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

Intimate Partner Violence and HIV Pre-Exposure Prophylaxis Care Engagement Among Sexual Minority Men: A Systematic Review

Sexual minority men (SMM) who experience intimate partner violence (IPV) may also be at increased risk for HIV; however, little is known about the relationship between these experiences and the utilization of pre-exposure prophylaxis (PrEP) for HIV prevention. This systematic review aimed to synthesize available literature to examine the complex interplay between IPV experiences and engagement in the PrEP care continuum among SMM. A comprehensive search following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines in Embase, PubMed, PsycINFO, Web of Science, Medline, and CINAHL identified only 13 relevant articles, most of which were conducted in the United States (n = 9) and only two in low- and middle-income countries (LMICs). Nearly all studies (n = 12, 92.3%) were quantitative in design and used cross-sectional data. The findings of this review identified critical gaps in measuring IPV and PrEP outcomes and revealed mixed findings regarding the complex interplay between IPV and PrEP care engagement in the context of syndemics experienced by SMM. The results highlight the critical need for future research to understand the impact of IPV on PrEP uptake and adherence and its underlying mechanisms. This includes investigating the effects of different types of IPV (e.g., emotional, physical, sexual) on PrEP utilization and how these experiences influence PrEP preferences, such as daily PrEP versus on-demand PrEP or long-acting injectable PrEP. The implications of this review call for comprehensive public health policies and integrated health care practices that provide tailored interventions for IPV screening in PrEP care settings to deliver IPV services and promote engagement in the PrEP care continuum among SMM, as well as further investigation in LMICs.

Examining the secondary impacts of the COVID-19 pandemic on syndemic production and PrEP use among gay, bisexual and other men who have sex with men (GBM) in Vancouver, Canada

BACKGROUND

The secondary impacts of the COVID-19 pandemic may disproportionately affect gay, bisexual, and other men who have sex with men (GBM), particularly related to HIV prevention and treatment outcomes. We applied syndemic theory to examine PrEP disruptions during the during the height of the COVID-19 pandemic in Vancouver, Canada.

METHODS

Sexually-active GBM, aged 16 + years, were enrolled through respondent-driven sampling (RDS) from February 2017 to August 2019. Participants completed a Computer-Assisted Self-Interview every six months and data were linked to the BC PrEP Program (program responsible for publicly funded PrEP in the province) to directly measure PrEP disruptions. The analysis period for this study was from March 2018-April 2021. We used univariable generalized linear mixed models to examine (1) six-month trends for syndemic conditions: the prevalence of moderate/severe depressive or anxiety symptoms, polysubstance use, harmful alcohol consumption, intimate partner violence, and (2) six-month trends for PrEP interruptions among HIV-negative/unknown GBM. We also applied 3-level mixed-effects logistic regression with RDS clustering to examine whether syndemic factors were associated with PrEP interruptions.

RESULTS

Our study included 766 participants, with 593 participants who had at least one follow-up visit. The proportion of respondents with abnormal depressive symptoms increased over the study period (OR = 1.35; 95%CI = 1.17, 1.56), but we found decreased prevalence for polysubstance use (OR = 0.89; 95%CI = 0.82, 0.97) and binge drinking (OR = 0.74; 95%CI = 0.67, 0.81). We also found an increase in PrEP interruptions (OR = 2.33; 95%CI = 1.85, 2.94). GBM with moderate/severe depressive symptoms had higher odds (aOR = 4.80; 95%CI = 1.43, 16.16) of PrEP interruptions, while GBM with experiences of IPV had lower odds (aOR = 0.38; 95%CI = 0.15, 0.95) of PrEP interruptions. GBM who met clinical eligibility for PrEP had lower odds of experiencing PrEP interruptions (aOR = 0.25; 95%CI = 0.11, 0.60).

CONCLUSION

There were increasing PrEP interruptions since March 2020. However, those most at risk for HIV were less likely to have interruptions. Additional mental health services and targeted follow-up for PrEP continuation may help to mitigate the impacts of the COVID-19 pandemic on GBM.

Intimate Partner Violence and the Sexual Health of Sexual Minority Men

Purpose: This qualitative study explores the pathways by which various forms of intimate partner violence (IPV) impact the sexual health behaviors of cisgender identified sexual minority men (SMM). Methods: Semi-structured interviews were conducted with 23 racially and ethnically diverse SMM who recently experienced IPV and 10 clinical and social service providers focused on how experiences of IPV directly or indirectly influences sexual risk as well as engagement in HIV prevention behaviors (e.g., pre-exposure prophylaxis [PrEP] use). Applied thematic analysis, including cycles of analytic memo writing and coding, aided the identification of patterns across the data. Results: Analyses yielded three overarching themes: use of condoms, use of PrEP, and HIV and sexually transmitted infections (STIs). Participants described different ways condom use or nonuse was a mechanism by which power and/or control might be asserted by one partner over the other partner. A range of responses to questions about PrEP were identified, including partners encouraging PrEP use, as well as avoidance of conversations about PrEP or actual PrEP use, to prevent experiencing aggression or IPV from partners. Responses regarding HIV/STIs included those ranging from a new diagnosis being a potential trigger for violence to the exploitation of status to control partners. Conclusion: These findings suggest that in relationships with IPV, HIV prevention strategies can be sources of relationship control and trigger abuse. Addressing IPV may help to prevent HIV/STI transmission and promote the health of SMM. In addition, long-acting formulations of PrEP may be a promising strategy for SMM experiencing IPV when oral PrEP medications may be a risk factor for violence.

High-risk polysubstance use among LGBTQ+ people who use drugs in the United States: An application of syndemic theory

BACKGROUND

Compared to heterosexual and cisgender people, lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) people are more likely to develop problems with high-risk polysubstance use. According to syndemic theory, this disparity in high-risk polysubstance use is produced by the LGBTQ+ community's increased vulnerability to experiencing psychosocial (e.g., discrimination, unwanted sex) and structural (e.g., food insecurity, homelessness) conditions, greater likelihood of coping with concurrent health problems (e.g., human immunodeficiency virus [HIV]), and decreased opportunities to develop protective factors (e.g., social support, resilience).

