HIV Testing Among US High School
Students and Young Adults
Michelle Van Handel, MPH,a Laura Kann, PhD,b Emily O’Malley Olsen, MSPH,b Patricia Dietz, DrPHa
BACKGROUND: We assessed HIV testing trends among high school students and young adults.
abstract
METHODS: We analyzed National Youth Risk Behavior Survey (YRBS) and Behavioral Risk
Factor Surveillance System (BRFSS) data to assess HIV testing prevalence among high
school students and young adults aged 18 to 24, respectively. Logistic regression models
for each sample stratified by gender and race/ethnicity were estimated to assess trends in
the percentages ever tested, with year as a continuous linear variable. We report absolute
differences in HIV testing prevalence and model results for 2005–2013 (YRBS) and 2011–
2013 (BRFSS).
RESULTS: During the study periods, an average of 22% of high school students (17% of male
and 27% of female students) who ever had sexual intercourse and 33% of young adults
reported ever being tested for HIV. Among high school students, no change was detected in
HIV testing prevalence during 2005–2013, regardless of gender or race/ethnicity. Among
young adult males, an average of 27% had ever been tested, and no significant changes were
detected overall or by race/ethnicity during 2011–2013. Significant decreases in testing
prevalence were detected during 2011–2013 among young adult females overall (from
42.4% to 39.5%), young adult white females (from 37.2% to 33.9%), and young adult black
females (from 68.9% to 59.9%).
CONCLUSIONS: HIV testing prevalence was low among high school students and young adults.
No increase in testing among young adult males and decreased testing among young adult
black females is concerning given their higher risk of HIV infection.
Divisions of aHIV/AIDS Prevention, and bAdolescent and School Health, Centers for Disease Control and
Prevention, Atlanta, Georgia
Ms Van Handel designed the study, led the writing, conducted analyses, and interpreted
findings; Dr Kann conceptualized and designed the study, reviewed and revised the writing,
and substantially contributed to the interpretation of findings; Ms O’Malley Olsen conducted
analyses and reviewed and revised the writing; Dr Dietz conceptualized the study and contributed
substantially to the writing and the interpretation of findings; and all authors approved the final
manuscript as submitted.
The findings and conclusions in this report are those of the authors and do not necessarily
represent the official position of the Centers for Disease Control and Prevention.
DOI: 10.1542/peds.2015-2700
Accepted for publication Oct 30, 2015
Address correspondence to Michelle Van Handel, MPH, Division of HIV/AIDS Prevention, Centers for
Disease Control and Prevention, 1600 Clifton Rd, Mail Stop E-59, Atlanta, GA 30333. E-mail: ioq4@
cdc.gov
WHAT’S KNOWN ON THIS SUBJECT: HIV
disproportionately affects adolescents and young
adults compared with the overall population.
The Centers for Disease Control and Prevention
recommends routine HIV screening for Americans
aged 13 to 64, yet 50% of adolescents and young
adults with HIV remain undiagnosed.
WHAT THIS STUDY ADDS: This study found HIV
testing prevalence was low among high school
students (25%) and young adults (33%). No increase
in testing among males and decreased testing
among young adult black females is concerning
given their higher risk of HIV infection.
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2016 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant
to this article to disclose.
FUNDING: No external funding.
To cite: Van Handel M, Kann L, Olsen EO, et al. HIV Testing
Among US High School Students and Young Adults.
Pediatrics. 2016;137(2):e20152700
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of
interest to disclose.
