Psychosocial health conditions and HIV prevalence and incidence in a cohort of men who have sex with men in Bangkok, Thailand: evidence of a syndemic effect

Depressive symptoms and HIV among a cohort of adolescent young men and transgender women who have sex with men, Bangkok and Nakhon Sawan, Thailand, 2017-2019

Screening for depression may identify persons for HIV prevention services and to ensure linkage to care for ART and mental health. We assessed factors associated with depressive symptoms using multiple logistic regression among 15- to 29-year-old gay, bisexual or other men who have sex with men (MSM) and transgender women who have sex with men (TGW) attending HIV prevention clinics at Silom Community Clinic or Bangrak Hospital in Bangkok or Rainbow Clinic in Nakhon Sawan, Thailand. We defined depressive symptoms as a self-report of feelings of sadness that impacted daily life in the past one month. Among 192 MSM, 51 TGW, and 11 gender-questioning persons screened: 12.6% met the criteria for depression; 5.9% had new HIV diagnosis. Independently associated factors which increase the risk of depressive symptoms included: studying in a private school (AOR 7.17); experiencing any type of bullying (AOR 2.8); having a partner with HIV (AOR 4.1); and learning about the study from sources other than a friend (AOR 4.2). Given many youths had depressive symptoms, screening for depression and connection to mental health services would be beneficial in sexual health settings to meet the needs of HIV-vulnerable youth.

Intersectional stigma and the non-communicable disease syndemic in the context of HIV: protocol for a multisite, observational study in the USA

INTRODUCTION

The increasing burden of non-communicable diseases, such as hypertension, diabetes and dyslipidaemia, presents key challenges to achieving optimal HIV care outcomes among ageing people living with HIV. These diseases are often comorbid and are exacerbated by psychosocial and structural inequities. This interaction among multiple health conditions and social factors is referred to as a syndemic. In the USA, there are substantial disparities by social position (ie, racial, ethnic and socioeconomic status) in the prevalence and/or control of non-communicable diseases and HIV. Intersecting stigmas, such as racism, classism and homophobia, may drive these health disparities by contributing to healthcare avoidance and by contributing to a psychosocial syndemic (stress, depression, violence victimisation and substance use), reducing success along the HIV and non-communicable disease continua of care. Our hypothesis is that marginalised populations experience disparities in non-communicable disease incidence, prevalence and control, mediated by intersectional stigma and the psychosocial syndemic.

METHODS AND ANALYSIS

Collecting data over a 4 year period, we will recruit sexual minority men (planned n=1800) enrolled in the MACS/WIHS Combined Cohort Study, a long-standing mixed-serostatus observational cohort in the USA, to investigate the following specific aims: (1) assess relationships between social position, intersectional stigma and the psychosocial syndemic among middle-aged and ageing sexual minority men, (2) assess relationships between social position and non-communicable disease incidence and prevalence and (3) assess relationships between social position and HIV and non-communicable disease continua of care outcomes, mediated by intersectional stigma and the psychosocial syndemic. Analyses will be conducted using generalised structural equation models using a cross-lagged panel model design.

ETHICS AND DISSEMINATION

This protocol is approved as a single-IRB study (Advarra Institutional Review Board: Protocol 00068335). We will disseminate results via peer-reviewed academic journals, scientific conferences, a dedicated website, site community advisory boards and forums hosted at participating sites.

The Effect of the Shikamana Peer-and-Provider Intervention on Depressive Symptoms, Alcohol Use, and Other Drug Use Among Gay, Bisexual, and Other Men Who Have Sex with Men in Kenya

Kenyan gay, bisexual, and other men who have sex with men (GBMSM) face stigma and discrimination, which may adversely impact mental health and limit antiretroviral therapy (ART) adherence among GBMSM living with HIV. We evaluated whether the Shikamana peer-and-provider intervention, which improved ART adherence among participants in a small randomized trial, was associated with changes in mental health or substance use. The intervention was associated with a significant decrease in PHQ-9 score between baseline and month 6 (estimated change - 2.7, 95% CI - 5.2 to - 0.2, p = 0.037) compared to standard care. In an exploratory analysis, each one-point increment in baseline HIV stigma score was associated with a - 0.7 point (95% CI - 1.3 to - 0.04, p = 0.037) greater decrease in PHQ-9 score over the study period in the intervention group. Additional research is required to understand factors that influence this intervention's effects on mental health outcomes.

Hi-fun among men who have sex with men in Bangkok: A scoping study exploring key informants' perspectives on hi-fun contexts, harms and support strategies

The use of specific drugs (e.g. methamphetamine, GHB/GBL and other stimulants) to enhance sex among men who have sex with men (MSM), is the focus of global public health concern because of links to social harms, poor mental and sexual health. Often called 'chemsex' in Western settings or 'hi-fun' in Southeast Asia, this type of sexualised drug use is increasingly visible in Thailand where the unique sociocultural and legislative environments shape sexual cultures and harms. This study aimed to develop an understanding of key informants' perspectives on hi-fun contexts, harms and current responses in Bangkok. In-depth interviews were conducted with thirteen key informants from clinical, community, policy and development organisations. Four key informants had personal experience of hi-fun. Interviews covered hi-fun contexts, harms and support, were transcribed verbatim, translated to English (where necessary) and analysed using a thematic framework. MSM hi-fun 'influencers' shape norms and provide support online, primarily through Twitter. Hi-fun was linked to Westernisation and wealth; complex hierarchies emerged from asymmetries in social/financial capital. Police coercion towards MSM engaged in hi-fun was a concern. Given the nature of their funding, HIV/HCV/STI transmission was the most pressing focus for many organisations, however key informants were concerned especially about drug overdoses and mental health/well-being impacts. The political and economic context means funding for MSM health in Thailand focuses primarily on HIV prevention/treatment; restrictions on development aid constrain holistic hi-fun focused service development. Most hi-fun support was informally developed; successful strategies relied on partnership working and peer developed/delivered services, some of which were adapted from high-income settings. Despite substantial barriers, organisations developed services responding to the needs of MSM engaged in hi-fun. Given that many were informally developed or adapted from high-income settings, establishing a theoretical basis for further interventions that is grounded in this unique context is a priority.

Adherence to antiretroviral therapy in people living with HIV with moderate or severe mental disorder

Human immunodeficiency virus (HIV) infection remains a serious public health concern, with an estimated 38 million people living with HIV (PLHIV). PLHIV are often affected by mental disorders at higher rate than the general population. One challenge in the control and prevention of new HIV infections is adherence to antiretroviral therapy (ART), with PLHIV with mental disorders having seemingly lower adherence than PLHIV without mental disorders. This cross-sectional study assessed adherence to ART in PLHIV with mental disorders who attended the Psychosocial Care Network health facilities in Campo Grande, Mato Grosso do Sul, Brazil, from January 2014 to December 2018. Data from health and medical databases were used to describe clinical-epidemiological profiles and adherence to ART. To assess the associated factors (potential risk or predisposing factors) with ART adherence, we used logistic regression model. Adherence was extremely low (16.4%). Factors associated with poor adherence were lack of clinical follow-up, particularly in middle-aged PLHIV. Other apparently associated factors were living on the streets and having suicidal ideation. Our findings reinforce the need for improvements in the care for PLHIV with mental disorders, especially in the integration between specialized mental health and infectious disease health facilities.

A nomogram of suicidal ideation among men who have sex with men in China: Based on the integrated motivational-volitional model of suicidal behavior

Introduction

Men who have sex with men (MSM) are a high-risk group for suicide, with a much higher prevalence of suicidal ideation (SI) than the general population and male population. The aim of this study was to explore the risk factors influencing the development of SI and to develop and validate a nomogram among MSM.

Methods

A cross-sectional study was conducted in 915 MSM from Shanghai, Shenyang, Shenzhen and Kunming, China using the snowball sampling method. The integrated motivational-volitional (IMV) model of suicidal behavior was used as a theoretical framework to collect different potential influencing factors of SI including diathesis-environment-life events factors and psychosocial factors. The risk factors of SI were screened by logistic regression analysis, and a nomogram for predicting SI were developed. Model properties including discrimination, calibration and decision curves were evaluated to validate the prediction model.

Results

882 MSM were included in the statistical analysis, with a lifetime prevalence of SI of 34.4% (303/882). Logistic regression analysis showed that age group, sexual orientation disclosure, high-risk sexual behavior, entrapment, defeat and interpersonal needs were associated with SI. A nomogram was constructed based on the above six predictors. AUC values of ROC for prediction model were 0.761 (0.641-0.770) and 0.754 (0.565-0.822) in the training set (n = 662) and validation set (n = 220), respectively. And there was no statistical difference of the AUC values between the two sets (P > 0.05). The calibration plots of the prediction model in both sets fit well with the ideal model (P > 0.05). The decision curves demonstrated that the threshold probability of prediction model in training set was 1-85%, whereas in validation set was 1-63%.

Conclusions

The lifetime prevalence of SI among Chinese MSM is high. The nomogram can serve as a useful tool to predict the development of SI among MSM. Defeat, entrapment and interpersonal needs, as significant predictors of SI, can be measured to identify SI in advance. Early assessment of SI and the enhancement of psychosocial interventions are important to prevent suicide-related behaviors. Future studies could incorporate more variables of interest to refine the prediction model to better guide behavioral and psychological intervention strategies among MSM.