METHODS

Data from 306 LGBTQ+ participants living in the United States (U.S.) with a lifetime history of alcohol and drug use were analyzed; 21.2% reported lifetime problems with 10 different drugs. Bootstrapped hierarchical multiple regression was used to test demographic correlates and syndemic predictors of high-risk polysubstance use. One-way ANOVA and post-hoc comparison tests were used to test subgroup differences by gender.

RESULTS

Results indicated that income, food insecurity, sexual orientation-based discrimination, and social support were associated with high-risk polysubstance use, explaining 43.9% of the variance of high-risk polysubstance use. Age, race, unwanted sex, gender identity-based discrimination, and resilience were not significant. Group comparison tests revealed that, compared to nonbinary people and cisgender sexual minority men and women, transgender individuals experienced significantly higher levels of high-risk polysubstance use and sexual orientation-based discrimination but significantly lower levels of homelessness and social support.

CONCLUSION

This study provided further evidence for conceptualizing polysubstance use as an adverse outcome of syndemic conditions. Harm reduction strategies, anti-discrimination laws, and gender-affirming residential treatment options should be considered in U.S. drug policy. Clinical implications include targeting syndemic conditions to reduce high-risk polysubstance use among LGBTQ+ people who use drugs.

Integrative Review of Methods From Youth Risk Behavior Survey Secondary Data Analyses Examining HIV Syndemic Factors Among Adolescent Gay and Bisexual Men

BACKGROUND

Adolescent gay/bisexual men exhibit the highest prevalence of undiagnosed HIV infections. Ascertaining antecedents of behaviorally acquired HIV infections among adolescent gay/bisexual men can be challenging; however, these challenges can be overcome through the utilization of secondary data, such as the Youth Risk Behavior Survey.

OBJECTIVE

Syndemics theory suggests that HIV infections are not a singular phenomenon; instead, many infections occur at the intersection of syndemic factors, such as substance use, violence, and mental health. Our objective is to describe and synthesize research methods of secondary data analyses that examine syndemic factors in relation to HIV risk behavior outcomes among subsamples of adolescent gay/bisexual men.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, PubMed, Cumulative Index to Nursing and Allied Health Literature, and PsycInfo were systematically searched. Inclusion criteria were (a) peer-reviewed Youth Risk Behavior Survey secondary data analyses conducted in the United States after 1991, (b) subsamples with adolescent gay/bisexual men, (c) one or more syndemic factor(s), and (d) one or more HIV risk behavior outcome(s). We used the National Institutes of Health Quality Assessment Tools for quality appraisal.

RESULTS

Of 1,036 citations retrieved, nine studies met inclusion criteria. Results included using logistic regression analysis and data from 2015 to 2017 in six studies and underpinnings with minority stress theory in four studies. Eight studies omitted race/ethnicity in subsamples and six grouped lesbians with adolescent gay/bisexual men. Seven studies examined substance use, six examined violence, and five examined mental health. Condom use and number of partners were the most studied HIV risk behavior outcomes in four studies, whereas intercourse in the last 3 months was an outcome in only one study. Protective factors were not present.

CONCLUSION

Limitations found the need to highlight better inclusion of race/ethnicity and sexual orientation. Adding contemporary survey items is also necessary, such as nonbinary sex and gender identity, access to HIV prevention (condoms, HIV testing, and preexposure prophylaxis), and experiences with stigma, to elucidate risk behaviors among populations disproportionately affected by HIV infections, including Blacks/African Americans and Hispanics/Latinos.

Psychosocial Risk Pathways from Childhood Sexual Abuse to Intimate Partner Violence among Sexual Minority Men: A Test of the Psychological Mediation Framework of Minority Stress

Although sexual minority men experience elevated rates of childhood sexual abuse (CSA) and equal or greater rates of intimate partner violence (IPV) victimization compared to heterosexual individuals, little research has examined mechanisms linking these forms of victimization in this high-need population. We examined general (i.e., emotion regulation difficulties) and sexual minority specific (i.e., internalized homophobia) mediational pathways between CSA and IPV victimization in a longitudinal sample of 940 sexual minority men. Path analyses revealed significant associations between CSA and internalized homophobia, between internalized homophobia and emotion regulation difficulties, and between emotion regulation difficulties and IPV victimization. No indirect effects of CSA on IPV via general or minority specific pathways were observed. Findings suggest that minority stress specific (i.e., internalized homophobia) and general psychological risk factors (i.e., emotion regulation difficulties) co-occur and may function along independent pathways to link CSA to IPV revictimization. Future work is needed to investigate how mitigation of these modifiable pathways may be targeted to inform violence prevention interventions for sexual minority men.

Associations between psychosocial factors and antiretroviral therapy outcomes differ by gender and sexual orientation among people living with HIV in British Columbia, Canada

Little is known about how the co-occurrence of psychosocial factors affect sub-populations of people living with HIV (PLWH). We used cross-sectional data from 999 PLWH, aged ≥19, accessing antiretroviral therapy (ART) in British Columbia, Canada (2007-2010) to examine associations between psychosocial factors and ART-related outcomes separately for trans/cis inclusive women; heterosexual men; and gay, bisexual, and other men who have sex with men (gbMSM). Multivariable logistic regression examined associations between psychosocial factors (0-3): any violence in the past 6 months, depressive symptoms in the past week, and current street drug use (heroin, crack, meth or speedball) with sub-optimal adherence (outcome 1: average annual ART adherence <95% from interview until end of follow-up, death, or December 31st, 2018) and ever viral rebound (outcome 2) adjusting for potential confounders. Of 999 PLWH (264 women, 382 heterosexual men, and 353 gbMSM), women and heterosexual men had significantly higher median counts than gbMSM. Overall, higher counts were associated with sub-optimal adherence (adjusted odds ratio [aOR] = 1.26/1-unit increase, 95%CI = 1.07-1.49). All effect estimates were of a greater magnitude among gbMSM, but not significant for women or heterosexual men, highlighting the need for population (e.g., gender and sexual orientation)-centered care and research.

