 12.6% said it was more than 30 minutes away. All but three participants (4.9%) who had ever tested for HIV provided their HIV status, and all were reported HIV negative.
      Approximately one half of participants (50.3%) reported ever having vaginal or anal sex in their lifetime. These sexually experienced adolescents were significantly more likely to have been tested for HIV than sexually inexperienced adolescents (OR, 3.91; 95% CI, 2.07–7.38; Table 1). HIV testing did not vary by demographic characteristics, including age, race, ethnicity, sexual identity, family income, or type of community resided in (urban vs. rural).
      In addition, participants who had never tested were more likely than those who had been tested to endorse “very untrue” or “somewhat untrue” in response to the statement “Most people my age who have sex get tested for HIV” (71.6% vs. 55.0%; χ2 = 13.9; p = .008).

      Human immunodeficiency virus testing barriers

      The most frequently endorsed barriers to getting tested for HIV among all youth included not knowing where to get tested (41.5% reported this item as a “very important” barrier), believing oneself to not be at risk for HIV (34.7%), and not wanting other people to learn that they had been tested (33.8%; Table 2). Conversely, thinking that testing is only for older people (10.5%) and preferring not to know if one was HIV infected (10.6%) were the least commonly cited barriers.
      Table 2Barriers to HIV testing among sexually experienced and inexperienced adolescent gay and bisexual men (n = 302)
      There are many reasons why people do not get tested for HIV. For each of the following items, please tell us how important the reason is for not testingTotal, n (%)Tested, n (%)Never tested, n (%)χ2 (p value)
      I don't have a way to get to the testing site/the site is too far away1.00 (.61)
       Very important81 (27.4)14 (23.0)67 (28.5)
       Somewhat important75 (25.3)15 (24.6)60 (25.5)
       Not important140 (47.3)32 (52.5)108 (46.0)
      I don't know where to go to get tested9.64 (.008)
       Very important124 (41.5)15 (24.6)109 (45.8)
       Somewhat important61 (20.4)14 (23.0)47 (19.8)
       Not important114 (38.1)32 (52.5)82 (34.4)
      I don't think the people who work at the testing site are friendly to gay/bisexual/queer guys.60 (.74)
       Very important62 (21.0)12 (19.7)50 (21.3)
       Somewhat important72 (24.3)13 (21.3)59 (25.1)
       Not important162 (54.7)36 (59.0)126 (53.6)
      I might run into people I know at the testing site1.17 (.56)
       Very important42 (14.1)6 (9.8)36 (15.3)
       Somewhat important74 (24.9)16 (26.2)58 (24.6)
       Not important181 (60.9)39 (63.9)142 (60.2)
      I don't want people I know (like parents or friends) to find out I was tested10.52 (.005)
       Very important101 (33.8)10 (16.4)91 (38.2)
       Somewhat important82 (27.4)20 (32.8)62 (26.1)
       Not important116 (38.8)31 (50.8)85 (35.7)
      I hate needles.63 (.73)
       Very important49 (16.4)12 (19.7)37 (15.6)
       Somewhat important54 (18.1)11 (18.0)43 (18.1)
       Not important196 (65.6)38 (62.3)158 (66.4)
      I would rather not know if I have HIV2.18 (.34)
       Very important31 (10.6)8 (13.1)23 (9.9)
       Somewhat important31 (10.6)9 (14.8)22 (9.5)
       Not important231 (78.8)44 (72.1)187 (80.6)
      I'm not at risk for HIV.84 (.66)
       Very important102 (34.7)20 (33.9)82 (34.9)
       Somewhat important67 (22.8)16 (27.1)51 (21.7)
       Not important125 (42.5)23 (39.0)102 (43.4)
      I'm young—testing is something people do when they are older1.33 (.51)
       Very important30 (10.5)4 (6.9)26 (11.4)
       Somewhat important55 (19.2)10 (17.2)45 (19.7)
       Not important202 (70.4)44 (75.9)158 (69.0)
      HIV = human immunodeficiency virus.
      An EFA was used to determine the number of subscales within the items measuring the HIV testing barriers. Significance tests showed that there was at least one common factor (H0: no common factors; χ2 = 430.8; p < .0001) and that a three-factor solution was an excellent fit to the data (χ2 = 10.9; p = .54). Reflecting the nonsignificant chi-square test of model fit, the three-factor model was an excellent fit for the data (root mean square error of approximation, .000; Tucker-Lewis index = 1.00).
