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June 2006, Vol 96, No. 6 | American Journal of Public Health 1031-1034
© 2006 American Public Health Association
DOI: 10.2105/AJPH.2005.063248

RESEARCH AND PRACTICE

HIV Testing Among Young Adults in the United States: Associations with Financial Resources and Geography

Trang Quyen Nguyen, PhD, MPH, Carol A. Ford, MD, Jay S. Kaufman, PhD, Peter A. Leone, MD, Chirayath Suchindran, PhD and William C. Miller, MD, PhD, MPH

At the time of the study, Trang Quyen Nguyen was a doctoral student in the Department of Epidemiology, School of Public Health, University of North Carolina, Chapel Hill. Chirayath Suchindran is with the Department of Biostatistics, University of North Carolina, Chapel Hill. Jay S. Kaufman is with the Department of Epidemiology, University of North Carolina, Chapel Hill. Peter A. Leone and Carol A. Ford are with the Department of Medicine, University of North Carolina, Chapel Hill. William C. Miller is with both the Department of Epidemiology and the Department of Medicine, University of North Carolina, Chapel Hill.

Correspondence: Requests for reprints should be sent to William C. Miller, Department of Epidemiology, CB#7435, 2105F McGavran-Greenberg, University of North Carolina, Chapel Hill, Chapel Hill, NC 27599–7435 (e-mail: bill_miller{at}unc.edu).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 

We estimated prevalence and odds ratios for self-reported HIV testing among sexually experienced young adults using nationally representative data obtained from Wave III of the National Longitudinal Study of Adolescent Health (Add Health). The prevalence of testing in the past year was 18.8%.

Young adults who had private or no health insurance were less likely to report testing than were young adults who had public health insurance, particularly in the South. Respondents with functional income were less likely to report testing than were those without functional income, particularly in the South and Northeast. Variable HIV testing based on finances and insurance should be addressed.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 References
 
Half of all new HIV infections in the United States are among adolescents (aged 10–19 years) and young adults (aged 20–24 years), but approximately 50% of those infected have not been tested.1 Detecting HIV infection early is critical to preventing transmission and limiting disease progression. HIV testing may lead to behaviors that reduce risk of infection.2–7 Unfortunately, many people at risk of infection lack health insurance or a regular care provider to enable testing,8 and socioeconomically disadvantaged groups are diagnosed later in their HIV disease.9,10

Young adults are in economic transition from childhood and constitute 20% of the population without health insurance11; therefore, they use fewer health services.12,13 Links between financial resources and HIV testing among young adults are important to understand. Furthermore, the number of incident and cumulative AIDS cases is now greatest in the South, making it critical to understanding HIV testing in this region.2 We hypothesized that sexually experienced young adults, i.e., those having ever had vaginal intercourse, with few resources or living in the South would report HIV testing less than comparison groups.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 References
 
Study Design
We conducted cross-sectional analyses of Wave III of the National Longitudinal Study of Adolescent Health (Add Health) from August 2001 to April 2002, when original participants were young adults (aged 18–26 years). The Add Health sampling design is described in detail elsewhere.14 During Wave III, an interviewer traveled to homes of all original Wave I respondents who could be contacted and were currently living in the continental United States, Hawaii, or Alaska. Consenting participants completed 90-minute interviews. We limited analyses to respondents who reported having ever had vaginal intercourse.

Measures
Outcome. Self-reported HIV testing in the past 12 months was coded as "yes" or "no."

Main factors of interest. Current health insurance coverage was defined as private (through parent, spouse, work, union, school, active-duty military, self), public (Medicaid, Indian Health Service), or uninsured (lacking health insurance). Functional income was an indicator of funds to pay for nonhousehold expenditures (e.g., health care). Respondents were coded as not having a functional income if they reported a financial inability to pay the full amount of (1) rent or mortgage or (2) bills for gas, electricity, or oil at any time in the past year.

Other characteristics and behaviors. Interview location zip codes identified regional location (Northeast, South, Midwest, West) according to the Centers for Disease Control and Prevention surveillance definitions. To assess potential confounding factors, our analyses included demographic, sexual history, healthcare-seeking, and trauma variables.

