INTRODUCTION: HIV disproportionally burdens adolescent men who have sex with men (AMSM) and transgender youth. This study explores barriers and facilitators that professionals face in delivering HIV preventive services and education. METHODS: Adolescent health providers (nurse practitioners, physicians, and other), school nurses, youth workers, and school educators were recruited nationally for this qualitative study. RESULTS: Thirty-four professionals participated. Common categories identified across professional group were (1) effective strategies for building trust with youth, (2) perceived barriers/facilitators to sexual health communication, (3) perceived barriers/facilitators to effective HIV prevention, and (4) preferred content for HIV prevention tools. DISCUSSION: Key elements for developing multidisciplinary resources to support AMSM and transgender youth should include (1) web-based or easily accessible sexual health educational materials, (2) resources for referrals, (3) trainings to support competence in caring for sexual and gender minority youth, and (4) guidance for navigating policies or eliciting policy change.

Transgender and gender diverse (TGD) youth experience significant risk for negative health outcomes, yet few studies exist that address TGD youth's experiences of health care. This paper explores the equitable access and utilization of health care in a sample of TGD youth of diverse gender and racial/ethnic identities. Data for this analysis are from the TGD subsample (n = 1415) of the 2018 Survey of Today's Adolescent Relationships and Transitions (START) Project. We assessed five health care experiences: being insured, having a current health care provider, being out to one's provider, believing your provider was knowledgeable about transgender issues, and barriers to accessing care due to gender identity/expression. We examined the proportion of TGD youth who reported each of these outcomes and within-group differences by gender identity and race/ethnicity using descriptive statistics, logistic regression, and predicted probabilities. When differences were examined by gender identity, barriers to equitable care were consistently more present among transgender females than youth of other gender identities. There were few significant differences by race/ethnicity; however, dual referent models demonstrated barriers to equitable care were particularly evident among Black and Hispanic transgender women. We discuss these findings through the lens of intersectionality and highlight the importance of research and intervention work focused on reducing barriers to equitable care for TGD youth.

Sexual and gender minority (SGM) youth are at disproportionate risk of acquiring HIV, and as such, SGM youth should be meaningfully engaged in research aimed at developing effective, tailored HIV interventions. Youth Community Advisory Boards (YCABs) are an important element of community-engaged research and support the development of community-informed interventions. This article describes recruitment, facilitation, and retention of a YCAB composed of SGM youth in Greater Boston, to inform a national HIV prevention research project. These lessons can serve as a guide to future researchers who want to form YCABs as part of community-engaged research.

BACKGROUND: There are notable disparities by race/ethnicity in the sexual health of US adolescents and young adults. Our objective was to examine change over time in racial-ethnic disparities in sexual behaviours among US high school students. METHODS: Data were analysed from six biennial cycles of the national Youth Risk Behavior Survey (2009-19), conducted among cross-sectional, nationally representative samples of 9th-12th grade students. Data were collected via self-administered questionnaires. Multivariable logistic regression models tested for linear trends by race/ethnicity (White, Black, Hispanic) and differences in these trends in: ever had sex, current sexual activity, having four or more lifetime sexual partners, and condomless sex. Prevalence ratios and risk differences by race/ethnicity for each cycle were used to calculate average percent change in the estimates to determine if health disparities changed over time. RESULTS: During 2009-19, prevalence estimates for ever had sex, current sexual activity, and having four or more lifetime sexual partners decreased overall and across all racial-ethnic groups. For condomless sex, prevalence estimates increased over time overall (38.9-45.7%) and for Black (37.6-51.8%) and White (36.7-44.2%) students, but not Hispanic (45.1-43.8%) students. Significant differences in trends by race/ethnicity were observed for all variables. Data suggest that racial-ethnic health disparities for sexual behaviours decreased over time, except for condomless sex. CONCLUSIONS: Although racial-ethnic gaps in sexual behaviours may be shrinking for many behaviours, work is still needed to achieve health equity in risks associated with HIV/AIDS, sexually transmitted infections, and pregnancy.

PURPOSE: The purpose of this research is to explore the relationship between substance use and sexual risk behaviors among transgender youth. METHODS: Data from the transgender subsample of the Survey of Today's Adolescent Relationships and Transitions (n=1567) were analyzed to assess associations between substance misuse (binge drinking, prescription drug misuse, illicit drugs) and sexual risk behaviors (condom use during sex). Multivariate logistic regression models calculated adjusted odds ratios (AORs) for substance use by sexual risk behavior controlling for race/ethnicity, gender identity (transgender male, transgender female, genderqueer/gender nonconforming), age, sexual identity, and region. RESULTS: Among participants, lifetime marijuana use (AOR=0.45), cocaine use (AOR=0.46), prescription drug misuse (AOR=0.52), and injecting substances with a needle (AOR=0.45) were all associated with lower odds of reporting condom use during the last act of receptive anal sex. Similarly, marijuana use in the last 30 days (AOR=0.46), lifetime marijuana use (AOR=0.25), heroin use (AOR=0.29), methamphetamine use (AOR=0.32), misuse of prescription drugs (AOR=0.40), and injecting substances with a needle (AOR=0.17) were all associated with lower odds of reporting condom use during the last act of insertive anal sex. No associations between substance use and condom use during last act of receptive frontal (vaginal) sex were found. CONCLUSION: We found that transgender youth who reported any lifetime substance use were more likely to report condomless sex during receptive and insertive anal sex than those who did not report substance use. Significant differences exist among demographic groups, type of substance use, and sexual risk behaviors for respondents based on gender identity.

