Racial/Ethnic Disparities in Club Drug Use, Situational Club Drug Use during Sex, and Sexual Risk Behaviors among Alcohol-Using Men Who Have Sex with Men (MSM) in San Francisco.

BACKGROUND: Club drug use-including 3,4-Methylenedioxymethamphetamine, ketamine, crack/cocaine, hallucinogens, gamma hydroxybutyrate, volatile nitrites, and methamphetamine-has been linked to sexual risk behaviors among MSM. Few studies examine how the use of club drugs and the association between club drug use during sex and sexual risk may differ by race/ethnicity. METHODS: Using data from a cross-sectional study among alcohol-using MSM in San Francisco (n = 252), we examined the associations between the interaction of race/ethnicity and club drug use during sex, and the following behavioral outcomes: any condomless anal intercourse (CAI), insertive CAI, receptive CAI, and any serodiscordant sex in the past six months. All models controlled for income, HIV status, relationship status, age, and current use of a biomedical HIV prevention tool (i.e., Pre-Exposure Prophylaxis [PrEP] or antiretroviral therapy). RESULTS: There were significant racial differences in club drug use (p < 0.001) and club drug use during sex (p = 0.01). Asian/Pacific Islander (API) and Latino participants reported using club drugs the most at 78.8% and 79%, respectively. Among users of club drugs, club drug use during sex was most common among Black (100%), and Latino MSM (93%). Significant interactions between race/ethnicity and club drug use during sex were observed for CAI (p = 0.02), insertive CAI (p = 0.01), and receptive CAI (p = 0.01). API participants who used club drug during sex had higher odds of reporting CAI (aOR = 15.27, CI = 1.50-155.34), insertive CAI (aOR = 21.11, CI = 2.04-218.10), and receptive CAI (aOR = 21.11, CI = 2.04-218.10). CONCLUSIONS: Given the differing rates of club drug use during sex by race/ethnicity and the role race/ethnicity plays in modifying the relationships between club drug use during sex and sexual risk behaviors, culturally-tailored interventions may be needed to address the needs of ethnically-diverse, club drug-using MSM.

High-risk human papillomavirus genotype distribution among women living with and at risk for HIV in Africa.

OBJECTIVE: Cervical cancer is a common preventable cancer among African women living with HIV (WLWH). Molecular diagnostics for high-risk human papillomavirus (HR-HPV) genotypes are standard components of cervical cancer screening in resource-rich countries but not in resource-limited settings. We evaluated HR-HPV genotypes among women with and without HIV in four African countries to inform cervical cancer preventive strategies. METHODS: The African Cohort Study (AFRICOS) enrolled participants with and without HIV at 12 clinics in Tanzania, Kenya, Uganda, and Nigeria. Cervical cytobrush specimens from women were genotyped for 14 HR-HPV types using the multiplex Seegene Anyplex real-time PCR assay. Robust Poisson regression was used to estimate relative risks (RRs) and 95% confidence intervals (CIs) for factors associated with HR-HPV in WLWH. RESULTS: From January 2015 to March 2020, 868 WLWH and 134 women living without HIV (WLWoH) were tested for HR-HPV with prevalence of 50.9 and 38.1%, respectively ( P  = 0.007). Among WLWH, 844 (97.4%) were antiretroviral therapy (ART)-experienced and 772 (89.7%) virally suppressed 1000 copies/ml or less. The most frequent HR-HPV types among WLWH were HPV-16 (13.5%), HPV-52 (9.5%), and HPV-35 (9.3%). HR-HPV infection was more common among Tanzanian WLWH (adjusted RR: 1.23, 95% CI 1.05-1.44, P  = 0.012). Also, WLWH with CD4 + T cells of less than 200 cell/µl had 1.51-fold increased risk of having HR-HPV (95% CI 1.23-1.86, P  < 0.001). CONCLUSION: HR-HPV was common in WLWH in four African countries, particularly among women with low CD4 + cell count. Scale up of HPV vaccines and development of vaccines with broader activity against less common HR-HPV types may improve cervical cancer prevention in Africa.

Effects of Mirtazapine for Methamphetamine Use Disorder Among Cisgender Men and Transgender Women Who Have Sex With Men: A Placebo-Controlled Randomized Clinical Trial.

