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Gay, bisexual, and other men who have sex with men and transgender individuals are more heavily affected by HIV and other sexually transmitted infections (STIs) than their cisgender, heterosexual peers. In addition, sexual and gender minorities who use substances are often at a further increased risk of HIV and other STIs. Increasing testing for HIV and other STIs allows this hardly reached population to receive early intervention, prevention, and education.
We explored HIV and STI testing patterns among 414 sexual and gender minority adolescents and young adults aged 15 to 29 years who self-reported substance use and lived in southeastern Michigan.
We analyzed data from the baseline survey of a 4-arm randomized controlled trial that aimed to examine the efficacy of a brief substance use intervention for creating gains in engagement in HIV prevention. We fit multinomial logistic regression models to 2 categorical HIV and STI testing variables (lifetime and previous 12 months) based on self-reports of testing (never, STIs only, HIV only, or both). In addition, we compared HIV and STI testing behaviors across demographic characteristics, structural factors, psychosocial barriers, substance use, and sexual behaviors.
Our findings showed that 35.5% (147/414) of adolescents and young adults reported not being tested for either HIV or STIs in the previous year, and less than half (168/414, 40.6%) of the sample achieved the Centers for Disease Control and Prevention recommendation of HIV and STI testing once per year. We observed HIV and STI testing disparities across sociodemographic (eg, sexual identity, education, and income) and health (eg, substance use) correlates. Specifically, cisgender gay men who have sex with men were more likely to report being tested for HIV compared with bisexual men and transgender individuals, who were more likely to be tested for STIs.
This study illustrates the results of an HIV prevention intervention in southeastern Michigan showing the need for HIV prevention interventions that leverage structural factors, psychosocial barriers, and substance use as key drivers to achieve HIV and STI testing rates to meet the Centers for Disease Control and Prevention guidelines.
ClinicalTrials.gov NCT02945436; http://clinicaltrials.gov/ct2/show/NCT02945436
RR2-10.2196/resprot.9414
In the United States, sexual and gender minority populations continue to experience disproportionate burdens of HIV and other sexually transmitted infections (STIs) compared with heterosexual and cisgender populations. Although <0.5% of the adult American population lives with HIV [
GBMSM and transgender populations have also been shown to be at an increased risk of STIs other than HIV [
Within sexual and gender minority populations, the rates of HIV and STIs are significantly higher among substance using individuals [
Testing for HIV and other STIs is a critical entry point into the HIV and STI care continuums, allowing people to be aware of their status, obtain treatment, and take appropriate action to prevent further transmission [
This study focused on understanding the factors associated with HIV and STI testing among sexual and gender minority adolescents and young adults (AYA) in Detroit, Michigan. The Detroit Metro Area contains the most heavily concentrated group of people living with HIV in the state of Michigan, where the highest HIV and STI infection rates are among those living in the city of Detroit [
This study used baseline data from a randomized controlled trial with substance using, sexual and gender minority AYA recruited in southeastern Michigan to understand patterns of testing for HIV and STIs. The primary aim of this analysis was to understand HIV and STI testing behaviors among substance using sexual and gender minority AYA, a group for whom it is critical to develop interventions that can increase testing uptake. Understanding the social determinants (eg, gender identity, sexual identity, and education) associated with HIV and STI testing among this vulnerable population has the potential to inform the development of interventions tailored to the unique needs of a population experiencing substance use and multiple structural and interpersonal barriers to engaging in routine testing.
We analyzed data from the baseline survey of a 4-arm randomized controlled trial of substance using, sexual and gender minority AYA (aged 15-29 years; N=414) that examined the efficacy of a brief substance use intervention for creating gains in engagement in HIV prevention. The eligibility criteria were as follows: being aged 15 to 29 years at the time of screening; living in southeastern Michigan (based on eligible zip codes); identifying as a man, male, or transgender person; having had condomless oral or anal sex at least once in the 6 months before screening; and having had at least one binge drinking or substance misuse experience (≥5 standard alcoholic beverages in a single setting) in the last 3 months before screening. The study recruitment period was from April 2017 to August 2019. Participants were walked through consent by a staff member, ensuring that they could opt out of the study at any time and were not forced to participate.