Integrating HIV and mental health interventions to address a global syndemic among men who have sex with men

In this Series paper, we review evidence on the co-occurring and synergistic epidemics (syndemic) of HIV and mental health problems worldwide among men who have sex with men (MSM). The multilevel determinants of this global syndemic include structural factors that enable stigma, systematic bias, and violence towards MSM across geographical and cultural contexts. Cumulative exposure to these factors over time results in population-level inequities in the burden of HIV infections and mental health problems among MSM. Evidence for this syndemic among MSM is strongest in the USA, Canada, western Europe, and parts of Asia and Latin America, with emerging evidence from sub-Saharan Africa. Integrated interventions are needed to address syndemics of HIV and mental health problems that challenge the wellbeing of MSM populations worldwide, and such interventions should consider various mental health conditions (eg, depression, anxiety, trauma, and suicidality) and their unique expressions and relationships with HIV outcomes depending on cultural contexts. In addition, interventions should identify and intervene with locally relevant structural factors that result in HIV and mental health vulnerabilities among MSM.

Syndemic Conditions, Sexual Risk Behavior, and HIV Infection Among Men Who Have Sex with Men in Taiwan

Men who have sex with men (MSM) continue to constitute the majority of HIV incidence in Taiwan. This study examined the associations between five co-occurring psychosocial health conditions (PHCs)-childhood physical abuse (CPA), childhood sexual abuse (CSA), intimate partner violence (IPV), internalized homophobia (IH), and methamphetamine use (MU), and two outcomes (HIV infection and condomless anal sex) among a community sample of 1,000 Taiwanese MSM (mean age 28.5 years). Compared to MSM who had never experienced any PHC, MSM with one or more PHCs had greater than twofold higher odds of being HIV-positive, and those with three or more PHCs had twofold higher odds of having condomless anal sex. Interactive effects on HIV infection were identified from CPA + CSA + MU and CPA + IPV + MU. An interactive effect on condomless anal sex was detected between IH and MU. In order to control the escalating HIV epidemic among MSM in Taiwan, interventions are needed to address syndemic psychosocial health conditions.

LGBT+ inclusion and human rights in Thailand: a scoping review of the literature

Background

Globally, LGBT+ people continue to struggle to achieve full realization of their human rights. Amid reported health and mental health disparities, and economic insecurity, we conducted a scoping review to explore the breadth of the literature, map and summarize the evidence, and identify knowledge gaps on LGBT+ inclusion and human rights in Thailand.

Methods

We conducted a scoping review in accordance with the methodology developed by the Joanna Briggs Institute and PRISMA-ScR guidelines. We systematically searched 16 databases for peer-reviewed literature, and government and nongovernmental organization websites for grey literature, published in English or Thai from January 1, 2000–August 21, 2020. Two reviewers independently screened studies according to pre-set criteria. We abstracted and analyzed data on publication characteristics and focal populations, and synthesized findings in six domains of LGBT+ inclusion: political and civic participation, education, family, personal security and violence, economic well-being, and health.

Results

The review captured 3327 results in total, which was scoped to 76 peer-reviewed articles and 39 grey literature sources, the majority published after 2010. Gay men and transgender women were the primary focal populations in the peer-reviewed literature, LGBT+ people as a whole in the grey literature. Health was the predominant domain across publications. Key findings include the absence of generalized antidiscrimination legislation for LGBT+ individuals and lack of recourse for transgender individuals to change their legal gender; multifaceted stigma and discrimination in the educational system; social isolation and exclusion in families; disproportionate prevalence of sexual violence and reluctance to report to police; discrimination and marginalization in employment; and LGBT+ disparities in health and mental health.

Conclusions

Future research and programmatic initiatives on LGBT+ inclusion in Thailand should aim to address: 1) understudied populations—lesbian and bisexual women, transmasculine persons; 2) underrepresented topics, including constraints to LGBT+ advocacy; 3) strategic policy initiatives around anti-discrimination laws and legal recognition of same-sex marriage and families; and 4) the need for consistent collection of disaggregated data on LGBT+ persons in education, family, economic, personal security/violence, and health domains in order to assess indicators of inclusion and progress in advancing human rights for LGBT+ people in Thailand.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11798-2.

The COVID-19 Pandemic Seen from a Syndemic Perspective: The LGBTQIA2SP+ Community

An adverse condition or a disease can (either directly or indirectly) interact in a synergistic fashion with other adverse conditions or diseases/maladies, and co-cluster together with them: this fundamental observation is at the basis of the term "syndemic" (a portmanteau for "synergistic epidemic") [...].

Understanding Patterns of Healthy Aging Among Men Who Have Sex With Men: Protocol for an Observational Cohort Study

BACKGROUND

With the graying of sexual and gender minority communities and the growing number of people aged ≥50 years living with HIV, it is increasingly important to understand resilience in the context of the psychosocial aspects of aging and aging well.

OBJECTIVE

This paper aims to describe the methods and sample for the Understanding Patterns of Healthy Aging Among Men Who Have Sex With Men study.

METHODS

This observational cohort study was conducted within the Multisite AIDS Cohort Study (MACS) and was designed to explore resiliencies to explain patterns of health and illness among middle-aged and older sexual minority men. To be eligible, a participant had to be an active participant in the MACS, be at least 40 years of age as of April 1, 2016, and report any sex with another man since enrollment in the MACS.

RESULTS

Eligible participants (N=1318) completed six biannual surveys between April 2016 and April 2019. The mean age of the sample was 59.6 years (range 40-91 years). The sample was mostly White, educated, gay-identified, and included both HIV-positive (656/1318, 49.77%) and HIV-negative (662/1318, 50.23%) men.

CONCLUSIONS

Understanding resiliencies in aging is a critical springboard for the development of more holistic public health theories and interventions that support healthy aging among older sexual minority men.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/25750.

The syndemic condition of psychosocial problems related to depression among sexually transmitted infections patients

BACKGROUND

The prevalence of depression in sexually transmitted infections (STIs) patients is much higher than general public. However, studies focusing on comprehensive psychosocial effects on depression among STIs patients are limited. This study aimed to examine association of multiple psychosocial syndemic conditions with depression among STIs patients in Shanghai, China.

METHODS

We conducted a cross-sectional study and recruited 910 STIs patients from Shanghai Skin Disease Hospital. Participants self-reported their demographics and themselves completed the scales of depression, self-esteem, loneliness, social support, entrapment, defeat and interpersonal needs. Logistic regressions were performed to detect the possible contributing psychosocial factors for depression and to verify the syndemic conditions of psychosocial problems.

RESULTS

Of the STIs patient sample, the prevalence of depression was 17.9%. Multivariable analysis showed low-level self-esteem (odds ratio [ORm]: 2.18, 95% CI [1.19-4.00]) and social support (ORm: 2.18, 95% CI [1.37-3.46]), high-level entrapment (ORm: 6.31, 95% CI [3.75-10.62]) and defeat (ORm: 2.60, 95% CI [1.51-4.48]) increased the risk of depression. Psychosocial syndemic conditions magnified effect in fusing depression (adjusted odds ratio [AOR]: 11.94, 95% CI [7.70-18.53]). Participants with more than 4 psychosocial problems were about 22 times more likely to have depression (AOR: 22.12, 95% CI [13.19-37.09]).

CONCLUSIONS

The psychosocial problems syndemic magnifying the risk of depression was confirmed and psychosocial interventions to prevent depression is needed among STIs patients.

A scoping review of HIV epidemiologic, sociocultural and programmatic studies related to transgender women and men who have sex with men in Cambodia, 1999-2019

Background

Cambodia is widely credited for its successful HIV epidemic control. However, in recent years there have been signs of increasing HIV prevalence among men who have sex with men (MSM) and transgender women (TGW). This paper reviews HIV epidemiological, social science and HIV program implementation studies conducted over the past 20 years to explore possible reasons for the rising HIV prevalence among these groups and to formulate recommendations for improved policies, HIV programmatic interventions and further research.

Methods

For this scoping review, we searched the PubMed and Google Scholar databases for scientific publications related to HIV and MSM and TGW in Cambodia published since 1999. From each of the returned citations we subsequently studied reference lists to find additional data sources. We also searched websites for reports commissioned by national and international governmental and non-governmental organizations.

Results

Twenty-seven relevant studies and papers were found and reviewed; most were epidemiological in nature. Recent epidemiological studies and reports show an increase in HIV prevalence among Cambodian MSM and TGW. The epidemiology of HIV infection in these groups has been relatively well-described and analyzed. While initially MSM and TGW were grouped together, in more recent years they have been studied in their own right, recognizing their specific HIV and other prevention needs. Few studies were found investigating Cambodian same-sex cultures and social and cultural contexts in which HIV transmission among MSM and TGW occurs. A few evaluation studies were found, but it remains unknown how effective current HIV service implementation modalities are, or how successful strategies to increase access to essential HIV prevention, testing and treatment services have been employed for MSM and TGW in Cambodia.

Conclusions

Research about Cambodian MSM and TGW in the context of HIV primarily concerns bio-behavioral knowledge generation. Cambodia is unlikely to achieve control of the HIV epidemic among MSM and TGW without doing better in-depth social science research on its multiple sexual- and gender minority cultures, and without understanding what differentiated implementation modalities, strategies and approaches are most effective to address HIV among its increasingly diverse MSM and TGW populations.

