Considerations for Addressing Low HIV Testing Rates Among Adolescent Men Who Have Sex With Men

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Considerations for Addressing Low HIV

Testing Rates Among Adolescent Men

Who Have Sex With Men

Errol L. Fields, MD, PhD, MPH,a_{Travis A. Gayles, MD, PhD}b

In“Factors Associated with HIV Testing in Teenage Men Who Have Sex with Men,”Mustanski et al1explore individual, family, school, and health care factors associated with lifetime receipt of an HIV test in a sample of adolescent men who have sex with men (AMSM) (n= 699) between ages 13 to 18. The authors report low testing rates (23.3%) in this sample but found the following factors to be signiﬁcant predictors of HIV testing: older age; sexual experience; HIV-related

information, motivation, and behavioral skills; and discussions with a doctor about sexual orientation or male partners. Mustanski et al1conclude with important recommendations for pediatricians to improve

physician–patient communication about sex and sexuality with adolescent patients.

The individual and practice-level changes suggested by Mustanski et al1 are important for pediatric providers and consistent with American Academy of Pediatrics (AAP)

recommendations.2,3There are numerous AAP policy statements and clinical reports emphasizing

importance of sexual and reproductive health (SRH) services for adolescents as well as speciﬁc guidelines for the care of sexual and gender minority youth issued by the AAP2,4and Society for Adolescent Health and Medicine,5yet gaps in SRH care provision persist for these youth.3Pediatricians, and physicians in general, are often undertrained in the care of sexual and

gender minority youth6,7; therefore, more upstream, educational interventions may be necessary to support effective implementation of the authors’recommended changes. The integration of lesbian, gay, bisexual, transgender, and questioning or queer health curricula in undergraduate, graduate, and continuing medical education of pediatric providers is critical to ensuring the pediatric workforce is consistently well equipped to provide culturally competent evidence-based care to sexual and gender minority youth.8

As the authors note, young men often have less primary care engagement compared with young women and may seek HIV testing in community

settings.9Indeed, nearly one-third of their sample (32.5%) did not have a regular doctor, and having a regular doctor was not associated with HIV testing.1Increasing the capacity of pediatricians to provide comprehensive SRH services for AMSM who access primary care is critical, but it is suggested in theseﬁndings that AMSM without a regular doctor require access to testing outside of primary care settings. Non–clinic-based testing venues that are highly used, accessible, and trusted spaces for teens may foster enhanced privacy and facilitate more candid disclosure related to sexual health concerns.10School-based health clinics,11health department sexual health clinics,12and community-based organizations13–15can all be effective venues to engage AMSM for HIV testing

a_{Division of General Pediatrics and Adolescent Medicine,}

Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland; andb_{Montgomery County}

Department of Health and Human Services, Rockville, Maryland

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

DOI:https://doi.org/10.1542/peds.2019-3996 Accepted for publication Dec 19, 2019

Address correspondence to Errol L. Fields, MD, PhD, MPH, Department of Pediatrics, Johns Hopkins School of Medicine, 200 N Wolfe St #2027, Baltimore, MD 21287. E-mail: errol.ﬁelds@jhmi.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

FINANCIAL DISCLOSURE:Dr Fields has served on HIV Preexposure Prophylaxis and Treatment Advisory Boards for Gilead Sciences and Dr Gayles has indicated he has noﬁnancial relationships relevant to this article to disclose.

FUNDING:No external funding.

POTENTIAL CONFLICT OF INTEREST:Dr Fields has served on an HIV Prevention and Preexposure Prophylaxis and Treatment Advisory Board for Gilead Sciences; and Dr Gayles has indicated he has no potential conﬂicts of interest to disclose.

COMPANION PAPER:A companion to this article can be found online at www.pediatrics.org/cgi/doi/10. 1542/peds.2019-2322.

To cite:Fields EL and Gayles TA. Considerations for Addressing Low HIV Testing Rates Among Adolescent Men Who Have Sex With Men.

Pediatrics. 2020;145(3):e20193996

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and other SRH services. Testing resources can be paired effectively with peer educators and other evidenced-based outreach and education practices to increase testing rates and partner with clinical providers to provide treatment and comprehensive linkage to care resources.16As noted by Mustanski et al,1increasing HIV-related information, motivation, and behavioral skills through outreach and education can also empower students to be more aware of and use community resources for HIV testing and preventive services8in addition to requesting testing in clinical encounters with their pediatricians.

The authors noted higher testing rates in African American AMSM but found no signiﬁcant associations between race and HIV testing. However, given the signiﬁcant racial disparities in HIV incidence and prevalence affecting African American AMSM,17additional consideration of the factors affecting testing in this racial subgroup is warranted. The higher rates of HIV testing in African American AMSM in this sample is consistent with past studies in which authors report higher testing rates in African American MSM overall, despite higher HIV prevalence in this population. In future studies,

researchers should stratify racial and ethnic subgroups to identify factors associated with testing in this priority population. In the interim, design of testing and prevention strategies focused on African American AMSM should be mindful of systemic and structural constructs that inﬂuence this group’s risk proﬁle and address unique barriers resulting from the intersectionality of race and ethnicity, age, and sexuality faced by this population.18

Finally, although HIV testing is an importantﬁrst step in the HIV treatment cascade, it is also an importantﬁrst step in the HIV prevention and preexposure

prophylaxis (PrEP) cascade. Given the

recent US Food and Drug

Administration approval of PrEP for minors$35 kg,19it is critical that AMSM at high risk for HIV acquisition not only have access to routine HIV testing but also access to PrEP and other HIV prevention services. AMSM, particularly African American AMSM, have had consistently low PrEP uptake relative to their rate of new HIV diagnoses.20Although PrEP access and uptake may be beyond the scope of the original article, many of the strategies and recommendations needed to improve limited access to testing for AMSM are equally needed to improve access to PrEP and mitigate HIV acquisition risk in this population.