Importance: Methamphetamine use is increasingly prevalent and associated with HIV transmission. A previous phase 2a study of mirtazapine demonstrated reductions in methamphetamine use and sexual risk behaviors among men who have sex with men. Objective: To determine the efficacy of mirtazapine for treatment of methamphetamine use disorder and reduction in HIV risk behaviors. Design, Setting, and Participants: This double-blind randomized clinical trial of mirtazapine vs placebo took place from August 2013 to September 2017 in an outpatient research clinic in San Francisco, California. Participants were community-recruited adults who were sexually active; cisgender men, transgender men, and transgender women who (1) had sex with men, (2) had methamphetamine use disorder, and (3) were actively using methamphetamine were eligible. Participants were randomized to receive the study drug or placebo for 24 weeks, with 12 more weeks of follow-up. Data analysis took place from February to June 2018. Exposures: Mirtazapine, 30 mg, or matched placebo orally once daily for 24 weeks, with background counseling. Main Outcomes and Measures: Positive urine test results for methamphetamine over 12, 24, and 36 weeks (primary outcomes) and sexual risk behaviors (secondary outcomes). Sleep, methamphetamine craving, dependence severity, and adverse events were assessed. Results: Of 241 persons assessed, 120 were enrolled (5 transgender women and 115 cisgender men). The mean (SD) age was 43.3 (9.8) years; 61 (50.8%) were white, 31 (25.8%) were African American, and 15 (12.5%) were Latinx. A mean (SD) of 66% (47%) of visits were completed overall. By week 12, the rate of methamphetamine-positive urine test results significantly declined among participants randomized to mirtazapine vs placebo (risk ratio [RR], 0.67 [95% CI, 0.51-0.87]). Mirtazapine resulted in reductions in positive urine test results at 24 weeks (RR, 0.75 [95% CI, 0.56-1.00]) and 36 weeks (RR, 0.73 [95% CI, 0.57-0.96]) vs placebo. Mean (SD) medication adherence by WisePill dispenser was 38.5% (27.0%) in the mirtazapine group vs 39.5% (26.2%) in the placebo group (P = .77) over 2 to 12 weeks and 28.1% (23.4%) vs 38.5% (27.0%) (P = .59) over 13 to 24 weeks. Changes in sexual risk behaviors were not significantly different by study arm at 12 weeks, but those assigned to receive mirtazapine had fewer sexual partners (RR, 0.52 [95% CI, 0.27-0.97]; P = .04), fewer episodes of condomless anal sex with partners who were serodiscordant (RR, 0.47 [95% CI, 0.23-0.97]; P = .04), and fewer episodes of condomless receptive anal sex with partners who were serodiscordant (RR, 0.37 [95% CI, 0.14-0.93]; P = .04) at week 24. Participants assigned to mirtazapine had net reductions in depressive symptoms (Center for Epidemiologic Studies Depression Scale score, 6.2 [95% CI, 1.3-11.1] points lower; P = .01) and insomnia severity (Athens score, 1.4 [95% CI, 0.1-2.7] points lower; P = .04) at week 24. There were no serious adverse events associated with the study drug. Conclusions and Relevance: In this expanded replication trial, adding mirtazapine to substance use counseling reduced methamphetamine use and some HIV risk behaviors among cisgender men and transgender women who have sex with men, with benefits extending after treatment despite suboptimal medication adherence. Trial Registration: ClinicalTrials.gov identifier: NCT01888835.

Randomized feasibility trial of directly observed versus unobserved hepatitis C treatment with ledipasvir-sofosbuvir among people who inject drugs.

AIMS: The advent of direct-acting antivirals for hepatitis C virus (HCV) and limited effectiveness of prevention have generated interest in "Treatment as Prevention" (TasP), in which those most likely to transmit HCV (i.e. people who inject drugs [PWID]) are treated to reduced secondary transmission. However, there are scant data regarding the feasibility of treating PWID at high risk for secondary transmission or the optimal approach to treatment delivery. METHODS: We conducted a 2:1 randomized trial of modified directly-observed (mDOT) versus unobserved HCV treatment with ledipasvir-sofosbuvir daily for 8 weeks among PWID with 36 weeks of follow-up in San Francisco from 2015-2017. We evaluated recruitment-enrollment, treatment completion, end-of-treatment and 12-week response, and reinfection rate. RESULTS: Of 83 individuals eligible for screening, 72 (87.6%) attended the screening visit, 33 were eligible, and 31 enrolled; mean age was 42 years, 81% were male, 74% white. All but one participant (in the mDOT arm) completed treatment and 89.4% of mDOT and 96.6% of unobserved arm visits were attended. HCV was undetectable for 96.8% (30/31) at end of treatment and 89.7% (26/29) 12 weeks later (1 relapse, 1 reinfection), with no differences by arm. Two additional reinfections were subsequently identified, for a reinfection rate of 16.3 (95% CI 5.3-50.5) per 100 person-years of observation. CONCLUSIONS: It was feasible to recruit active PWID for HCV treatment and achieve high retention, viral response, and satisfaction with either mDOT or unobserved protocols, supporting treatment of PWID at risk of transmitting HCV to others. The reinfection rate suggests we successfully reached a high-risk population and that successful HCV TasP initiatives may aim to be sufficient in scope to significantly lower prevalence in the community. TRIAL REGISTRATION: clinicaltrials.gov NCT02609893.