OBJECTIVES: National guidelines call for annual testing for certain sexually transmitted infections (STIs) among specific adolescent populations, yet we have limited population-based data on STI testing prevalence among adolescents. With inclusion of a new item in the 2019 national Youth Risk Behavior Survey, we provide generalizable estimates of annual STI testing among sexually active high school students. METHODS: We report weighted prevalence estimates of STI testing (other than HIV) in the past 12 months among sexually active students (n = 2501) and bivariate associations between testing and demographic characteristics (sex, age, race and ethnicity, sexual identity, and sex of sexual contact). Multivariable models stratified by sex and adjusted for demographics examine the relationships between testing and sexual behaviors (age of initiation, number of sex partners, condom nonuse at last sexual intercourse, and substance use at last sexual intercourse). RESULTS: One-fifth (20.4%) of sexually active high school students reported testing for an STI in the previous year. A significantly higher proportion of female (26.1%) than male (13.7%) students reported testing. Among female students, prevalence differed by age (15 years = 12.6%, age 16 = 22.8%, age 17 = 28.5%, or 18 years = 36.9%). For male students, there were no differences by demographic characteristics, including sexual identity, but most sexual risk behaviors were associated with increased likelihood of STI testing (adjusted prevalence ratios ranging from 1.48 to 2.47). CONCLUSIONS: Low prevalence of STI testing suggests suboptimal adherence to national guidelines, particularly for sexually active adolescent females and young men who have sex with men who should be tested for Chlamydia and gonorrhea annually.

PURPOSE: The Michigan Department of Health and Human Services, in collaboration with St. John Providence Health System, initiated voluntary school-wide sexually transmitted disease (STD) screenings in four Detroit public high schools. We sought to assess the cost-effectiveness of the STD screening program from 2010 to 2015, with a focus on chlamydia. METHODS: The costs and effectiveness of the school-based screening were compared with those of a "no school screening" scenario using a healthcare system perspective. A decision tree model was constructed to project cases of chlamydia, epididymitis, and pelvic inflammatory disease (PID) in each of the two scenarios among students tested positive and their partners. Health effects were measured as cases of PID prevented, and quality-adjusted life-years (QALYs) gained. Cost estimates included program costs, chlamydia testing/treatment costs in the absence of school screening, and treatment costs for epididymitis, PID, and PID sequelae. The incremental cost-effectiveness ratio (ICER) was measured as cost/QALY gained. Multivariate sensitivity analyses were conducted on key parameter estimates and assumptions used. RESULTS: Under base-case assumptions, at a total program cost of $333,848 over 5 years, the program prevented an estimated 1.9 cases of epididymitis and 17.3 cases of PID, resulting in an ICER of $38,235/QALY gained (yearly ICER ranging from $27,417 to $50,945/QALY). Of 10,000 Monte Carlo simulation runs, the yearly ICER remained ≤$50,000/QALY in 64%-98% of the simulation runs. CONCLUSIONS: We found favorable cost-effectiveness ratios for Michigan's school-wide STD screening program in Detroit. School-based STD screening programs of this type warrant careful considerations by policy makers and program planners.

INTRODUCTION: Adolescent sexual minority males (ASMM) are at disproportionate risk of HIV infection. The purpose of this study was to assess ASMM's attitudes about sexual health, barriers/facilitators to accessing HIV prevention, and actual versus ideal interactions for receiving sexual health care and information. METHOD: Two online and two in-person focus groups were conducted with ASMM from across the United States. Qualitative data were analyzed using content analysis. RESULTS: Twenty-one racially diverse ASMM participated (average age = 16.4 years). Online focus groups were superior for reaching the target population. Four themes emerged: ( 1: ) identity formation and sources of support, ( 2: ) challenges to obtaining sexual health information, ( 3: ) attitudes/beliefs about sex and sexual behaviors, and ( 4: ) barriers to HIV prevention. DISCUSSION: These findings illustrate current gaps in sexual health knowledge, as well as barriers and facilitators to obtaining sexual health information, sexual health care, and affirming education and support for ASMM.

