138 th American Public Health Association Annual Meeting Denver, Colorado November 8, 2010 Determinants of HIV Testing Among High School Students with a History of Substance Use in the United States, 2009 National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention Division of HIV/AIDS Prevention Presented by: Shubha Rao, MBBS, MPH Co-Authors: Alexandra Balaji, PhD; Sonia Singh, PhD, MHS; Mesfin Mulatu, PhD; John Beltrami, MD, MPH&TM

Presenter’s Disclosure Shubha Rao Personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months No relationships to disclose

Acknowledgements  Steve Kinchen, Division of Adolescent and School Health, CDC  Laura Kahn, Division of Adolescent and School Health, CDC  Salaam Semaan, National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention, CDC  Tonji Durant, Division of HIV/AIDS Prevention, CDC  Merriah Croston, Division of HIV/AIDS Prevention, Northrop Grumman (Contractor)

Background  In 2009, 46.7% of high school students used illicit substances in the United States  Substance use is a risk factor for HIV infection  An estimated 48.0% of HIV-infected persons aged years are unaware of their infection  Two national surveys documented that 10.0%-12.7% of adolescents and young adults in the United States were ever tested for HIV

Local studies of HIV testing among U.S. adolescents using substances  Small, non-nationally representative samples  High-risk adolescent populations  Adolescents tested for HIV ranged from 11.5% to 62.5%  HIV-related sexual risk factors associated with testing

National analysis of HIV testing among U.S. adolescents and young adults  Wave III of the National Longitudinal Study of Adolescent Health (2006)  Sexually-experienced adolescents and young adults, aged years  18.8% were tested for HIV in the past 12 months

Objective  To examine the association between HIV testing and health-risk and violence-related behaviors among high school students who have ever used substances

METHODS

Data Source  2009 National Youth Risk Behavior Survey (YRBS)  Monitors the prevalence of health risk behaviors among nationally representative high school students (grades 9-12)  Three-stage cluster sample design  Overall student response rate was 71% (N=16,410)  Analytic Sample  Selected all students with a history of ever using substances (n= 12,260), i.e., intake of alcohol, marijuana, cocaine, heroin, methamphetamine, ecstasy, steroids, and injecting illegal substances

Variables Used in Analysis  Demographic characteristics  age, sex, and race/ethnicity  HIV testing  Sexual risk behaviors  ever had sexual intercourse  ever forced to have sexual intercourse  unprotected sex at last sexual intercourse  first sexual intercourse before 13 years of age  sexual intercourse with >=4 sexual partners  alcohol or drug use before last sexual intercourse  Violence-related behaviors  initiated/injured in fight within the past 12 months  carried a gun within the past 30 days  hit by boyfriend or girlfriend within the past 12 months

Analytic Methods  Analyses were conducted using SUDAAN version  Accounted for the complex sampling design and weighting  Multivariate logistic regression  Unadjusted and Adjusted Odds Ratio (ORs) 95% Confidence Intervals (CIs)  Demographic characteristics, sexual risk, and violence-related behaviors  Estimated group matched interactions Substance use by sexual risk behaviors Substance use by violence-related behaviors

RESULTS

Demographic Characteristics Among High School Students Using Substances – YRBS, 2009* CharacteristicsSubstance users No.% Overall Age <= 14 years years years years >= 18 years Sex Male Female Race/ethnicity White, non-Hispanic Black, non-Hispanic Hispanic Other * Missing values were excluded from the analysis. The number of records for each variable does not sum to the total number of records due to missing information.

Sexual Risk Behaviors Among High School Students Using Substances – YRBS, 2009* CharacteristicsSubstance users No.% Ever had sexual intercourse Yes No Ever forced to have sexual intercourse Yes No Unprotected sex at last sexual intercourse Yes No First intercourse before 13 years of age Yes No Sexual intercourse with >= 4 partners Yes No * Missing values were excluded from the analysis. The number of records for each variable does not sum to the total number of records due to missing information.