PEDIATRICS Volume 137, number 2, February 2016:e20152700
ARTICLE
In 2010, persons aged 13 to 24 years
made up 17% of the US population
but accounted for 26% of estimated
new HIV infections.1 The majority
of HIV infections occur among gay,
bisexual, and other men who have
sex with men (MSM) and among
black females.1 Among adolescents
and young adults living with HIV
infection, 44% were undiagnosed,
the highest percentage of any age
group.2 Without HIV testing and
diagnosis, adolescents and young
adults cannot take advantage of HIV
care and treatment that can improve
their health and reduce the risk of
transmission to others.3,4 In 2006,
the Centers for Disease Control
and Prevention (CDC) released the
“Revised Recommendations for HIV
Testing of Adults, Adolescents, and
Pregnant Women in Health Care
Settings” (referred to hereafter
as Revised Recommendations)
encouraging clinicians to screen
all persons aged 13 to 64 years for
HIV infection.5 Since then, multiple
organizations, including the US
Preventive Services Task Force
(USPSTF) in 2013, also recommended
that all adolescents and adults be
screened for HIV infection.6 The
CDC has implemented several
testing initiatives, including the
Expanded Testing Initiative (since
2007) and social media campaigns
(eg, Act Against AIDS since 2009),
to increase the number of persons
(both adolescents and adults) tested
and diagnosed with HIV, particularly
persons disproportionately affected
by HIV (ie, blacks or African
Americans [referred to as black
females or black males], Hispanics or
Latinos, and MSM).7,8 In addition, HIV
prevention projects for young MSM of
color and young transgender persons
of color (since 2011) specifically
focus on intensifying prevention
efforts among these populations.9
The CDC reported no evidence of
increases in HIV testing among high
school students during 2005–2011
or among young adults aged 18–24
2
years during 2000–2010.10 In this
article, we update previous trend
analyses because it is important to
understand whether current testing
programs have led to an increase
in HIV testing. Increased testing
would lead to a decrease in the high
percentage unaware of their HIV
infection. This study investigated
trends in HIV testing among high
school students during 2005–2013
and trends in HIV testing among
young adults during 2011–2013 to
determine if trends have changed
from the stable testing patterns
previously reported and to expand
on the previous report by assessing
trends for specific subgroups (eg,
high school students who have ever
had sexual intercourse).10
METHODS
Data Sources
The Youth Risk Behavior Surveillance
System includes a national schoolbased Youth Risk Behavior Survey
(YRBS) conducted biennially among
students in grades 9 through 12.
The survey methodology has been
previously described.11 Briefly, the
sampling frame for the 2005–2013
national YRBSs consisted of all
regular public (might include charter
schools and public alternative, special
education, or vocational schools)
and private (might include religious
and other private schools, but not
private alternative, special education,
or vocational schools) schools with
students in at least 1 of grades 9
through 12 in the 50 states and
the District of Columbia. A 3-stage
cluster sample design was used.
Survey procedures were designed to
protect students’ privacy by allowing
for anonymous and voluntary
participation. The CDC’s Institutional
Review Board approved the protocol
for the national YRBSs. The school,
student, and overall response rates
during 2005–2013 averaged 80%,
87%, and 69%, respectively, and
the average sample size was 14 675
students. A weight based on student
gender, race/ethnicity, and grade was
applied to each record to adjust for
school and student nonresponse and
oversampling of black and Hispanic/
Latino students. Weighted estimates
are representative of all students in
grades 9 through 12 attending public
and private schools in the United
States. The YRBS questionnaire is
self-administered during regular
class time and includes a question
on HIV testing: “Have you ever been
tested for HIV, the virus that causes
AIDS (Do not count tests done if you
donated blood).”
BRFSS is a state-based, annual
cross-sectional random-digitdialed telephone (landline and cell)
survey that collects information
on preventive health practices
and health care access. State-level
data were combined to produce
annual national estimates for the
civilian, noninstitutionalized adult
US population. BRFSS interviewers
asked respondents 2 questions:
“Have you ever been tested for HIV?
Do not count tests you may have had
as part of a blood donation. Include
testing fluid from your mouth” and
“Where did you have your last HIV
test – [specific settings listed]?” The
average median weighted survey
response rate was 47% (average
state range: 30%–62%) during
2011–2013.12 We analyzed 2011–
2013 BRFSS data for respondents
residing in the 50 states and District
of Columbia to match the area
covered by the national YRBSs and
included those who were aged 18
to 24 years and reported a “yes” or
“no” response to having ever been
tested. We limited our analysis to
2011–2013 data because of recent
methodological changes that could
affect assessment of HIV testing
trends.13 The final sample included
90% of respondents who were aged
18 to 24 years, which was an average
of 21 790 respondents annually.