Analyses
We used Stata, version 7.0 (StataCorp LP, College Station, TX), to account for the complex survey design of Add Health. We determined the prevalence of HIV testing and calculated bivariable relationships between testing and sociodemographics, behaviors, and health care utilization, which are nationally representative of young adults (aged 18–26 years). We analyzed survey data using logistic regression to assess the association between financial resources, region, and reported HIV testing, and examined potential confounding by individual characteristics and behaviors.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 References
 
Of the 75.7% (n = 14 322) of Wave I respondents who completed the Wave III interview, 85% (n = 12 334) reported ever having vaginal intercourse. The overall prevalence of reported HIV testing in the past year was 18.8% (Table 1Go). Women reported more HIV testing than men (P < .001). HIV testing also varied by race/ethnicity, marital status, employment status, sexual orientation, sexual behaviors, and health care. HIV testing did not significantly differ by region (P = .388).


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  		TABLE 1— Characteristics and Reported HIV Testing of Respondents Who Reported Ever Having Vaginal Intercourse: Wave III of the National Longitudinal Study of Adolescent Health, 2001–2002
 
Overall, respondents without a functional income were significantly more likely to report HIV testing than those with a functional income. Results were similar, after stratification, by region in the South and Northeast. Overall, after adjusting for gender (the only confounding variable), privately insured or uninsured young adults were less likely than publicly insured young adults to report HIV testing. In stratified analyses, we found similar results in the South (Table 2Go).


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  		TABLE 2— Prevalence, Odds Ratio (OR), and 95% Confidence Interval (CI) Estimates for the Association Between Current Insurance Status and Functional Income and HIV Testing Among Add Health Respondents Who Reported Ever Having Vaginal Intercourse, by Geographic Region: Wave III of the National Longitudinal Study of Adolescent Health, 2001–2002
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
References
 
Although routine HIV screening is suggested for sexually active people, the prevalence of reported HIV testing among sexually experienced young adults is low. Young adults with private insurance or functional income were less likely to be tested for HIV than were those with public insurance or no functional income. Financial factors should not influence testing behavior, because public health departments offer HIV testing at no or low cost to everyone. Furthermore, young adults with financial resources should have access to testing through other sites, including private practices.

People who generally seek care at health departments (i.e., those with few financial resources) likely benefit from being seen within a public health infrastructure that continually seeks to increase sexually transmitted infection (STI)/HIV testing. On the other hand, many private providers do not feel comfortable discussing sexual activity with their patients, and do not regularly test for STIs.15

Given the overall low HIV testing prevalence among young adults, efforts to increase testing should be widespread. Special focus on privately insured or uninsured young adults who are not financially constrained is needed. Providers should discuss HIV testing with all their patients, thereby avoiding any biases held by the providers or patients regarding risk.


   Acknowledgments
 
Trang Q. Nguyen was funded as a Pre-Doctoral Fellow through National Institutes of Health (NIH) (grant NIH NIAID 5 T32 AI07001-28: Training in Sexually Transmitted Diseases and AIDS) to complete this work. Support for William C. Miller and Carol A. Ford was provided in part by the University of North Carolina Sexually Transmitted Diseases Cooperative Research Center (National Institute of Allergy and Infectious Diseases grant UO131496), the NIH (grant HD38210), and the Robert Wood Johnson Foundation Generalist Physician Faculty Scholar Award Program.

We used data from Add Health, a program project designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris, and funded by the National Institute of Child Health and Human Development (grant P01-HD31921), with cooperative funding from 17 other agencies. Special acknowledgment is given to Ronald R. Rindfuss and Barbara Entwisle for providing assistance with the original design. Persons interested in obtaining data files from Add Health should contact Add Health, Carolina Population Center, 123 W. Franklin Street, Chapel Hill, NC 27516–2524 (www.cpc.unc.edu/addhealth/contract.html).

Human Participant Protection
This study was approved by the institutional review board of the University of North Carolina, Chapel Hill.