PURPOSE: We examined condom use patterns and potential population-level effects of a hypothetical condom intervention on HIV transmission among adolescent sexual minority males (ASMM). METHODS: Using three datasets: national Youth Risk Behavior Survey 2015-2017 (YRBS-National), local YRBS data from 8 jurisdictions with sex of partner questions from 2011-2017 (YRBS-Trends), and American Men's Internet Survey (AMIS) 2014-2017, we assessed associations of condom use with year, age, and race/ethnicity among sexually-active ASMM. Using a stochastic agent-based network epidemic model, structured and parameterized based on the above analyses, we calculated the percent of HIV infections averted over 10 years among ASMM ages 13-18 by an intervention that increased condom use by 37% for 5 years and was delivered to 62% of ASMM at age 14. RESULTS: In YRBS, 51.8% (95% confidence interval [CI] = 41.3-62.3%) and 37.9% (32.7-42.3%) reported condom use at last sexual intercourse in national and trend datasets, respectively. In AMIS, 47.3% (95%CI = 44.6-49.9%) reported condom use at last anal sex with a male partner. Temporal trends were not observed in any dataset (p > 0.1). Condom use varied significantly by age in YRBS-National (p < 0.0001) and YRBS-Trends (p = 0.032) with 13-15-year-olds reporting the lowest use in both; age differences were not significant in AMIS (p = 0.919). Our hypothetical intervention averted a mean of 9.0% (95% simulation interval = -5.4%-21.2%) of infections among ASMM. CONCLUSIONS: Condom use among ASMM is low and appears to have remained stable during 2011-2017. Modeling suggests that condom use increases consistent with previous interventions have potential to avert 1 in 11 new HIV infections among ASMM.

INTRODUCTION: Few studies have examined the factors associated with HIV testing, specifically among U.S. high-school girls. METHODS: Investigators analyzed 2015 and 2017 Youth Risk Behavior Survey data to calculate the prevalence ratios and the corresponding 95% CIs for the association of HIV-related risk behaviors and other factors with HIV testing. Analyses were completed in March 2020. RESULTS: Approximately 1 in 10 high-school girls reported ever having had an HIV test. Ever having had an HIV test was most common among girls who had ≥4 lifetime sexual partners and those who had ever injected illegal drugs. CONCLUSIONS: High-school girls who engage in behaviors or experience other factors that put them at higher risk for HIV are more likely to have ever gotten tested. However, the prevalence of having ever had an HIV test remains relatively low, indicating that continued efforts may be warranted to reduce risk behaviors and increase testing among high-school girls.

Purpose: We assessed the association of receipt of medical gender affirmation services (e.g., hormones, surgery) with HIV and other sexually transmitted disease (STD) prevention and knowledge indicators among transgender youth. Methods: A United States online sample of sexually experienced transgender youth ages 13-24 years (N = 1029) in 2018 completed a cross-sectional survey, including questions about sociodemographics, medical gender affirmation, and HIV and STD prevention outcomes (HIV testing, STD testing, pre-exposure prophylaxis [PrEP] awareness, and nonoccupational postexposure prophylaxis [nPEP] awareness). Logistic regression models were fit to assess the association of medical gender affirmation with HIV and STD prevention outcomes. Interaction terms and stratified models assessed differences in the association between medical gender affirmation and outcomes by gender identity. Results: Participants' mean age was 19.1 (standard deviation = 2.7), 45% were transgender female, 29% transgender male, 26% nonbinary, 53% were youth of color, and 19% accessed medical gender affirmation services. Medical gender affirmation was associated with increased odds of STD testing (adjusted odds ratio [aOR] = 1.90; 95% confidence interval [CI] = 1.33-2.73) with no significant interactions by gender identity. Associations between medical gender affirmation and awareness of PrEP and nPEP varied by gender identity. Among transgender male youth, medical gender affirmation was associated with awareness of PrEP (aOR = 2.65; 95% CI = 1.50-4.71) and nPEP (aOR = 2.03; 95% CI = 1.12-3.71). Among nonbinary youth, medical gender affirmation was associated with awareness of PrEP (aOR = 3.47; 95% CI = 1.26-11.27). Conclusion: Medical gender affirmation was associated with uptake and awareness of sexual health services. Bolstering medical gender affirmation for transgender youth may also bolster preventive health services broadly.

BACKGROUND: Rates of adolescent sexual activity have long been declining in the United States. We sought to estimate the number of cases of gonorrhea and chlamydia averted over one decade associated with these declines, and associated costs saved. METHODS: We analyzed data from the CDC's Youth Risk Behavior Survey of US high-school students from 2007-2017 and combined it with epidemiological estimates drawn from the literature to parameterize a dynamic population transmission model. We compared transmissions from observed behavioral trends to a counterfactual scenario that assumed sexual behaviors from 2007 remained constant over 10 years. We calculated outcomes by age and for three racial/ethnic groups (Hispanic, non-Hispanic Black, and non-Hispanic White adolescents) who vary on underlying burden and amount of behavioral change. RESULTS: We estimated 1,118,483 cases of chlamydia and 214,762 cases of gonorrhea were averted (19.5% of burden across all ages). This yielded $474 million (2017 dollars) savings in medical costs over the decade. The largest number of averted cases (767,543) was among Black adolescents, but the largest proportion (28.7%) was among Hispanic adolescents. CONCLUSIONS: Whatever its origins, changing sexual behavior among adolescents results in large estimated reductions in STI burden and medical costs relative to previous cohorts. Although diagnoses among adolescents have not declined at this rate, multiple explanations could make these apparently divergent trends consistent. Efforts to continue supporting effective sex education in and out of school along with STI screening for adolescents should reinforce these gains.

