By Melinda Young

A new study that looks at how state-level confidentiality mandates affect human immunodeficiency virus (HIV)/sexually transmitted infection (STI) testing among high school students found that youth were more likely to be tested in states with confidentiality mandates.¹ Nearly half of all new STIs in the United States are among young people, ages 15 to 24 years. These include infections of chlamydia, gonorrhea, hepatitis B virus, herpes simplex virus type 2, human papillomavirus (HPV), syphilis, and trichomoniasis. Youth ages 13 to 24 years account for 19% of new HIV diagnoses based on 2021 data.^1,2,3

In 2014, the United States Preventive Services Task Force and the Centers for Disease Control and Prevention recommended screening adolescents for HIV and STIs.^1,2,3 The direct medical costs from STIs are in the billions — $16 billion in 2018. Despite this, most young people are unaware of their HIV status and are hesitant to engage in preventive measures, testing, and treatment, partly because of stigma, cost, and the risk of disclosure, the new study finds.^1,2

“The purpose of my study was to understand the relationship between state-level confidentiality mandates and testing in the United States,” says Siena Senn, PhD student, department of epidemiology, Emory University Rollins School of Public Health in Atlanta, and graduate research assistant in the department of epidemiology at Milken Institute School of Public Health at George Washington University in Washington, D.C. “Little is known about these laws, especially from a legal epidemiological perspective, and I wanted to contribute to literature with a very large sample in the U.S.,” she adds. “We pulled data from 2019 because it was the first year that had questions about HIV and STI testing on the youth risk behavior survey.”

The other advantage to using data from 2019 was because it was pre-COVID and before health departments diverted resources from STI testing to testing for COVID-19. “We wanted to ensure we had the best quality [data],” Senn explains. “And we wanted to ensure there were no other factors that may have impacted testing and healthcare access, in general.” Data were likely to be messier during the early pandemic years because of disruptions in healthcare and testing, she added.

The youth risk behavior survey has important data because young people experience a disproportionate burden of STIs and HIV, Senn notes. The study’s key finding was that adolescents who resided in a state with confidentiality mandates were more likely to report HIV and STI testing, respectfully, after adjusting for confounders like age, race, sexual orientation, and smoking status.¹

“All adolescents have the ability to consent to STI and HIV testing, but the mandates prohibit disclosure to parents and guardians,” Senn says. “They are aware the information would remain anonymous.”

In 2019, 14 states had confidentiality mandates for HIV testing, and 13 states had mandates for STI testing.¹ “The key finding is that residing in states with confidentiality mandates meant they were more likely to report HIV and STI testing,” Senn says. In a sub-analysis of those with previous voluntary sexual contact (an at-risk population), that relationship was even stronger.

These findings suggest that clinicians should keep in mind that confidentiality matters when they are seeing teenage patients, Senn says.

“We found that these mandates that explicitly prohibit disclosure of information to parents and guardians appear to improve uptake,” she adds. “The absence of these protections may deter youth from seeking these preventive services, meaning HIV and STI testing.”

When providers emphasize confidentiality, it can strengthen trust between patients and providers, Senn says. “When adolescents know their provider will keep their information private, that ensures better trust in their care,” she explains. “Providers can say they won’t share information with parents,” Senn says. “In states with confidentiality mandates, there is additional training amongst providers.”

In states without mandates, clinicians are not able to give adolescents an absolute reassurance of confidentiality because even if they do not disclose information to the adolescents’ parents, there are other ways guardians could learn about HIV/STI testing. “Adolescents fear that electronic health messages could be linked to their family account, or there might be insurance billing [that guardians see],” Senn explains. “There are other avenues where their HIV/STI status or where they sought those services could be disclosed.”

This possibility is why it is important for providers in all states to take extra steps and think about how patient privacy could be maintained as young patients interact in the clinic, she adds. “Although there are these anonymous sites for testing, such as Title X family clinics, they’re not always available to where youth live, and adolescents are often unaware of these options,” Senn says.

The study used data from 1.5 million youth who completed the survey. There was a uniform distribution according to sex and race/ethnicity as follows:

• 49.6% white;
• 15.3% Hispanic or Latino;
• 14.8% Black or African American;
• 2.6% Asian;
• 1.2% American Indian or Alaska native;
• 0.5% Native Hawaiian or Pacific Islander; and
• 2.0% multiple races.¹

One of the study’s findings was that fewer adolescents living in states with privacy policies smoked, and a greater proportion of youth in states with confidentiality mandates reported lifetime testing for HIV when compared to adolescents living in states that did not have protective privacy policies.¹

The takeaway is that confidentiality matters. Clinicians need to let patients know about possible insurance disclosures and billing practices and how they might code or word the services to provide greater privacy for patients, she adds.

Melinda Young has been a healthcare and medical writer for 30 years. She currently writes about contraceptive technology.

References

1. Senn S, Quinlan S. The relationship between state-level confidentiality mandates and HIV/sexually transmitted infection testing among high school students in the United States. J Adolesc Health. 2025;77:963-968.

2. Centers for Disease Control and Prevention. Sexually transmitted infections prevalence, incidence, and cost estimates in the United States. April 3, 2024. https://www.cdc.gov/sti/php/communication-resources/prevalence-incidence-and-cost-estimates.html

3. Centers for Disease Control and Prevention. HIV Testing and Youth. Nov. 29, 2024. https://www.cdc.gov/healthy-youth/nyhaad/hiv-testing-and-youth.html