      The three subscales identified by the EFA were named as follows: barriers due to external factors, barriers due to fear, and barriers due to feelings of invincibility (Table 3). All factor scores were scaled to mean = 0 and standard deviation = 1. Therefore, an increase of one in the OR represents a one standard deviation increase in the factor score. Among sexually experienced participants, those with greater scores for external factors (OR, 1.63; 95% CI, 1.01–2.66) and fear (OR, 1.88; 95% CI, 1.11–3.19; Table 4) were significantly more likely to have never tested for HIV. There was no significant association between a history of testing and feelings of invincibility (p = .32). No factors were associated with HIV testing among sexually inexperienced youth.
      Table 3Exploratory factor analysis of HIV testing barriers and factor loadings among adolescent gay and bisexual men
      Testing barriers
      External factorsFearFeelings of invincibility
      I don't have a way to get to the testing site/the site is too far away.6322
      I don't know where to go to get tested.7770
      I don't think the people who work at the testing site are friendly to gay/bisexual/queer guys.3991
      I might run into people I know at the testing site.7501
      I don't want people I know (like parents or friends) to find out I was tested.6059
      I hate needles.3444
      I would rather not know if I have HIV.6182
      I'm not at risk for HIV.3864
      I'm young—testing is something people do when they are older.5872
      Cronbach's α.673.594.533
      Variance explained (weighted)3.013 (33.5%)
      Combination of three factors explains 79.9% of total variance = 9.
      2.539 (28.2%)
      Combination of three factors explains 79.9% of total variance = 9.
      1.643 (18.3%)
      Combination of three factors explains 79.9% of total variance = 9.
      HIV = human immunodeficiency virus.
      a Combination of three factors explains 79.9% of total variance = 9.
      Table 4Multivariate associations between factor scores and never testing for HIV among all youth and among specific subpopulations of interest
      NExternal factors; OR (95% CI)Fear; OR (95% CI)Feelings of invincibility; OR (95% CI)
      Full model (all youth)2891.49 (1.03–2.16)1.28 (.86–1.89).80 (.54–1.19)
      Sexually inexperienced
      Mutually exclusive categories.
      1411.08 (.56–2.10).94 (.48–1.84).95 (.46–1.89)
      Sexually experienced
      Mutually exclusive categories.
      1381.63 (1.01–2.66)
      That is, among sexually experienced AGBM, a one-unit increase in the external factors score is associated with a 1.63 times increase in the odds of having never tested for HIV.
      1.88 (1.11–3.19).77 (.46–1.28)
      Among sexually experienced AGBM
       Gay-identified
      Mutually exclusive categories.
      851.33 (.73–2.44)3.32 (1.35–8.18).56 (.28–1.15)
       Bisexual-identified
      Mutually exclusive categories.
      452.41 (.84–6.98).87 (.39–1.93)1.27 (.48–3.38)
       14–15 year old
      Mutually exclusive categories.
      521.33 (.52–3.38)2.19 (.89–5.38).65 (.24–1.79)
       16–18 year old
      Mutually exclusive categories.
      861.92 (1.06–3.48)1.61 (.82–3.14).84 (.46–1.53)
       Black
      Mutually exclusive categories.
      223.06 (.42–22.2)4.21 (.60–29.6).30 (.05–1.87)
       White
      Mutually exclusive categories.
      971.79 (1.00–3.21)1.85 (1.03–3.33).84 (.43–1.64)
       Other race
      Mutually exclusive categories.
      19.43 (.09–2.18)1.86 (.25–13.8).35 (.08–1.68)
      Bold: p < .05.
      AGBM = adolescent gay and bisexual men; CI = confidence interval; HIV = human immunodeficiency virus; OR = odds ratio.
      a Mutually exclusive categories.
      b That is, among sexually experienced AGBM, a one-unit increase in the external factors score is associated with a 1.63 times increase in the odds of having never tested for HIV.
      Among gay-identified sexually active participants, only fear was significantly associated with not testing for HIV (OR, 3.32; 95% CI, 1.35–8.18; Table 4). For bisexual-identified sexually active participants, there were no significant associations between HIV testing and factor scores. Although no factor scores were associated with HIV testing among sexually active individuals aged 14–15 years, those aged 16–18 years had an association between fear and not testing for HIV similar to, but weaker than, that found among gay-identified youth (OR, 1.92; 95% CI, 1.06–3.48). Finally, among sexually experienced youth stratified by race, only white individuals had an association between external factors and fear and never testing for HIV.