Examining Cultural Competency and Sexual Abuse Training Needs Among Service Providers Working with Black and Latino Sexual Minority Men

Black and Latino sexual minority men (SMM) with a history of childhood sexual abuse (CSA) may be reluctant to disclose such experiences or may appraise them as consensual because of cultural norms. Anticipated stigma, medical mistrust, and concerns that providers lack training in sexuality may complicate their efforts to obtain treatment for long-term health consequences of CSA. It is important to examine the training needs of service providers working with SMM who may disclose sexual abuse. Qualitative interviews were conducted with 35 substance use disorder (SUD) treatment and allied health service providers across the New York City area. Themes included the importance of training in cultural competence, trauma-informed care, and assessment of-and counseling for-CSA. Further education in these areas can enable providers to recognize indicators of abuse in their clients' sexual histories and to more effectively and safely respond to this information. Future studies are encouraged to test a trauma-informed approach to screening for CSA history with Black and Latino SMM who present to SUD treatment and allied health service providers. This research should consider provider perspectives in developing such an approach and will likely involve training and evaluation to ensure adequate preparedness and effective service delivery.

Psychosocial and Culturally-Specific Factors Related to Intimate Partner Violence Victimization among a Sample of Latino Sexual Minority Cis Men in the U.S

A growing body of research illustrates that sexual minority men (SMM) experience elevated rates of intimate partner violence (IPV) compared to heterosexual individuals. Researchers have examined the relationship between minority stress and IPV victimization among sexual minority men. A majority of the IPV research identifying risk factors associated with IPV victimization among SMM have sampled predominately non-Hispanic White SMM, while Latino SMM are consistently under-represented in IPV research. This study examines the associations between (1) co-occurring psychosocial factors (e.g., depression, anxiety, childhood sexual abuse, drug use, and problematic drinking) and (2) Latino-specific minority stress factors (e.g., U.S.-born, language, race/ethnic identities, and discrimination) on IPV victimization in a nationwide sample of Latino SMM. Data were collected from Latino SMM aged 18 or older, identified as cis-male, and in a romantic relationship with a cis-male partner (N = 530). The participants were recruited through social media and geo-location-based dating mobile applications. A majority (72%) of the sample reported IPV victimization in their lifetime. Specific to forms of IPV, more than half (51.9%) of the sample reported monitoring behaviors, while 49.6% reported emotional IPV, 45.1% reported physical IPV, 31.5% reported controlling behaviors, and 22.3% reported HIV-related IPV. In multivariable models, psychosocial and Latino-specific factors were associated with the increased likelihood of IPV victimization. Regarding Latino-specific factors, being born in the U.S. and race-based discrimination predicted IPV victimization. These findings highlight the extent to which minority stress elevates the risk of IPV for Latino SMM and point to the need to address social factors in IPV prevention services. Further, work on SMM IPV victimization tends to focus on the potential role of sexual orientation-related discrimination, whereas the current study points to the importance of race-based discrimination.

Running with Scissors: a Systematic Review of Substance Use and the Pre-exposure Prophylaxis Care Continuum Among Sexual Minority Men

Purpose of Review

Patterns of sexualized drug use, including stimulants (e.g., methamphetamine) and chemsex drugs, are key drivers of HIV incidence among sexual minority men (SMM). Although pre-exposure prophylaxis (PrEP) mitigates HIV risk, there is no consensus regarding the associations of substance use with the PrEP care continuum.

Recent Findings

SMM who use substances are as likely or more likely to use PrEP. Although SMM who use stimulants experience greater difficulties with daily oral PrEP adherence, some evidence shows that SMM who use stimulants or chemsex drugs may achieve better adherence in the context of recent condomless anal sex. Finally, SMM who use substances may experience greater difficulties with PrEP persistence (including retention in PrEP care).

Summary

SMM who use stimulants and other substances would benefit from more comprehensive efforts to support PrEP re-uptake, adherence, and persistence, including delivering behavioral interventions, considering event-based dosing, and providing injectable PrEP.

Indirect effects of dissociation on the relationship between lifetime PTSD symptoms and condomless sex among men who have sex with men with a history of childhood sexual abuse

Posttraumatic stress disorder (PTSD) symptoms may interfere with gay, bisexual and other men who have sex with men's (MSM) ability to engage in safe sex practices. An indirect relationship with dissociation may help to elucidate the relationship between PTSD symptom severity and condomless sex among MSM with childhood sexual abuse (CSA) histories. These relationships have not previously been examined in this group, which has a unique vulnerability for HIV acquisition. A cross-sectional sample of MSM with histories of CSA (N=290) was recruited at study sites in Boston, MA, and Miami, FL. Participants had a mean age of 37.95 years (SD=11.68), 22% were African American and 29.4% identified as Latino. The sample reported a mean of 10.47 (SD=4.38) lifetime PTSD symptoms and 26.4% met the clinical threshold for dissociation. Logistic regression models (adjusted for age, education, and substance use disorder) were used to assess indirect effects of dissociation on the relationship between lifetime PTSD symptoms and condomless anal/vaginal sex episodes with serodiscordant or unknown status partners in the past 3 months. Dissociation accounted for the association between lifetime PTSD symptom severity and condomless sex episodes. The Sobel test (Sobel = 2.04, p= .042; CI 95% bias-corrected bootstrap) suggested significant indirect effects for dissociation. Dissociation among MSM with CSA histories may compromise accurate appraisals of sexual risk and safety and increase vulnerability for HIV acquisition. Further research is warranted to address HIV prevention in the context of PTSD symptom severity to improve the mental health of MSM and increase the effectiveness of HIV prevention interventions.