Understanding discrepancies in adolescent HIV testing practices is a critical component of understanding the larger risk proﬁle of AMSM. This information will further inform efforts to end the epidemic and revolutionize how pediatricians discuss sexual health and

communicate with adolescent sexual and gender minorities.

ABBREVIATIONS

AAP: American Academy of Pediatrics

AMSM: adolescent men who have sex with men

PrEP: preexposure prophylaxis SRH: sexual and reproductive

health

REFERENCES

1. Mustanski B, Moskowitz D, Moran K, et al. Factors associated with HIV testing in teenage men who have sex with men.Pediatrics. 2020;145(3): e20192322

2. Committee On Adolescence. Ofﬁ ce-based care for lesbian, gay, bisexual, transgender, and questioning youth.

Pediatrics. 2013;132(1):198–203

3. Marcell AV, Burstein GR; Committee on Adolescence. Sexual and reproductive health care services in the pediatric

setting.Pediatrics. 2017;140(5): e20172858

4. Rafferty J; Committee on Psychosocial Aspects of Child and Family Health; Committee on Adolescence; Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness. Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents.Pediatrics. 2018;142(4):e20182162

5. Society for Adolescent Health and Medicine. Recommendations for promoting the health and well-being of lesbian, gay, bisexual, and transgender adolescents: a position paper of the Society for Adolescent Health and Medicine.J Adolesc Health. 2013;52(4): 506–510

6. Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education.

JAMA. 2011;306(9):971–977

7. Vance SR Jr., Halpern-Felsher BL, Rosenthal SM. Health care providers’ comfort with and barriers to care of transgender youth.J Adolesc Health. 2015;56(2):251–253

8. Phillips G II, Ybarra ML, Prescott TL, Parsons JT, Mustanski B. Low rates of human immunodeﬁciency virus testing among adolescent gay, bisexual, and queer men.J Adolesc Health. 2015; 57(4):407–412

9. Marcell AV, Klein JD, Fischer I, Allan MJ, Kokotailo PK. Male adolescent use of health care services: where are the boys?J Adolesc Health. 2002;30(1): 35–43

10. Pampati S, Liddon N, Dittus PJ, Adkins SH, Steiner RJ. Conﬁdentiality matters but how do we improve implementation in adolescent sexual and reproductive health care?J Adolesc Health. 2019; 65(3):315–322

11. Centers for Disease Control and Prevention (CDC). HIV testing among high school students--United States, 2007.MMWR Morb Mortal Wkly Rep. 2009;58(24):665–668

12. Ritter S, Kelley K. A call to action planning: local health department and school partnerships for adolescent sexual health.J Public Health Manag Pract. 2019;25(4):408–410

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13. World Health Organization. HIV and adolescents: guidance for HIV testing and counselling and care for adolescents living with HIV:

recommendations for a public health approach and considerations for policy-makers and managers. 2013. Available at: https://apps.who.int/iris/handle/ 10665/94334. Accessed December 15, 2019.

14. Camacho-Gonzalez AF, Gillespie SE, Thomas-Seaton L, et al. The Metropolitan Atlanta community adolescent rapid testing initiative study: closing the gaps in HIV care among youth in Atlanta, Georgia, USA.AIDS. 2017;31(suppl 3):S267–S275

15. Marano MR, Stein R, Williams WO, et al. HIV testing in nonhealthcare facilities

among adolescent MSM.AIDS. 2017; 31(suppl 3):S261–S265

16. Layzer C, Rosapep L, Barr S. Student voices: perspectives on peer-to-peer sexual health education.J Sch Health. 2017;87(7):513–523

17. Centers for Disease Control and Prevention. HIV surveillance report, vol. 28: diagnoses of HIV infection in the United States and dependent areas, 2016. Available at: https://www.cdc.gov/ hiv/pdf/library/reports/surveillance/ cdc-hiv-surveillance-report-2016-vol-28. pdf. Accessed December 15, 2019

18. Fields E, Morgan A, Sanders RA. The intersection of sociocultural factors and health-related behavior in lesbian, gay, bisexual, and transgender youth:

experiences among young black gay males as an example.Pediatr Clin North Am. 2016;63(6):1091–1106

19. Adolescent Medicine Trials Network. PrEP now approved by FDA for adolescents at risk for HIV.Adolescent Medicine Trials Network for HIV/AIDS Interventions. May 25, 2018. Available at: https://atnweb.org/atnweb/node/ 194. Accessed December 16, 2019

20. Kanny D, Jeffries WL IV, Chapin-Bardales J, et al; National HIV Behavioral Surveillance Study Group. Racial/ethnic disparities in HIV preexposure prophylaxis among men who have sex with men-23 urban areas, 2017.MMWR Morb Mortal Wkly Rep. 2019;68(37): 801–806

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DOI: 10.1542/peds.2019-3996 originally published online February 11, 2020;

2020;145;

Pediatrics

Errol L. Fields and Travis A. Gayles

Who Have Sex With Men

Considerations for Addressing Low HIV Testing Rates Among Adolescent Men

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DOI: 10.1542/peds.2019-3996 originally published online February 11, 2020;

2020;145;

Pediatrics

Errol L. Fields and Travis A. Gayles

Who Have Sex With Men

Considerations for Addressing Low HIV Testing Rates Among Adolescent Men

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