      Discussion

      Similar to previous studies of adolescent men [
      • Finlayson T.J.
      • Le B.
      • Smith A.
      • et al.
      HIV risk, prevention, and testing behaviors among men who have sex with men—National HIV Behavioral Surveillance System, 21 U.S. cities, United States, 2008.
      ,
      • Sumartojo E.
      • Lyles C.
      • Choi K.
      • et al.
      Prevalence and correlates of HIV testing in a multi-site sample of young men who have sex with men.
      ,
      • Kann L.
      • Kinchen S.
      • Shanklin S.L.
      • et al.
      Youth risk behavior surveillance—United States, 2013.
      ], HIV testing rates were low among sexually active AGBM in this sample, with less than one third having ever been tested. Three times as many 18- to 19-year-old YMSM (75%) reported ever being tested in NHBS [
      • Finlayson T.J.
      • Le B.
      • Smith A.
      • et al.
      HIV risk, prevention, and testing behaviors among men who have sex with men—National HIV Behavioral Surveillance System, 21 U.S. cities, United States, 2008.
      ]. Perhaps, there is an increase in testing in the transition from adolescence to young adulthood as defined by age 18 years, potentially because of newfound independence in attending college or moving out of one's parents' home. Given that adolescent males <18 years are having sex, the need to invigorate testing at an earlier age is clear. One potential reason for the dearth of HIV testing could be lack of knowledge about testing locations: nearly half of AGBM were unaware of a local facility where they could get tested for HIV. Unfamiliarity with testing locations could easily be addressed by solutions offered by the CDC, which include school-based testing or school-based referral programs that link students with HIV testing sites [
      ] or by use of an online locator designed to find nearby testing sites, such as https://aids.gov/locator/. However, interventions such as those described by the CDC might encounter difficulties in gaining traction; only 33 states and the District of Columbia mandate HIV education in schools. Many students therefore never receive information about the importance of regular HIV testing on becoming sexually active [
      Guttmacher Institute
      State policies in brief: Sex and HIV education.
      ]. Increasing awareness of the necessity of HIV testing and awareness of testing facilities, possibly through school-based programs, could easily address these knowledge gaps identified within this study. In locations where school-based programs may not be acceptable, online or text messaging–based programs such as Guy2Guy could be successful at addressing these deficiencies.
      Barriers to HIV testing among AGBM fell into three factors: external factors, fear, and feelings of invincibility. Although external factors and fear barriers were significantly associated with not testing for HIV, there was no corresponding association for feelings of invincibility as a barrier. Many prior studies have cited a perception of invincibility or invulnerability among youth as a key factor in HIV acquisition, especially among YMSM [
      • Flores 3rd, D.D.
      • Blake B.J.
      • Sowell R.L.
      “Get them while they're young”: Reflections of young gay men newly diagnosed with HIV infection.
      ,
      • Mustanski B.
      • Rendina H.J.
      • Greene G.J.
      • et al.
      Testing negative means I'm lucky, making good choices, or immune: Diverse reactions to HIV test results are associated with risk behaviors.