'Those tablets, they are finding an empty stomach': a qualitative investigation of HIV risk among sexual and gender minority migrants in Cape Town, South Africa

ABSTRACTObjectives: HIV prevalence among sexual and gender minority (SGM) individuals in South Africa is among the highest in the world; however, SGM migrants, an especially vulnerable subgroup of both the SGM and migrant populations, have frequently been overlooked in the country's robust public health response. This qualitative study, guided by syndemics theory, explored the processes by which SGM migrants in South Africa are exposed to HIV risk and those that may reduce this risk.Design: We conducted 6 focus groups with a total of 30 SGM migrants living in Cape Town. Participants were men who have sex with men, women who have sex with women, and transgender women. Transcripts were analyzed using grounded theory.Results: Participants identified a number of interrelated factors (insecure immigration status, financial and housing instability, food insecurity, stigma and discrimination, and lack of social support) contributing to HIV risk. While some took PrEP or HIV medication, adherence could be affected by structural and psychosocial barriers.Conclusion: Interventions that respond to the syndemic impacts on HIV outcomes are needed to reduce disease burden among SGM migrants in South Africa.

Global research on syndemics: a meta-knowledge analysis (2001-2020)

BACKGROUND

Syndemics or synergies of cooccurring epidemics are widely studied across health and social sciences in recent years.

METHODS

We conducted a meta-knowledge analysis of articles published between 2001 to 2020 in this growing field of academic scholarship.

RESULTS

We found a total of 830 articles authored by 3025 authors, mostly from high-income countries. Publications on syndemics are gradually increasing since 2003, with rapid development in 2013. Each article was cited more than 15 times on average, and most (n = 604) articles were original studies. Syndemics research focused on several areas, including HIV/AIDS, substance abuse, mental health, gender minority stressors, racism, violence, chronic physical and mental disorders, food insecurity, social determinants of health, and coronavirus disease 2019. Moreover, biopsychosocial interactions between multiple health problems were studied across medical, anthropological, public health, and other disciplines of science.

CONCLUSIONS

The limited yet rapidly evolving literature on syndemics informs transdisciplinary interests to understand complex coexisting health challenges in the context of systematic exclusion and structural violence in vulnerable populations. The findings also suggest applications of syndemic theory to evaluate clinical and public health problems, examine the socioecological dynamics of factors influencing health and wellbeing, and use the insights to alleviate health inequities in the intersections of synergistic epidemics and persistent contextual challenges for population health.

Examining the Relative Contributions of Methamphetamine Use, Depression, and Sexual Risk Behavior on Rectal Gonorrhea/Chlamydia Among a Cohort of Men Who Have Sex With Men in Los Angeles, California

BACKGROUND

Methamphetamine use, sexual risk behaviors, and depression contribute to ongoing human immunodeficiency virus (HIV) and sexually transmitted infection (STI) disparities among men who have sex with men (MSM). The relative contributions of these effects longitudinally are not well understood.

METHODS

This analysis used visit-level data from a longitudinal cohort of MSM, half with HIV, in Los Angeles, CA. From August 2014 to March 2020, participants completed follow-up visits every 6 months and underwent testing for rectal gonorrhea/chlamydia (GC/CT) and completed questionnaires including depressive symptoms, number of receptive anal intercourse (RAI) partners, and methamphetamine use. Path analysis with structural equation modeling using concurrent and lagged covariates was used to identify relative contributions of methamphetamine use and depression on number of RAI partners and rectal GC/CT across time.

RESULTS

Five hundred fifty-seven MSM with up to 6 visits (3 years) were included for a total of 2437 observations. Methamphetamine use and depressive symptoms were positively associated with number of RAI partners (β = 0.28, P < 0.001; β = 0.33, P = 0.018, respectively), which was positively associated with rectal GC/CT (β = 0.02, P < 0.001). When stratified by HIV status, depressive symptoms were positively associated with RAI partners for HIV-negative MSM (β = 0.50, P = 0.007) but were not associated for MSM living with HIV (β = 0.12, P = 0.57). Methamphetamine use was positively associated with RAI partners in both strata.

CONCLUSIONS

Factors and patterns, which contribute to risk behaviors associated with rectal GC/CT, may differ by HIV status. Our findings demonstrate the importance of combined treatment and prevention efforts that link screening and treatment of stimulant use and depression with STI prevention and treatment.

Global research on syndemics: a meta-knowledge analysis (2001-2020)

BACKGROUND

Syndemics or synergies of cooccurring epidemics are widely studied across health and social sciences in recent years.

METHODS

We conducted a meta-knowledge analysis of articles published between 2001 to 2020 in this growing field of academic scholarship.

RESULTS

We found a total of 830 articles authored by 3025 authors, mostly from high-income countries. Publications on syndemics are gradually increasing since 2003, with rapid development in 2013. Each article was cited more than 15 times on average, and most (n = 604) articles were original studies. Syndemics research focused on several areas, including HIV/AIDS, substance abuse, mental health, gender minority stressors, racism, violence, chronic physical and mental disorders, food insecurity, social determinants of health, and coronavirus disease 2019. Moreover, biopsychosocial interactions between multiple health problems were studied across medical, anthropological, public health, and other disciplines of science.

CONCLUSIONS

The limited yet rapidly evolving literature on syndemics informs transdisciplinary interests to understand complex coexisting health challenges in the context of systematic exclusion and structural violence in vulnerable populations. The findings also suggest applications of syndemic theory to evaluate clinical and public health problems, examine the socioecological dynamics of factors influencing health and wellbeing, and use the insights to alleviate health inequities in the intersections of synergistic epidemics and persistent contextual challenges for population health.

Familism and HIV Risk Among Men Who Have Sex With Men in Taiwan: The Mediating Roles of Stressful Life Events and Coping Strategies

Familism may play an important role in HIV risk behaviors among men who have sex with men (MSM) living in a collectivist culture. This study examined a hypothesized path from familism, stressful life events (i.e., adverse childhood experiences, intimate partner violence, and sexuality-related discriminatory experiences), and coping strategies to condomless anal sex (CAS) among Taiwanese MSM. Participants were 1,000 MSM (mean age = 28.5 years) recruited through five community-based organizations. Structural equation modeling using bootstrapping with 3,000 iterations evaluated the mediating effects of 14 coping strategies. We found a pathway from familism to CAS through stressful life events and substance use coping. The protective effects of familism on stressful life events and CAS suggest that integrating components of family support and family connection into HIV prevention and education programs may increase the effectiveness of these programs in reducing HIV risk behaviors and dysfunctional coping strategies among MSM in Taiwan.