Data are weighted to account for the
complex survey design, nonresponse,
VAN HandEL et al
FIGURE 1
Trends in HIV testing prevalence among US high school students and young adults aged 18 to 24 years. A–C, Trends in HIV testing prevalence among high
school students who ever had sexual intercourse, had sexual intercourse with ≥4 persons, and had sexual intercourse with ≥1 persons during the past
3 months were assessed overall and by gender using the YRBS data from 2005 to 2013. The prevalence of HIV testing did not change overall or by gender
among these 3 subgroups (P > .05). D, Trends in HIV testing among young adults aged 18 to 24 years were assessed overall and by gender using the BRFSS
data from 2011 to 2013. The prevalence of HIV testing decreased significantly overall from 34.5% in 2011% to 32.7% in 2013 (P = .016), did not change
significantly among young men (average 27%, P > .05), and decreased significantly among young women from 42.4% in 2011% to 39.5% in 2013 (P = .016).
a No linear change.
and sociodemographic factors to
yield estimates representative of
civilian, noninstitutionalized young
adults aged 18 to 24 years in the
United States.
Data Analysis
We report the prevalence of HIV
testing among high school students
(YRBS) and young adults aged
18 to 24 years (BRFSS). Analyses
were conducted using YRBS data
overall and by gender and race/
ethnicity among 3 subgroups:
students who reported ever having
sexual intercourse, having sexual
intercourse with ≥4 persons, and
having sexual intercourse with ≥1
persons during the past 3 months.
Analyses were conducted using
BRFSS data overall, by gender and
race/ethnicity. Statistical analyses
were conducted on weighted
data using SUDAAN (for YRBS)
PEDIATRICS Volume 137, number 2, February 2016
and SAS version 9.3 (for BRFSS)
and accounted for the complex
sampling designs for each survey.
For each subgroup, separate logistic
regression models were used to
assess linear time trends in the
percentages of students and young
adults who reported having ever
been tested for HIV, with year as a
continuous linear variable, adjusting
for gender, race/ethnicity, and grade
(YRBS only) when applicable. We
report the absolute difference and
the linear β and associated P value
from 2005 to 2013 for YRBS and
from 2011 to 2013 for BRFSS data.
students who had sexual intercourse
with ≥4 persons, and 24% of
students who had sexual intercourse
with ≥1 person during the past 3
months had ever been tested for HIV.
The prevalence of HIV testing did not
change overall, by gender, or by race/
ethnicity within gender, among any
of the 3 subgroups (Fig 1A, B, and C;
Table 1). An average of 17% of male
and 27% of female students who ever
had sexual intercourse had ever been
tested for HIV. The lowest average
prevalence rate was among white
male students (15%), and the highest
average prevalence rate was among
black female students (36%).
RESULTS
HIV Testing Among Young Adults,
BRFSS
HIV Testing Among High School
Students, YRBS
During 2005–2013, an average of
22% of high school students who
ever had sexual intercourse, 34% of
During 2011–2013, an average
of 33% of young adults had ever
been tested for HIV. Trends varied
significantly by gender and race/
3
4
VAN HandEL et al
a
2005
11.6–15.9
18.2–26.7
14.1–20.0
20.2–25.6
29.0–37.8
16.6–25.8
18.5–30.7
22.7–34.4
17.8–34.3
31.7–46.7
36.8–54.8
24.2–50.2
12.8–18.4
20.9–30.2
14.4–25.4
21.4–29.4
30.4–41.6
17.4–28.3
22.8
33.2
20.8
24.1
28.2
25.2
39.0
45.7
36.2
15.4
25.3
19.3
25.2
35.8
22.4
95% CI
13.6
22.1
16.8
% Tested
2007
25.8
43.5
23.1
16.8
27.5
20.2
39.9
46.4
34.4
29.4
28.2
24.0
23.8
38.7
21.3
16.3
21.4
17.1
% Tested
Logistic regression modeling conducted controlling for grade.