Longitudinal Associations of Syndemic Conditions with Antiretroviral Therapy Adherence and HIV Viral Suppression Among HIV-Infected Patients in Primary Care

Psychosocial syndemic conditions have received more attention regarding their deleterious effects on HIV acquisition risk than for their potential impact on HIV treatment and viral suppression. To examine syndemic conditions' impact on the HIV care continuum, we analyzed data collected from people living with HIV (N = 14,261) receiving care through The Centers for AIDS Research Network of Integrated Clinical Systems at seven sites from 2007 to 2017 who provided patient-reported outcomes ∼4-6 months apart. Syndemic condition count (depression, anxiety, substance use, and hazardous drinking), sexual risk group, and time in care were modeled to predict antiretroviral therapy (ART) adherence and viral suppression (HIV RNA <400 copies/mL) using multilevel logistic regression. Comparing patients with each other, odds of ART adherence were 61.6% lower per between-patient syndemic condition [adjusted odds ratio (AOR) = 0.384; 95% confidence interval (CI), 0.362-0.408]; comparing patients with themselves, odds of ART adherence were 36.4% lower per within-patient syndemic condition (AOR = 0.636 95% CI, 0.606-0.667). Odds of viral suppression were 29.3% lower per between-patient syndemic condition (AOR = 0.707; 95% CI, 0.644-0.778) and 27.7% lower per within-patient syndemic condition (AOR = 0.723; 95% CI, 0.671-0.780). Controlling for the effects of adherence (AOR = 5.522; 95% CI, 4.67-6.53), each additional clinic visit was associated with 1.296 times higher odds of viral suppression (AOR = 1.296; 95% CI, 1.22-1.38), but syndemic conditions were not significant. Deploying effective interventions within clinics to identify and treat syndemic conditions and bolster ART adherence and continued engagement in care can help control the HIV epidemic, even within academic medical settings in the era of increasingly potent ART.

HIV and mental health among young people in low-resource contexts in Southeast Asia: A qualitative investigation

Young people aged 15-24 years comprise one-fourth of incident HIV infections in Southeast Asia. Given the high prevalence and impact of mental health issues among young people, we explored intersections of HIV and mental health, with a focus on adolescent and young key populations (AYKP) in Indonesia, the Philippines, Thailand, and Vietnam. Sixteen focus group discussions (4/country) with young people (n = 132; 16-24 years) and 41 key informant interviews with multisectoral HIV experts explored young people's lived experiences and unmet needs, existing programmes, and strategic directions for local and regional HIV responses. Cross-cutting challenges emerged in healthcare, family, school, and peer domains amid fragmented and under-resourced HIV and mental health services in socio-politically fraught environments. We identified strategic opportunities and initiatives in development and integration of youth-friendly HIV and mental health services; programmes to promote parent-adolescent communication about sex and HIV; and teacher training and resources to advance HIV and mental health awareness, serve as first-responders, and provide community referrals. Youth-led peer education programmes and LGBT-networks were central to the HIV response-promoting HIV prevention, sexual health, and mental health awareness for young people, and resilience and socioeconomic empowerment of peer educators themselves-thereby transforming sociocultural and political contexts of vulnerability.

Estimating HIV transmissions in a large U.S. clinic-based sample: effects of time and syndemic conditions

INTRODUCTION

Little is known about onward HIV transmissions from people living with HIV (PLWH) in care. Antiretroviral therapy (ART) has increased in potency, and treatment as prevention (TasP) is an important component of ending the epidemic. Syndemic theory has informed modelling of HIV risk but has yet to inform modelling of HIV transmissions.

METHODS

Data were from 61,198 primary HIV care visits for 14,261 PLWH receiving care through the Centers for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS) at seven United States (U.S.) sites from 2007 to 2017. Patient-reported outcomes and measures (PROs) of syndemic conditions - depressive symptoms, anxiety symptoms, drug use (opiates, amphetamines, crack/cocaine) and alcohol use - were collected approximately four to six months apart along with sexual behaviours (mean = 4.3 observations). Counts of syndemic conditions, HIV sexual risk group and time in care were modelled to predict estimated HIV transmissions resulting from sexual behaviour and viral suppression status (HIV RNA < 400/mL) using hierarchical linear modelling.

RESULTS

Patients averaged 0.38 estimated HIV transmissions/100 patients/year for all visits with syndemic conditions measured (down from 0.83, first visit). The final multivariate model showed that per 100 patients, each care visit predicted 0.05 fewer estimated transmissions annually (95% confidence interval (CI): 0.03 to 0.06; p < 0.0005). Cisgender women, cisgender heterosexual men and cisgender men of undisclosed sexual orientation had, respectively, 0.47 (95% CI: 0.35 to 0.59; p < 0.0005), 0.34 (95% CI: 0.20 to 0.49; p < 0.0005) and 0.22 (95% CI: 0.09 to 0.35; p < 0.005) fewer estimated HIV transmissions/100 patients/year than cisgender men who have sex with men (MSM). Each within-patient syndemic condition predicted 0.18 estimated transmissions/100 patients/year (95% CI: 0.12 to 0.24; p < 0.0005). Each between-syndemic condition predicted 0.23 estimated HIV transmissions/100 patients/year (95% CI: 0.17 to 0.28; p < 0.0005).

CONCLUSIONS

Estimated HIV transmissions among PLWH receiving care in well-resourced U.S. clinical settings varied by HIV sexual risk group and decreased with time in care, highlighting the importance of TasP efforts. Syndemic conditions remained a significant predictor of estimated HIV transmissions notwithstanding the effects of HIV sexual risk group and time in care.

Theories of change for e-health interventions targeting HIV/STIs and sexual risk, substance use and mental ill health amongst men who have sex with men: systematic review and synthesis

BACKGROUND

Sexual risk, substance use, and mental ill health constitute a syndemic of co-occurring, mutually reinforcing epidemics amongst men who have sex with men (MSM). Developed since 1995, e-health interventions offer accessible, anonymous support and can be effective in addressing these outcomes, suggesting the potential value of developing e-health interventions that address these simultaneously amongst MSM. We conducted a systematic review of e-health interventions addressing one or more of these outcomes amongst MSM and in this paper describe the theories of change underpinning relevant interventions, what these offer and how they might complement each other.

METHODS

We identified eligible reports via expert requests, reference-checking and database and Google searches. Results were screened for reports published in 1995 or later; focused on MSM; reporting on e-health interventions providing ongoing support to prevent HIV/STIs, sexual risk behaviour, substance use, anxiety or depression; and describing intervention theories of change. Reviewers assessed report quality, extracted intervention and theory of change data, and developed a novel method of synthesis using diagrammatic representations of theories of change.

RESULTS

Thirty-three reports on 22 intervention theories of change were included, largely of low/medium-quality. Inductively grouping these theories according to their core constructs, we identified three distinct groupings of theorised pathways. In the largest, the 'cognitive/skills' grouping, interventions provide information and activities which are theorised to influence behaviour via motivation/intention and self-efficacy/perceived control. In the 'self-monitoring' grouping, interventions are theorised to trigger reflection, self-reward/critique and self-regulation. In the 'cognitive therapy' grouping, the theory of change is rooted in cognitive therapy techniques, aiming to reframe negative emotions to improve mental health.

CONCLUSIONS

The synthesised theories of change provide a framework for developing e-health interventions that might holistically address syndemic health problems amongst MSM. Improving reporting on theories of change in primary studies of e-health interventions would enable a better understanding of how they are intended to work and the evidence supporting this. The novel diagrammatic method of theory of change synthesis used here could be used for future reviews where interventions are driven by existing well-defined behaviour and behaviour change theories.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018110317.

P, David JK, Rajan S, Adhikary R, Arumugam E. Substance use and risk of HIV infection among Men who have Sex with Men in India: Analysis of National IBBS data, India

HIV prevalence is higher among Men who have Sex with Men (MSM), owing to their unsafe sexual behavior. Further, MSM indulge in behaviors such as consumption of alcohol/oral drugs and/or injecting during/before sex that poses the risk of unsafe behaviors, thereby increasing their vulnerability to HIV. The study aims to analyze the factors associated with HIV infection among the multi-risk MSM using any substances with those MSM who do not use substances.Community-based cross-sectional survey design using probability-based sampling between October 2014 and November 2015.For the nation-wide Integrated Biological and Behavioral Surveillance (IBBS), 23,081 MSM were recruited from 4067 hotspots in 108 districts across India. Information on demographics, sexual behaviors, substance use, sexual partners, and awareness on HIV and its management was collected from the consented respondents using computer-assisted personal interview (CAPI) by trained personnel. Blood samples were tested for HIV. Statistical analyses were done, to study the associations between substance use and its influence on high-risk sexual behaviors and HIV infection.One in 3 MSM (33.88%) in India were substance users, thus exhibiting "multi-risk" (MR) behaviors. Significantly higher HIV prevalence (3.8%, P < .05) was reported among MR-MSM, despite 97.2% of them being aware of HIV. Higher HIV prevalence among MSM exhibiting homosexual behavior for ≤1 year is of specific concern, as this accounts to recent infections and indicates the increased vulnerability of the infection among the new entrants.Substance-use resulting in high-risk sexual behavior was significantly associated with higher HIV prevalence among MR-MSM. Integrated targeted interventions focusing on safe sex and safe-IDU practices among MR-MSM are required to end the disease transmission.