Polysubstance use in a community sample of Black cisgender sexual minority men and transgender women in Chicago during initial COVID-19 pandemic peak

BACKGROUND

In response to COVID-19, the city of Chicago issued stay-at-home orders, which began on March 20, 2020, and restrictions meant to "flatten the curve" remained in effect until June 2, 2020. On June 3, 2020, Chicago entered the reopening phase. This study compares rates of polysubstance use by COVID-19 lockdown phase and across sociodemographic characteristics in a Chicago-based sample of Black cisgender sexual minority men (SMM) and transgender women.

METHOD

Data come from the Neighborhood and Networks (N2) cohort, an ongoing study of Black cisgender SMM and transgender women living in Chicago. Participants (N = 226) completed a survey between April 20, 2020, and July 30, 2020, during the initial peak of the COVID-19 pandemic in Chicago. We conducted chi-square tests of independence and modified Poisson regression models with robust error variance and estimated adjusted prevalence ratios.

RESULTS

Alcohol and marijuana were the most used substances, with 73.5% reporting at least one drinking day and 71.2% of the sample reporting marijuana use in the past 14 days. Tobacco was used by 41.6% of the sample, and illegal drug use, which does not include marijuana, was reported by 17.7% of the sample. Substance use was consistently associated with the use of other substances. As such, polysubstance use (i.e., using two or more substances) was common in this sample (63.7%). Few sociodemographic differences emerged, and substance use was not associated with lockdown phase.

CONCLUSION

Substance use, including polysubstance use, was high in our sample of Black SMM and transgender women during the initial peak of the COVID-19 pandemic. Continued monitoring is needed given the duration of the COVID-19 pandemic and the negative health consequences associated with substance use in this population.

Relationship Power and Intimate Partner Violence in Sexual Minority Male Couples

Objective: The objective of the present study was to test pathways implied by Disempowerment Theory to predict intimate partner violence (IPV) among men in a same-sex relationship. Background: Sexual minority men in relationships experience rates of IPV comparable with heterosexual women, yet most research on IPV focuses on heterosexual couples. Disempowerment Theory suggests that a range of individual, family-of-origin, and intimate relationship risk factors predict the use of violence to re-establish power in a relationship. Method: Data for the present study were gathered from an online survey completed by sexual minority men currently in a same-sex relationship (n = 339). Analysis of data included two steps: (a) we tested the direct effect of individual, family, and relational predictors on the odds of IPV and (b) we calculated a path model that included relationship power as a link between the predictors (individual, family, and relational) and IPV. Results: In line with Disempowerment Theory, relationship power was negatively associated with IPV. Bivariate analysis indicated an association between childhood sexual abuse and IPV, but childhood sexual abuse was not predictive of IPV through relationship power. Other individual (depression) and relationship-specific (sexual communication and relationship satisfaction) risk factors were associated with IPV indirectly through relationship power. Conclusion: Disempowerment Theory may provide a useful framework for understanding the occurrence of IPV in sexual minority male couples. It may also provide a starting point for the development of multi-component interventions to reduce violence in these couples.

The Impact of COVID-19 on Sexual Behavior and Psychosocial Functioning in a Clinical Sample of Men who have Sex with Men Using HIV Pre-exposure Prophylaxis

The purpose of this study was to evaluate the impact of the Coronavirus Disease 2019 (COVID-19) pandemic on sexual behavior, mental health, and substance use among men who have sex with men (MSM) engaged in pre-exposure prophylaxis (PrEP) care. Generalized linear mixed models and logistic mixed-effect models examined change over time for number of sexual partners, mood, and alcohol consumption. From February 29, 2020 to July 31, 2020, 177 MSM actively engaged in PrEP care were evaluated. The median age was 37 [interquartile range (IQR 30, 51]. Patients in the sample were largely representative of the clinic population and identified as White (73.0%), Black/African American (9.2%), and other race (17.2%), and 11.8% identified as Hispanic/Latino ethnicity. Men reported an average of 2.60 fewer sexual partners (95% CI −4.04, −1.40) during the pandemic compared to pre-COVID-19. Rates of depressive symptoms and alcohol use remained stable and few patients reported substance use. The reduced number of sexual partners may be explained by patients’ efforts to reduce risk of exposure to COVID-19 and low rates of psychosocial symptoms may be indicative of only the highest functioning patients continuing to engage in care. Reductions in sexual partners may offset reduced engagement in care and help mitigate risk of HIV and other sexually transmitted infections (STIs).

Syndemic Profiles and Sexual Minority Men's HIV-Risk Behavior: A Latent Class Analysis

Syndemic theory posits that "syndemic conditions" (e.g., alcohol misuse, polydrug use, suicidality) co-occur among sexual minority men and influence HIV-risk behavior, namely HIV acquisition and transmission risk. To examine how four syndemic conditions cluster among sexual minority men and contribute to HIV-risk behavior, we conducted latent class analysis (LCA) to: (1) classify sexual minority men (n = 937) into subgroups based on their probability of experiencing each syndemic condition; (2) examine the demographic (e.g., race/ethnicity) and social status (e.g., level of socioeconomic distress) characteristics of the most optimally fitting four syndemic classes; (3) examine between-group differences in HIV-risk behavior across classes; and (4) use syndemic class membership to predict HIV-risk behavior with sexual minority men reporting no syndemic conditions as the reference group. The four classes were: (1) no syndemic, (2) alcohol misuse and polydrug use syndemic, (3) polydrug use and HIV syndemic, and (4) alcohol misuse. HIV-risk behavior differed across these latent classes. Demographic and social status characteristics predicted class membership, suggesting that syndemic conditions disproportionately co-occur in vulnerable subpopulations of sexual minority men, such as those experiencing high socioeconomic distress. When predicting HIV-risk behavior, men in the polydrug use and HIV syndemic class were more likely (Adjusted Risk Ratio [ARR] = 2.93, 95% CI: 1.05, 8.21) and men in the alcohol misuse class were less likely (ARR = 0.17, 95% CI: 0.07, 0.44) to report HIV-risk behavior than were men in the no syndemic class. LCA represents a promising methodology to inform the development and delivery of tailored interventions targeting distinct combinations of syndemic conditions to reduce sexual minority men's HIV-risk behavior.