   Footnotes
 
Peer Reviewed

Contributors
T. Q. Nguyen, W. C. Miller, and C. A. Ford developed the research topic. T. Q. Nguyen performed the data analysis and was the main author of the brief. W. C. Miller supervised all aspects of study design, analyses, and writing. C. A. Ford, P. A. Leone, J. S. Kaufman, and C. Suchindran made significant contributions to analysis and writing. All authors helped to originate ideas, interpret findings, and review drafts of the article.

Accepted for publication August 7, 2005.


   References
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 
1. American Academy of Pediatrics; Committee on Pediatric AIDS and Committee on Adolescence. Adolescents and human immunodeficiency virus infection: the role of the pediatrician in prevention and intervention. Pediatrics. 2001;107:188–190.[Abstract/Free Full Text]

2. Rosenberg ES, Altfeld M, Poon SH, et al. Immune control of HIV-1 after early treatment of acute infection. Nature 2000;407:523–526.[CrossRef][Medline]

3. Oxenius A, Price DA, Easterbrook PJ, et al. Early highly active antiretroviral therapy for acute HIV-1 infection preserves immune function of CD8+ and CD4+ T lymphocytes. Proc Natl Acad Sci USA. 2000;97: 3382–3387.[Abstract/Free Full Text]

4. Cates W, Jr, Chesney MA, Cohen MS. Primary HIV infection: a public health opportunity. Am J Public Health 1997;87:1928–1930.[Abstract/Free Full Text]

5. Pilcher CD, Eron JJ Jr, Vemazza PL, et al. Sexual transmission during the incubation period of primary HIV infection. JAMA. 2001;286:1713–1714.[Free Full Text]

6. Pilcher CD, Shugars DC, Fiscus SA, et al. HIV in body fluids during primary HIV infection: implications for pathogenesis, treatment and public health. AIDS. 2001;15:837–845.[CrossRef][ISI][Medline]

7. Yerly S, Vora S, Rizzardi P, et al. Acute HIV infection: impact on the spread of HIV and transmission of drug resistance. AIDS. 2001;15:2287–2292.[CrossRef][ISI][Medline]

8. Blake DR, Kearney MH, Oakes JM, Druker SK, Bibace R Improving participation in Chlamydia screening programs: perspectives of high-risk youth. Arch Pediatr Adolesc Med. 2003;157:523–529.[Abstract/Free Full Text]

9. Mosen DM, Wenger NS, Shapiro MF, Andersen RM, Cunningham WE. Is access to medical care associated with receipt of HIV testing and counselling? AIDS Care. 1998;10:617–628.[CrossRef][Medline]

10. Krueger LE, Wood RW, Diehr PH, Maxwell CL. Poverty and HIV seropositivity: the poor are more likely to be infected. AIDS. 1990;4:811–814.[ISI][Medline]

11. Merzel C. Gender differences in health care access indicators in an urban, low-income community. Am J Public Health. 2000;90:909–916.[Abstract/Free Full Text]

12. Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies: inequality in education, income, and occupation exacerbates the gaps between the health "haves" and "have-nots." Health Aff (Millwood). 2002;21:60–76.[Abstract/Free Full Text]

13. Bartman BA, Moy E, D’Angelo LJ. Access to ambulatory care for adolescents: the role of a usual source of care. J Health Care Poor Underserved. 1997;8: 214–226.[ISI][Medline]

14. Harris KM, Florey F, Tabor J, Bearman PS, Jones J, Udry JR. The National Longitudinal Study of Adolescent Health: Research Design. 2003. Available at: http://www.cpc.unc.edu/projects/addhealth/design. Accessed December 15, 2004.

15. Ellen JM, Lane MA, McCright J. Are adolescents being screened for sexually transmitted diseases? A study of low income African American adolescents in San Francisco. Sex Transm Infect 2000;76:94–97.[Abstract/Free Full Text]





This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow All Versions of this Article:
AJPH.2005.063248v1
96/6/1031    most recent
Right arrow Submit a response
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Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
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Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via ISI Web of Science (3)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Nguyen, T. Q.
Right arrow Articles by Miller, W. C.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Nguyen, T. Q.
Right arrow Articles by Miller, W. C.
Related Collections
Right arrow Epidemiology
Right arrow Access to Care
Right arrow HIV/AIDS
Right arrow Rural Health

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