Does HIV Pre-Exposure Prophylaxis Modify the Effect of Partnership Characteristics on Condom Use? A Cross-Sectional Study of Sexual Partnerships Among Men Who Have Sex with Men in San Francisco, California.

Increasing rates of sexually transmitted infections (STIs) in the United States among men who have sex with men (MSM) have raised concerns that pre-exposure prophylaxis (PrEP) has been associated with higher engagement in condomless anal intercourse (CAI). While partnership characteristics have previously been found to influence condom use, the extent to which PrEP use may modify their effect on CAI remains unknown. A secondary analysis of 535 sexual partnerships from a cross-sectional study in San Francisco was conducted to evaluate interactions between PrEP use and partnership characteristics on CAI. Bivariate and multivariate generalized estimating equation (GEE) logistic regression models were used to estimate relative measures of association, adjusted for confounding by seroconcordance and partnership type, as well as account for repeated partnerships per respondent. Partnerships where both partners used biomedical prevention had significantly greater odds of CAI [odds ratio (OR) = 5.19, 95% confidence interval (CI): 2.27-11.9] compared to those where only one partner used biomedical prevention, while those where neither partner used biomedical prevention had significantly lower odds of CAI (OR = 0.61, 95% CI: 0.40-0.93). There was no significant association between meeting place (online vs. offline) and sexual risk taking (OR = 1.03, p = 0.894). Having one partner disclose their HIV status (compared to neither partner having disclosed) was associated with significantly higher odds of CAI among partnerships of PrEP-using MSM [adjusted OR (aOR) = 5.28, 95% CI: 1.91-14.61], while the association was not significant among the partnerships of non-PrEP-using MSM (aOR = 1.29, 95% CI: 0.75-2.21). Differences in condom use among MSM using PrEP may not be well explained by differences in the effect of partnership characteristics. MSM using PrEP appear to commonly practice biomedical matching and high engagement in CAI with other biomedical prevention users, which could indicate relatively concentrated sexual networks and partly explain their disproportionate risk for STIs. Future studies should further investigate biomedical matching to develop interventions that further promote the sexual health of those using PrEP.

Acceptability of pharmacotherapy for hazardous alcohol use among men who have sex with men: Findings from a qualitative study.

INTRODUCTION: Men who have sex with men (MSM) experience high rates of binge drinking, alcohol use disorder (AUD), and alcohol-related health issues. Pharmacotherapy for AUD can reduce hazardous drinking, yet remains underutilized among MSM. This qualitative study examined knowledge and perceptions regarding AUD medications among MSM, with an emphasis on naltrexone. METHODS: Three focus group discussions (FGDs) with MSM who consumed alcohol in the past year were conducted in February 2015 (N = 39) in the San Francisco Bay Area. The FGD guide generated discussions about hazardous drinking, the social contexts of drinking, and alcohol reduction and cessation options, including pharmacotherapy. Interviews were analyzed via directed content analysis to codify themes. RESULTS: For participants, drinking at LGBTQ bars was an important social activity. Many expressed interest in reducing alcohol use, but few had heard of pharmacotherapy for AUD. Potential uptake was limited by perceptions of disulfiram as the prototype medication, side effects associated with disulfiram, and concerns that medications do not address alcohol-related stigma or social drivers of drinking. Participants were more receptive to pharmacotherapy when presented with medication options that did not require abstinence. Participants reported being more likely to try pharmacotherapy as part of a peer group or treatment program. CONCLUSIONS: Efforts to increase the knowledge and availability of naltrexone and harm reduction approaches, while addressing addiction- and medication-related stigma, might improve pharmacotherapy uptake for AUD and decrease hazardous drinking among MSM for whom alcohol holds social significance.