Estimated Prevalence and Demographic Correlates of Compulsive Sexual Behavior Among Gay Men in the United States

BACKGROUND

Compulsive sexual behavior (CSB) is a clinical syndrome that causes significant distress and impairment for many individuals in the United States. Gay men are thought to have a higher prevalence of CSB, and it is associated with many relevant health outcomes including HIV risk behavior.

AIM

To estimate the prevalence and examine demographic correlates of CSB among gay men in the United States.

METHODS

A U.S. national probability sample of 227 gay-identified men were collected as part of the 2015 National Survey of Sexual Health and Behavior (NSSHB).

OUTCOMES

Participants completed the Compulsive Sexual Behavior Inventory (CSBI-13) and demographic measures.

RESULTS

Eighteen participants (7.93%) scored above the CSBI-13 clinical cut point, indicating they would likely meet criteria for clinically significant compulsive sexual behavior. To assess demographic correlates of CSB, demographic variables were entered into a logistic regression. Results of the logistic regression indicated that participant age, education, and religious affiliation were significant predictors of CSB status. Individuals scoring above the cut point were younger on average (M = 39.17; SD = 14.84) than those scoring below the cut point (M = 47.52; SD = 14.62; P = .02). Odds of scoring above the cut point were about six times greater for religiously affiliated participants compared to non-religiously affiliated participants (P = .005), and four times greater for those who had attended college compared to those who had not (P = .03).

CLINICAL IMPLICATIONS

These results indicate the prevalence of CSB in gay men is more modest than previously estimated, and is similar to the general population prevalence estimated in a previous study. The strongest predictor of CSB in this sample was religious affiliation, which underscores the importance of evaluating the role of religiosity in the etiology and/or identification of this clinical syndrome.

STRENGTHS AND LIMITATIONS

These findings are strengthened by the national probability sampling methodology and the use of the empirically validated CSBI-13 cut point. However, this sample was also older and had higher income and educational attainment than the larger population of gay men in the U.S.

CONCLUSION

These results indicate gay men may have a CSB prevalence rate similar to the general population, which contradicts previous research suggesting they are at greater risk for CSB. Gleason N, Finotelli I, Miner MH, et al. Estimated Prevalence and Demographic Correlates of Compulsive Sexual Behavior Among Gay Men in the United States. J Sex Med 2021;18:1545-1554.

Syndemics and preexposure prophylaxis are independently associated with rectal immune dysregulation in sexual minority men

OBJECTIVE

Syndemic conditions have been linked to engagement in receptive condomless anal sex (CAS) and HIV seroconversion. However, little is known about the biological pathways whereby syndemics could amplify vulnerability to HIV and other sexually transmitted infections (STIs).

DESIGN

HIV-negative sexual minority men (i.e. gay, bisexual and other MSM) were recruited from four STI clinics in South Florida for a cross-sectional study.

METHODS

Participants completed assessments for four syndemic conditions: depression, posttraumatic stress disorder, hazardous alcohol use and any stimulant use (i.e. any self-reported use or reactive urine toxicology results). Cytokine and chemokine levels were measured using LEGENDplex from the rectal swabs of 92 participants reporting receptive CAS and no antibiotic use in the past three months.

RESULTS

After controlling for age, race/ethnicity, preexposure prophylaxis (PrEP) use and number of receptive CAS partners, a greater number of syndemic conditions was associated with higher levels of rectal cytokines/chemokines relevant to immune activation, inflammation and the expansion and maintenance of T-helper 17 target cells, including rectal interferon-gamma (β = 0.22; P = 0.047), CXCL-8 (β = 0.24; P = 0.025) and interleukin-23 (β = 0.22; P = 0.049). Elevations in rectal cytokine or chemokine levels were most pronounced among participants experiencing two or more syndemic conditions compared with those experiencing no syndemic conditions. PrEP use was independently associated with elevations in multiple rectal cytokines/chemokines.

CONCLUSION

Syndemic conditions could increase biological vulnerability to HIV and other STIs in sexual minority men by potentiating rectal immune dysregulation.

Who Aren't We Reaching? Young Sexual Minority Men's Non-participation in an HIV-Prevention and Mental Health Clinical Trial

Despite many successful clinical trials to test HIV-prevention interventions for sexual minority men (SMM), not all SMM are reached by these trials. Identifying factors associated with non-participation in these trials could help to ensure the benefits of research extend to all SMM. Prospective participants in New York City and Miami were screened to determine eligibility for a baseline assessment for a mental health/HIV-prevention trial (N = 633 eligible on screen). Logistic regression and classification and regression tree (CART) analysis identified predictors of non-participation in the baseline, among those who were screened as eligible and invited to participate. Individuals who reported unknown HIV status were more likely to be non-participators than those who reported being HIV-negative (OR = 2.39; 95% CI 1.41, 4.04). In New York City, Latinx SMM were more likely to be non-participators than non-Latinx white SMM (OR = 1.81; 95% CI, 1.09, 2.98). A CART model pruned two predictors of non-participation: knowledge of HIV status and age, such that SMM with unknown HIV status and SMM ages 18-19 were less likely to participate. Young SMM who did not know their HIV status, and thus are more likely to acquire and transmit HIV, were less likely to participate. Additionally, younger SMM (18-19 years) and Latinx SMM in New York City were less likely to participate. The findings suggest the importance of tailored recruitment to ensure HIV-prevention/mental health trials reach all SMM.

