1. Division of Adolescent and School Health
Why the Disparities: The First National Look at HIV-Related Risk Behaviors Among Sexual Minority Male High School Students, United States, 2015
Laura Kann PhD, Emily O’Malley Olsen MSPH, Tim McManus MS, and Stephanie Zaza MD
AIDS 2016
July 20, 2016
Thank you. Before I begin - I would like to thank my co-authors that you see listed on this slide. All of us are from the Division of Adolescent and School Health at the CDC in Atlanta.

2. Background
22% of all new HIV diagnoses in the US in 2014 occurred among year olds
Most of these diagnoses occurred among males who have sex with males (MSM)
Insufficient information exists about
The number of young sexual minority males nationwide
How HIV-related risk behaviors vary between young sexual minority males and non-sexual minority males
In the United States, an estimated 22% of all new HIV diagnoses occur among year olds and most of these diagnoses occur among males who have sex with males. This makes young males – an important focus for HIV prevention efforts. Key to these prevention efforts is a clear and accurate understanding of the number of young sexual minority males nationwide and an understanding of how HIV-related risk behaviors vary (or not) between young sexual minority and non-sexual minority males. To date, insufficient information has existed about both of these issues in the US.

3. Purpose
To use 2015 National Youth Risk Behavior Survey (YRBS) data to describe
The number of sexual minority males in US high schools
How HIV-related risk behaviors vary between sexual minority and non-sexual minority males
Sexual behaviors directly related to HIV infection
Drug use directly related to and associated with HIV infection
Consequently, the purpose of this presentation is to describe (1) the number of sexual minority males in US high schools and (2) how HIV-related risk behaviors vary between sexual minority and non-sexual minority males.

4. Turning to our Methods…

5. Sample
3-stage cluster sample design
Schools selected with probability proportional to size
Classes selected randomly
All students in sampled classes included
Nationally representative of public and private school students in grades 9-12 in the US
The 2015 National YRBS used a 3-stage cluster sample design with schools selected with probability proportional to enrollment in grades 9-12 followed by random selection of classes. All students in sampled classes were included in the survey. The 2015 National YRBS data are representative of public and private school students in grades 9-12 in the US.

6. Sampling Outcome
Response rates
School – 69%
Student – 86%
Overall – 60%
Sample size - 15,624
This slide shows the school, student, and overall response rates from the 2015 national YRBS. More than 15,000 students participated.

7. Survey Administration
Anonymous and voluntary
Parental permission following local procedures
Self-administered, computer-scannable questionnaire with 99 multiple choice questions
Completed in one class period
The National YRBS is an anonymous and voluntary survey. Parental permission was obtained prior to survey administration following local procedures. The students were provided with a self-administered, computer scannable questionnaire with 99 multiple choice questions that they completed on their own during one regular class period. IRB approval for the survey was obtained at CDC.

8. Questionnaire Content
Behaviors that contribute to unintentional injuries and violence
Tobacco use
Sexual behaviors
Alcohol and other drug use
Unhealthy dietary behaviors
Inadequate physical activity
The National YRBS has always measured the 6 categories of behaviors that you see on this slide.

9. Questionnaire Content
Behaviors that contribute to unintentional injuries and violence
Tobacco use
Sexual behaviors
Alcohol and other drug use
Unhealthy dietary behaviors
Inadequate physical activity
This presentation will focus on selected sexual behaviors and alcohol and other drug use behaviors that are most closely linked with HIV infection.

10. Questionnaire Content: Measurement of Sexual Minority Status
Sex of sexual contacts
Sexual identity
In addition, starting with the 2015 national YRBS questionnaire 2 questions were added for the first time to measure sexual minority status. The first focused on sex of sexual contacts. The second question focused on sexual identity regardless of whether or not the student had had sexual contact.
Both constructs were deemed important for identifying sexual minority students and for gaining the most complete understanding of how HIV-related risk behaviors vary between sexual minority and non-sexual minority students. Because adolescence is a time when many people develop and explore their sexuality it is possible for dissonance to occur between sexual identity and sex of sexual contacts.