The study was approved by the Institutional Review Board of the University of Michigan (HUM00105125). The trial is also registered at ClinicalTrials.gov (NCT02945436). More information regarding the randomized controlled trial is available in a detailed protocol paper [
The participants responded whether they had ever been tested for HIV or STIs in their lifetime. On the basis of the participants’ responses, we created a categorical variable of lifetime HIV and STI testing with 4 groups: never tested for either HIV or STIs, tested for STIs only, tested for HIV only, or tested for both HIV and STIs. If they had been tested in the past, the participants responded whether they had been tested in the 12 months before the survey. Similar to lifetime testing, we created a categorical variable of previous–12-month HIV and STI testing: never tested for HIV and STIs, tested for STIs only, tested for HIV only, or tested for both HIV and STIs.
We included demographic characteristics (ie, age, race, ethnicity [Hispanic or Latinx], gender identity, sexual identity, and disability) in the analysis. Age was dichotomized as 15 to 21 years or 22 to 29 years. The participants were asked about their gender identity using 4 response options (cisgender, transgender men, transgender women, or nonbinary). Owing to the small number of responses in each category, transgender men, transgender women, and nonbinary individuals were combined into
The participants self-reported incarceration history (never incarcerated, incarcerated in their lifetime but not incarcerated in the last 12 months, and incarcerated in the last 12 months), employment (full-time or other), health insurance enrollment (currently insured or not insured), and housing stability (residing in stable housing or not residing in stable housing). The participants responded with the highest level of education that they had completed (some high school, graduated high school or obtained General Educational Development, and some college and higher). The participants reported their household income in the previous year from all sources before tax, which we divided into <US $15,000, ≥US $15,000 but <US $40,000, and ≥US $40,000.
The participants indicated how likely they felt they were to contract HIV with responses on a 4-point Likert scale from
The 7-item General Anxiety Disorder scale assessed frequency of anxiety symptoms in the previous 2 weeks; symptomatology comprised (1) minimal, (2) mild, (3) moderate, and (4) severe [
We used the Alcohol Use Disorders Identification Test [
The participants reported the total incidence of receptive or insertive condomless anal intercourse in the previous 3 months. In addition, the participants reported the total incidence of condomless vaginal intercourse in the previous 3 months.
Descriptive analyses were conducted to characterize the sample (eg, means, SDs, and proportions). Bivariate multinomial logistic regression models were fitted to the 2 categorical outcomes measuring lifetime and previous–12-month HIV and STI testing. Among the 4 different HIV and STI testing outcomes (never, STIs only, HIV only, or both), the largest group was selected as the reference group. Each model compared HIV and STI testing categories according to demographic characteristics, structural factors, psychosocial barriers, and substance use and sexual behaviors. Dummy variables were created for gender and sexual identity, and ordinal variables (education, income, incarceration, HIV likely, PrEP awareness and use, and anxiety) were considered continuous variables in the modeling. Models were fit using SAS statistical software (version 9.4; SAS Institute Inc).
Regarding
Approximately half of the participants reported moderate to severe anxiety symptoms (175/414, 42.3%) and depressive symptoms (262/414, 63.3%). Most participants (284/414, 68.6%) reported experience with cannabis, and nearly half of the participants (178/414, 43%) reported experience with other drugs in the previous 3 months. More than half of the participants (257/414, 62.1%) reported condomless anal intercourse, and 14% (58/414) had had condomless vaginal intercourse in the previous 3 months.