Scaling Up and Out HIV Prevention and Behavioral Health Services to Latino Sexual Minority Men in South Florida: Multi-Level Implementation Barriers, Facilitators, and Strategies

Latino sexual minority men (LSMM) are disproportionately affected by HIV in the United States. Concurrently, behavioral health disparities, including mental health and substance use concerns, worsen HIV disparities affecting LSMM. Yet, evidence-based HIV prevention and behavioral health services are insufficiently scaled up and out to this population, perpetuating health disparities, thwarting efforts to control the HIV epidemic, and highlighting the need for culturally relevant evidence-based implementation strategies that address these disparities. Participants included 28 LSMM with varying degrees of engagement in HIV prevention and behavioral health services, and 10 stakeholders with experience delivering HIV prevention and behavioral health services to LSMM in South Florida, an HIV epicenter in general and in particular for LSMM. Participants completed semistructured interviews (English/Spanish) regarding LSMM's barriers and facilitators to engaging in HIV prevention and behavioral health services. Interviews were audio recorded and analyzed using thematic analysis. The 16 themes that emerged from the qualitative analysis were consistent with the consolidated framework for implementation research, an implementation research framework that articulates barriers and facilitators to implementing clinical interventions. Findings suggested the need for implementation strategies that simplify and reduce costs of HIV prevention and behavioral health services, address syndemic challenges impacting service use among LSMM, reduce stigma about service utilization, leverage peer networks, increase provider and community knowledge about services, and build LSMM's readiness and motivation to engage in services. Such strategies may ultimately address HIV and behavioral health disparities among LSMM and facilitate achievement of ending the HIV epidemic goals in this disproportionally affected population.

Perceived Confidentiality Risks of Mobile Technology-Based Ecologic Momentary Assessment to Assess High-Risk Behaviors Among Rural Men Who Have Sex with Men

Although men who have sex with men (MSM) within rural communities are disproportionately impacted by HIV, limited HIV research and programmatic resources are directed to these communities within the U.S. There is a need for improved behavioral data collection methods to obtain more detailed information on the relationship between rural environments, sexual behavior, and substance use. Utilization of mobile health (mHealth) technologies, such as ecologic momentary assessment (EMA), has been advocated for; however, limited research has evaluated its utility among rural MSM. Forty MSM residing in rural Oklahoma were recruited to complete in-depth interviews related to participating online/mobile-based HIV prevention research. Men described a willingness to participate in HIV and substance use studies that use EMA methodologies for data collection; however, they raised various research-related concerns. In particular, participants indicated potential privacy and confidentiality concerns related to the use of the mobile technology-based EMA in public and the storage of data by researchers. Given the varying degree of sexual orientation and substance use disclosure by participants, rural MSM were largely concerned with being inadvertently "outed" within their communities. Men described the various strategies they could employ to protect private information and methods to minimize research risk. Study findings suggest that EMA is an acceptable research methodology for use among rural MSM in the context of HIV and sexual health information, when privacy and confidentiality concerns are adequately addressed. Input from community members and stakeholders is necessary to identify potential areas of concerns for participants prior to data collection.

Correlates of Transactional Sex and Violent Victimization among Men Who Inject Drugs in Los Angeles and San Francisco, California

Men who inject drugs (MWID) and engage in transactional sex (i.e., receive money or drugs in exchange for sex) are vulnerable to HIV and violence. However, MWID who engage in transactional sex have been less studied than women. We examine factors associated with transactional sex among MWID in Los Angeles and San Francisco and whether transactional sex is associated with violent victimization. MWID were recruited using targeted sampling methods in 2011-2013 and completed surveys that covered demographics, drug use, HIV risk, violence, transactional sex, and other items. Multivariable logistic regression was used to (1) determine factors independently associated with transactional sex and (2) determine if transactional sex was independently associated with violence victimization in the last 6 months among MWID. An interaction term between income source and sexual identity was included in the transactional sex model. Of the 572 male PWID in the sample, 47 (8%) reported transactional sex in the past 6 months. Self-reported HIV infection was 7% for MWID who did not report transactional sex, 17% for MWID who reported transactional sex, and 24% for MWID who reported transactional sex and reported gay or bisexual identity. In multivariable analysis, transactional sex was positively associated with gay or bisexual identity (GB without illegal income adjusted odds ratio [AOR] = 5.16; 95% confidence interval [CI] = 1.86-14.27; GB with illegal income AOR = 13.55, CI = 4.57-40.13), coerced sex in the last 12 months (AOR = 11.66, CI = 1.94-70.12), and violent victimization in the last 12 months (AOR = 2.31, CI = 1.13-4.75). Transactional sex was negatively associated with heroin injection (last 30 days) (AOR = 0.37; 95% CI = 0.18-0.78). Transactional sex was independently associated with violent victimization in the last 12 months (AOR = 2.04; 95% CI = 1.00-4.14) while controlling for confounders. MWID who engaged in transactional sex are at elevated risk for HIV and multiple forms of violent victimization. Interventions focused on this at-risk subpopulation are urgently needed and should include access to substance use disorder treatment, victimization services, and harm reduction services across the HIV care continuum.

Increasing HIV Testing and Viral Suppression via Stigma Reduction in a Social Networking Mobile Health Intervention Among Black and Latinx Young Men and Transgender Women Who Have Sex With Men (HealthMpowerment): Protocol for a Randomized Controlled Trial

BACKGROUND

Stigma and discrimination related to sexuality, race, ethnicity, and HIV status negatively impact HIV testing, engagement in care, and consistent viral suppression (VS) among young Black and Latinx men who have sex with men and transgender women who have sex with men (YBLMT). Few interventions address the effects of intersectional stigma among youth living with HIV and those at risk for HIV within the same virtual space.

OBJECTIVE

Building on the success of the HealthMpowerment (HMP) mobile health (mHealth) intervention (HMP 1.0) and with the input of a youth advisory board, HMP 2.0 is an app-based intervention that promotes user-generated content and social support to reduce intersectional stigma and improve HIV-related outcomes among YBLMT. The primary objective of this study is to test whether participants randomized to HMP 2.0 report improvement in HIV prevention and care continuum outcomes compared with an information-only control arm. We will also explore whether participant engagement, as measured by paradata (data collected as users interact with an mHealth intervention, eg, time spent using the intervention), mediates stigma- and HIV care-related outcomes. Finally, we will assess whether changes in intersectional stigma and improvements in HIV care continuum outcomes vary across different types of social networks formed within the intervention study arms.