11. Questionnaire Content: Measurement of Sex of Sexual Contacts
During your life, with whom have you had sexual contact?
I have never had sexual contact
Females
Males
Females and males
This is the question used to measure sex of sexual contacts. Sexual contact was not defined but presumably students considered a wide range of sexual activities including, but not limited to, kissing, touching, and sexual intercourse as well as involuntary sexual activities.

12. Questionnaire Content: Measurement of Sex of Sexual Contacts
During your life, with whom have you had sexual contact?
I have never had sexual contact
Females
Males
Females and males
Sexual minority
For this analysis, male students who selected response option C (males) or response option D (females and males) were combined into a single sexual minority subgroup

13. Questionnaire Content: Measurement of Sex of Sexual Contacts
During your life, with whom have you had sexual contact?
I have never had sexual contact
Females
Males
Females and males
Sexual minority
and compared to male students who selected response option A (I have never had sexual contact) and to male students who selected response option B (females).

14. Questionnaire Content: Measurement of Sexual Identity
Which of the following best describes you?
Heterosexual (straight)
Gay or lesbian
Bisexual
Not sure
This is the question used to measure sexual identity.

15. Questionnaire Content: Measurement of Sexual Identity
Which of the following best describes you?
Heterosexual (straight)
Gay or lesbian
Bisexual
Not sure
Sexual minority
For this analysis, male students who selected response option B (gay) or response option C (bisexual) were combined into a single sexual minority subgroup

16. Questionnaire Content: Measurement of Sexual Identity
Which of the following best describes you?
Heterosexual (straight)
Gay or lesbian
Bisexual
Not sure
Sexual minority
and compared to male students who selected response option A (heterosexual or straight).

17. Data Analysis
Weighting
Based on student sex, race/ethnicity, and grade in school
Adjusted for non-response and oversampling of black and Hispanic students
All females excluded
T-tests to detect significant (p<0.05) pairwise differences in HIV-related risk behaviors by sexual identity and by sex of sexual contact subgroups
Prior to data analyses - The national YRBS data were weighted and adjusted for non-response and the oversampling of black and Hispanic students. For this analysis, all females were excluded. T-tests were then used to detect significant pairwise differences in HIV-related risk behaviors by sexual identity and by sex of sexual contact subgroups

18. And now for the results…

19. Never Had Sexual Contact
Distribution of sexual identity and sex of sexual contact subgroups among male high school students in the US, 2015
Sexual Identity
Sex of Sexual Contacts
Heterosexual
Gay
Bisexual
Unsure
Females Only
Males
Only
Both Males and Females
Never Had Sexual Contact
93.1%
2.0%
2.4%
2.6%
53.3%
1.3%
1.9%
43.6%
7,479,188
160,670
192,804
208,871
4,281,856
104,436
152,636
3,502,606
This first slide provides the first ever estimates of the number of sexual minority male students in US high schools.
2015 National Youth Risk Behavior Survey

20. Never Had Sexual Contact
Distribution of sexual identity and sex of sexual contact subgroups among male high school students in the US, 2015
Sexual Identity
Sex of Sexual Contacts
Heterosexual
Gay
Bisexual
Unsure
Females Only
Males
Only
Both Males and Females
Never Had Sexual Contact
93.1%
2.0%
2.4%
2.6%
53.3%
1.3%
1.9%
43.6%
7,479,188
160,670
192,804
208,871
4,281,856
104,436
152,636
3,502,606
Of the approximately 8 million male high school students in the US, 4.4% identify as gay or bisexual.
2015 National Youth Risk Behavior Survey

21. Never Had Sexual Contact
Distribution of sexual identity and sex of sexual contact subgroups among male high school students in the US, 2015
Sexual Identity
Sex of Sexual Contacts
Heterosexual
Gay
Bisexual
Unsure
Females Only
Males
Only
Both Males and Females
Never Had Sexual Contact
93.1%
2.0%
2.4%
2.6%
53.3%
1.3%
1.9%
43.6%
7,479,188
160,670
192,804
208,871
4,281,856
104,436
152,636
3,502,606
And about 3.2% have had sexual contact with only males or with both males and females.
2015 National Youth Risk Behavior Survey

22. Behaviors related directly and indirectly to HIV infection
The next slides show estimates for sexual behaviors that are directly related to HIV infection and drug use behaviors related to HIV infection directly (when injection is the mode of administration) and indirectly (when drug use increases the likelihood of unsafe sexual behaviors).
These estimates are shown for male high school students by sexual identity and by sex of sexual contact subgroups. Red arrows indicate where statistically significant differences were identified.

