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

In “Factors Associated with HIV Testing in Teenage Men Who Have Sex with Men,” Mustanski et al¹  explore 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 al¹  conclude 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.^2,3  There 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 AAP^2,4  and Society for Adolescent Health and Medicine,⁵  yet gaps in SRH care provision persist for these youth.³  Pediatricians, and physicians in general, are often undertrained in the care of sexual and gender minority youth^6,7 ; 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.⁹  Indeed, 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.¹  Increasing the capacity of pediatricians to provide comprehensive SRH services for AMSM who access primary care is critical, but it is suggested in these findings 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.¹⁰  School-based health clinics,¹¹  health department sexual health clinics,¹²  and community-based organizations^13–15  can all be effective venues to engage AMSM for HIV testing 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.¹⁶  As noted by Mustanski et al,¹  increasing 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 services⁸  in 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,¹⁷  additional 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 important first step in the HIV treatment cascade, it is also an important first 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,¹⁹  it 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.²⁰  Although 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.

AAP

American Academy of Pediatrics

AMSM

adolescent men who have sex with men

PrEP

preexposure prophylaxis

SRH

sexual and reproductive health