Purpose: The purpose of this study was to assess the feasibility and efficacy of using advertisements (ads) on Facebook, Instagram, and Snapchat to recruit a national sample of adolescent sexual minority males ages 13-18 and transgender youth ages 13-24 for a web survey. Methods: The Survey of Today's Adolescent Relationships and Transitions (START) used targeted ads as survey recruitment tools. We assessed the efficacy of these varied forms of recruitment ads in reaching our target population. To understand how our sample differed from a national probability sample targeting the general adolescent population, we compared START respondents with sexual minority men identified from the 2017 Youth Risk Behavior Survey (YRBS). Results: The use of targeted language produced higher rates of completes per click compared with ads without targeted language. Video ads (compared with static images) were more effective at recruiting younger respondents. START and YRBS samples differed along lines of sexual identity, race and ethnicity, and age. The START sample had a greater percentage of Hispanic/Latino and Other/Multiracial respondents relative to the YRBS sample, thus providing additional data on these underserved sexual minority youth. Conclusion: The factors associated with design decisions for a hard-to-reach, non-probability sample impact the likelihood that respondents engage in and complete a survey. The ads proved to be effective and efficient at recruiting the targeted population.

BACKGROUND: Chlamydia screening in high schools offers a way to reach adolescents outside of a traditional clinic setting. Using transmission dynamic modeling, we examined the potential impact of high-school-based chlamydia screening programs on the burden of infection within intervention schools and surrounding communities, under varying epidemiological and programmatic conditions. METHODS: A chlamydia transmission model was calibrated to epidemiological data from three different settings. Philadelphia and Chicago are two high-burden cities with existing school-based screening programs. Rural Iowa does not have an existing program but represents a low-burden setting. We modeled the effects of the two existing programs to analyze the potential influence of program coverage and student participation. All three settings were used to examine a broader set of hypothetical programs with varying coverage levels and time trends in participation. RESULTS: In the modeled Philadelphia program, prevalence among the intervention schools' sexually active 15-18 years old population was 4.34% (95% credible interval 3.75-4.71%)after 12 program years compared to 5.03% (4.39-5.43%) in absence of the program. In the modeled Chicago program, prevalence was estimated as 5.97% (2.60-7.88%) after 4 program years compared to 7.00% (3.08-9.29%) without the program. In the broader hypothetical scenarios including both high-burden and low-burden settings, impact of school-based screening programs was greater in absolute terms in the higher-prevalence settings, and benefits in the community were approximately proportional to population coverage of intervention schools. Most benefits were garnered if the student participation did not decline over time. CONCLUSIONS: Sustained high student participation in school-based screening programs and broad coverage of schools within a target community are likely needed to maximize program benefits in terms of reduced burden of chlamydia in the adolescent population.

PURPOSE: Pre-exposure prophylaxis (PrEP)-an effective and safe intervention to prevent HIV transmission-was recently approved by the Food and Drug Administration for use by adolescents. Informed by studies of sexual behavior and PrEP adherence, retention, and promotion, we model the potential impact of PrEP use among at-risk adolescent sexual minority males. METHODS: We simulate an HIV epidemic among men who have sex with men (MSM) aged 13-39. We assume adult MSM ages 19-39 have had PrEP available for 3 years with 20% coverage among eligible MSM based on the Centers for Disease Control and Prevention guidelines. PrEP interventions for ages 16-18 are then simulated using adherence and retention profiles drawn from the ATN113 and Enhancing Preexposure Prophylaxis in Community studies across a range of uptake parameters (10%-100%). Partnerships across age groups were modeled using parameterizations from the RADAR study. We compare the percent of incident infections averted (impact), person-years on PrEP per infection averted (efficiency), and changes in prevalence over 10 years. RESULTS: As compared to no PrEP use, baseline PrEP adherence and retention among adolescent sexual minority males drawn from the ATN113 and Enhancing Preexposure Prophylaxis in Community studies averted from 2.8% to 41.0% of HIV infections depending on the fraction of eligible adolescent sexual minority males that initiated PrEP at their annual health-care visit. Improved adherence and retention achieved with an array of focused interventions from real-world settings increased the percent of infections averted by as much as 26%-70%. CONCLUSIONS: Empirically demonstrated improvements in the PrEP continuum of care in response to existing interventions can substantially reduce incident HIV infections among adolescent sexual minority males.

