Confidentiality-promoting state laws and sex differences in HIV testing among sexually experienced U.S. high school students.

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Published in final edited form as: AIDS Care. 2025 Mar 6;37(6):901–913. doi: 10.1080/09540121.2025.2473945 Confidentiality-Promoting State Laws and Sex Differences in HIV Testing Among Sexually Experienced U.S. High School Students Christina Aivadyan 1 , Nabila El-Bassel 2 , Mingway Chang 3 , Morgan Philbin 4 , Elwin Wu 5 Author information Article notes Copyright and License information 1 School of Public Health, Yale University, New Haven, CT, USA 2 School of Social Work, Columbia University, New York, NY, USA 3 School of Social Work, Columbia University, New York, NY, USA 4 School of Medicine, University of California San Francisco, San Francisco, CA, USA 5 School of Social Work, Columbia University, New York, NY, USA ✉ Please direct correspondence to : Christina Aivadyan, Yale School of Public Health, 35 College Street, Suite 200, New Haven, CT 06510, christina.aivadyan@yale.edu Issue date 2025 Jun. PMC Copyright notice PMCID: PMC12167680  NIHMSID: NIHMS2065827  PMID: 40047278 The publisher's version of this article is available at AIDS Care Abstract Confidentiality concerns are a well-established barrier to sexual health services for adolescents. Given that gender is one of the most salient individual-level factors associated with adolescent HIV testing, we examined whether associations between confidentiality-promoting state laws (i.e., states that explicitly allowed minors to consent to HIV testing, did not have an age clause which set a minimum age to consent to sexual health services , did not permit parental notification, had confidentiality protections for insured dependents) and HIV testing varied between sexually experienced male and female high school students in the 2019 state-level Youth Risk Behavior Surveillance System ( N =46,444). In most cases, females were more likely than males to test for HIV – regardless of whether laws were confidentiality-promoting. Males were significantly more likely to report HIV testing in states that explicitly allowed minors to consent to HIV testing, did not permit parental notification, or had confidentiality protections for insured dependents. Females were significantly less likely to report HIV testing in states that had confidentiality protections for insured dependents. These findings suggest that the potential impact of state laws regulating minors’ access to confidential sexual health services on adolescent HIV testing may vary substantially by sex, and that certain confidentiality-promoting laws may facilitate HIV testing for male adolescents in particular. Keywords: Confidentiality, Adolescents, HIV testing, Good health and well-being, Gender equality, Reduced inequalities Introduction Despite population-level progress in reducing the number of new HIV infections in the United States (U.S.), adolescents – particularly minors under age 18 – continue to face distinct inequities in access to HIV prevention services ( Guilamo-Ramos et al., 2019 ). Although long-standing clinical guidelines recommend universal, opt-out HIV screening for patients aged 13 to 64 in all health care settings ( Branson et al., 2006 ), rates of lifetime HIV testing among U.S. high school students are very low and have significantly declined in recent years, from 13% in 2011 to 6% in 2021 ( Centers for Disease Control and Prevention, 2023a ). Adolescents with HIV are much less likely to know their status than adults, leading to disproportionately low rates of viral suppression and increased risk of HIV transmission ( Centers for Disease Control and Prevention, 2023b ). HIV testing is an important step toward prevention; diagnosing “all people with HIV as early as possible” is a key strategy of the Ending the HIV Epidemic in the U.S. initiative because rapid detection and linkage to care are crucial to improving health outcomes for people living with HIV and connecting those who test negative with prevention services ( Health Resources and Services Administration, 2023 ). Increasing adolescent HIV testing is pivotal to diagnosing all people with HIV as early as possible and improving health outcomes at every step of the HIV care continuum. Research has shown that structural factors (e.g., social, economic, policy, or other aspects of the environment that affect HIV risk and serve as barriers or facilitators to HIV prevention) can have a large impact on HIV prevention behaviors ( Adimora & Auerbach, 2010 ; Gupta et al., 2008 ; Parker et al., 2000 ; Sumartojo, 2000 ). Given that confidentiality concerns (i.e., fears that parents will be informed of test results or that their consent will be required) are a well-established barrier to sexual health services for adolescents ( Fuentes et al., 2018 ; Leichliter et al., 2017 ; Pampati et al., 2019 ; Rakhmanina et al., 2014 ), state laws regulating minors’ access to confidential sexual health services are structural factors that may affect adolescents’ HIV testing practices. To alleviate confidentiality concerns, states have significantly expanded minor consent laws giving adolescents the authority to autonomously consent to sexual health services ( Guttmacher Institute, 2023a ). However, inequities in access to confidential HIV testing persist; there is wide cross-state variation in laws explicitly allowing minors to consent to HIV testing (i.e., HIV testing is included in the package of sexual health services to which minors may consent to), setting a minimum age (e.g., age 12 or 14) to self-consent to sexual health services, permitting physicians to inform parents that their child is seeking or receiving sexual health services, and protecting the confidentiality of individuals insured as dependents (e.g., to prevent parental disclosure through a health insurance explanation of benefits statement) ( Guttmacher