Prevalence and correlates of hazardous alcohol consumption and binge drinking among men who have sex with men (MSM) in San Francisco.

OBJECTIVES: To describe heavy alcohol use patterns and correlates in a diverse sample of MSM. METHODS: We used respondent-driven sampling (RDS) to enroll 252 alcohol-using MSM in San Francisco from March 2015-July 2017. We examined heavy alcohol use patterns and conducted RDS-adjusted multivariable analyses to characterize correlates of hazardous alcohol consumption and binge drinking. RESULTS: RDS-adjusted prevalence of weekly and at least weekly binge drinking was 24.9% and 19.3%, respectively. Hazardous consumption was common; prevalence of mid- and high-levels of hazardous drinking was 11.4% and 29.9%, respectively. In multivariable analyses, identifying as Hispanic/Latino or mixed/other race; being moderately or extremely interested in reducing alcohol use; ever receiving alcohol treatment; using ecstasy; reporting syphilis diagnosis; and having more than 5 male partners were independently associated with hazardous alcohol consumption. Less hazardous consumption was associated with having a bachelor's degree or completing post-graduate studies; and not being in a relationship. Reporting chlamydia infection; being somewhat, moderately or extremely interested in reducing alcohol use; and having multiple male sex partners were associated with higher odds of at least weekly binge drinking. Lower odds of binge drinking were associated with completing post-graduate studies. Moreover, for the outcomes of hazardous alcohol consumption and binge-drinking, we observed significant interaction effects between race/ethnicity and interest in reducing alcohol, past receipt of alcohol treatment, use of ecstasy, syphilis diagnosis, and number of male partners. CONCLUSION: Among alcohol-using MSM in San Francisco, heavy drinking patterns were common and independently associated with greater number of male sexual partners and sexually transmitted infections (STI). Moreover, significant racial/ethnic and socioeconomic disparities related to heavy alcohol use were observed and race/ethnicity modified the effect of the risk factors associated with these outcomes. These findings underscore the need to develop more MSM-specific interventions that jointly address heavy alcohol use and HIV/STI risk, as well as culturally-tailored and targeted strategies to alleviate health disparities.

Extended-release naltrexone for methamphetamine dependence among men who have sex with men: a randomized placebo-controlled trial.

BACKGROUND AND AIMS: Methamphetamine use is increasingly prevalent and associated with HIV transmission. Early-phase human studies suggested naltrexone reduced amphetamine use among dependent individuals. We tested if extended-release naltrexone (XRNTX) reduces methamphetamine use and associated sexual risk behaviors among high-risk methamphetamine-dependent men who have sex with men (MSM). DESIGN: Double-blind, placebo-controlled, randomized trial of XRTNX versus placebo over 12 weeks from 2012 to 2015. SETTING: San Francisco Department of Public Health, California, USA. PARTICIPANTS: One hundred community-recruited, sexually-active, actively-using methamphetamine-dependent MSM. Mean age was 43.2 years; 96% were male, 3% transfemale, and 1% transmale; 55.0% were white, 19.0% African American, and 18.0% Latino. INTERVENTIONS: XRNTX 380 mg (n = 50) or matched placebo (n = 50) administered by gluteal injection at 4-week intervals. MEASUREMENTS: Regression estimated average level and change in level of positive urines during the period 2-12 weeks (primary outcomes) and sexual risk behaviors (secondary outcome). FINDINGS: Ninety per cent of visits were completed. By intent-to-treat, participants assigned to XRNTX had similar differences during 2-12 weeks in methamphetamine-positive urines as participants assigned to placebo [incidence rate ratio (IRR) = 0.95, 95% confidence interval (CI) = 0.76-1.20; Bayes factor < 0.3]. Observed urine positivity declined from 78 to 70% in the XRNTX arm and 74 to 64% in the placebo arm. Adherence to injections was 96.7% in the XRNTX arm and 91.3% in the placebo arm. Sexual risk behaviors declined similarly among participants in both arms (all P > 0.05). There were no serious adverse events related to study drug and no differences in frequency of adverse events by treatment arm. CONCLUSIONS: Notwithstanding very high medication adherence for this study, extended-release naltrexone does not appear to reduce methamphetamine use or sexual risk behaviors among methamphetamine-dependent men who have sex with men compared with placebo.