      ]. However, this study suggests that feelings of HIV invincibility are not the main obstacle preventing AGBM from testing for HIV. Thus, by focusing attention and resources on combating invincibility, we may be missing the most effective targets. Instead, we should continue to focus on these external and fear barriers to have a maximum impact on increasing HIV testing rates. Predominant among these barriers are an inability to access testing sites, worry about the testing process, and fear of potential disclosure to family or friends. Knowledge and education are the best ways we have to overcome these barriers for youth; however, these should focus more on the HIV testing experience to empower them to seek HIV testing resources. Ensuring all adolescents know places where they can get tested, and addressing fears by communicating that adolescents can be tested confidentially or anonymously and without the use of needles would likely help to invigorate HIV testing among AGBM because these items had the largest effects within the barrier scales.
      Of additional interest are the demographic differences in scores on these subscales. Although these analyses are exploratory and results should be interpreted with caution, they provide insight into potential areas of future study. Again, feelings of invincibility were not associated with testing within any demographic subgroup. Surprisingly, although rates of sexual experience were similar to older youth, none of the factors were associated with testing within the youngest age group. We anticipated that lack of testing among 14- and 15-year-old AGBM would be strongly associated with external factor barriers, particularly because they are unable to drive and have likely received less information about HIV testing than their older counterparts. One possible explanation for this is also related to access to transportation; youth who are fully reliant on their parents to drive them places are less likely to have opportunities to engage in sex and would therefore be less likely to appear as sexually active in our sample.
      This study had several limitations. Findings may not be generalizable to AGBM samples recruited through other strategies, including those that are face to face. They also may not extend to MSM but do not self-identify with a gay or bisexual identity. Additionally, because participants were purposefully recruited, the percentages should not be seen as estimates of population prevalence, although they are likely more representative than many samples given the purposeful diversity of participants. The Cronbach α statistics for each of the subscales was suboptimal—this may be due to the small number of items within each factor [
      • Tavakol M.
      • Dennick R.
      Making sense of Cronbach's alpha.
      ]; future researchers should develop and test additional questions that can strengthen these measures. Furthermore, all data were reliant on self-report and could have been affected by social desirability bias. However, this was minimized by using an Internet-based survey in which participants did not need to interact with study staff when providing responses. Inability to accurately recall behaviors (i.e., time of last HIV test) may have affected participant answers. This was mitigated by time anchoring questions to the last act or the last 3 months, and participants were asked to provide a memorable event that occurred 3 months before the survey to facilitate memory. Finally, our adapted scale of barriers to HIV testing might not fully capture the array of perceived barriers among AGBM as youth were not fully involved in the development of the scale.
      As one of the first studies to investigate the HIV testing behaviors of AGBM, findings highlight the many modifiable barriers that young men face in accessing testing services. Barriers such as lack of knowledge about the closest testing site are ones that can easily be addressed through interventions and programs that target high school–age adolescents.

      Acknowledgments

      The authors acknowledge all study participants for their vital role in completing this study.

      Funding Sources

      This study was supported by a grant from the National Institute of Mental Health ( R01MH096660 ).

      References

        • Centers for Disease Control and Prevention
        HIV surveillance—Men who have sex with men.
        2015
      1. Centers for Disease Control and Prevention. Prevalence and awareness of HIV infection among men who have sex with men—21 cities, United States, 2008. 2010:1201–1207.