Ever had sexual
intercourse
Male
White
Black
Hispanic/Latino
Female
White
Black
Hispanic/Latino
Had sexual
intercourse with
≥4 persons
Male
White
Black
Hispanic/Latino
Female
White
Black
Hispanic/Latino
Had sexual
intercourse with
≥1 persons
during the past
3 mo
Male
White
Black
Hispanic/Latino
Female
White
Black
Hispanic/Latino
Subgroup
22.4–29.4
37.3–50.0
18.5–28.4
14.3–19.7
23.3–32.2
15.8–25.4
32.5–47.9
38.1–54.9
25.8–44.2
25.6–33.6
24.5–32.3
18.8–30.1
21.0–26.8
33.0–44.7
17.5–25.8
14.4–18.6
18.4–24.8
13.8–21.1
95% CI
28.6
42.4
25.4
19.0
26.0
19.6
41.9
54.9
35.0
30.4
28.0
29.3
26.4
37.3
24.5
16.5
21.6
18.9
% Tested
2009
24.2–33.5
36.3–48.7
22.1–29.0
16.7–21.5
20.6–32.2
15.3–24.8
34.2–50.0
42.3–66.9
27.6–43.2
25.6–35.5
21.5–35.5
23.1–36.3
23.0–30.0
31.1–43.9
22.0–27.1
14.6–18.7
17.6–26.2
15.4–22.9
95% CI
Prevalence of Tested for HIV
TABLE 1 Trends in HIV Testing Among High School Students, 2005 to 2013, YRBS
2011
26.4
38.2
27.3
15.6
32.8
18.9
39.8
43.9
37.2
25.4
38.3
24.4
25.4
35.2
25.2
14.2
29.1
15.9
% Tested
22.7–30.5
29.8–47.3
22.5–32.7
12.7–18.9
23.6–43.5
15.2–23.1
33.0–47.1
34.9–53.3
28.2–47.1
21.3–29.9
29.0–48.6
19.4–30.2
22.3–28.7
28.2–42.9
22.0–28.6
11.6–17.4
20.1–40.2
12.4–20.2
95% CI
2013
27.0
37.1
25.3
15.6
27.5
20.9
39.3
42.4
43.4
24.7
32.6
27.0
25.2
33.4
24.3
14.8
23.9
17.8
% Tested
24.1–30.0
32.1–42.4
18.3–33.8
12.6–19.3
23.5–32.0
17.0–25.4
32.8–46.3
36.3–48.9
32.5–54.9
19.5–30.7
28.1–37.4
19.4–36.1
22.3–28.3
28.2–39.1
18.2–31.5
11.9–18.2
20.6–27.5
15.2–20.7
95% CI
1.8
1.3
2.9
0.2
2.2
1.6
0.3
−3.3
7.2
0.6
4.4
1.8
2.4
0.2
3.5
1.2
1.8
1.0
Absolute
Difference
.97
.46
.37
.91
.27
.60
−0.01
−0.12
0.23
−0.01
0.14
0.08
.46
.61
.49
.71
.05
.57
−0.05
0.26
0.12
0.07
−0.06
0.12
.17
.50
.37
.95
.17
.71
Linear P
0.11
−0.08
0.14
0.01
0.19
0.04
Linear βa
No change
No change
No change
No change
No change
No change
No change
No change
No change
No change
No change
No change
No change
No change
No change
No change
No change
No change
Summary
2005–2013
Significant decrease
Significant decrease
No change
.02
.002
.11
−3.3
−9.0
4.6
32.1–35.6
55.8–64.0
42.4–50.6
−0.07
−0.20
0.10
No change
No change
No change
.31
.62
.48
−1.2
−1.7
1.8
21.4–24.2
40.6–50.0
23.5–30.1
−0.03
−0.03
0.04
Summary 2011–2013
Linear P
Linear β
Absolute
Difference
HIV test settings for young adults ever tested for HIV. Among young adults ever tested for HIV,
the test settings where they were last tested included private doctor offices/health maintenance
organizations, other clinics, hospitals (inpatient or emergency department), HIV counseling and
testing sites, correctional facilities, or other settings (ie, at home, somewhere else, drug treatment
facility).
