Title: Assessing the Impact of State-Level Confidentiality-Relevant Laws on U.S. Adolescents’ HIV Testing Practices
Description: Background. In the United States, adolescents are the age group least likely to be aware of their HIV infection and linked to care in a timely manner, contributing to disproportionately low rates of viral suppression and increased risk of transmitting HIV to others. A major barrier to health care for adolescents relates to confidentiality concerns, such as fears that parent/guardian consent will be required or that parents, guardians, or others will be informed of test results. This suggests that state laws related to confidentiality in sexual and reproductive health services could influence their HIV testing practices. Guided by Andersen’s Behavioral Model of Health Services Use, this dissertation utilizes a large, representative sample of sexually active high school students from the 2019 state-level Youth Risk Behavior Surveillance System (YRBSS) to investigate the potential impact of five state-level confidentiality-relevant laws on U.S. adolescents’ HIV testing practices. Methods.

Data on HIV testing and individual characteristics (i.e., potential individual-level confounders/covariates) were aggregated from 25 states that participated in the 2019 state-level YRBSS. Data on contextual characteristics (i.e., potential state-level confounders/covariates) were obtained from the United States Census Bureau and the Behavior Risk Factor Surveillance System. Information about state-level confidentiality-relevant laws was compiled from the Guttmacher Institute and the Center for HIV Law and Policy to create five variables indicating whether state laws were confidentiality-promoting at the time of the 2019 state-level YRBSS. Multilevel logistic regression was used to test the following hypotheses: 1. After adjusting for individual and contextual characteristics, confidentiality-promoting state laws will be positively associated with HIV testing among sexually active U.S. high school students, such that odds of self-reported lifetime HIV testing will be significantly higher when states (a) explicitly allow minors to consent to HIV testing, (b) do not have age of consent requirements, (c) do not permit parental/guardian notification, (d) protect the confidentiality of minors insured as dependents, and (e) do not have HIV-specific criminal laws that require disclosure to sexual and/or needle-sharing partners, as compared to states with non-confidentiality-promoting laws. 2.

After adjusting for individual and contextual characteristics, sex will moderate the relationship between state-level confidentiality-relevant laws and HIV testing among sexually active U.S. high school students, such that associations between confidentiality-promoting state laws and self-reported lifetime HIV testing will significantly differ between males and females. 3. After adjusting for individual and contextual characteristics, young men who have sex with men (YMSM) status will moderate the relationship between state-level confidentiality-relevant laws and HIV testing among sexually active male high school students, such that associations between confidentiality-promoting state laws and lifetime HIV testing will be significantly stronger among males who report same-sex sexual contact than among males who report opposite-sex sexual contact only. Results. Findings supported the first hypothesis that parental notification not being permitted would be positively associated with HIV testing among sexually active U.S. high school students.

After adjusting for individual (i.e., sex, grade level, race/ethnicity, sexual identity) and contextual (i.e., percentage of the state population aged 25 and older with a high school diploma or higher, median household income, lifetime HIV testing among adults) characteristics, odds of self-reported lifetime HIV testing were significantly higher in states that do not permit parent/guardian notification (adjusted odds ratio [aOR]: 1.07; 95% confidence interval [CI]: 1.04-1.11; p<.001) than in states that allow health care providers to inform parents or guardians that their child is seeking or receiving STI services. However, results did not support the hypothesis that the other confidentiality-promoting state laws would be positively associated with HIV testing among sexually active U.S. high school students; as compared to states with non-confidentiality-promoting laws, odds of self-reported lifetime HIV testing were significantly lower in states that explicitly allow minors to consent to HIV testing, do not have age requirements to consent to HIV testing, and do not have HIV-specific criminal laws that require disclosure.

Results supported the second hypothesis that sex would moderate the relationship between state-level confidentiality-relevant laws and HIV testing among sexually active U.S. high school students, as associations between confidentiality-promoting state laws and lifetime HIV testing differed significantly between males and females. After adjusting for individual and contextual characteristics, the effects of living in a state without age requirements or HIV-specific criminal laws with disclosure requirements on lifetime HIV testing for females were 1.53 (CI: 1.07-2.20; p=.020) and 1.56 (CI: 1.16-2.10; p=.003) times those of males, respectively. Meanwhile, the effects of state laws that explicitly allow minors to consent to HIV testing, do not permit parental notification, and protect the confidentiality of minors insured as dependents on lifetime HIV testing for females were 0.73 (CI: 0.55-0.96; p=.025), 0.72 (CI: 0.52-0.99; p=.043), and 0.66 (CI: 0.48-0.90; p=.008) times those of males, respectively.

Analyses with these data failed to reject the null hypothesis for the third [alternative] hypothesis that associations between confidentiality-promoting state laws and self-reported lifetime HIV testing would be significantly stronger among sexually active males who report same-sex sexual contact than among males who report opposite-sex sexual contact only. Conclusions. Findings provide evidence that parental notification not being permitted is associated with significantly increased odds of lifetime HIV testing among sexually active U.S. adolescents, and that sex differentially affects associations between state-level confidentiality-relevant laws and sexually active U.S. adolescents’ HIV testing practices. Parental/guardian notification not being permitted may increase access to and utilization of HIV testing among sexually active U.S. adolescents. Furthermore, confidentiality-promoting laws – particularly those that explicitly include HIV testing in the package of STI services to which minors may consent, do not permit health care providers to notify parents/guardians that their child is seeking or receiving STI services, and protect the confidentiality of minors insured as dependents – may facilitate access to and utilization of HIV testing for sexually active male adolescents.

Altogether, this dissertation provides compelling preliminary evidence for efforts to better understand and address structural determinants of HIV and HIV prevention among sexually active U.S. adolescents. Results underscore the need for a comprehensive, multi-level approach to adolescent HIV prevention that goes beyond a focus on reducing individual-level risk factors to increase protective factors at the structural level (e.g., confidentiality-promoting state laws). To address HIV-related health inequities among young people in the United States, advocates must fight for the passage of state laws that protect adolescents’ right to confidential sexual and reproductive health care.