        • Valleroy L.A.
        • MacKellar D.A.
        • Karon J.M.
        HIV prevalence and associated risks in young men who have sex with men: Young Men's Survey Study Group.
        J Am Med Assoc. 2000; 284: 198-204
        • Workowski K.A.
        • Berman S.
        Sexually transmitted diseases treatment guidelines, 2010.
        Atlanta, GA: Centers for Disease Control and Prevention. MMWR Recomm Rep. 2010; 59: 1-110
        • Finlayson T.J.
        • Le B.
        • Smith A.
        • et al.
        HIV risk, prevention, and testing behaviors among men who have sex with men—National HIV Behavioral Surveillance System, 21 U.S. cities, United States, 2008.
        MMWR Surveill Summ. 2011; 60: 1-34
        • Sumartojo E.
        • Lyles C.
        • Choi K.
        • et al.
        Prevalence and correlates of HIV testing in a multi-site sample of young men who have sex with men.
        AIDS Care. 2008; 20: 1-14
        • Kann L.
        • Kinchen S.
        • Shanklin S.L.
        • et al.
        Youth risk behavior surveillance—United States, 2013.
        MMWR Surveill Summ. 2014; 63: 1-168
        • Phillips 2nd, G.
        • Hightow-Weidman L.B.
        • Arya M.
        • et al.
        HIV testing behaviors of a cohort of HIV-positive racial/ethnic minority YMSM.
        AIDS Behav. 2012; 16: 1917-1925
        • Leonard N.R.
        • Rajan S.
        • Gwadz M.V.
        • Aregbesola T.
        HIV testing patterns among urban YMSM of color.
        Health Educ Behav. 2014; 41: 673-681
        • Centers for Disease Control and Prevention
        HIV testing among men who have sex with men—21 cities, United States, 2008.
        MMWR Morb Mortal Wkly Rep. 2011; 60: 694-699
        • Mustanski B.
        Ethical and regulatory issues with conducting sexuality research with LGBT youth.
        International Academy of Sex Researchers, San Juan, PR2009
        • Mustanski B.
        Ethical and regulatory issues with conducting sexuality research with LGBT adolescents: A call to action for a scientifically informed approach.
        Arch Sex Behav. 2011; 40: 673-686
        • Pew Internet & American Life Project
        Teens and technology.
        2013
        • Pew Internet & American Life Project
        Teens, smartphones & texting.
        2012
        • United States Census Bureau
        Selected characteristics of the native and foreign-born populations. 2013 American community survey 1-year estimates.
        2013
        • Misovich S.J.
        • Fisher W.A.
        • Fisher J.D.
        A measure of AIDS prevention information, motivation, behavioral skills, and behavior.
        in: Davis C. Yarber W. Bauserman R. Handbook of Sexuality-Related Measures. SAGE, Thousand Oaks, CA1998: 328-337
        • Awad G.H.
        • Sagrestano L.M.
        • Kittleson M.J.
        • Sarvela P.D.
        Development of a measure of barriers to HIV testing among individuals at high risk.
        AIDS Educ Prev. 2004; 16: 115-125
        • Steiger J.H.
        Structural model evaluation and modification—an interval estimation approach.
        Multivariate Behav Res. 1990; 25: 173-180
        • Tucker L.R.
        • Lewis C.
        The reliability coefficient for maximum likelihood factor analysis.
        Psychometrika. 1973; 38: 1-10
      2. HIV testing among adolescents: What schools and education agencies can do. 2014 (Available at:) (Accessed January 8, 2015)
        • Guttmacher Institute
        State policies in brief: Sex and HIV education.
        2015
        • Flores 3rd, D.D.
        • Blake B.J.
        • Sowell R.L.
        “Get them while they're young”: Reflections of young gay men newly diagnosed with HIV infection.
        J Assoc Nurses AIDS Care. 2011; 22: 376-387
        • Mustanski B.
        • Rendina H.J.
        • Greene G.J.
        • et al.
        Testing negative means I'm lucky, making good choices, or immune: Diverse reactions to HIV test results are associated with risk behaviors.
        Ann Behav Med. 2014; 48: 371-383
        • Tavakol M.
        • Dennick R.
        Making sense of Cronbach's alpha.
        Int J Med Education. 2011; 2: 53-55