A Syndemic Model of Exchange Sex Among HIV-Positive Men Who Have Sex With Men

Exchange sex is a behavior associated with HIV transmission risk among men who have sex with men (MSM). Few studies have examined exchange sex among HIV-positive MSM. We utilize a syndemic framework to account for co-occurring psychosocial problems that suggest the presence of intertwining epidemics (i.e., syndemics), which have not been examined within the context of exchange sex among HIV-positive MSM. In 2015, MSM were recruited via online sexual networking Web site and app advertisements for Sex Positive![+], a video-based online intervention that aimed to improve health outcomes for men living with HIV. Participants completed surveys every three months for a year. Surveys covered demographics, drug use, exchange sex, intimate partner violence (IPV), and past 2-week depressive symptoms. We conducted three logistic regression models to assess syndemic factors associated with exchange sex in the past 3 months. Of the 722 HIV-positive MSM included in the sample, 59 (8%) reported exchange sex in the past 3 months at 12-month follow-up. HIV-positive MSM who had more syndemic factors had greater odds of exchange sex. Exchange sex was associated with being African-American/Black, age 18-29 years, past and present experiences with IPV, stimulant use, polysubstance use, and depressive symptoms. Exchange sex was associated with multiple psychosocial factors, indicating exchange sex may be part of a syndemic involving substance use, depression, HIV, and IPV. Interventions should address the social and behavioral circumstances that perpetuate environments that can foster multiple negative health outcomes.

Enhancing help-seeking behaviour among men who have sex with men at risk for sexually transmitted infections: the syn.bas.in randomised controlled trial

Objectives

Men who have sex with men (MSM) are at increased risk for STIs and mental disorders. Syndemic theory holds that psychosocial issues co-occur and interact, and thus increase sexual risk behaviour. Psychosocial issue identification, referral and management might reduce risk behaviour.

Methods

In the syndemic-based intervention study, an open-label randomised controlled trial, MSM were enrolled at the STI outpatient clinic of the Public Health Service of Amsterdam. We screened participants using validated questionnaires on the following problem domains: alcohol and substance use, sexual compulsivity, anxiety, depression, attention deficit hyperactivity disorder, alexithymia, intimate partner violence and childhood sexual abuse. Individuals were randomly assigned (1:1) to receive either tailored, face-to-face feedback and help-seeking advice on mental health screening, or no feedback and no help-seeking advice. Participants were followed trimonthly for a year. The primary outcomes were self-reported and confirmed help-seeking behaviour.

Results

We included 155 MSM: 76 in the intervention group and 79 in the control group. At inclusion, 128 participants (83.1%) scored positive in at least one problem domain. We found no significant differences in self-reported or confirmed help-seeking behaviour between the intervention and the control group: 41% vs 29% (p=0.14) and 28% vs 22% (p=0.44), respectively. There were also no differences in STI incidence and condomless anal sex acts between the two groups.

Conclusion

Screening showed high prevalence of problems related to mental health and substance use, while tailored feedback, advice and referral did not significantly increase help-seeking behaviour. Other interventions are needed to tackle the high burden of mental disorders among MSM.

Trial registration number

NCT02859935.

Connecting the dots: a comparison of network analysis and exploratory factor analysis to examine psychosocial syndemic indicators among HIV-negative sexual minority men

Syndemics, or comorbid and mutually reinforcing psychosocial problems, are associated with increased HIV risk among men who have sex with men (MSM). Although the dynamic interplay among syndemic indicators is theorized to be crucial for increasing risk of HIV acquisition, novel approaches are needed to understand how these syndemic problems interrelate. This study examined the associations between nine self-reported syndemic indicators in 194 MSM at high risk of HIV acquisition. We compared exploratory factor analyses (EFA) to a network analysis. In the present study, network analysis consisted of edges representing bidirectional partial polychoric correlations between nodes, which represent psychosocial syndemic indicators. EFA yielded a 1-factor solution including suicidal ideation (SI), injection drug use (IDU), depression, social anxiety, intimate partner violence, substance use, and sexual compulsivity, and excluded heavy drinking and childhood sexual abuse. Network analysis yielded a pattern of interconnectedness with the most central nodes being SI, IDU, substance use, and depression. Statistically significant relationships (absolute edge weights) were found between SI and depression, social anxiety, and IDU, and IDU and substance use. These results suggest that depression and substance use, especially more severe presentations of these conditions such as SI and IDU, are prominent interconnected components of the HIV syndemic among MSM at high risk for HIV acquisition. SI, IDU, substance use, and depression may indeed be prudent targets of intervention. Future research on the inclusion of these syndemic indicators in analytical models involving interaction terms may be warranted.

Association of co-occurring psychosocial health conditions and HIV infection among MSM in Malaysia: Implication of a syndemic effect

In Malaysia, the HIV epidemic is concentrated in a highly stigmatized population, men who have sex with men (MSM). The relationship of multiple psychosocial health conditions and HIV risks have not been investigated. This study aims to assess the association of multiple psychosocial factors with risky sexual behaviour and HIV infection among MSM. Data on demographic characteristics, psychosocial health conditions, condomless anal intercourse (CAI), HIV testing and HIV status were collected via an anonymous online survey. Multivariable logistic regression model was used to determine whether psychosocial health conditions among MSM have a syndemic association with HIV status. Between July 2017 and February 2018, 622 MSM completed the online survey. Overall, 54.3% of participants reported engaging in CAI in the past three months and 46.0% were found to have two or more psychosocial health conditions. Increasing numbers of psychosocial health conditions (1, 2, 3, 4 or more) were significantly associated with HIV infection compared to those without psychosocial health condition (odds ratio [OR] 3.39, 95% confidence interval [CI]: 1.41–8.14; OR 3.51, 95% CI: 1.43–8.61; OR 4.22, 95% CI: 1.68–10.96, and OR 7.58, 95% CI: 2.44–23.55, respectively). Comprehensive HIV prevention programs addressing mental health and substance use are needed for MSM in Malaysia.

Repeat symptomatic Neisseria gonorrhoeae infections among men who have sex with men in Bangkok, Thailand, 2006-2016

We analyzed the incidence and predictors of symptomatic repeat Neisseria gonorrhoeae (NG) infection among men who have sex with men (MSM) enrolled in the Bangkok MSM Cohort Study. Thai MSM aged ≥18 years were enrolled during 2006–2010 and followed every four months. At baseline, participants were screened for rectal and urethral NG and Chlamydia trachomatis (CT) infections using nucleic acid amplification testing (NAAT), rectal and pharyngeal NG by culture, and pharyngeal CT by NAAT. During follow-up, symptomatic participants were tested for NG infection by NAAT and Gram stain of rectal or urethral specimens. Among 1464 participants without NG infection at the baseline visit and having at least one follow-up visit, 11.2% (164/1464) developed symptomatic NG infection, for a total of 251 infections. Symptomatic repeat NG infection occurred in 28.0% (46/164) of participants. The incidence rate was 3.9 cases per 100 person-years. Baseline predictors of repeat symptomatic NG were as follows: unknown human immunodeficiency virus (HIV) status despite history of HIV testing, previous sexually transmitted infection diagnosis by physician, insertive-only anal intercourse without a condom, amyl nitrate use at baseline, CT infection at baseline, age 18–24 years, and being a student; HIV infection at baseline or during the study period was also associated with repeat symptomatic NG infection.

Group sex, suicidality and online partners: implications for HIV and suicide prevention: a short report

HIV-related factors and suicide-risk status were assessed among YMSM aged 18-24 years recruited through various MSM-related online social apps in Bangkok (N = 1394). The online survey assessed demographic characteristics, sexual behaviours and suicide-risk status. Measure of suicide risk was taken from the Suicidal Behaviors Questionnaire-Revised (cut-off score of seven or higher). Among participants, 249 (17.9%) reported suicide-risk. In multivariable logistic regression, correlates of suicide-risk status included having sometimes or often ever participated in group sex (AOR=1.58, 95% CI: 1.17-2.14), having received money or opportunities for sex (AOR=1.54, 95% CI: 1.09-2.17), often seeking partners online (AOR=1.59, 95% CI: 1.05-2.39), inconsistent condom use (AOR=1.67, 95% CI: 1.26-2.21), and self-assessed as having "medium" or "high" HIV risk (AOR=2.53, 95% CI: 1.61-3.98 and AOR=3.35, 95% CI: 1.92-5.82, respectively). Findings suggest that HIV risk behaviours shown by YMSM are significantly associated with higher risk of suicide.

Examining a Syndemics Network Among Young Latino Men Who Have Sex with Men

BACKGROUND

Although studies consistently find that syndemic indicators are additively associated with increased HIV/STI risk behavior (e.g., condomless anal sex; CAS) among men who have sex with men (MSM), information is lacking about how syndemic indicators are associated with each other. Young Latino MSM are one of the most at-risk groups for acquiring HIV in the U.S. Understanding the associations of syndemic indicators with each other and with CAS may improve understanding of how to enhance sexual and behavioral health in this population.

METHOD

Network analysis using the graphical LASSO (glasso) algorithm was employed to explore associations between CAS and syndemic indicators among 139 young Latino MSM. Structural and psychosocial syndemic indicators were assessed via self-report. CAS was defined as the number of partners in the past 3 months with whom one engaged in CAS.

RESULTS

Results of the network analysis suggested the variables with the highest centrality were unstable housing, prison history, childhood sexual abuse, and CAS. Specific significant associations included links between CAS and alcohol use (b = 0.40), childhood sexual abuse and unstable housing (b = - 0.75), alcohol use and childhood sexual abuse (b = 0.40), and substance use and intimate partner violence (b = 0.43).

CONCLUSION

This pattern of interconnectedness demonstrates the potential for network analysis to examine nuanced interrelationships of syndemic indicators. The specific associations in this sample raise the question whether a primary focus of interventions should address the more central syndemic indicators for this population, such as alcohol use and unstable housing, and whether this would, via downstream effects, affect other aspects of behavioral health in this population.