33.9
59.9
46.5
31.8–35.5
61.6–70.1
33.9–42.1
22.8
45.3
26.8
21.6–24.8
43.6–53.3
25.5–32.9
95% CI
Males
White
Black
Hispanic/Latino
Females
White
Black
Hispanic/Latina
Note: CI confidence interval; HIV human immunodeficiency syndrome.
35.1–39.2
65.0–72.8
37.7–46.1
37.2
68.9
41.9
33.6
65.8
38.0
22.2–25.8
41.9–52.0
21.6–28.5
24.0
47.0
25.0
23.2
48.4
29.2
2012
% Tested
95% CI
2011
% Tested
Prevalence of Tested for HIV
TABLE 2 Trends in HIV Testing Among Young Adults Aged 18 to 24 Years, 2011–2013, BRFSS
% Tested
2013
95% CI
FIGURE 2
PEDIATRICS Volume 137, number 2, February 2016
ethnicity. Among young adult males,
an average of 27% had ever been
tested for HIV. No significant changes
were detected in the prevalence of
HIV testing among males overall
or by race/ethnicity subgroup (Fig
1D; Table 2). Among young adult
females, a significant decrease in
the prevalence of HIV testing was
detected overall from 42.4% in 2011
to 39.5% in 2013 (Fig 1D, 3.0%
decrease, β = –0.06, P = .02), among
young adult white females from
37.2% in 2011 to 33.9% in 2013
(3.3% decrease, β = –0.07, P = .02),
and among young adult black females
from 68.9% in 2011 to 59.9% in
2013 (9.0% decrease, β = –0.20, P
= .002). Young adults who had ever
been tested for HIV reported that
their last HIV test was at a private
doctor office/health maintenance
organization (40.5%), clinic (31.2%),
hospital (8.8%), HIV testing site
(4.8%), correctional facility (1.2%),
or other setting (13.6%) (Fig 2).
DISCUSSION
Less than one-quarter of high school
students who have had sexual
intercourse and one-third of young
adults have ever been tested for HIV.
During 2005–2013, the percentage
of sexually experienced high school
students who had ever been tested
for HIV did not change overall or for
any subgroup. During 2011–2013,
the percentage of young adults
who have ever been tested did not
increase among young adult males
and decreased significantly among
young adult females overall and
among young adult white and black
females. No increase in testing among
young adult males and decreased
testing among young adult black
females is concerning because they
account for the majority of new
HIV infections among persons aged
13–24 years. These results indicate
that recommendations to screen all
adolescents and young adults for HIV
infection, regardless of risk, have
not been widely implemented. HIV
testing programs do not appear to
be successfully reaching high school
students and young adults.