PURPOSE: Sexual and gender minority youth (SGM), an umbrella term encompassing gay, bisexual, and transgender youth, experience disproportionately high rates of new HIV infections, and recent advances in biomedical HIV prevention modalities hold promise in reducing new infections. However, the extent to which SGM youth are aware of and willing to use these modalities is unknown. METHODS: Using data from the Survey of Today's Adolescents Relationships and Transitions, we analyze awareness of and willingness to take HIV pre-exposure prophylaxis (PrEP), nonoccupational HIV post-exposure prophylaxis, and rectal microbicides among adolescent sexual minority males aged 13-18 years and transgender youth aged 13-24 years. RESULTS: Overall, we found a majority of our respondents were not aware of any of these prevention modalities. Across both subsamples, age and outness to a health care provider were associated with increased PrEP awareness, and any anal sex was associated with PrEP willingness. CONCLUSIONS: These findings highlight the importance of provider education on how to discuss SGM issues with patients and educate them about HIV prevention options.

Purpose: Adolescents aged 13–18 years bear a large burden of sexually transmitted infections (STIs) and changing adolescent sexual risk behavior is a key component of reducing this burden. We demonstrate a novel publicly available modeling tool (teen-SPARC) to help state and local health departments predict the impact of behavioral change on gonorrhea, chlamydia, and HIV burden among adolescents. Methods: Teen-SPARC is built in Excel for familiarity and ease and parameterized using data from CDC's Youth Risk Behavior Surveillance System. We present teen-SPARC's methods, including derivation of national parameters and instructions to obtain local parameters. We model multiple scenarios of increasing condom use and estimate the impact on gonorrhea, chlamydia, and HIV incidence, comparing national and New York State (NYS) results. Results: A 1% annual increase in condom use (consistent with Healthy People 2020 goals) could prevent nearly 10,000 cases of STIs nationwide. Increases in condom use of 17.1%, 2.2%, and 25.5% in NYS would be necessary to avert 1000 cases of gonorrhea, 1000 cases of chlamydia, and 10 cases of HIV infection, respectively. Additional results disaggregate outcomes by age, sex, partner sex, jurisdiction, and pathogen. Conclusion: Teen-SPARC may be able to assist health departments aiming to tailor behavioral interventions for STI prevention among adolescents.

Social media recruitment is no longer an uncharted avenue for survey research. The results thus far provide evidence of an engaging means of recruiting hard-to-reach populations. Questions remain, however, regarding whether the data collected using this method of recruitment produce quality data. This article assesses one aspect that may influence the quality of data gathered through nonprobability sampling using social media advertisements for a hard-to-reach sexual and gender minority youth population: recruitment design formats. The data come from the Survey of Today’s Adolescent Relationships and Transitions, which used a variety of forms of advertisements as survey recruitment tools on Facebook, Instagram, and Snapchat. Results demonstrate that design decisions such as the format of the advertisement (e.g., video or static) and the use of eligibility language on the advertisements impact the quality of the data as measured by break-off rates and the use of nonsubstantive responses. Additionally, the type of device used affected the measures of data quality.

Preexposure prophylaxis (PrEP) with antiretroviral medication has been proven effective in reducing the risk for acquiring human immunodeficiency virus (HIV). The fixed-dose combination tablet of tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) was approved by the U.S. Food and Drug Administration (FDA) for use as PrEP for adults in 2012. Since then, recognition has been increasing that adolescents at risk for acquiring HIV can benefit from PrEP. In 2018, FDA approved revised labeling for TDF/FTC that expanded the indication for PrEP to include adolescents weighing at least 77 lb (35 kg) who are at risk for acquiring HIV. In 2019, FDA approved the combination product tenofovir alafenamide (TAF)/FTC as PrEP for adolescents and adults weighing at least 77 lb (35 kg), excluding those at risk for acquiring HIV through receptive vaginal sex. This exclusion is due to the lack of clinical data regarding the efficacy of TAF/FTC in cisgender women.Clinical providers who evaluate adolescents for PrEP use must consider certain topics that are unique to the adolescent population. Important considerations related to adolescents include PrEP safety data, legal issues about consent for clinical care and confidentiality, the therapeutic partnership with adolescents and their parents or guardians, the approach to the adolescent patient's clinical visit, and medication initiation, adherence, and persistence during adolescence. Overall, data support the safety of PrEP for adolescents. PrEP providers should be familiar with the statutes and regulations about the provision of health care to minors in their states. Providers should partner with the adolescent patient for PrEP decisions, recognizing the adolescent's autonomy to the extent allowable by law and including parents in the conversation about PrEP when it is safe and reasonable to do so. A comprehensive approach to adolescent health is recommended, including considering PrEP as one possible component of providing medical care to adolescents who inject drugs or engage in sexual behaviors that place them at risk for acquiring HIV. PrEP adherence declined over time in the studies evaluating PrEP among adolescents, a trend that also has been observed among adult patients. Clinicians should implement strategies to address medication adherence as a routine part of prescribing PrEP; more frequent clinical follow-up is one possible approach.PrEP is an effective HIV prevention tool for protecting adolescents at risk for HIV acquisition. For providers, unique considerations that are part of providing PrEP to adolescents include the possible need for more frequent, supportive interactions to promote medication adherence. Recommendations for PrEP medical management and additional resources for providers are available in the U.S. Public Health Service clinical practice guideline Preexposure Prophylaxis for the Prevention of HIV Infection in the United States - 2017 Update and the clinical providers' supplement Preexposure Prophylaxis for the Prevention of HIV Infection in the United States - 2017 Update: Clinical Providers' Supplement (https://www.cdc.gov/hiv/clinicians/prevention/prep.html).