Syndemics and the PrEP Cascade: Results from a Sample of Young Latino Men Who Have Sex with Men

Young Latino men who have sex with men (MSM) are a highly vulnerable population for HIV infection. Pre-exposure prophylaxis (PrEP) is a novel biomedical HIV prevention tool that may aid in reducing the disparity in HIV incidence among Latino MSM. However, PrEP use is disproportionally low among Latino MSM and, therefore, identifying barriers along the PrEP continuum of care (the "PrEP cascade") would provide insight into how to best deploy PrEP interventions. Syndemics theory is a prominent framework employed in HIV prevention; however, to date, no known studies have applied this theory to PrEP. Thus, the aim of the current study was to explore the association between syndemics and the PrEP cascade, including the degree to which psychosocial and structural syndemic constructs are related to the PrEP cascade. Participants were 151 young Latino MSM (M age = 24 years; SD = 3) residing in San Diego, California, who completed a battery of online self-report measures. Results indicated high levels of syndemic indicators and varying levels of engagement across the PrEP cascade. As syndemic indicators increased, the odds of engagement across the PrEP cascade were significantly lowered. Psychosocial and structural syndemic factors accounted for unique variance in the PrEP cascade. Results highlight the need for combination interventions that address both psychosocial and structural barriers to PrEP use and persistence among young Latino MSM.

Syndemic Factors and HIV Risk Among Men Who Have Sex with Men in Guangzhou, China: Evidence from Synergy and Moderated Analyses

Syndemic factors tend to co-occur and increase the risks of condomless anal intercourse (CAI), multiple sexual partners (MSP) and HIV vulnerability among men who have sex with men (MSM). This study aimed to test the synergistic effects of syndemic factors on HIV risk and to further explore the moderators between syndemics and HIV risk among Chinese MSM. A cross-sectional study was conducted to recruit MSM in Guangzhou to collect data on syndemic factors (depression, intimate partner violence, childhood sexual abuse [CSA], alcohol, and rush popper use before anal sex). The relative excess risk due to interactions (RERIs) was calculated to test the synergy in adjusted regression models. A moderated analysis was conducted to test the buffer effects of potential resilience factors (education and income). Among the 976 included MSM, individuals experiencing more syndemic factors were more likely to have CAI (odds ratio [OR]= 1.26, 95% confidence interval [CI] 1.11-1.44), MSP (OR= 1.33, 95% CI 1.16-1.52), and HIV infection (OR= 1.46, 95% CI 1.12-1.90). RERIs showed a synergy of depression and rush popper use prior to sex for MSP (1.17, 95% CI 0.03-2.03) and CSA and rush popper use prior to sex for HIV infection (1.72, 95% CI 0.05-3.43). However, no significant association was found for the interaction between the number of syndemic factors and education or income. Our findings support the synergy approach in syndemic studies and highlight the need for comprehensive and multifactorial intervention strategies on sexual health of MSM. Future studies are needed to identify potential resilience factors among Chinese MSM.

The association between involuntary subordination and common mental disorders among men who have sex with men (MSM) in Shanghai, China

BACKGROUND

Involuntary subordination is a mechanism that switches off fighting behaviors when a losing organism is unable to continue in a struggle. The study aim was to investigate the association between involuntary subordination and the common mental disorders of anxiety and depression among men who have sex with men (MSM) in Shanghai, China.

METHODS

A cross-sectional study was conducted of 547 MSM in four Shanghai districts. Sociodemographic and psychosocial participant data were collected. Logistic regression was used to assess the association between anxiety, depression, and involuntary subordination.

RESULTS

12.2 and 30.9% Of the MSM demonstrated high levels of anxiety and depression respectively. Univariate analysis showed that involuntary subordination and the involuntary subordination constructs of defeat, social comparison, submissive behavior, and entrapment were associated with anxiety and depression. Multivariate analysis indicated that defeat (ORm = 1.091, 95% CI = 1.004-1.185) and entrapment (ORm = 1.174, 95% CI = 1.079-1.278) were significantly associated with anxiety. Defeat (ORm = 1.265, 95% CI = 1.166-1.372), social comparison (ORm = 1.119, 95% CI = 1.061-1.181), entrapment (ORm = 1.132, 95% CI = 1.047-1.224), and submissive behavior (ORm = 0.897, 95% CI = 0.825-0.975) were significantly associated with depression.

CONCLUSIONS

The findings confirmed an association between anxiety, depression, and involuntary subordination among MSM. These findings could form the basis of a new, integrated, and holistic approach to the identification of high-risk groups and the development of interventions for anxiety and depression among MSM.

High Levels of Syndemics and Their Association with Adherence, Viral Non-suppression, and Biobehavioral Transmission Risk in Miami, a U.S. City with an HIV/AIDS Epidemic

Miami is a Southeastern United States (U.S.) city with high health, mental health, and economic disparities, high ethnic/racial diversity, low resources, and the highest HIV incidence and prevalence in the country. Syndemic theory proposes that multiple, psychosocial comorbidities synergistically fuel the HIV/AIDS epidemic. People living with HIV/AIDS in Miami may be particularly affected by this due to the unique socioeconomic context. From April 2017 to October 2018, 800 persons living with HIV/AIDS in a public HIV clinic in Miami completed an interviewer-administered behavioral and chart-review cross-sectional assessment to examine the prevalence and association of number of syndemics (unstable housing, low education, depression, anxiety, binge drinking, drug use, violence, HIV-related stigma) with poor ART adherence, unsuppressed HIV viral load (≥ 200 copies/mL), and biobehavioral transmission risk (condomless sex in the context of unsuppressed viral load). Overall, the sample had high prevalence of syndemics (M = 3.8), with almost everyone (99%) endorsing at least one. Each syndemic endorsed was associated with greater odds of: less than 80% ART adherence (aOR 1.64, 95% CI 1.38, 1.98); having unsuppressed viral load (aOR 1.16, 95% CI 1.01, 1.33); and engaging in condomless sex in the context of unsuppressed viral load (1.78, 95% CI 1.30, 2.46). The complex syndemic of HIV threatens to undermine the benefits of HIV care and are important to consider in comprehensive efforts to address the disproportionate burden of HIV/AIDS in the Southern U.S. Achieving the 90-90-90 UNAIDS and the recent U.S. "ending the epidemic" targets will require efforts addressing the structural, social, and other syndemic determinants of HIV treatment and prevention.

Latent classes of sexual risk and corresponding STI and HIV positivity among MSM attending centres for sexual health in the Netherlands

OBJECTIVES

Continuing high STI positivity among men who have sex with men (MSM) attending centres for sexual health (CSH) indicates that high-risk behaviour is ongoing. The objective of this study was to gain a better insight into risk behaviours among MSM attending CSH and to explore STI and HIV positivity by subgroups.

METHODS

We used national data routinely collected during CSH consultations for this study. From September to December 2017, questions on group sex, substance use and sex with HIV-positive partners were asked at each CSH consultation. We analysed latent classes of client-related factors and sexual risk behaviour among MSM attending CSH in this period. We examined STI positivity and prevalence ratios by latent classes.

RESULTS

A total of six classes were identified in order of increasing risk: 'overall low-risk behaviour' (n=2974; 22.0%), 'Western origin and multiple sex partners' (MSP) (n=4182; 30.9%), 'Non-Western origin and MSP' (n=2496; 18.5%), 'living with HIV' (n=827; 6.1%), 'group sex and HIV-positive partners' (n=1798; 13.3%) and 'group sex and chemsex' (n=1239; 9.2%). The any STI positivity ranged from 14.0% in the overall low-risk behaviour class to 35.5% in the group sex and chemsex class. HIV positivity did not differ significantly between classes. The Western origin and MSP class was largest and accounted for the majority of STI and HIV infections.

CONCLUSIONS

Although STI positivity increased with increased risky behaviours, considerable STI positivity was found in all six latent classes. Comparable HIV positivity between classes indicates risk reduction strategies among subgroups engaged in risky behaviours. The differences in risk behaviour and STI positivity require preventive strategies tailored to each subgroup.

Longitudinal Effects of Syndemics on HIV-Positive Sexual Minority Men's Sexual Health Behaviors

This study examined the longitudinal effects of co-occurring psychosocial concerns, or syndemics, on HIV-positive sexual minority men's likelihood of engaging in serodiscordant condomless anal sex (CAS), a health behavior with implications for personal and public health. Participants included 390 HIV-positive sexual minority men from two prior secondary prevention trials. Over the course of the 1-year data collection period (up to 5 observations per participant), participants completed self-report measures of CAS, as well as six syndemic factors: post-traumatic stress disorder, childhood sexual abuse, depression, anxiety, alcohol abuse, and polysubstance/stimulant use. We employed multilevel modeling to examine the longitudinal additive effect of syndemics on serodiscordant CAS (binary) over the 1-year period. The number of syndemic conditions was a significant predictor of CAS, with each additional syndemic associated with 1.41 greater odds of CAS (p = .0004; 95% CI [1.16, 1.70]). Both the between-person (p = .0121, 95% CI [1.07, 1.69]) and within-person (p = .01, 95% CI [1.11, 2.10]) effects of syndemics were significant predictors, showing that an increase in the number of syndemic conditions across person and time both increased odds of CAS. Interventions addressing HIV-positive sexual minority men's sexual health behaviors should address the potential impact of co-occurring psychosocial concerns that affect these behaviors. This will benefit this population's personal sexual health and reduce transmission of HIV and STIs among sexual minority men.