Institute, 2023a , 2023b ). At the individual level, gender is one of the most salient factors associated with adolescent HIV testing ( Adebayo & González-Guarda, 2017 ). During adolescence, females are at least twice as likely than males to test for HIV ( Adebayo & González-Guarda, 2017 ; Jawla et al., 2020 ). Gender differences in HIV testing may stem from disparities in health literacy ( Siegel et al., 2010 ), risk perception ( Stein & Nyamathi, 2000 ), and health care utilization ( Arrington-Sanders & Ellen, 2008 ). HIV knowledge is associated with HIV testing for female – but not male – adolescents ( Swenson et al., 2009 ), who receive more HIV prevention counseling through routine gynecological care ( Siegel et al., 2010 ). In addition, although males engage in more HIV risk behaviors, their perceived HIV risk is often lower than that of females ( Stein & Nyamathi, 2000 ); high risk perception may facilitate HIV testing for females, while low risk perception may serve as a barrier to HIV testing for males ( Adebayo & González-Guarda, 2017 ). Females also report higher health care utilization than males, particularly for sexually transmitted infections (STIs) and pregnancy concerns ( Arrington-Sanders & Ellen, 2008 ). Gender differences in HIV testing may also exist in part due to recommendations for universal HIV screening in all pregnant persons ( Branson et al., 2006 ). In addition to differences in HIV testing between males and females, HIV testing rates within males and females vary widely across the U.S. In 2019, lifetime HIV testing among sexually experienced high school students ranged from 8.1% in Missouri to 24.3% in Alabama for males and from 11.4% in Iowa to 25.6% in Maryland for females ( Centers for Disease Control and Prevention, 2023a ). This suggests that structural factors such as state laws regulating minors’ access to confidential sexual health services may also contribute to gender differences in adolescent HIV testing. Although minor consent laws were intended to address confidentiality concerns, research on whether such laws affect adolescent HIV testing rates is limited ( Cordoba et al., 2022 ; Nelson et al., 2019 ; Phillips et al., 2021 ). Furthermore, despite calls for research using a gendered lens to evaluate HIV testing patterns ( Decker et al., 2014 ), many representative state-level data sources on adolescent HIV testing have not comprehensively assessed sex assigned at birth and current gender identity, precluding inclusive evaluation of gender differences in the potential impact of minor consent laws on adolescent HIV testing. However, one study evaluated associations between minor consent laws and HIV testing and stratified results by sex: Phillips et al. (2021) found that state laws explicitly allowing minors to consent to HIV testing and age clauses were positively associated with lifetime HIV testing for sexually experienced male – but not female – high school students in the 2017 Youth Risk Behavior Surveillance System (YRBSS). However, Phillips et al. (2021) did not investigate whether observed associations between such laws and HIV testing were moderated by sex, account for students being clustered within states in their analyses, or evaluate state laws permitting parental notification or protecting the confidentiality of insured dependents. Regardless of whether minors have the authority to autonomously consent, parental notification laws may deter them from HIV testing ( Jackson & Hafemeister, 2001 ). In addition, confidentiality protections for insured dependents may mitigate confidentiality concerns, thus facilitating testing. This study aimed to address these knowledge gaps by examining whether confidentiality-promoting state laws are associated with differences in HIV testing among a large, population-based sample of sexually experienced U.S. high school students. We hypothesized that lifetime HIV testing would be significantly more likely in states that explicitly allow minors to consent to HIV testing, do not have age clauses, do not permit parental notification, and protect the confidentiality of insured dependents than in states that do not explicitly allow minors to consent to HIV testing, have age clauses, permit parental notification, and do not protect the confidentiality of insured dependents, respectively. In addition, we hypothesized that sex would moderate observed associations such that lifetime HIV testing would significantly differ between self-identified males and females – we did not hypothesize a direction due to the dearth of extant research. Methods Sample This study utilized data from the YRBSS (Underwood et al., 2020), a system of cross-sectional, self-administered Youth Risk Behavior Surveys (YRBS) conducted by the Centers of Disease Control and Prevention (CDC) at the national, state, and local level every two years to monitor health risk behaviors among high school students. The reliability and validity of the YRBS is well- documented ( Brener et al., 2002 ). Participant data were aggregated from states that participated in the 2019 state-level YRBSS, assessed sex of sexual contacts and/or sexual intercourse, sexual identity, and HIV testing in their YRBS, and made their data publicly available (25 states; N =125,723). We utilized data from the 2019 state-level YRBSS instead of the 2021 state-level YRBSS because of disruptions in access to sexual health services during the COVID-19 pandemic. Analyses were limited to sexually experienced participants (i.e., reported ever having had sexual contact and/or intercourse; ~40.3%) with the legal authority to consent to HIV testing (i.e., resided in a state without an age clause or was at least the age specified in the clause at the time of the 2019 YRBSS; ~99.5%). Of these participants ( N =50,423), 8.0% were excluded because they did not answer questions about demographics (i.e., sex: 0.5%, grade: 1.1%, race/ethnicity: 2.3%, sexual