23. Percentage of male high school students who reported HIV-related sexual behaviors, by sexual identity, 2015
Ever had sexual Had intercourse Current sexual Condom use**
intercourse with 4+ persons activity*
Starting first with the sexual behaviors - This slides shows the percentage of male high school students by sexual identity who ever had sexual intercourse, had sexual intercourse with 4 or more persons, were currently sexually active, and who used a condom at last sexual intercourse. Sexual intercourse was not defined and could include vaginal, anal, or oral sex. None of these behaviors varied statistically between heterosexual and gay or bisexual male students.
*Had sexual intercourse during the 3 months before the survey.
**Among students who were currently sexually active.
2015 National Youth Risk Behavior Survey

24. Percentage of male high school students who reported HIV-related sexual behaviors, by sex of sexual contact, 2015
Ever had sexual Had intercourse Current sexual Condom use**
intercourse with 4+ persons activity*
Similarly, this slide shows the percentage of male high school students by sex of sexual contact who reported the same 4 sexual behaviors. Again, there were no statistical differences between the 2 sex of sexual contact subgroups.
Note: Male students who had no sexual contact were excluded from these analyses.
*Had sexual intercourse during the 3 months before the survey.
**Among students who were currently sexually active.
2015 National Youth Risk Behavior Survey

25. Percentage of male high school students who ever used a needle to inject any illegal drug into their body,* by subgroup, 2015
Sexual Identity Sex of Sexual Contacts
However, when we look at the drug use behaviors we see a different story. This slide shows the percentage of male high school students who ever used a needle to inject any illegal drug into their body one or more times during their life by sexual identity and by sex of sexual contact subgroups. Note that gay and bisexual male students were significantly more likely than heterosexual male students to have injected drugs and that male students who had sexual contact with only males or with both males and females were significantly more likely than the other 2 sexual contact subgroups to report injected drug use.
*One or more times during their life.
2015 National Youth Risk Behavior Survey

26. Percentage of male high school students who ever used heroin,
Percentage of male high school students who ever used heroin,* by subgroup, 2015
This slide shows the percentage of male high school students who ever used heroin. Gay and bisexual male students and male students who had sexual contact with only males or with both males and females were significantly more likely than the other subgroups to report heroin use.
Sexual Identity Sex of Sexual Contacts
*One or more times during their life.
2015 National Youth Risk Behavior Survey

27. Percentage of male high school students who ever used cocaine,
Percentage of male high school students who ever used cocaine,* by subgroup, 2015
Sexual Identity Sex of Sexual Contacts
This slide shows the percentage of male high school students who ever used cocaine. Note the same pattern of statistically significant differences.
*Any form of cocaine (e.g., powder, crack, or freebase) one or more times during their life.
2015 National Youth Risk Behavior Survey

28. Percentage of male high school students who ever used methamphetamines,* by subgroup, 2015
This slide shows the percentage of male high school students who ever used methamphetamines. Again, the same pattern of differences exist between subgroups.
Sexual Identity Sex of Sexual Contacts
*One or more times during their life.
2015 National Youth Risk Behavior Survey

29. Percentage of male high school students who ever took prescription drugs without a doctor’s prescription,* by subgroup, 2015
Sexual Identity Sex of Sexual Contacts
Finally, this slide shows the percentage of male high school students who ever took prescription drugs without a doctor’s prescription and the statistically significant differences.
*Such as Oxycontin, Percocet, Vicodin, codeine, Adderall, Ritalin, or Xanax, one or more times during their life.
2015 National Youth Risk Behavior Survey