Adolescents and young adults living
with HIV infection are more likely
to be unaware of their HIV infection
5
than any other age group, with
an estimated 25 300 living with
undiagnosed HIV infection,2 yet our
results indicate that HIV testing
rates are low and not increasing
among this population, regardless
of sexual behavior, race/ethnicity,
and gender. CDC and the USPSTF
recommend that all adolescents
and adults be screened for HIV
infection.5,6 The USPSTF considered
prevalence of sexual activity and STIs
by age to determine the age range
to recommend screening. Because
nearly half of US high school students
had engaged in sexual intercourse14
and prevalence of STIs is high among
high school–age adolescents,15
routine HIV screening starting at age
15 years was chosen.6 We limited
our analysis to sexually experienced
high school students to focus our
analysis on persons who may have
been exposed to HIV through sexual
intercourse. Although our analysis
is the first to assess trends in HIV
testing among sexually experienced
high school students, previous
analyses of YRBS data found similarly
low HIV testing rates. For example,
in 2007, 13% of all high school
students had ever been tested for
HIV. The prevalence of HIV testing
was higher among students who had
ever had sexual intercourse (22%)
than those who had never had sexual
intercourse (4%).16 More recently,
Coeytaux et al (2014) used YRBS
data pooled from 2005 to 2011 and
found that HIV testing was positively
associated with HIV-related
risk behaviors among sexually
experienced high school students.17
Similarly, CDC previously reported no
change in the percentages of young
adults ever tested for HIV (34%)
using 2000–2010 National Health
Interview Survey data.10 In contrast,
data from 1999–2010 NHANES
indicated a decreasing trend, from
38% in 1999–2000 to 30% in 2009–
2010 among young adults aged 18
to 24 years.10 Although the previous
report including National Health
6
Interview Survey and NHANES data
did not further investigate trends
by subgroup and therefore could
not identify the groups driving the
overall trends among young adults,
its results and our results indicate
testing is not increasing among
young adults.
Additional efforts are needed to
achieve widespread uptake of HIV
testing among high school students
and young adults. HIV testing
programs should consider how to
best reach young persons in racial/
ethnic minority groups, especially
blacks and Hispanics/Latinos and
all MSM, because these groups are
disproportionately affected by
HIV infection. Black adolescents
and young adults account for an
estimated 57% of all new HIV
infections among this age group
in the United States, followed by
Hispanic/Latino adolescents and
young adults (20%).9 Evidence
indicates increasing racial/ethnic
disparities in new HIV infections
among adolescents and young
adults.18 Although HIV testing was
higher among young adult black
males compared with young adult
white males, the prevalence of HIV
testing among young adult males did
not change among any race/ethnicity
subgroup to reflect increasing
disparities.
We found a decrease in the
prevalence of HIV testing among
young adult black females during
2011–2013, which is disconcerting
given the high rate of infection among
black adult females. In 2013, the
diagnosis rate among black females
(34.8 per 100 000) was higher than
the rate for females of any other
race/ethnicity subgroup.19 Black
females remain an important target
population for HIV testing programs.
For example, an Act Against AIDS
campaign, “Take Charge. Take
the Test,” is a national campaign
implemented in 2012 to encourage
HIV testing among black/African
American females aged 18 to 34
years.8
Adolescents and young adults may
face unique barriers that need to be
addressed to increase access to and
utilization of HIV testing services,
such as lack of access to health
care, low provider awareness of
recommendations, and insufficient
sexual health knowledge.17,20–23
Inadequate access to HIV prevention
and treatment services is a major
barrier for adolescents, particularly
those of racial/ethnic minority
subgroups, because many have only
limited contact with the health care
system and are less likely to receive
regular preventive health care.17,20
Even among those with access to
preventive health care, studies
have found limited knowledge
of HIV testing recommendations
for adolescents and young adults
among pediatricians and health
care providers.21 In an analysis
of adolescents at a large urban
pediatric emergency department,
78% of providers were unaware
of the revised recommendations.21
Provider recommendation has been
shown to be the most important
predictor of obtaining an HIV test
among adolescents.24,25 Our results
support the importance of provider
recommendation because 80% of
young adults who were ever tested
for HIV last tested in a clinical setting.
Provider education and
implementation of system-level
interventions, such as those
used to implement routine HIV
screening in prenatal and urgent
care settings,26–28 could be applied
to testing for adolescents and
young adults. These interventions
should also consider the complex
issues of confidentiality, disclosure,
and consent in adolescent care
because adolescents also cite
concerns about confidentiality.29,30
As currently structured, routine
clinic visits for adolescents often
do not include blood tests. The
Committee on Pediatric AIDS
VAN HandEL et al
provides recommendations on how
health care providers for adolescents
can successfully provide HIV
screening and prevention services
to their clients.23 The American
Academy of Pediatrics, Committee
on Pediatric AIDS, can build on
these recommendations to better
understand when, where, and by
whom adolescents should be tested.