Partner-level substance use associated with increased sexual risk behaviors among men who have sex with men in San Francisco, CA.

BACKGROUND: Substance use is highly prevalent among men who have sex with men (MSM) and is associated with individual-level sexual risk behaviors. However, few studies have explored the relationship between substance use and HIV risk behaviors within partnerships. METHODS: We examined partner-level data between MSM participants (n=23) and their sexual partners (n=52). We used multivariable generalized estimating equations (GEE) logistic regression to assess the relationship between partner-level substance use during their last sexual encounter with each partner, and engaging in condomless anal intercourse (CAI) and serodiscordant CAI. RESULTS: In multivariable analyses, participants had significantly higher adjusted odds ratio (AOR) of CAI when the participant (AOR=22.2, 95%CI=2.5-199.5) or their partners used any drugs (AOR=21.8, 95%CI=3.3-144.3); their partners (AOR=5.7, 95%CI=1.7-19.3) or both participant and partner had concordant use of methamphetamine (AOR=10.5, 95%CI=2.2-50.6); or when both used poppers (AOR=11.4, 95%CI=1.5-87). There were higher odds of SDCAI if the participant binge drank (AOR=4, 95%CI=1.01-15.8), used more than one substance (AOR=15.8, 95%CI=1.9-133), or used other drugs (AOR=4.8, 95%CI=1.3-18.4); if their partner used poppers (AOR=7.6, 95%CI=1.5-37.6), or used more than one substance (AOR=7.9, 95%CI=1.9-34.1); and when both participant and partner had concordant use of poppers (AOR=4.4, 95%CI=1.2-16.8). CONCLUSIONS: This study observed significant relationship between substance use and HIV risk behaviors within partnerships. Specifically, when either the participant, the partner, or both used any drugs there was an increased odds of sexual risk behaviors. Findings suggest that partner-level substance use behaviors should be taken in account when developing sexual risk reduction interventions.

Interruptions of antiretroviral therapy in children and adolescents with HIV infection in clinical practice: a retrospective cohort study in the USA.

INTRODUCTION: Changes in combination antiretroviral therapy (cART) throughout childhood challenge the continuity of paediatric HIV treatment. This study aimed to evaluate the prevalence of treatment interruption (TI), including lamivudine (3TC) monotherapy, and the relationship of TI to virologic and immunologic parameters in HIV-infected paediatric patients. METHODS: Nested within a prospective observational study of a city-wide cohort of HIV-infected persons in the District of Columbia, this sub-study collected retrospective data on antiretroviral therapy, enrolment (endpoint) and historic (lifelong) CD4 counts and HIV RNA viral load (VL) of the paediatric cohort. TI was defined as interruption of cART ≥4 consecutive weeks. Data on TI, including 3TC monotherapy TI (MTI), were collected. Descriptive statistics and univariate testing were used to compare children with TI and MTI to children on continuous treatment (CT). RESULTS: Thirty-eight (28%) out of 136 enrolled children (median age=12.9 years) experienced TI, with 14 (37%) of those placed on 3TC MTI. Significantly lower endpoint median CD4 counts (598 cells/mm3 vs. 815 cells/mm3; p=0.003) and CD4% (27.5% vs. 33%; p=0.006) were observed in the TI cohort as compared to the CT cohort. The median endpoint VL in the overall TI cohort was ~4 times higher than among the CT cohort (1427 copies/mL vs. 5581 copies/mL; p<0.0001). After a median TI duration of one year, a majority (n=31; 82%) of patients with TI restarted cART, including 100% of those with total TI and 53% of those on MTI, respectively. CONCLUSIONS: In our study, we observed high frequency of the TI in HIV in paediatric HIV clinical practice. All TIs, including 3TC MTI, were associated with significantly lower endpoint median CD4 counts and higher median VLs, as compared to CT in paediatric patients. The high frequency of TI and associated poor outcomes suggest a need for a better strategy in managing the course of the paediatric and adolescent cART.

Concordance of Text Message Ecological Momentary Assessment and Retrospective Survey Data Among Substance-Using Men Who Have Sex With Men: A Secondary Analysis of a Randomized Controlled Trial.