identity: 1.1%) or HIV testing (4.4%), resulting in a final sample size of 46,444. This study was deemed exempt by the Columbia University (Morningside) Institutional Review Board. Measures Independent Variables Sex was assessed with the YRBS question, “What is your sex?” (0=Male, 1=Female; only 7 states assessed transgender status, precluding inclusive measurement of gender identity). Using information compiled by the Guttmacher Institute ( Guttmacher Institute, 2023a , 2023b ), we created four variables to indicate whether state laws were confidentiality-promoting at the time of the 2019 YRBSS: Minors explicitly allowed to consent to HIV testing (0=No, 1=Yes) No age clause (0=No, 1=Yes) Parental notification not permitted (0=No, 1=Yes) Confidentiality protections for insured dependents (0=No, 1=Yes) Outcome variable Lifetime HIV testing was assessed with the YRBS question, “Have you ever been tested for HIV, the virus that causes AIDS? (Do not count tests done if you donated blood.)” Response options included “Yes,” “No,” and “Not sure.” Students who responded “Not sure” were excluded from the analysis. (0=No, 1=Yes). Covariates To reduce the potential effect of confounding, analyses adjusted for individual- and state-level characteristics that that have been identified as the strongest predictors of HIV testing among adolescents (Adebayo & González-Guarda, 2017 ). Individual-level covariates included grade, race/ethnicity, and sexual identity. Grade was assessed with the YRBS question, “In what grade are you?” (1=9 th grade, 2=10 th grade, 3=11 th grade, 4=12 th grade). Race/ethnicity was based on a variable created by the CDC (1= non-Hispanic White, 2= non-Hispanic Black, 3=Hispanic/Latino, 4=All other races). Sexual identity was assessed with the YRBS question, “Which of the following best describes you? (1=Heterosexual, 2=Gay or lesbian, 3=Bisexual, 4=Not sure). State-level covariates included the population with a high school diploma or higher and median household income, which were obtained from the U.S. Census Bureau (n.d.). In addition, lifetime HIV testing among adults was obtained from the 2019 Behavior Risk Factor Surveillance System ( Centers for Disease Control and Prevention, 2023c ) and included to control for unobserved factors that may shape differences in HIV testing across states. State-level covariates were divided by quartiles for inclusion in analyses and linked to participant data based on state of residence. Analyses Descriptive statistics and Rao-Scott chi-square tests were used to evaluate sample characteristics and differences in lifetime HIV testing. Associations between each law and lifetime HIV testing were examined using two multilevel logistic regression models which incorporated state-specific random effects to account for participants being clustered within states; Model 1 adjusted for individual-level covariates and Model 2 added state-level covariates. Models were stratified by sex and then repeated with interaction terms between each law and sex to evaluate whether associations varied significantly between males and females. To probe interaction effects, predicted probabilities of HIV testing were examined for all combinations of laws and sex, fixed at the mean covariate values for the sample. Analyses were conducted in Stata version 15.1 to appropriately weight estimates and account for the complex sampling design of the YRBSS. YRBSS weights adjust for school and student nonresponse to make the data representative of the population from which the sample was drawn (Underwood et al., 2020). All statistical tests were two-sided, and p -values <.05 were considered statistically significant. Results Unweighted frequencies and weighted percentages of characteristics of the full sample ( N =46,444), males ( n =22,792), and females ( n =23,652) are presented in Table 1 . Table 1. Characteristics of the Sample, 2019 State-Level Youth Risk Behavior Surveillance System Full Sample ( N =46,444) Males ( n =22,792) Females ( n =23,652) n % n % n % p -value Individual-Level Characteristics Sex Male 22,792 50.4 - - - - Female 23,652 49.6 - - - - Grade 9 th 8,186 16.9 4,177 17.4 4,009 16.5 .51 10 th 11,308 23.4 5,511 22.9 5,797 23.8 11 th 13,557 27.5 6,577 27.8 6,980 27.1 12 th 13,393 32.3 6,527 32.0 6,866 32.6 Race/Ethnicity White 25,380 48.2 12,088 46.7 13,292 49.8 .02 Black 6,072 13.8 3,229 14.9 2,843 12.6 Hispanic 10,536 29.8 5,312 30.3 5,224 29.3 Other 4,456 8.2 2,163 8.0 2,293 8.4 Sexual Identity Heterosexual 38,095 83.0 20,469 90.0 17,626 75.9 <.001 Gay or lesbian 1,596 3.3 719 3.3 877 3.4 Bisexual 5,295 10.6 1,048 4.5 4,247 16.9 Not sure 1,458 3.1 556 2.3 902 3.9 State-Level Characteristics High School Education a <86.5% 12,549 48.6 6,173 47.8 6,376 49.4 .38 86.5 - 90% 18,529 34.9 9,120 35.3 9,409 34.4 90.0 - 90.5% 3,925 12.8 1,982 13.1 1,943 12.4 >90.5% 11,441 3.8 5,517 3.8 5,924 3.8 Median Income b <$53,267 12,992 27.7 6,452 28.1 6,540 27.2 .67 $53,267 - $63,575 11,203 43.3 5,495 43.3 5,708 43.3 63,575 - $76,106 11,107 23.2 5,426 22.7 5,681 23.7 >$76,106 11,142 5.8 5,419 5.8 5,723 5.8 Adult HIV Testing c <37.3% 13,681 10.1 6,610 10.0 7,071 10.0 .85 37.3 - 40.7% 10,274 24.4 5,140 24.5 5,134 24.4 40.7 - 49.9% 16,296 46.1 7,991 45.7 8,305 46.4 >49.9% 6,193 19.5 3,051 19.7 3,142 19.3 Confidentiality-Promoting State Laws Minors Explicitly Allowed to Consent to HIV Testing d No 23,911 11.5 11,573 11.5 12,338 11.5 .96 Yes 22,533 88.5 11,219 88.5 11,314 88.5 No Age Clause d No 10,385 30.0 5,120 29.4 5,265 30.2 .60 Yes 36,059 70.0 17,672 70.6 18,387 69.8 Parental Notification Not Permitted d No 23,335 46.5 11,381 46.1 11,954 47.0 .50 Yes 23,109 53.5 11,411 53.9 11,698 53.0 Confidentiality Protections for Insured Dependents e No 24,074 60.4 11,828 60.4 12,246 60.4 .97 Yes 22,370 39.6 10,964 39.6 11,406 39.6 Open in a new tab Note: Unweighted frequencies and weighted percentages are presented. Participant data were aggregated from states