Older participants were more likely to have been tested for both HIV and STIs in their lifetime (odds ratio [OR] 1.27, 95% CI 1.16-1.38) and in the previous 12 months (OR 1.12, 95% CI 1.04-1.21). In addition, older participants were less likely to have only been tested for STIs in their lifetime (OR 0.82, 95% CI 0.72-0.94), whereas older participants were more likely to have been tested for HIV in the previous 12 months (OR 1.12, 95% CI 1.02-1.23). Participants who identified as cisgender were 77% less likely to have been tested only for STIs (OR 0.23, 95% CI 0.10-0.50) than to have been tested for both HIV and STIs in their lifetime, whereas cisgender participants were 5 times more likely to have only been tested for HIV (OR 5.16, 95% CI 1.53-17.45) in the previous 12 months. Participants who identified as gay were less likely to have been tested only for STIs in their lifetime (OR 0.29, 95% CI 0.13-0.64) and in the previous 12 months (OR 0.45, 95% CI 0.21-0.94) than those who had been tested for both HIV and STIs. However, participants who identified as bisexual were more likely to have been tested only for STIs in their lifetime (OR 4.24, 95% CI 1.87-9.59) and to have not been tested for either HIV or STIs in the previous 12 months (OR 1.97, 95% CI 1.10-3.52). Participants with higher levels of education were more likely to have been tested for HIV and STIs in their lifetime (OR 2.19, 95% CI 1.48-3.25) and in the previous 12 months (OR 1.76, 95% CI 1.19-2.56) than to have never been tested for either HIV or STIs. Those with higher incomes were less likely to have only been tested for STIs in their lifetime (OR 0.52, 95% CI 0.28-0.96) than to have been tested for both HIV and STIs.
Participants who reported higher awareness and use of PrEP were less likely to have been tested only for HIV in their lifetime (OR 0.25, 95% CI 0.07-0.83) and in the previous 12 months (OR 0.36, 95% CI 0.19-0.70).
Participants with greater anxiety symptoms were more likely to have only been tested for STIs in their lifetime (OR 1.42, 95% CI 1.01-1.99), although depressive symptomatology was not associated with HIV and STI testing.
Tobacco use and hazardous drinking were not associated with HIV and STI testing in their lifetime and in the previous 12 months; however, sedative and opioid use were associated with HIV and STI testing in their lifetime, and cannabis, opioid, and amyl-nitrite use was associated with previous-year HIV and STI testing. Participants who used sedatives (OR 2.05, 95% CI 1.04-4.03) and opioids (OR 4.38, 95% CI 1.58-12.16) were more likely to not have been tested for either HIV or STIs in their lifetime compared with those who had been tested for both. AYA who used opioids were more likely to have not been tested for HIV or STIs in the previous 12 months (OR 3.64, 95% CI 1.15-11.56), whereas AYA who used amyl-nitrites were less likely to have been tested for either HIV or STIs in the previous 12 months (OR 0.52, 95% CI 0.27-0.97). Participants who used cannabis were less likely to have only been tested for HIV (OR 0.54, 95% CI 0.29-0.98) in the previous 12 months.
Participants who reported condomless anal intercourse were more likely to have been tested for both HIV and STIs in their lifetime (OR 2.89, 95% CI 1.74-4.79) and in the previous 12 months (OR 2.76, 95% CI 1.73-4.40) compared with those who had not been tested for either HIV or STIs. Specifically, receptive condomless anal intercourse was associated with HIV and STI testing in their lifetime (OR 0.50, 95% CI 0.30-0.82) and in the previous 12 months (OR 0.46, 95% CI 0.29-0.72). Similarly, participants who reported condomless anal intercourse (OR 0.26, 95% CI 0.12-0.58), especially receptive condomless anal intercourse (OR 0.27, 95% CI 0.12-0.64), in the previous 3 months were less likely to have been tested only for STIs in their lifetime. However, participants who reported condomless vaginal intercourse (OR 3.19, 95% CI 1.34-7.62), especially receptive condomless vaginal intercourse (OR 3.30, 95% CI 1.20-9.07), were more likely to have been tested for only an STI compared with testing for both HIV and STIs in their lifetime.