Schools can also play a critical role
in increasing access to HIV testing
services for students.31 Federal Title
X clinics must provide confidential
sexual health services; however,
other clinical settings might not
offer such protections depending
on the state. Teens may need access
to confidential services, meaning
services are provided without
parental involvement in either the
delivery or payment of the service.
Consequently, parent’s insurance may
not be a viable payment option if an
“Explanation of Benefits” statement
reveals the receipt of services to
parents. In addition, young people
might not have the ability to get to
services that are only open during
school hours. Schools can either
provide services at onsite or nearby
clinics or create referral systems to
clinics that have been assessed for
their teen-friendly (ie, confidential)
nature and accessibility. In addition to
overcoming barriers related to access
to care, knowledge about HIV among
adolescents and young adults is
limited, and often they underestimate
their personal infection risk.22,23
Sexual health education could
improve the ability of adolescents and
young adults to assess their risk for
HIV infection and increase testing.16
At least 5 limitations to this
analysis should be noted. First,
the cross-sectional design of
YRBS prevents identification of
temporal order between HIV testing
and risk behaviors. Second, the
PEDIATRICS Volume 137, number 2, February 2016
self-reported nature of YRBS and
BRFSS can introduce bias (eg,
recall, nonresponse, social
desirability). The extent of
underreporting or overreporting of
behaviors cannot be determined,
although the survey questions in
YRBS demonstrate good test–retest
reliability.32 Third, YRBS data apply
only to youth who attend school and
therefore are not representative
of all persons in this age group.
Nationwide, in 2009, of persons
aged 16 to 17 years, ∼4% were not
enrolled in a high school program
and had not completed high
school.33 Fourth, the gender
of sexual partners is not included
in these surveys. Therefore, we
could not identify MSM who
account for the greatest number of
adolescents and young adults living
with HIV infection. However, all
adolescents and young adults should
be screened for HIV, regardless
of risk, specifically in areas with
prevalence of undiagnosed HIV
≥0.1%. Annual HIV testing, not
addressed in this analysis, should
focus on those at higher risk and
in need of repeat HIV testing.
Fourth, we could not determine if
respondents were tested for other
STIs, which would provide useful
context information about potential
risk for HIV and other sexual health
care interactions. Lastly, sexually
experienced respondents in BRFSS
could not be identified; therefore,
some persons included in the
analysis may not have been exposed
to HIV through sexual intercourse,
the most common transmission risk
behavior. However, on the basis
of data from National Survey of
Family Growth, 86% of women and
83% of men aged 18 to 24 years
have had sexual intercourse by
age 22, indicating the effect of this
nonsexually experienced population
on our results is likely minimal.34,35
CONCLUSIONS
Increasing the percentage of
adolescents and young adults
screened for HIV is important
for increasing awareness of HIV
infection and reducing new HIV
infections among this population.
However, less than one-quarter of
high school students who have had
sexual intercourse and one-third of
young adults have ever been tested
for HIV, and there was no evidence
of increased testing. No increase in
testing among male students and
young adult males and decreased
testing among young adult black
females is of special concern given
the higher risk of HIV infection
among men and black women.
Multipronged testing strategies,
including provider education,
system-level interventions in clinical
settings, adolescent-friendly testing
services, and sexual health education
will likely be needed to increase
testing and reduce the percentage of
adolescents and young adults living
with HIV infection.
ACKNOWLEDGMENTS
The authors thank Janet Heitgerd,
PhD, and Dale Stratford, PhD, for
their expertise and helpful feedback
on earlier drafts of this article.
ABBREVIATIONS
BRFSS: Behavioral Risk Factor
Surveillance System
CDC: Centers for Disease Control
and Prevention
MSM: gay, bisexual, and other
men who have sex with
men
USPSTF: United States Preventive
Services Task Force
YRBS: National Youth Risk
Behavior Survey
7
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