that participated in the 2019 state-level Youth Risk Behavior Surveillance System (YRBSS), assessed sex of sexual contacts and/or sexual intercourse, sexual identity, and HIV testing in their YRBS, and made their data publicly available (25 states; N =125,723). Analyses were limited to sexually experienced participants (i.e., reported ever having had sexual contact and/or intercourse; ~40.3%) with the legal authority to consent to HIV testing (i.e., resided in a state without an age clause or was at least the age specified in the clause at the time of the 2019 YRBSS; ~99.5%). Of these participants ( N =50,423), 8.0% were excluded because they did not answer questions about demographics (i.e., sex: 0.5%, grade: 1.1%, race/ethnicity: 2.3%, sexual identity: 1.1%) or HIV testing (4.4%), resulting in a final sample size of 46,444. a Percentage of state population aged 25 and older that is a high school graduate or higher (2014-2018; quartiles); Source: U.S. Census Bureau [29] b Median household income (2014-2018; quartiles); Source: U.S. Census Bureau [29] c Lifetime HIV testing among adults (2019; quartiles); Source: Behavior Risk Factor Surveillance System, 2019 [30] d Source: Guttmacher Institute [20] e Source: Guttmacher Institute [21] Approximately 16.0% of students reported ever being tested for HIV, with rates of lifetime HIV testing varying widely across states ( Table 2 ). Table 2. Cross-State Variation in Confidentiality-Promoting Laws and Lifetime HIV Testing, 2019 State-Level Youth Risk Behavior Surveillance System ( N =46,444) State Minors Explicitly Allowed to Consent to HIV Testing a No Age Clause a Parental Notification Not Permitted a Confidentiality Protections for Insured Dependents b Lifetime HIV Testing – Full Sample (%) Lifetime HIV Testing - Males (%) Lifetime HIV Testing - Females (%) Alabama X 24.3 24.3 24.3 Arizona X X 18.3 14.5 22.2 Arkansas X 18.8 15.0 22.5 California X X X 14.4 17.0 11.8 Connecticut X X X X 15.5 13.9 17.3 Florida X X X X 18.7 17.9 19.6 Illinois X X 16.5 15.9 17.1 Iowa X X X 12.1 12.9 11.4 Kentucky X X 16.3 15.4 17.2 Maine X X 14.0 11.4 16.3 Maryland X X 22.4 19.3 25.6 Michigan X X 17.6 16.7 18.4 Mississippi X X X 15.2 11.6 19.0 Missouri X 11.3 8.1 14.6 Nebraska X X 12.3 9.5 15.4 New Hampshire X 12.6 11.1 14.1 New Jersey X 12.4 10.8 14.1 New Mexico X X X 17.8 15.9 19.7 New York X X X X 20.1 21.1 19.1 North Carolina X X X 18.8 18.6 19.0 Oklahoma X X 16.2 14.6 17.9 Pennsylvania X X X 15.5 12.6 18.9 South Carolina X X 18.3 19.8 16.9 Texas X X 13.4 10.1 16.6 West Virginia X X 18.1 18.2 18.0 Total 17 19 14 7 16.0 15.0 17.1 Open in a new tab Note: Participant data were aggregated from states that participated in the 2019 state-level Youth Risk Behavior Surveillance System (YRBSS), assessed sex of sexual contacts and/or sexual intercourse, sexual identity, and HIV testing in their YRBS, and made their data publicly available (25 states; N =125,723). Analyses were limited to sexually experienced participants (i.e., reported ever having had sexual contact and/or intercourse; ~40.3%) with the legal authority to consent to HIV testing (i.e., resided in a state without an age clause or was at least the age specified in the clause at the time of the 2019 YRBSS; ~99.5%). Of these participants ( N =50,423), 8.0% were excluded because they did not answer questions about demographics (i.e., sex: 0.5%, grade: 1.1%, race/ethnicity: 2.3%, sexual identity: 1.1%) or HIV testing (4.4%), resulting in a final sample size of 46,444. a Source: Guttmacher Institute [20] b Source: Guttmacher Institute [21] Differences in lifetime HIV testing were observed by sample characteristics ( Table 3 ). Among the full sample, rates of HIV testing were higher among females (17.1%) than males (15.0%; p= .01), and increased by grade level, from 13.9% of 9 th grade students to 18.6% of 12 th grade students ( p <.01). Differences in lifetime HIV testing were also observed by race, with HIV testing highest among Black students (22.6%) and lowest among White students (13.9%; p <.001). In regards to sexual identity, sexual minority students were more likely than heterosexual students (15.2%) to report ever being tested for HIV, with lifetime HIV testing highest among gay or lesbian students (21.9%; p <.001). As for state-level characteristics, lifetime HIV testing significantly decreased as median household income increased ( p <.01) and significantly increased as lifetime HIV testing among adults increased ( p =.04). Students reported higher levels of HIV testing in states that explicitly allowed minors to consent to HIV testing (16.0% vs. 15.9%), did not have age clauses (16.3% vs. 15.5%), and did not permit parental notification (16.6% vs. 15.3%); however, none of these associations were statistically significant. Table 3. Lifetime HIV Testing Among Sexually Experienced U.S. High School Students, by Sample Characteristics, 2019 State-Level Youth Risk Behavior Surveillance System Full Sample ( N =46,444) % p -value Males n =22,792 (%) p -value Females n =23,652 (%) p -value Individual-Level Characteristics Sex Male 15.0 .01 - - - - Female 17.1 - - Grade 9 th 13.9 .001 13.1 .29 14.8 <.001 10 th 14.6 14.5 14.8 11 th 15.6 15.0 16.1 12 th 18.6 16.5 20.7 Race/Ethnicity White 13.9 <.001 12.6 <.001 15.0 <.001 Black 22.6 21.5 23.9 Hispanic 17.0 15.7 18.4 Other 14.3 14.3 14.4 Sexual Identity Heterosexual 15.2 <.001 14.1 <.001 16.5 .26 Gay or lesbian 21.9 26.2 17.7 Bisexual 19.9 21.8 19.3 Not sure 20.4 23.2 18.7 State-Level Characteristics High School Education a <86.5% 15.7 .16 15.1 .32 16.3 .16 86.5 - 90% 16.8 15.6 18.1 90.0 - 90.5% 16.3 14.2 18.5 >90.5% 12.6 11.4 13.7 Median Income b <$53,267 18.5 <.001 17.7 <.001 19.5 <.001 $53,267 - $63,575 14.6 12.2 17.1 63,575 - $76,106 16.0 17.7 14.3 >$76,106 14.9 12.9 16.8 Adult HIV Testing c <37.3% 13.5 .04 11.8 .06 15.3 .09 37.3 - 40.7% 16.8 14.9 18.8 40.7 - 49.9% 15.5 14.8 16.1 >49.9% 17.7 17.3 18.1 Confidentiality-Promoting