30. Limitations Results apply only to males who attend school
3% of all year olds not enrolled and not completed high school
Sexual minority youth might represent disproportionate percent of dropouts
Extent of underreporting or overreporting cannot be determined
Some students may not know their sexual identity, may be unwilling to disclose it or label themselves, or may not have understood the question
As with all studies, this one has its limitations. Obviously, because this was a school-based survey, the results apply only to males who attend school and not all young males. While most young sexual minority males are in school other research also documents that sexual minority youth might represent a disproportionate percent of school dropouts.
Second, as is common with surveys like the YRBS, the extent of under and over reporting cannot be determined although the survey questions demonstrate good test-retest reliability.
Third, it is possible that some students may not know their sexual identity, may be unwilling to disclose it or label themselves, or may not have understood the question. However, we do not have evidence that the words used to describe various types of sexual identity are unclear to high school students in the US.

31. Conclusions
Collecting high quality, national population-based data on the number of young sexual minority males is possible
The prevalence of injected drug use among young sexual minority males is disturbing
Prevalence of sexual behaviors alone that directly cause HIV infection are not causing disparities in rates of HIV diagnoses between young MSM and young males who have sex with females
Other factors to be considered
Sexual practices
Sexual networks
Social issues
There are three main conclusions from these analyses …
First, to support HIV-prevention efforts, it is important to have high quality, national population-based data on the number of sexual minority males in US high schools. It is hard to respond appropriately to a population that has not been counted. We now know that collecting those data is possible.
Second, the prevalence of injected drug use among young sexual minority males is disturbing and a cause for great concern because of the efficiency with which injected drug use transmits not only HIV infection, but hepatitis and other diseases.
Third, these analyses do not provide evidence that differences in the prevalence of sexual behaviors alone are causing the disparities in HIV diagnoses between young MSM and other young males. This finding is consistent with similar research done among older MSM. This finding also suggests that other factors are placing young MSM at substantially higher risk for HIV infection.
For example, we know from other research that the frequency of receptive anal sex and the prevalence of HIV, the amount of undiagnosed and untreated HIV infection, and the prevalence of other STI among the sex partners of young MSM increases risk of HIV infection from any single act of sex. The sexual practices and sexual networks of young MSM simply put young MSM at far greater risk of infection.
In addition, many young MSM suffer from social isolation, stress from self-concealment and coming out, discrimination, and even hatred which may occur at home, at school, and within their communities among both their peers and the adults responsible for their care and protection. These factors may lead to harmful coping behaviors (such as drug use as evidenced in this presentation) that can further increase risk for HIV infection.

32. Recommendations
Address the social issues that result in social isolation, stress, and discrimination
Conduct new research on injected drug use among young sexual minority males
Improve access to HIV testing
Improve linkage to and retention in medical care
Provide more risk reduction education and HIV prevention strategies
Offer more school-centered HIV prevention
Continue measurement of health-risk behaviors among young sexual minority males through large, population-based surveys
So – it is hard to imagine how even the best intervention technology will be able eliminate the disparities in HIV diagnoses unless these social issues are addressed.
Further, new research is needed to better understand injected drug use among young sexual minority males and what can be done to minimize if not eliminate this very high risk behavior that is occurring at alarming rates.
In addition, young sexual minority males need improved access to HIV testing. Those who are infected also need to be linked to treatment and retained in medical care. Further, all young sexual minority males need access to the full range of HIV prevention strategies, including condoms, biomedical interventions, as appropriate, and more school-centered HIV prevention. School programs should focus on providing a safe and supportive environment for all youth including reduced bullying and harassment, on access to youth-friendly health care, and on primary prevention of HIV-related sexual and drug use behaviors.
Further, it is important to continue to measure health-risk behaviors among young sexual minority males through large, population-based surveys.
Reducing HIV infection among young sexual minority males is key to reducing HIV infection in the US. Thank you.

33. Thank you!
Thank you.