BACKGROUND: In the United States, transgender youth are at especially high risk for HIV infection. Literature regarding HIV prevention strategies for this vulnerable, often-hidden population is scant. Before effective, population-based HIV prevention strategies may be adequately developed, it is necessary to first enhance the contextual understanding of transgender youth HIV risk and experiences with HIV preventive services. METHODS: Two 3-day, online, asynchronous focus groups were conducted with transgender youth from across the United States to better understand participant HIV risk and experiences with HIV preventive services. Participants were recruited by using online advertisements posted via youth organizations. Qualitative data were analyzed by using content analysis. RESULTS: A total of 30 transgender youth participated. The average age was 18.6 years, and youth reported a wide range of gender identities (eg, 27% were transgender male, 17% were transgender female, and 27% used >/=1 term) and sexual orientations. Four themes emerged: (1) barriers to self-efficacy in sexual decision-making; (2) safety concerns, fear, and other challenges in forming romantic and/or sexual relationships; (3) need for support and education; and (4) desire for affirmative and culturally competent experiences and interactions (eg, home, school, and health care). CONCLUSIONS: Youth discussed experiences and perspectives related to their gender identities, sexual health education, and HIV preventive services. Findings should inform intervention development to improve support and/or services, including the following: (1) increasing provider knowledge and skills to provide gender-affirming care, (2) addressing barriers to services (eg, accessibility and affordability as well as stigma and discrimination), and (3) expanding sexual health education to be inclusive of all gender identities, sexual orientations, and definitions of sex and sexual activity.

PURPOSE: Pre-exposure prophylaxis (PrEP) has been proven safe and effective in preventing HIV among adolescent sexual minority males (ASMM), but the cost-effectiveness of PrEP in ASMM remains unknown. Building on a recent epidemiological network modeling study of PrEP among ASMM, we estimated the cost-effectiveness of PrEP use in a high prevalence U.S. setting with significant disparities in HIV between black and white ASMM. METHODS: Based on the estimated number of infections averted and the number of ASMM on PrEP from the previous model and published estimates of PrEP costs, HIV treatment costs, and quality-adjusted life years (QALYs) gained per infection prevented, we estimated the cost-effectiveness of PrEP use in black and white ASMM over 10 years using a societal perspective and lifetime horizon. Effectiveness was measured as lifetime QALYs gained. Cost estimates included 10-year PrEP costs and lifetime HIV treatment costs saved. Cost-effectiveness was measured as cost/QALY gained. Multiple sensitivity analyses were performed on key model input parameters and assumptions used. RESULTS: Under base-case assumptions, PrEP use yielded an incremental cost-effectiveness ratio of $33,064 per QALY in black ASMM and $427,788 per QALY in white ASMM. In all sensitivity analyses, the cost-effectiveness ratio of PrEP use remained <$100,000 per QALY in black ASMM and >$100,000 per QALY in white ASMM. CONCLUSIONS: We found favorable cost-effectiveness ratios for PrEP use among black ASMM or other ASMM in communities with high HIV burden at current PrEP costs. Clinicians providing services in high-prevalence communities, and particularly those serving high-prevalence communities of color, should consider including PrEP services.

BACKGROUND: Pre-exposure prophylaxis (PrEP) is an effective and safe intervention approved for use to prevent HIV transmission. PrEP scale-up strategies and clinical practice are currently being informed by modeling studies, which have estimated the impact of PrEP in adult and adolescent MSM populations separately. This partitioning may miss important effects or yield biased estimates by excluding dependencies between populations. METHODS: We combined two published models of HIV transmission among adults and adolescent MSM. We simulated an HIV epidemic among MSM aged 13-39 without PrEP, with PrEP for adult MSM ages (19-39) and with the addition of PrEP for adolescents ages (16-18), comparing percent of incident infections averted (impact), the number of person-years on PrEP per infection averted (efficiency), and changes in prevalence. RESULTS: PrEP use among eligible 19-39 year old MSM averted 29.0% of infections and reduced HIV prevalence from 23.2% to 17.0% over ten years in the population as a whole. Despite being ineligible for PrEP in this scenario, prevalence among sexually active 18 year-olds declined from 6.0% to 4.3% due to reduced transmissions across age cohorts. The addition of PrEP for adolescents ages 16-18 had a small impact on the overall epidemic, further reducing overall prevalence from 17.0% to 16.8%; however prevalence among the sexually active 18 year-olds further declined from 4.3% to 3.8%. CONCLUSIONS: PrEP use among adults may significantly reduce HIV prevalence among MSM and may also have significant downstream effects on HIV incidence among adolescents; PrEP targeting adolescents remains an important intervention for HIV prevention.