State Laws Minors Explicitly Allowed to Consent to HIV Testing d No 15.9 .87 13.0 .009 18.9 .03 Yes 16.1 15.3 16.8 No Age Clause d No 15.5 .42 16.5 .08 14.6 .005 Yes 16.3 14.4 18.2 Parental Notification Not Permitted d No 15.3 .10 13.2 .002 17.5 .46 Yes 16.6 16.6 16.7 Confidentiality Protections for Insured Dependents e No 15.5 .09 13.4 <.001 17.6 .22 Yes 16.9 17.5 16.3 Open in a new tab Note: Unweighted frequencies, weighted percentages, and p -values of Rao-Scott chi-square tests are presented. Participant data were aggregated from states that participated in the 2019 state-level Youth Risk Behavior Surveillance System (YRBSS), assessed sex of sexual contacts and/or sexual intercourse, sexual identity, and HIV testing in their YRBS, and made their data publicly available (25 states; N =125,723). Analyses were limited to sexually experienced participants (i.e., reported ever having had sexual contact and/or intercourse; ~40.3%) with the legal authority to consent to HIV testing (i.e., resided in a state without an age clause or was at least the age specified in the clause at the time of the 2019 YRBSS; ~99.5%). Of these participants ( N =50,423), 8.0% were excluded because they did not answer questions about demographics (i.e., sex: 0.5%, grade: 1.1%, race/ethnicity: 2.3%, sexual identity: 1.1%) or HIV testing (4.4%), resulting in a final sample size of 46,444. a Percentage of state population aged 25 and older that is a high school graduate or higher (2014-2018; quartiles); Source: U.S. Census Bureau [29] b Median household income (2014-2018; quartiles); Source: U.S. Census Bureau [29] c Lifetime HIV testing among adults (2019; quartiles); Source: Behavior Risk Factor Surveillance System, 2019 [30] d Source: Guttmacher Institute [20] e Source: Guttmacher Institute [21] Most of these patterns remained for males and females. However, grade level was associated with lifetime HIV testing for females only ( p <.001). In addition, HIV testing was lowest for heterosexual males (14.1%) and females (16.5%) and highest for gay or lesbian males (26.2%) and bisexual females (19.3%); however, sexual identity was significantly associated with lifetime HIV testing for males only ( p <.001). Sex differences in lifetime HIV testing were observed by confidentiality-promoting state laws. Males reported significantly higher levels of HIV testing in states that explicitly allowed minors to consent to HIV testing (15.3% vs. 13.0%; p =.009), did not permit parental notification (16.6% vs. 13.2%; p =.002), or had confidentiality protections for insured dependents (17.5% vs. 13.4%; p <.001) than in states that did not explicitly allow minors to consent to HIV testing, permitted parental notification, or did not protect the confidentiality of insured dependents, respectively. Females reported significantly lower levels of HIV testing in states that explicitly allowed minors to consent to HIV testing than in states that did not include HIV testing in the package of sexual health services to which minors may consent to (16.8% vs. 18.9%; p =.03) and significantly higher levels of HIV testing in states that lacked age clauses than in states that specified that minors be a certain age to waive parental permission for HIV testing (18.2% vs. 14.6%; p =.005). In multilevel models, associations between confidentiality-promoting state laws and lifetime HIV testing differed significantly by sex ( Table 4 ). Table 4. Lifetime HIV Testing Among Sexually Experienced U.S. High School Students, by Confidentiality-Promoting State Laws and Sex, 2019 State-Level Youth Risk Behavior Surveillance System Males ( n =22,792) Females ( n =23,652) Model 1 a Model 2 b Model 1 a Model 2 b aOR 95% CI aOR 95% CI aOR 95% CI aOR 95% CI Minors Explicitly Allowed to Consent to HIV Testing f Law 1.82 (1.68-1.98) 1.46 (1.38-1.53) 0.71 (0.68-0.75) 0.61 (0.59-0.63) Grade 9th (Ref) 1.00 - 1.00 - 1.00 - 1.00 - 10th 1.15 (0.93-1.41) 1.15 (0.93-1.42) 1.02 (0.88-1.18) 1.02 (0.88-1.19) 11th 1.18 (1.06-1.31) 1.18 (1.06-1.31) 1.13 (0.89-1.43) 1.13 (0.88-1.44) 12th 1.34 (1.04-1.73) 1.34 (1.04-1.73) 1.54 (1.31-1.80) 1.53 (1.31-1.80) Race/Ethnicity White (Ref) 1.00 - 1.00 - 1.00 - 1.00 - Black 1.85 (1.46-2.34) 1.88 (1.47-2.40) 1.75 (1.36-2.26) 1.74 (1.34-2.26) Hispanic 1.41 (1.01-1.98) 1.42 (1.02-1.98) 1.41 (1.14-1.75) 1.43 (1.16-1.78) Other 1.14 (0.89-1.46) 1.12 (0.85-1.46) 1.05 (0.74-1.49) 1.05 (0.75-1.49) Sexual Identity Heterosexual (Ref) 1.00 - 1.00 - 1.00 - 1.00 - Gay or lesbian 1.95 (1.34-2.83) 1.96 (1.35-2.86) 0.98 (0.73-1.32) 0.98 (0.73-1.31) Bisexual 1.65 (1.31-2.09) 1.65 (1.30-2.10) 1.22 (1.07-1.37) 1.21 (1.07-1.37) Not sure 1.67 (1.16-2.41) 1.67 (1.16-2.42) 1.16 (0.72-1.88) 1.16 (0.72-1.87) High School Education c 0.97 (0.94-1.01) 1.06 (1.04-1.08) Median Income d 0.92 (0.89-0.94) 0.86 (0.85-0.87) Adult HIV Testing e 1.09 (1.07-1.12) 1.11 (1.09-1.14) No Age Clause f Law 0.77 (0.72-0.82) 0.60 (0.57-0.62) 1.21 (1.16-1.25) 1.21 (1.17-1.25) Grade 9th (Ref) 1.00 - 1.00 - 1.00 - 1.00 - 10th 1.15 (0.94-1.42) 1.15 (0.93-1.42) 1.02 (0.88-1.19) 1.02 (0.88-1.19) 11th 1.19 (1.07-1.32) 1.18 (1.06-1.32) 1.13 (0.88-1.44) 1.13 (0.88-1.44) 12th 1.35 (1.04-1.74) 1.34 (1.04-1.74) 1.54 (1.31-1.81) 1.53 (1.31-1.80) Race/Ethnicity White (Ref) 1.00 - 1.00 - 1.00 - 1.00 - Black 1.88 (1.47-2.41) 1.87 (1.47-2.39) 1.74 (1.36-2.24) 1.74 (1.34-2.26) Hispanic 1.42 (1.01-1.99) 1.42 (1.02-1.98) 1.44 (1.17-1.76) 1.44 (1.16-1.79) Other 1.12 (0.85-1.47) 1.12 (0.85-1.46) 1.05 (0.75-1.49) 1.06 (0.75-1.50) Sexual Identity Heterosexual (Ref) 1.00 - 1.00 - 1.00 - 1.00 - Gay or lesbian 1.97 (1.36-2.87) 1.97 (1.35-2.86) 0.98 (0.723-1.31) 0.97 (0.73-1.31) Bisexual 1.66 (1.30-2.11) 1.65 (1.30-2.10) 1.21 (1.07-1.37) 1.21 (1.07-1.37) Not sure 1.67 (1.15-2.42) 1.67 (1.15-2.42) 1.15 (0.71-1.86) 1.16 (0.72-1.86) High School Education c 1.08 (1.05-1.12) 1.08 (1.05-1.11) Median Income d 0.88 (0.86-0.91) 0.91 (0.89-0.93) Adult HIV Testing e 1.02 (0.99-1.05) 1.04 (1.02-1.06) Parental Notification Not Permitted f Law 1.09 (1.02-1.16) 1.08 (1.02-1.14) 0.82 (0.78-0.87) 0.77 (0.76-0.79) Grade 9th (Ref) 1.00 - 1.00 - 1.00 - 1.00 - 10th 1.15 (0.94-1.42) 1.16 (0.94-1.42) 1.02 (0.88-1.18) 1.02 (0.88-1.19) 11th 1.18 (1.07-1.32) 1.19 (1.07-1.32) 1.13 (0.89-1.44) 1.13 (0.88-1.44) 12th 1.34 (1.04-1.74) 1.34 (1.04-1.74) 1.53 (1.31-1.80) 1.54 (1.31-1.80) Race/Ethnicity White (Ref) 1.00 - 1.00 - 1.00 - 1.00 - Black 1.90 (1.49-2.43) 1.89 (1.48-2.42) 1.76 (1.36-2.28) 1.73 (1.33-2.25) Hispanic 1.43 (1.03-2.00) 1.42 (1.02-1.96) 1.44 (1.15-1.82) 1.44 (1.16-1.79) Other 1.12 (0.85-1.47) 1.11 (0.85-1.46) 1.05 (0.75-1.47) 1.06 (0.75-1.49) Sexual Identity Heterosexual (Ref) 1.00 - 1.00 - 1.00 - 1.00 - Gay or lesbian 1.98 (1.36-2.87) 1.97 (1.36-2.86) 0.98 (0.73-1.31) 0.98 (0.73-1.31) Bisexual 1.66 (1.31-2.11) 1.66 (1.30-2.10) 1.21 (1.07-1.37) 1.21 (1.08-1.37) Not sure 1.67 (1.15-2.43) 1.67 (1.15-2.43) 1.16 (0.72-1.87) 1.16 (0.72-1.87) High School Education c 0.96 (0.92-1.01) 1.11 (1.09-1.13) Median Income d 0.99 (0.97-1.02) 0.87 (0.86-0.89) Adult HIV Testing e 1.02 (0.99-1.04) 1.07 (1.04-1.10) Confidentiality Protections for Insured Dependents g Law 1.08 (0.95-1.24) 1.20 (1.12-1.30) 0.84 (0.80-0.87) 0.77 (0.75-0.79) Grade 9th (Ref) 1.00 - 1.00 - 1.00 - 1.00 - 10th 1.15 (0.94-1.42) 1.15 (0.93-1.42) 1.02 (0.88-1.19) 1.02 (0.88-1.19) 11th 1.18 (1.07-1.31) 1.18 (1.06-1.31) 1.13 (0.88-1.44) 1.13 (0.88-1.44) 12th 1.34 (1.04-1.74) 1.34 (1.03-1.73) 1.53 (1.31-1.80) 1.53 (1.31-1.80) Race/Ethnicity White (Ref) 1.00 - 1.00 - 1.00 - 1.00 - Black 1.89 (1.48-2.41) 1.89 (1.48-2.42) 1.73 (1.35-2.22) 1.74 (1.34-2.26) Hispanic 1.41 (0.99-2.01) 1.42 (1.01-2.00) 1.42 (1.16-1.74) 1.44 (1.16-1.78) Other 1.11 (0.85-1.45) 1.12 (0.85-1.47) 1.05 (0.74-1.49) 1.06 (0.75-1.49) Sexual Identity Heterosexual (Ref) 1.00 - 1.00 - 1.00 - 1.00 - Gay or lesbian 1.98 (1.36-2.87) 1.95 (1.34-2.84) 0.98 (0.73-1.31) 0.97 (0.73-1.31) Bisexual 1.65 (1.30-2.10) 1.64 (1.29-2.09) 1.21 (1.07-1.37) 1.21 (1.07-1.37) Not sure 1.68 (1.15-2.44) 1.66 (1.15-2.40) 1.16 (0.72-1.87) 1.16 (0.72-1.87) High School Education c 1.04 (1.01-1.08) 1.08 (1.05-1.10) Median Income d 0.94 (0.92-0.97) 0.88 (0.86-0.89) Adult HIV Testing e 1.02 (0.99-1.06) 1.08 (1.05-1.11) Open in a new tab Note: Boldface indicates statistical significance ( p <.05). aOR = adjusted odds ratio; 95% CI = confidence interval. Participant data were aggregated from states that participated in the 2019 state-level Youth Risk Behavior Surveillance System (YRBSS), assessed sex of sexual contacts and/or sexual intercourse, sexual identity, and HIV testing in their YRBS, and made their data publicly available (25 states; N =125,723). Analyses were limited to sexually experienced participants (i.e., reported ever having had sexual contact and/or intercourse; ~40.3%) with the legal authority to consent to HIV testing (i.e., resided in a state without an age clause or was at least the age specified in the clause at the time of the 2019 YRBSS; ~99.5%). Of these participants ( N =50,423), 8.0% were excluded because they did not answer questions about demographics (i.e., sex: 0.5%, grade: 1.1%, race/ethnicity: 2.3%, sexual identity: 1.1%) or HIV testing (4.4%), resulting in a final sample size of 46,444. a Model 1 adjusted for individual-level covariates (i.e., grade, race/ethnicity, sexual identity) b Model 2 adjusted for individual- and state-level covariates (i.e., grade, race/ethnicity, sexual identity, high school education, median income, adult HIV testing) c Percentage of state population aged 25 and older that is a high school graduate or higher (2014-2018; quartiles); Source: U.S. Census Bureau [29] d Median household income (2014-2018; quartiles); Source: U.S. Census Bureau [29] e Lifetime HIV testing among adults (2019; quartiles); Source: Behavior Risk Factor Surveillance System, 2019 [30] f Source: Guttmacher Institute [20] g Source: Guttmacher Institute [21] The unconditional model indicated significant variation in HIV testing across states (Variance Component=0.07; p <0.001), supporting the use of multilevel modeling. In stratified analyses, the directions of associations were consistently opposite for males and females. After adjusting for individual- and state-level covariates ( Table 4 , Model 2), males were significantly more likely to report HIV testing in states that explicitly allowed minors to consent to HIV testing (adjusted odds ratio [ aOR ]: 1.46; 95% confidence interval [ CI ]: 1.38-1.53; p <.001), did not permit parental notification ( aOR : 1.08; CI : 1.02-1.14; p =.01), or had confidentiality protections for insured dependents ( aOR : 1.20; CI : 1.12-1.30; p <.001) than in states that did not explicitly allow minors to consent to HIV testing, permitted parental notification, did not protect the confidentiality of insured dependents, and significantly less likely to report HIV testing in states that lacked age clauses ( aOR : 0.60; CI : 0.57-0.62; p <.001) than in states that had age clauses, respectively. Inversely, females were significantly less likely to report HIV testing in states that explicitly allowed minors to consent to HIV testing ( aOR : 0.61; CI : 0.59-0.63; p <.001), did not permit parental notification ( aOR : 0.77; CI : 0.76-0.79; p <.001), or had confidentiality protections for insured dependents ( aOR : 0.77; CI : 0.75-0.79; p <.001) than in states that did not explicitly allow minors to consent to HIV testing, permitted parental notification, did not protect the confidentiality of insured dependents, and significantly more likely to report HIV testing in states that lacked age clauses ( aOR : 1.21; CI : 1.17-1.25; p <.001) than in states that had age clauses, respectively. There were statistically significant interactions between every confidentiality-promoting state law and sex on lifetime HIV testing. However, the differential effect of sex on probabilities of HIV testing varied widely across laws ( Figure 1 ). Figure 1. Open in a new tab Predicted Probabilities of Lifetime HIV Testing Among Sexually Experienced U.S. High School Students, 2019 State-Level Youth Risk Behavior Surveillance System ( N =46,444) Males were significantly more likely to report HIV testing in states that explicitly allowed minors to consent to HIV testing than in states that did not include HIV testing in the package of sexual health services to which minors may consent to (0.351 vs. 0.339; ∆ = 0.012; p =.03). Females were less likely to report HIV testing in states that explicitly allowed minors to consent to HIV testing than in states that did not include HIV testing in the package of sexual health services to which minors may consent to (0.357 vs. 0.366), but this difference was not statistically significant (∆ = 0.009; p =.05). The effect of minors being explicitly allowed to consent to HIV testing was significantly larger for males than for females (∆ = 0.021; p =.03). Males were significantly less likely to report HIV testing in states that lacked age clauses than in states that specified that minors be a certain age to waive parental permission for HIV testing (0.337 vs. 0.361; ∆ = 0.024; p <.001). Females were more likely to report HIV testing in states that lacked age clauses than in states that specified that minors be a certain age to waive parental permission for HIV testing (0.353 vs. 0.349), but this difference was not statistically significant (∆ = 0.004; p =.53). The effect of a lack of an age clause was significantly larger for males than for females (∆ = 0.028; p =.02). Males were significantly more likely to report HIV testing in states that did not permit parental notification than in states that allowed physicians to inform parents that their child was seeking or receiving HIV-related services (0.366 vs. 0.341; ∆ = 0.025; p <.001). Females were more likely to report HIV testing in states that did not permit parental notification than in states that allowed physicians to inform parents that their child was seeking or receiving HIV-related services (0.365 vs. 0.362), but this difference was not statistically significant (∆ = 0.003; p =.62). The effect of parental notification not being permitted was larger for males than for females (∆ = 0.022), but not statistically significant ( p =.06). Males were significantly more likely to report HIV testing in states that had confidentiality protections for insured dependents than in states that did not have such protections (0.351 vs. 0.339; ∆ = 0.012; p =.02). Females were significantly less likely to report HIV testing in states that had confidentiality protections for insured dependents than in states that had such protections (0.343 vs. 0.358; ∆ = 0.015; p =.004). The effect of confidentiality protections for insured dependents was significantly larger for females than for males (∆ = 0.027; p =.007). Discussion Only 16% of sexually experienced high school students in the present study reported ever being tested for HIV, indicating that low rates of HIV testing remain an obstacle to reducing adolescent HIV transmission in the U.S. Identification of structural factors that can be modified to address barriers to adolescent HIV testing is essential to diagnosing all people with HIV as early as possible ( Health Resources and Services Administration, 2023 ). Results revealed not only a potential impact of confidentiality-promoting state laws on adolescent HIV testing, but that the impact can vary substantially by sex. Consistent with the wide body of literature documenting gender differences in adolescent HIV testing ( Adebayo & González-Guarda, 2017 ; Jawla et al., 2020 ), associations between confidentiality-promoting state laws and HIV testing significantly differed between males and females. In most cases, females were more likely than males to test for HIV – regardless of whether laws were confidentiality-promoting. In fact, with the exception of states that protected the confidentiality of insured dependents (where females were significantly less likely to report lifetime HIV testing), findings suggest that confidentiality-promoting state laws may not make much of an impact on females’ HIV testing practices. However, results revealed that confidentiality-promoting state laws may facilitate HIV testing for males, who were significantly more likely to report lifetime HIV testing in states that explicitly allowed minors to consent to HIV testing, did not permit parental notification, or had confidentiality protections for insured dependents than in states did not include HIV testing in the package of sexual health services to which minors may consent to, permitted parental notification, or did not have confidentiality protections for insured dependents, respectively. While the reason for sex differences in associations between confidentiality-promoting state laws and HIV testing is not fully clear, males and females have unique sexual and reproductive health care needs (e.g., STI vs. pregnancy concerns) and engage with very different healthcare systems (e.g., pediatric primary care vs. family planning clinics). Although it is unclear why females would be less likely to test for HIV in states with confidentiality protections for insured dependents, it is possible that unobserved factors in the seven states that had such protections may explain this counterintuitive finding. Additionally, HIV testing utilization among females is likely driven in large part by individual-level factors, including higher levels of HIV knowledge ( Swenson et al., 2009 ) and perceived HIV risk ( Stein & Nyamathi, 2000 ), and more opportunities for HIV testing through routine gynecological and pregnancy-related care ( Adebayo & González-Guarda, 2017 ; Siegel et al., 2010 ). Meanwhile,males’ sexual health needs often go unmet in pediatric primary care settings ( Grubb & Powers, 2020 ). State laws explicitly allowing minors to consent