Syndemics and HIV-related sexual risk among men who have sex with men in India: influences of stigma and resilience

Using syndemics theory as a framework, we explored the experience of men who have sex with men in India in relation to four syndemic conditions (depression, alcohol use, internalised homonegativity and violence victimisation) and to understand their resilience resources. Five focus groups were conducted among a purposive sample of diverse men along with seven key informant interviews with HIV service providers. Participants' narratives suggested various pathways by which syndemic conditions interact with one another to sequentially or concurrently increase HIV risk. Experiences of discrimination and violence from a range of perpetrators (family, ruffians and police) contributed to internalised homonegativity and/or depression, which in turn led some men to use alcohol as a coping strategy. Stigma related to same-sex sexuality, gender non-conformity and sex work contributed to the production of one or more syndemic conditions. While rejection by family and male regular partners contributed to depression/alcohol use, support from family, regular partners and peers served as resources of resilience. In India, HIV prevention and health promotion efforts among men who have sex with men could be strengthened by multi-level multi-component interventions to reduce intersectional/intersecting stigma, address syndemic conditions and foster resilience - especially by promoting family acceptance and peer support.

The syndemic of violence victimisation, drug use, frequent alcohol use, and HIV transmission risk behaviour among men who have sex with men: Cross-sectional, population-based study in India

The theory of syndemics has been used to explain elevated HIV risk facing men who have sex with men (MSM). However, few studies have employed suitable analytical methods to test this theory. Using data from a probability-based sample of MSM in India, we tested three proposed models linking the co-occurring epidemics of violence victimisation, drug use, and frequent alcohol use to HIV risk: 1) the syndemic model of synergistically interacting epidemics; 2) the "chains of risk" model; and 3) the model of mutually causal epidemics. The primary outcome was inconsistent condom use with male or hijra (transgender women) partners in the past month. For the syndemic model, we included product terms between the exposures and assessed for interaction on the additive (linear probability regression) and multiplicative (logistic regression) scales. Path analysis was used to test the models of serially causal epidemics and mutually causal epidemics. Among 22,297 HIV-negative MSM, violence victimisation (24.7%), frequent alcohol use (27.5%), and drug use (10.9%) frequently co-occurred. We found evidence for a three-way interaction between violence victimisation, drug use and frequent alcohol use on both the multiplicative (semi-elasticity = 0.28; 95% CI 0.10, 0.47) and additive (b = 0.14; 95% CI 0.01, .27) scales. We also estimated statistically significant two-way interactions between violence victimisation and frequent alcohol use on the multiplicative (semi-elasticity = .10; 95% CI 0.008, 0.20) and additive (b = 0.05, 95% CI 0.002, 0.107) scales, and between drug use and frequent alcohol use on the multiplicative (semi-elasticity = 0.13, 95% CI 0.02, 0.24) and additive (b = 0.06, 95% CI 0.007, 0.129) scales. Thus, we found strong evidence for the syndemic model. The models of serially causal and mutually causal epidemics were partially supported. These findings highlight the need to sharpen how syndemic models are specified so that their empirical predictions can be adequately tested and distinguished from other theories of disease distribution.

Illicit Drug Use and Social Victimization among Thai Sexual and Gender Minority Adolescents

Objectives: We examined the prevalence of lifetime illicit drug use and social victimization, and their association, among sexual and gender minority (SGM) and non-SGM Thai adolescents. Methods: In 2013, we conducted a school-based national survey among students grades 7-12 (aged 13-20 years) from 15 secondary schools (n = 2,070) around Thailand. We classified adolescents with same-sex attraction, sexual or gender non-conforming identities as SGM. Generalized estimating equations were used to estimate the odds of illicit drug use by SGM and non-SGM status. Results: Prevalence of lifetime illicit drug use was significantly higher among SGM adolescents than non-SGM adolescents (10.3 vs. 5.3%), but did not differ between those with same-sex attraction and SGM identity (10.3 vs. 10.8%). Among non-SGM adolescents, general social victimization, sexual experience and any school truancy were associated with lifetime illicit drug use (OR = 2.59, 95% CI: 1.53, 4.38; OR = 6.59, 95% CI: 4.90, 8.86; and OR = 4.93, 95% CI: 3.13, 7.75, respectively). Among SGM adolescents, SGM-based social victimization, depressive symptomology and suicidal ideation were associated with lifetime illicit drug use (OR = 3.17, 95% CI: 2.03, 4.95; OR = 5.03, 95% CI: 2.32, 10.90; and OR = 5.03, 95% CI: 2.76, 9.16, respectively). Conclusions: SGM adolescents have higher burden of illicit drug use. Moreover, illicit drug use among SGM adolescents is indicative of depressive symptomology and suicidal ideation. Tailored and comprehensive programs are needed to reduce the gap in burden of illicit drug use between SGM and non-SGM adolescents.

Syndemic Vulnerability and Condomless Sex Among Incarcerated Men in Mexico City: A Latent Class Analysis

In order to address common statistical and population-based limitations in epidemiological literature applying syndemic theory, this study uses latent class analysis (LCA) to explore how health and social problems coalesce and shape sexual risk behaviors linked to HIV transmission in three Mexico City prisons. Among the studied male inmates, LCA identified four classes, defined by low syndemic risk (61.4%); marijuana (14.3%); depression, substances, and trauma (19.7%); and depression, substances, and marijuana (4.7%). In multinomial regression models, classes with a greater number of syndemic exposures were associated with increased odds of condomless anal sex during incarceration. In analyses stratified by pre-incarceration sexual risk behaviors, however, high syndemic burden classes were associated with condomless anal sex during incarceration differently. Overall, the study findings suggest that LCA has potential utility for syndemic analyses and highlight the need to attend to health and social adversities when addressing sexual risk behaviors and HIV transmission during incarceration.

Selling and buying sex in the city: men who have sex with men in the Bangkok men who have sex with men Cohort Study

We describe participants in the Bangkok Men who have sex with men Cohort Study (BMCS) who sold or bought sex. Men who have sex with men (MSM) and transgender women aged ≥18 years had HIV testing and behavioral data collected at enrollment and every four months. We evaluated report of receiving money or goods for sex (selling sex) or giving money or goods for sex (buying sex) at enrollment using logistic regression models; we also describe sex work over time, and HIV and syphilis incidence among those who report sex work. At enrollment, 511 (29.3%) of 1744 participants reported buying or selling sex. Factors associated with selling sex were young age, lower education, living alone or living with a friend, being unemployed, higher HIV knowledge, binge drinking and club drug use, a higher number of casual male partners, meeting sex partners at specific venues, having a foreign sex partner, and being HSV-1 seropositive. MSM aged 18-21 years who sold sex had an HIV incidence of 11.1 per 100 person-years (95% CI: 6.7-17.4). Almost one-third of participants from BMCS reported sex work at enrollment. Young men who sold sex had high HIV incidence and HIV prevention interventions are needed for this at-risk population in Bangkok, Thailand.

Condom-use self-efficacy as a mediator between syndemics and condomless sex in men who have sex with men (MSM)

OBJECTIVE

Among men who have sex with men (MSM), HIV sexual risk and poor self-care behavior is associated with syndemics, or co-occurring psychosocial problems. Though prior research has demonstrated an additive total effect of syndemics on HIV risk behavior and infection, mostly within cross-sectional designs, it is possible that these associations are not direct but rather that syndemics disrupt relevant individual-level mediating psychological variables. One of the more common individual-level psychological variables that predicts health behavior generally, and HIV risk behavior specifically, is self-efficacy. This study sought to examine the potential effects of syndemics on condomless sex via condom-use self-efficacy as an intermediary variable.

METHOD

In high-risk MSM (N = 197), across 3 time points (baseline, 3 months, and 6 months) we used latent growth curve modeling to test the degree to which self-efficacy mediated the relationship between syndemics (heavy alcohol use, substance use disorder, sexual compulsivity, depression, social anxiety, intimate partner violence, childhood sexual abuse) and condomless anal sex.

RESULTS

The baseline analyses were consistent with an indirect effect of the association between syndemics and condomless sex through self-efficacy. Prospective longitudinal mediation was partially supported, such that baseline syndemics were associated with lower baseline self-efficacy, which in turn predicted higher increases in condomless anal sex across time.

CONCLUSIONS

These findings provide preliminary evidence (due to the partial support for the longitudinal model) that syndemics themselves may not be directly causal in their association with condomless sex, but the association may be through modifiable social-cognitive mechanisms such as condom self-efficacy. (PsycINFO Database Record

Longitudinal Effects of Syndemics on ART Non-adherence Among Sexual Minority Men

This study examined longitudinally the additive effect of syndemics, or co-occurring psychosocial problems, on antiretroviral treatment (ART) non-adherence among 390 HIV-positive sexual minority men. Participants completed measures of ART adherence (reduced to a non-adherence score using exploratory factor analysis) and six syndemic conditions. We employed multilevel modeling with the number of syndemics as a longitudinal predictor of non-adherence, and logistic regression with baseline syndemics predicting follow up viral load. Number of syndemics was a significant longitudinal predictor of non-adherence, with each additional syndemic associated with a 0.13 increase in non-adherence (p = 0.004). Each additional syndemic was also associated with 1.27 greater odds of detectable viral load (p = 0.002). Among HIV-positive sexual minority men in this sample, more syndemics were associated with lower ART adherence and greater odds of detectable viral load, suggesting the need for behavioral intervention to facilitate care for this population.