Violence-Related Behaviors Among High School Students Using Substances – YRBS, 2009* CharacteristicsSubstance users No.% Initiated/injured in a fight within the past 12 months Yes No Carried gun within the past 30 days Yes No Experienced dating violence within the past 12 months Yes No * Missing values were excluded from the analysis. The number of records for each variable does not sum to the total number of records due to missing information.

Association of HIV Testing and Demographic Factors Among High School Students Using Substances – YRBS, 2009* CharacteristicsStudents tested for HIV No. (%) Adjusted Odds Ratio (95% CI) Overall 1780 (16.1) Age <= 14 years 80 (7.6)1.00 (Referent) 15 years 259 (10.8)1.32 ( ) 16 years 417 (13.2)1.51 ( ) 17 years 573 (18.5)1.92 ( ) >= 18 years 439 (21.8)2.05 ( ) Sex Female 1020 (17.4)1.92 ( ) Male 748 (12.3)1.00 (Referent) Race/ethnicity White, non-Hispanic 692 (13.2)1.00 (Referent) Black, non-Hispanic 484 (24.1)1.53 ( ) Hispanic 453 (14.1)1.02 ( ) Other 110 (11.4)0.78 ( ) * Missing values were excluded from the analysis. The number of records for each variable does not sum to the total number of records due to missing information.

Association of HIV Testing and Sexual Risk Behaviors Among High School Students Using Substances – YRBS, 2009* CharacteristicsStudents tested for HIV No. (%) Adjusted Odds Ratio (95% CI) Ever had sexual intercourse Yes 1471 (22.9)3.81 ( ) No 183 (3.9)1.00 (Referent) Ever forced to have sexual intercourse Yes 370 (15.7)1.10 ( ) No 1405 (14.7)1.00 (Referent) Unprotected sex at last sexual intercourse Yes 691 (29.5)1.39 ( ) No 938 (10.8)1.00 (Referent) First intercourse before 13 years of age Yes 260 (31.7)1.24 ( ) No 1391 (13.4)1.00 (Referent) Sexual intercourse with >= 4 partners Yes 707 (35.0)2.17 ( ) No 931 (10.3)1.00 (Referent) Alcohol or drug use before last sexual intercourse Yes 389 (27.6)1.04 ( ) No 1261 (12.8)1.00 (Referent) * Missing values were excluded. The number of records for each variable does not sum to the total number of records due to missing information.

Association of HIV Testing and Violence-Related Behaviors Among High School Students Using Substances – YRBS, 2009* CharacteristicsStudents tested for HIV No. (%) Adjusted Odds Ratio (95% CI) Initiated/injured in a fight within the past 12 months Yes 171 (31.6)1.87 ( ) No 1567 (14.0)1.00 (Referent) Carried gun within the past 30 days Yes 450 (19.5)1.39 ( ) No 1270 (13.4)1.00 (Referent) Experienced dating violence within the past 12 months Yes 333 (33.9)1.45 ( ) No 1386 (13.0)1.00 (Referent) * Missing values were excluded from the analysis. The number of records for each variable does not sum to the total number of records due to missing information.

Limitations  Cross-sectional design of the study  Self-reported data  Results apply to adolescents attending high school  10% non-response rate on the HIV testing question  Multiple imputation analysis is planned to impute missing values

Conclusions  The overall prevalence of HIV testing among U.S. high school students with a history of substance use is low  Substance users with a history of high-risk sexual and violence-related behaviors were more likely to be tested for HIV

Recommendations  Increased HIV testing is needed for adolescents using substances - Involve communities, families, and schools  Strategies for expanding HIV testing services and developing effective behavioral interventions for adolescents using substances should address sexual and violence-related behaviors

For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA Telephone, CDC-INFO ( )/TTY: Web: 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. FOLLOW-UP CONTACT Shubha Rao, MBBS, MPH Shubha Rao, MBBS, MPH Epidemiologist Data Systems and Analysis Team Program Evaluation Branch 1600 Clifton Road NE, Mailstop E-59 Atlanta, GA voice: fax: National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention Division of HIV/AIDS Prevention