Although adolescent sexual minority males (ASMM) are at increased risk for human immunodeficiency virus (HIV) in the United States (US), studies that estimate sexual risk behaviors that contribute to HIV risk in ASMM are limited. We completed a systematic review and meta-analysis to compile available data and estimate the prevalence of risk behaviors in this population. We searched four databases for key terms related to ASMM, defined as males aged 14 through 19 who identified as gay or bisexual, reported sex with a male in their lifetime, and/or were considered sexual minority by the study. Articles eligible for inclusion were in English, from US studies, and reported quantitative data on sexual risk behaviors among ASMM. We extracted data from eligible articles and meta-analyzed outcomes reported in three or more articles using random effects. Of 3864 articles identified, 21 were eligible for data extraction. We meta-analyzed nine outcomes. Sixty-two percent of adolescent males self-identifying as gay or bisexual ever had sex with a male, and 67% of participants from ASMM studies recently had sex. Among ASMM who had sex in the last 6 months or were described as sexually active, 44% had condomless anal intercourse in the past 6 months, 50% did not use a condom at last sex, and 32% used alcohol or drugs at their last sexual experience. Available data indicate that sexual risk behaviors are prevalent among ASMM. We need more data to obtain estimates with better precision and generalizability. Understanding HIV risk in ASMM will assist in intervention development and evaluation, and inform behavioral mathematical models.

Youths identifying as lesbian, gay, bisexual, or another nonheterosexual identity (sexual minority youths) report more violence victimization, substance use, and suicide risk than do heterosexual youths (1). These disparities are generally attributed to minority stress (the process through which stigma directed toward sexual minorities influences health outcomes) (2,3). Sexual minority youths might experience negative outcomes associated with minority stress differently across sexual identities, but to date, no nationally representative study has examined differences in victimization, substance use, and suicide risk within sexual minority youth. Using pooled data from the 2015 and 2017 national Youth Risk Behavior Surveys (YRBS), relationships between sexual identity groups and victimization, substance use, and suicide risk were evaluated with sex-stratified logistic regression models. Compared with heterosexual students, bisexual females and all sexual minority males reported more victimization; lesbian and bisexual females reported more use of alcohol, cigarettes, and marijuana; and all sexual minority youths reported elevated high-risk substance use and suicide risk. Programmatic efforts to reduce and prevent victimization, substance use, and suicide risk among sexual minority youths might benefit from consideration of issues within group differences.

OBJECTIVES: To assess the potential impact of preexposure prophylaxis (PrEP) on the HIV epidemic among Black and White adolescent sexual minority males (ASMM). METHODS: We used a network model and race-specific data from recent trials to simulate HIV transmission among a population of Black and White 13- to 18-year-old ASMM over 20 years. We estimated the number of infections prevented (impact) and the number needed to treat to prevent an infection (efficiency) under multiple coverage and adherence scenarios. RESULTS: At modeled coverage and adherence, PrEP could avert 3% to 20% of infections among Black ASMM and 8% to 51% among White ASMM. A larger number, but smaller percentage, of infections were prevented in Black ASMM in all scenarios examined. PrEP was more efficient among Black ASMM (number needed to treat to avert an infection = 25-32) compared with White ASMM (146-237). CONCLUSIONS: PrEP can reduce HIV incidence among both Black and White ASMM but is far more efficient for Black ASMM because of higher incidence. Public Health Implications. Black ASMM communities suffer disproportionate HIV burden; despite imperfect adherence, PrEP programs could prevent HIV efficiently in these communities.

Sexual health education, including HIV prevention information, can help prevent unintended pregnancy and sexually transmitted infections. National Youth Risk Behavior Survey data from 2011 and 2013 were used to determine HIV education prevalence among 9,825 currently sexually active students in grades 912. Associations between HIV education and contraceptive methods used at last sexual intercourse were examined for: (1) condom use; (2) any contraceptive method; (3) dual use of a condom and either birth control pills; IUD or implant; or shot, patch, or birth control ring; and (4) primary contraceptive method. Primary contraceptive method options were (1) no method; (2) birth control pills; (3) condoms; (4) IUD or implant; (5) shot, patch, or birth control ring; (6) withdrawal or some other method; and (7) not sure. Logistic regression (prevalence ratios [PRs] and 95% confidence intervals [CIs]) and Chi-squares were used for testing. Students who received HIV education were more likely than students who did not to use a condom (PR:1.09;CI:1.01,1.18) and any contraceptive method (PR:1.08;CI:1.04,1.12); there was no significant association with dual use. Primary contraceptive method varied significantly by receipt of HIV education (p<.001). School-based HIV education may be important for promotion of adolescent condom and contraceptive use.