The additive effects of depressive symptoms and polysubstance use on HIV risk among gay, bisexual, and other men who have sex with men

INTRODUCTION

Among gay, bisexual, and other men who have sex with men (GBM), collinearity between polysubstance use and mental health concerns has obscured their combined effects on HIV risk with multivariable results often highlighting only one or the other.

METHODS

We used mediation and moderation analyses to examine the effects of polysubstance use and depressive symptoms on high-risk sex (i.e., condomless anal sex with serodiscordant/unknown status partner) in a sample of sexually-active GBM, aged ≥16 years, recruited in Metro Vancouver using respondent driven sampling. Hospital Anxiety and Depression Scale scores assessed mental health. Alcohol Use Disorder Identification Test scores assessed alcohol disorders. Poly-use of multiple drug types (e.g., stimulants, sedatives, opiates, hallucinogens) was assessed over the previous six months.

RESULTS

Among 719 predominantly white (68.0%), gay-identified (80.7%) GBM, alcohol use was not associated with increased prevalence of high-risk sex. Controlling for demographic factors and partner number, an interaction between polysubstance use and depressive symptoms revealed that the combined effects were additively associated with increased odds for high-risk sex. Mediation models showed that polysubstance use partially mediated the relationship between depressive symptoms and high-risk sex.

CONCLUSION

An interaction effect between polysubstance use (defined by using 3 or more substances in the past six months) and depressive symptoms (defined by HADS scores) revealed that the combination of these factors was associated with increased risk for high-risk sex - supporting a syndemic understanding of the production of HIV risk.

The finding of casual sex partners on the internet, methamphetamine use for sexual pleasure, and incidence of HIV infection among men who have sex with men in Bangkok, Thailand: an observational cohort study

BACKGROUND

The finding of casual sex partners on the internet and methamphetamine use have been described as risk factors for HIV infection in men who have sex with men (MSM). However, the interplay between these factors has not been studied prospectively in one design. This study aims to determine the associations between finding casual sex partners on the internet and incident methamphetamine use and HIV infection.

METHODS

In this observational cohort study of Thai MSM, we recruited Bangkok residents aged 18 years or older with a history of penetrative male-to-male sex in the past 6 months. Baseline and follow-up visits were done at a dedicated study clinic in central Bangkok. Men were tested for HIV infection at every study visit and for sexually transmitted infections at baseline. Baseline demographics and HIV risk behaviour information were collected at every visit by audio computer-assisted self-interview. We used a descriptive model using bivariate odds ratios to elucidate the order of risk factors in the causal pathway to HIV incidence and methamphetamine use. We used Cox proportional hazard regression analysis to evaluate covariates for incident methamphetamine use and HIV infection.

FINDINGS

From April 6, 2006, to Dec 31, 2010, 1977 men were screened and 1764 were found eligible. 1744 men were enrolled, of whom 1372 tested negative for HIV and were followed up until March 20, 2012. Per 100 person-years of follow-up, incidence of methamphetamine use was 3·8 (128 events in 3371 person-years) and incidence of HIV infection was 6·0 (212 events in 3554 person-years). In our descriptive model, methamphetamine use, anal sex, and various other behaviours cluster together but their effect on HIV incidence was mediated by the occurrence of ulcerative sexually transmitted infections. Dual risk factors for both incident methamphetamine use and HIV infection were younger age and finding casual sex partners on the internet. Having ever received money for sex was predictive for incident methamphetamine use; living alone or with a housemate, recent anal sex, and ulcerative sexually transmitted infections at baseline were predictive for incident HIV infection.

INTERPRETATION

In MSM in Bangkok, casual sex partner recruitment on the internet, methamphetamine use, and sexually transmitted infections have important roles in sustaining the HIV epidemic. Virtual HIV prevention education, drug use harm reduction, and biomedical HIV prevention methods, such as pre-exposure prophylaxis, could help to reduce or revert the HIV epidemic among MSM in Bangkok.

FUNDING

US Centers for Disease Control and Prevention and the Johns Hopkins Fogarty AIDS International Training and Research Program.

The Associations of Perceived Social Support with Key HIV Risk and Protective Factors Among Young Males Who Have Sex with Males in Bangkok and Chiang Mai, Thailand

This study used respondent-driven sampling to explore the effects of social support on HIV risk and protective factors among young males who have sex with males (YMSM) in Bangkok (N = 273) and Chiang Mai (N = 243), Thailand. It compared different measures of social support, including living situation, the proportion of family and friends to whom the respondent had disclosed their same-sex attraction, and scores on the multi-dimensional scale of perceived social support as predictors of two outcomes of interest-coerced first sex and HIV knowledge. Social support from family played a mediating role in both outcomes among YMSM in Bangkok but not those from Chiang Mai. Though social support from friends was also studied, it was less strongly associated with the outcomes of interest. The findings support interventions designed to leverage social support networks to increase HIV knowledge and decrease coerced first sex among YMSM. At the same time, they demonstrate that there is not a single risk or demographic profile encompassing all YMSM. Successful programs and policies will need to consider the specific attributes and social environment of YMSM in particular locations in order to effectively address HIV risks.

High prevalence of syndemic health problems in patients seeking post-exposure prophylaxis for sexual exposures to HIV

Introduction

The standard clinical approach to non-occupational HIV post-exposure prophylaxis (nPEP) focuses on biomedical aspects of the intervention, but may overlook co-occurring or ‘syndemic’ psychosocial problems that reinforce future vulnerability to HIV. We therefore sought to determine the prevalence of syndemic health problems in a cohort of Ontario nPEP patients, and explored the relationship between syndemic burden and HIV risk.

Methods

Between 07/2013-08/2016, we distributed a self-administered questionnaire to patients presenting to three clinics in Toronto and Ottawa seeking nPEP for sexual HIV exposures. We used validated screening tools to estimate the prevalence of depression (CES-D score ≥16), harmful alcohol use (AUDIT ≥8), problematic drug use (DUDIT ≥6 men/≥2 women), and sexual compulsivity (SCS ≥24) among men who have sex with men (MSM) respondents. In exploratory analyses, we examined the relationships between syndemic conditions using univariable logistic regression models, and the relationship between syndemic count (total number of syndemic conditions per participant) and HIV risk, as estimated by the HIRI-MSM score, using linear regression models.

Results

The 186 MSM included in the analysis had median age 31 (IQR = 26–36), including 87.6% having a college/undergraduate degree or higher. Overall, 53.8% screened positive for depression, 34.4% for harmful alcohol use, 30.1% for problematic drug use, and 16.1% for sexual compulsivity. Most participants (74.2%) had at least one syndemic condition and 46.8% had more than one. Exploratory analyses suggested positive associations between depression and harmful alcohol use (OR = 2.11, 95%CI = 1.13, 3.94) and between harmful alcohol use and problematic drug use (OR = 1.22, 95%CI = 0.65, 2.29). Syndemic count was associated with increased HIRI-MSM risk scores in univariable (2.2, 95%CI = 1.0, 3.3 per syndemic condition) and multivariable (2.1, 95%CI = 0.6, 3.6) linear regression models.

Conclusions

The prevalence of syndemic conditions in MSM seeking nPEP for sexual exposure is alarmingly high, and is associated with underlying HIV risk. Routine screening for these conditions may identify opportunities for intervention and could alleviate future vulnerability to HIV.

Ice parties among young men who have sex with men in Thailand: Pleasures, secrecy and risks

BACKGROUND

Crystal methamphetamine (ice) has become the substance of choice among young men who have sex with men (YMSM) in urban Thailand. Yet, there is scarce data on this phenomenon, partly due to the difficulty in accessing men who will disclose and openly discuss the social contexts, meanings and risks surrounding ice practice. We present an ethnography of ice parties, critically discussing the in-depth social meanings of ice; the sexual socialities and the secrecy surrounding its use; the transactions between older and younger men; and the role of the Internet and mobile technology.

METHODS

Forty repeated narrative interviews (life stories), ten focus group discussions, as well as systematic online and offline observations were conducted over a three-year period. Purposive sampling was used to recruit study participants in a variety of online and offline spaces and through working closely with local Thai community-based organizations serving MSM. To be eligible, participants had to be between 18 and 29 years, able to converse in Thai, had used ice, and had anal sex with another man in the past 6 months. We also strived for sample variability with respects to socio-demographic characteristics (e.g., age, educational attainment and living situation). Data analysis was conducted in Thai by two researchers using the constant comparative method based on grounded theory.

RESULTS

On surface, participants described ice parties as exclusive, in trend, luxurious, fun and pleasurable-a kind of modern camaraderie among beautiful men. In reality, however, this group phenomenon was a social hierarchy containing several important players with relational power to one another, to the ice itself and to the physical space where ice was being consumed. These players included ice suppliers, party hosts, party guests and "icetenders." The paper also discusses the sociality of secrecy that surrounds ice parties as well as the power relations between older relatively rich men who provide ice and the younger men who crave for the chemical, pointing to the risks associated with engagement at ice parties, including instances of rape, violence and unsafe sex. For some participants, ice use was part of their "everyday life," or even believed to be a "rites of passage." For others, it involved sexual silence in cases where they were forced to have (unprotected) sex with certain persons or engage in high-risk activities against their will.

CONCLUSIONS

Ice parties, where high-risk practices were common, power and agency quickly became relational and negotiable. This paper illuminated the secret sociality of ice so that public health efforts will be better equipped with understanding and reaching out to young men who may be at heightened risk for HIV, STI, violence and other health concerns. Ice parties can, for example, be seen as opportunities for harm-reduction strategies whereby young men are not judged for the activities they engage, but are instead respected and approached in a contextualized, non-judgmental way. Finally, icetenders and party hosts may be individuals where public health practitioners can target and include in the development of novel harm-reduction programs.