BACKGROUND: Alcohol and illicit drug use is more prevalent among men who have sex with men (MSM) compared to the general population and has been linked to HIV transmission in this population. Research assessing individual patterns of substance use often utilizes questionnaires or interviews that rely on retrospective self-reported information, which can be subject to recall bias. Ecological momentary assessment (EMA) is a set of methods developed to mitigate recall bias by collecting data about subjects' mental states and behaviors on a near real-time basis. EMA remains underutilized in substance use and HIV research. OBJECTIVE: To assess the concordance between daily reports of substance use collected by EMA text messages (short message service, SMS) and retrospective questionnaires and identify predictors of daily concordance in a sample of MSM. METHODS: We conducted a secondary analysis of EMA text responses (regarding behavior on the previous day) and audio computer-assisted self-interview (ACASI) survey data (14-day recall) from June 2013 to September 2014 as part of a randomized controlled trial assessing a pharmacologic intervention to reduce methamphetamine and alcohol use among nondependent MSM in San Francisco, California. Reports of daily methamphetamine use, alcohol use, and binge alcohol use (5 or more drinks on one occasion) were collected via EMA and ACASI and compared using McNemar's tests. Demographic and behavioral correlates of daily concordance between EMA and ACASI were assessed for each substance, using separate multivariable logistic regression models, fit with generalized estimating equations. RESULTS: Among 30 MSM, a total of 994 days were included in the analysis for methamphetamine use, 987 for alcohol use, and 981 for binge alcohol use. Methamphetamine (EMA 20%, ACASI 11%, P<.001) and alcohol use (EMA 40%, ACASI 35%, P=.001) were reported significantly more frequently via EMA versus ACASI. In multivariable analysis, text reporting of methamphetamine (adjusted odds ratio 0.06, 95% CI 0.04-0.10), alcohol (0.48, 0.33-0.69), and binge alcohol use (0.27, 0.17-0.42) was negatively associated with daily concordance in the reporting of each respective substance. Compared to white participants, African American participants were less likely to have daily concordance in methamphetamine (0.15, 0.05-0.43) and alcohol (0.2, 0.05-0.54) reporting, and other participants of color (ie, Asian, Hispanic, multi-racial) were less likely to have daily concordance in methamphetamine reporting (0.34, 0.12-1.00). College graduates were more likely to have daily concordance in methamphetamine reporting (6.79, 1.84-25.04) compared to those with no college experience. CONCLUSIONS: We found that methamphetamine and alcohol use were reported more frequently with daily EMA texts compared to retrospective ACASI, concordance varied among different racial/ethnic subgroups and education levels, and reported substance use by EMA text was associated with lower daily concordance with retrospective ACASI. These findings suggest that EMA methods may provide more complete reporting of frequent, discrete behaviors such as substance use.

Factors affecting acceptance of routine human immunodeficiency virus screening by adolescents in pediatric emergency departments.

PURPOSE: Human immunodeficiency virus (HIV) screening in health care settings including emergency departments (EDs) is recommended for adolescents in the United States. This study aimed to evaluate the acceptance of and the factors affecting the HIV screening in pediatric EDs. METHODS: A prospective, cross-sectional study of rapid opt-out oral HIV screening among adolescents ≥13 years of age was conducted in two pediatric EDs during 2009-2011. Descriptive statistics and logistic regression models were used to identify factors associated with the acceptance of HIV screening. RESULTS: During 24 months, 8,519 adolescents were approached for HIV screening; 6,184 (72.6%) did not opt out, and of those 5,764 (93.2%) were tested for HIV. Most adolescents who accepted testing were black (80.5%), female (57.6%), aged 15-17 years (50.1%), and District of Columbia residents (67.7%), and were accompanied by a guardian (69.1%). Acceptance of HIV screening varied by age, race/ethnicity, and state of residence, with younger (<15 years) (adjusted odds ratio [aOR], 1.67; 95% confidence interval [CI], 1.33-2.09), non-black adolescents (aOR, .88; 95% CI, .77-.99) and non-District of Columbia residents (aOR, .86; 95% CI, .77-.96) being more likely to opt out of testing. Lower odds of opt-out of HIV testing were seen among adolescents with a guardian present (aOR, .42; 95% CI, .34-.53). The reasons for opt-out varied significantly by age and the presence of a guardian. CONCLUSIONS: The patient's age and the presence of a guardian were significantly associated with adolescents' decision and reasons to opt out of HIV screening in pediatric EDs. Further studies are necessary to evaluate the interventions needed to increase routine ED HIV screening in adolescents.