Sexual minority youths (i.e., those identifying as gay, lesbian, bisexual, or another nonheterosexual identity or reporting same-sex attraction or sexual partners) are at higher risk than youths who are not sexual minority youth (nonsexual minority youth) for negative health behaviors and outcomes, including human immunodeficiency virus (HIV) infection, other sexually transmitted diseases (STDs), pregnancy (1),* and related sexual risk behaviors (2). Less is known about sexual risk behavior differences between sexual minority youth subgroups. This is the first analysis of subgroup differences among sexual minority youths using nationally representative Youth Risk Behavior Survey (YRBS) data. CDC analyzed pooled data from the 2015 and 2017 cycles of the national YRBS, a cross-sectional, school-based survey assessing health behaviors among U.S. students in grades 9-12. Analyses examined differences in eight sexual risk behaviors between subgroups of sexual minority youths and nonsexual minority youths, as well as within sexual minority youths. Logistic regression models controlling for race/ethnicity and grade found that bisexual females and "not sure" males reported higher prevalences for many behaviors than did heterosexual students. For behavior-based subgroups, the largest number of differences were seen between students who had sexual contact with both sexes compared with students with only opposite-sex sexual contact. Findings highlight subgroup differences within sexual minority youths that could inform interventions to promote healthy behavior.

This study sought to determine why young men who have sex with men (MSM) have higher HIV incidence rates than older MSM in the United States. We developed hypotheses that may explain this disparity. Data came from peer-reviewed studies published during 1996-2016. We compared young and older MSM with respect to behavioral, clinical, psychosocial, and structural factors that promote HIV vulnerability. Compared with older MSM, young MSM were more likely to have HIV-discordant condomless receptive intercourse. Young MSM also were more likely to have "any" sexually transmitted infection and gonorrhea. Among HIV-positive MSM, young MSM were less likely to be virally suppressed, use antiretroviral therapy, and be aware of their infection. Moreover, young MSM were more likely than older MSM to experience depression, polysubstance use, low income, decreased health care access, and early ages of sexual expression. These factors likely converge to exacerbate age-associated HIV incidence disparities among MSM.

In 2014, persons aged 13-29 years represented 23% of the U.S. population, yet accounted for 40% of diagnoses of human immunodeficiency virus (HIV) infection during the same year (1). During 2010-2014, the rates of diagnosis of HIV infection decreased among persons aged 15-19 years, were stable among persons aged 20-24 years, and increased among persons aged 25-29 years (1). However, these 5-year age groups encompass multiple developmental stages and potentially mask trends associated with the rapid psychosocial changes during adolescence through young adulthood. To better understand HIV infection among adolescents aged 13-17 years and young adults aged 18-29 years in the United States and identify ideal ages to target primary HIV prevention efforts, CDC analyzed data from the National HIV Surveillance System (NHSS)* using narrow age groups. During 2010-2014, rates of diagnosis of HIV infection per 100,000 population varied substantially among persons aged 13-15 years (0.7), 16-17 years (4.5), 18-19 years (16.5), and 20-21 years (28.6), and were higher, but less variable, among persons aged 22-23 years (34.0), 24-25 years (33.8), 26-27 years (31.3), and 28-29 years (28.7). In light of the remarkable increase in rates between ages 16-17, 18-19, and 20-21 years, and a recent study revealing that infection precedes diagnosis for young persons by an average of 2.7 years (2), these findings demonstrate the importance of targeting primary prevention efforts to persons aged <18 years and continuing through the period of elevated risk in their mid-twenties.

PURPOSE: To assess the optimal age at which a one-time HIV screen should begin for adolescents and young adults (AYA) in the U.S. without identified HIV risk factors, incorporating clinical impact, costs, and cost-effectiveness. METHODS: We simulated HIV-uninfected 12-year-olds in the U.S. without identified risk factors who faced age-specific risks of HIV infection (.6-71.3/100,000PY). We modeled a one-time screen ($36) at age 15, 18, 21, 25, or 30, each in addition to current U.S. screening practices (30% screened by age 24). Outcomes included retention in care, virologic suppression, life expectancy, lifetime costs, and incremental cost-effectiveness ratios in $/year-of-life saved (YLS) from the health-care system perspective. In sensitivity analyses, we varied HIV incidence, screening and linkage rates, and costs. RESULTS: All one-time screens detected a small proportion of lifetime infections (.1%-10.3%). Compared with current U.S. screening practices, a screen at age 25 led to the most favorable care continuum outcomes at age 25: proportion diagnosed (77% vs. 51%), linked to care (71% vs. 51%), retained in care (68% vs. 44%), and virologically suppressed (49% vs. 32%). Compared with the next most effective screen, a screen at age 25 provided the greatest clinical benefit, and was cost-effective ($96,000/YLS) by U.S. standards (<$100,000/YLS). CONCLUSIONS: For U.S. AYA without identified risk factors, a one-time routine HIV screen at age 25, after the peak of incidence, would optimize clinical outcomes and be cost-effective compared with current U.S. screening practices. Focusing screening on AYA ages 18 or younger is a less efficient use of a one-time screen among AYA than screening at a later age.