Syndemics among individuals enrolled in the PrEP Brasil Study

BACKGROUND

Concurrent psychosocial problems may synergistically increase the risk of HIV infection (syndemics), representing a challenge for prevention. We aimed to evaluate the prevalence and associated factors of syndemics among men who have sex with men (MSM) and transgender women (TGW) enrolled in the Brazilian pre-exposure prophylaxis demonstration study (PrEP Brasil Study).

METHODS

Secondary cross-sectional analysis of the PrEP Brasil Study was performed. Of 450 HIV-seronegative MSM/TGW enrolled in the PrEP Brasil Study- conducted at Rio de Janeiro and São Paulo, Brazil- 421 participants with complete data were included in the present analysis. Syndemics was defined as occurrence of ≥2 of the following conditions: polysubstance (≥2) use, binge drinking, positive depression screen, compulsive sexual behavior, and intimate partner violence (IPV).

RESULTS

The prevalence of recent polysubstance use was 22.8%, binge drinking 51.1%, positive depression screening 5.2%, compulsive sexual behavior 7.1%, and IPV 7.3%. Syndemics prevalence was 24.2%, and associated factors were younger age (adjusted Odds Ratio (aOR) 0.95, 95% Confidence Interval (95% CI) 0.92-0.98 per year increase), TGW vs. MSM (aOR 3.09, 95% CI: 1.2-8.0), some college education or more vs. less than college (aOR 2.49, 95% CI: 1.31-4.75), and multiple male sexual partners in prior 3 months (aOR 1.69, 95% CI: 0.92-3.14).

CONCLUSION

Given the high prevalence of syndemics, particularly of polysubstance use and binge drinking, PrEP delivery offers an opportunity to diagnose and intervene in mental and social well-being.

Psychosocial health and suicidal ideation among people living with HIV/AIDS: A cross-sectional study in Nanjing, China

Background

Suicide is a serious cause of mortality worldwide and is considered as a psychiatric emergency. People living with HIV/AIDS (PLWHA) have higher rates of suicidal behavior than the general population. This study assessed the prevalence and verified the syndemic effect of psychosocial health conditions on suicidal ideation among PLWHA in China.

Methods

An institutional-based cross-sectional study was conducted from July to August 2016 in Nanjing, China, using a self-report questionnaire. Sociodemographic characteristics, infection status, psychosocial variables and suicide ideation reports of participants were collected. Logistic regressions were used to identify potential factors associated with suicidal ideation and to verify the syndemic effect of psychosocial factors. Additionally, odds ratios (ORs) with 95% confidence intervals (95% CI) were computed.

Results

In total, four hundred sixty-five PLWHA participated, 31.6% (n = 147) of whom had suicidal ideation. The results from univariate analysis showed that older age, low education level, being married, having children, and psychosocial variables (high perceived stigma, depression, low self-esteem, social support and resilience) were significantly associated with increased suicidal ideation. Multiple logistic regression models revealed that depression (OR = 2.70, 95%CI = 1.62–4.51), perceived stigma (OR = 1.97, 95%CI = 1.17–3.32), and low social support (OR = 1.85, 95%CI = 1.08–3.20) and self-esteem (OR = 4.11, 95%CI = 2.06–8.16) were statistically significant. PLWHA with at least two psychosocial health problems were nearly 5 times more likely (OR = 4.72, 95% CI 3.11–7.17) to have had suicidal ideation.

Conclusions

Suicidal ideation is frequent among PLWHA in China and is consistent with prevalence estimates from abroad. Psychosocial health problems were the determining factors associated with suicidal ideation, and a syndemic effect of psychosocial health conditions was confirmed in predicting suicidal ideation. Therefore, early screening of high-risk groups for suicidal ideation and more psychosocial health care among PLWHA are needed.

Challenges and emerging opportunities for the HIV prevention, treatment and care cascade in men who have sex with men in Asia Pacific

In Asia Pacific, most countries have expanded HIV treatment guidelines to include all those with HIV infection and adopted antiretroviral treatment for prevention (TFP) as a blanket strategy for HIV control. Although the overall epidemic development associated with this focus is positive, the HIV epidemic in men who have sex with men (MSM) is continuing unperturbed without any signs of decline or reversal. This raises doubt about whether TFP as a blanket HIV prevention policy is the right approach. This paper reviews currently available biomedical HIV prevention strategies, national HIV prevention policies and guidelines from selected countries and published data on the HIV cascade in MSM. No evidence for efficacy of TFP in protecting MSM from HIV infection was found. The rationale for this approach is based on assumptions about biological plausibility and external validity of latency-based efficacy found in heterosexual couples. This is different from the route and timing of HIV transmission in MSM. New HIV infections in MSM principally occur in chains of acutely HIV-infected highly sexually active young men, in whom acquisition and transmission are correlated in space and time. By the time TFP renders its effects, most new HIV infections in MSM will have already occurred. On a global level, less than 6% of all reports regarding the HIV care cascade from 1990 to 2016 included MSM, and only 2.3% concerned MSM in low/middle-income countries. Only one report originated from Asia Pacific. Generally, HIV cascade data in MSM show a sobering picture of TFP in engaging and retaining MSM along the continuum. Widening the cascade with a preventive extension, including pre-exposure prophylaxis, the first proven efficacious and only biomedical HIV prevention strategy in MSM, will be instrumental in achieving HIV epidemic control in this group.

Design of a syndemic based intervention to facilitate care for men who have sex with men with high risk behaviour: the syn.bas.in randomized controlled trial

Background

Men who have sex with men (MSM) constitute a risk group for sexual transmitted infections (STIs), including HIV. Despite counselling interventions, risk behaviour remains high. Syndemic theory holds that psychosocial problems often co-occur, interact and mutually reinforce each other, thereby increasing high risk behaviours and co-occurring diseases. Therefore, if co-occurring psychosocial problems were assessed and treated simultaneously, this might decrease high risk behaviour and disease.

Method

An open label randomized controlled trial will be conducted among 150 MSM with high risk behaviour recruited from the STI clinic of Amsterdam. Inclusion criteria are: HIV negative MSM with two STI and/or PEP treatment in the last 24 months, or HIV positive MSM with one STI in the last 24 months. All participants get questionnaires on the following syndemic domains: ADHD, depression, anxiety disorder, alexithymia and sex- and drug addiction. Participants in the control group receive standard care: STI screenings every three months and motivational interviewing based counselling. Participants in the experimental group receive standard care plus feedback based on the results of the questionnaires. All participants can be referred to co-located mental health or addiction services.

The primary outcome is help seeking behaviour for mental health problems and/or drug use problems. The secondary outcomes are STI incidence and changes in sexual risk behaviour (i.e. condom use, number of anal sex partners, drug use during sex).

Discussion

This study will provide information on syndemic domains among MSM who show high risk behaviour and on the effect of screening and referral on help seeking behaviour and health (behaviour) outcomes.

Trial registration

Trial Registration at clinicaltrail.gov, identifier NCT02859935.

Syndemic conditions and HIV transmission risk behavior among HIV-negative gay and bisexual men in a U.S. national sample

OBJECTIVE

The syndemics framework has been used to explain the high rates of HIV infection among gay and bisexual men. However, most studies have relied primarily on urban or otherwise limited (e.g., single location) samples. We evaluated the prevalence of syndemics-here, depression, polydrug use, childhood sexual abuse, intimate partner violence, and sexual compulsivity-among gay and bisexual men from across the United States, including nonurban areas.

METHOD

Using data from a national sample of 1,033 HIV-negative gay and bisexual men, demographic differences in the prevalence of each syndemic condition and associations with HIV transmission risk behavior were examined.

RESULTS

More than 62% of men reported at least 1 syndemic condition. Prevalence did not vary by U.S. region-however, a larger proportion of nonurban men and those with lower income and education levels were above the median number of syndemic conditions. In bivariate analyses, HIV transmission risk behavior was associated with each syndemic condition except for childhood sexual abuse, whereas in multivariate analyses, it was associated with polydrug use, sexual compulsivity, being Latino, and being single and was highest among those reporting 3 or more syndemic conditions.

CONCLUSIONS

Rates of syndemic conditions among this national sample of gay and bisexual men were generally comparable to previous studies, however elevated rates in nonurban men suggest the need for targeted intervention and support. Links observed between syndemics and HIV transmission risk behavior highlight the ongoing need to address psychosocial concerns among gay and bisexual men in order to reduce their disproportionately high rates of HIV infection. (PsycINFO Database Record

Prospective Effects of a Syndemic on HIV and STI Incidence and Risk Behaviors in a Cohort of Young Men Who Have Sex with Men

Young men who have sex with men continue to be highly affected by HIV. To improve understanding of the role that multiple co-occurring health issues (i.e., syndemics) play in HIV acquisition, sophisticated modeling methods are needed. The purpose of this study was to use structural equation modeling to understand the structure of the syndemic and to test its longitudinal association with condomless anal sex. Data are from a longitudinal study of 450 YMSM. A primary syndemic component comprised of substance use, violence, and internalizing mental health factors significantly predicted the number of condomless anal sex partners in the full sample. Analyses exploring associations by race/ethnicity found a significant association among White YMSM, but not among Black or Latino YMSM. Higher-order factor modeling suggests these psychosocial factors form a syndemic in all racial/ethnic groups, but the syndemic, as conceptualized here, may be less relevant to racial/ethnic minority YMSM.