to HIV testing may encourage pediatricians to offer HIV testing to adolescent patients, increasing males’ opportunities for HIV testing. Fears of parental notification may be more of a barrier to HIV testing for males, who are less likely than females to talk with their parents about sex ( Donaldson et al., 2013 ; Lindberg et al., 2016 ). Physicians are more likely to offer HIV screening to sexually experienced adolescents than to adolescents who report no sexual history ( Leonard et al., 2010 ) and often cite adolescents’ fears about parental notification as an obstacle to HIV testing in pediatric settings ( Henry-Reid et al., 2010 ). Meanwhile, adolescents who receive confidential care – i.e., have time alone with a health care provider during visits, the ability to self-consent to services, and the privacy of their health information maintained ( Pampati et al., 2019 ) – are significantly more likely to engage in important discussions about sexual health issues, disclose sensitive sexual health information (e.g., condomless sex), and receive appropriate sexual health services (e.g., HIV testing) ( Gilbert et al., 2014 ; O’Sullivan et al., 2010 ; Santelli et al., 2019 ). Thus, parental notification not being permitted and confidentiality protections for insured dependents may enable pediatricians to address patients’ confidentiality concerns, encouraging discussion of sexual behavior and HIV testing for males in particular. Findings must be considered within the context of several limitations. The cross-sectional nature of the data prohibits causal inference from being drawn. Associations between laws and HIV testing were evaluated individually; however, these laws do not exist in isolation from each other and may reflect the larger sociopolitical climate within a state. Furthermore, provider awareness and implementation of these laws may vary substantially within states; in fact, a survey of American Academy of Pediatrics members found that 25% of pediatricians did not know whether their state allowed minors to be tested for HIV without parental permission ( Henry-Reid et al., 2010 ). Nevertheless, analyses controlled for unobserved factors that affect HIV testing across states; this methodological strength suggests that the identified associations are robust. Although the use of representative data increases the generalizability of results, findings are only generalizable to sexually experienced high school students in the 25 states in the sample. We utilized state-level YRBSS data collected in 2019 rather than 2021 because of disruptions in access to sexual health services during the COVID-19 pandemic; however, it is possible that results may differ with more recent data. The YRBS collects limited information, precluding adjustment for other factors that influence HIV testing (e.g., health insurance). Only seven states in the sample assessed transgender identity; in other states, the binary assessment of sex required transgender adolescents to choose between disclosing their sex assigned at birth and current gender identity and provided nonbinary adolescents with no means of expressing their gender identity. Future health survey research, including the state-level YRBSS, must include comprehensive assessment of sex assigned at birth and current gender identity to understand the HIV testing practices of gender minority youth. Lastly, all YRBS measures were self-reported and vulnerable to recall and social desirability biases, which may have affected estimates of HIV testing. This study provides evidence that the potential impact of state laws regulating minors’ access to confidential sexual health services on adolescent HIV testing may vary by sex, and that the passage of confidentiality-promoting laws may be particularly effective for increasing HIV testing among males during adolescence. Additional research is needed to elucidate the ways in which confidentiality-promoting state laws may uniquely affect HIV testing for adolescent males and females and develop HIV prevention strategies to meet the needs of distinct adolescent populations (e.g., sex-specific interventions targeting males in pediatric settings). To increase adolescent HIV testing, pediatricians and other adolescent health care providers should routinely provide confidential care and create a safe, nonjudgmental environment to discuss sexual health, provide HIV prevention counseling, and offer opt-out HIV testing. Above all, confidentiality-related barriers to HIV prevention should be eliminated across all states; adolescents should have the authority to autonomously consent to confidential HIV testing without fears of parental notification. Acknowledgments We are grateful to the Centers for Disease Control and Prevention for designing, organizing, and publishing data collected in the Youth Risk Behavior Surveillance System and all participants who participated in 2019 state-level surveys. We also thank John Santelli for providing expert guidance and invaluable feedback on earlier versions of this manuscript. This research was supported by the National Institute of Mental Health under award numbers F31MH128107, T32MH020031, and K01MH136929. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Footnotes Declaration of Interest Statement The authors report there are no competing interests to declare. Contributor Information Christina Aivadyan, School of Public Health, Yale University, New Haven, CT, USA. Nabila El-Bassel, School of Social Work, Columbia University, New York, NY, USA. Mingway Chang, School of Social Work, Columbia University, New York, NY, USA. Morgan Philbin, School of Medicine, University of California San Francisco, San Francisco, CA, USA. Elwin Wu, School of Social Work, Columbia University, New York, NY, USA. References Adimora AA, & Auerbach JD (2010). Structural interventions for HIV prevention in the United States. 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