In this sample of substance using sexual and gender minority AYA, approximately two-thirds of the participants reported being tested for both HIV and STIs in their lifetime (259/414, 62.6%); however, 20% (83/414) of the sample had not been tested for either in the previous year, a concerning rate given the Centers for Disease Control and Prevention (CDC) recommendation that all sexually active, young, substance using, sexual and gender minority individuals should be tested for STIs annually and for HIV every 3 to 6 months [
Transgender individuals and bisexual men reported having been tested for STIs but not HIV, whereas cisgender gay men were more likely to have been tested for HIV than for STIs. These patterns of HIV and STI testing may be attributed to differing perceived susceptibility to HIV or STIs across sexual and gender minority communities but also to the targeting that is often used in HIV and STI programs. HIV testing has long focused on the need for GBMSM to be tested regularly, and only recently in the epidemic have promotional materials begun to include the transgender community [
Both self-reported mental health and substance use were associated with HIV and STI testing. Participants with higher levels of anxiety were more likely to have only been tested for STIs, perhaps suggesting that anxiety is a barrier to engaging in HIV testing, although further research is warranted to understand the pathways between anxiety and engagement in testing. Opioid- and sedative using participants were more likely to not have been tested for either HIV or STIs compared with those who had been tested for both HIV and STIs in their lifetime. In general, substance using AYA may have specific barriers to engaging in testing—for example, fear of having to report their substance use, which prevents them from seeking testing services [
There are several limitations to this analysis. First, the cross-sectional nature of the data precludes any inference of causality, but it does provide a foundation for further examinations to draw from. Second, the small number of participants reporting noncisgender identities precluded a thorough examination of associations between gender identity and HIV and STI testing, a common limitation of the literature, which often aggregates gender identities [
The goal of this study was to understand the HIV and STI testing behaviors of substance using sexual and gender minority AYA living in southeastern Michigan. Our results show that, contrary to CDC testing guidelines, 35.5% (147/414) of AYA had not been tested for either HIV or STIs in the previous year, and less than half (168/414, 40.6%) meet the CDC testing recommendations. To meet the CDC’s guidelines on testing, HIV and STI testing interventions need to recognize the specific barriers to engaging in testing experienced by substance using sexual and gender minority AYA, who experience multiple layers of potential stigma grounded in their age, sexual and gender identities, and substance use behavior. Central to this is the recognition that not all substances are linked to testing behaviors in the same way, and research and programmatic efforts need to consider the differential testing needs, attitudes, and barriers of different types of substance using AYA.
Demographic and behavioral characteristics of a sample of substance-using sexual and gender minority adolescents and young adults in the Detroit Metro Area (aged 15-29 years; N=414).
Distribution of demographic characteristics, structural factors, psychosocial barriers, and substance use and sexual behaviors by lifetime HIV testing among substance-using sexual and gender minority adolescents and young adults (N=414).
Distribution of demographic characteristics, structural factors, psychosocial barriers, and substance use and sexual behaviors by previous-year HIV and sexually transmitted infection testing among substance-using sexual and gender minority adolescents and young adults (N=414).
Odds of lifetime HIV and sexually transmitted infection testing by demographic characteristics, structural factors, psychosocial barriers, and substance use and sexual behaviors among substance-using sexual and gender minority adolescents and young adults (N=414).
Odds of previous-year HIV and sexually transmitted infection testing by demographic characteristics, structural factors, psychosocial barriers, and substance use and sexual behaviors among substance-using sexual and gender minority adolescents and young adults (N=414).
adolescents and young adults
Centers for Disease Control and Prevention
gay, bisexual, and other men who have sex with men
odds ratio
pre-exposure prophylaxis
sexually transmitted infection
None declared.