METHODS

We will enroll 1050 YBLMT aged 15 to 29 years affected by HIV across the United States. Using an HIV-status stratified, randomized trial design, participants will be randomly assigned to 1 of the 3 app-based conditions (information-only app-based control arm, a researcher-created network arm of HMP 2.0, or a peer-referred network arm of HMP 2.0). Behavioral assessments will occur at baseline, 3, 6, 9, and 12 months. For participants living with HIV, self-collected biomarkers (viral load) are scheduled for baseline, 6, and 12 months. For HIV-negative participants, up to 3 HIV self-testing kits will be available during the study period.

RESULTS

Research activities began in September 2018 and are ongoing. The University of Pennsylvania is the central institutional review board for this study (protocol #829805) with institutional reliance agreements with the University of North Carolina at Chapel Hill, Duke University, and SUNY Downstate Health Sciences University. Study recruitment began on July 20, 2020. A total of 205 participants have been enrolled as of November 20, 2020.

CONCLUSIONS

Among a large sample of US-based YBLMT, this study will assess whether HMP 2.0, an app-based intervention designed to ameliorate stigma and its negative sequelae, can increase routine HIV testing among HIV-negative participants and consistent VS among participants living with HIV. If efficacious and brought to scale, this intervention has the potential to significantly impact the disproportionate burden of HIV among YBLMT in the United States.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03678181; https://clinicaltrials.gov/ct2/show/study/NCT03678181.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/24043.

Patterns of Exposure to Socio-structural Stressors and HIV Care Engagement Among Transgender Women of Color

Transgender women are disproportionately affected by HIV and experiences of social adversity that may interfere with engagement in care and viral suppression. We used latent class analysis to examine patterns of social adversity and their impact on HIV care continuum outcomes in an urban sample of transgender women of color. Participants (n = 224) were median age 29 and 86% non-Hispanic Black. Lack of resources, unemployment, and housing instability were reported by over 50%, and 41% reported history of incarceration. Latent class analysis identified 2 distinct classes representing higher and lower levels of social adversity. In latent class regression, membership in the higher social adversity class was associated with statistically significantly lower odds of viral suppression and HIV care engagement in univariate analysis; when adjusted for age, race, and recruitment site the association remained statistically significant for viral suppression (aOR 0.38, 95% CI 0.18-0.79; chi-square = 6.681, d.f. = 1, p = 0.010), though not for HIV care engagement. Our findings highlight the impact of socio-structural barriers on engagement in the HIV care continuum among transgender women.

Evaluating the impact of COVID-19: A cohort comparison study of drug use and risky sexual behavior among sexual minority men in the U.S.A

BACKGROUND

Sexual minority men who use drugs have high sexual HIV transmission risk. Sexual interactions may also increase COVID-19 risk.This study compared marijuana use, other illegal drugs use (i.e. cocaine/crack, methamphetamine, MDMA/ecstasy, GHB, and ketamine) and sexual behavior with casual partners among sexual minority cismen active on social networking and dating applications before and during the COVID-19 epidemic.

METHODS

This cohort-control study compared 455 adult respondents (surveyed May 6th to 17th, 2020) and a matched sample selected from 65,707 respondents surveyed pre-COVID. Participants were recruited on social networking and dating applications and completed surveys online.

RESULTS

The proportion reporting marijuana use declined significantly in the COVID cohort (34.5 % versus 45.7 % pre-COVID,p < .001) as did their illegal drug use (11.0 % versus 22.9 % pre-COVID, p < .001). While the number of casual partners per month was stable, the proportion reporting condomless anal sex with casual partners declined significantly during COVID (26.4 % versus 71.6 % pre-COVID, p < .001). The effect of illegal drug use (excluding marijuana) on number of casual partners per month (aRR = 1.45 pre-COVID versus 2.84, p < .01) and odds of condomless anal sex (aOR = 2.00 pre-COVID versus 5.22, p = .04) were significantly greater in the COVID cohort.

CONCLUSIONS

While the proportion of participants reporting drug use and condomless anal sex with casual partners declined in the COVID cohort, the association between drug use and sexual behavior was magnified. Sexual minority men who use drugs are significantly more likely to engage in sexual behaviors that place them at risk for HIV and COVID-19 transmission.

Changes in mental health and drug use among men who have sex with men using daily and event-driven pre-exposure prophylaxis: Results from a prospective demonstration project in Amsterdam, the Netherlands

BACKGROUND

Gay, bisexual and other men who have sex with men (GBMSM) are at increased risk of mental health disorders and drug use. In GBMSM taking pre-exposure prophylaxis (PrEP) for HIV, the proportion engaging in risk behaviors could increase due to decreased perception in HIV risk. In turn, this could leave them further susceptible to mental health disorders.

METHODS

The AMsterdam PrEP study (AMPrEP) is a demonstration project offering a choice of daily PrEP or event-driven PrEP regimen at the STI clinic of the Public Health Service of Amsterdam. Eligible participants were HIV-negative GBMSM and transgender people at risk of HIV, aged ≥18 years. We assessed anxiety and depressive mood disorders (Mental Health Inventory 5), sexual compulsivity (Sexual Compulsivity Scale), alcohol use disorder (Alcohol Use Disorder Identification Test), and drug use disorder (Drug Use Disorder Identification Test) using yearly self-administered assessments (August 2015-September 2018). The proportion of mental health problems were analyzed and changes over time and between regimen were assessed using a logistic regression model. Variables associated with the development or recovery of disorders were assessed using a multistate Markov model.

OUTCOMES

Of 376 enrolled, we analyzed 341 participants with data at baseline and at least one follow-up visit. During a median follow-up of 2.5 years (IQR=2.3-2.7), the proportion assessed with sexual compulsivity decreased from 23% at baseline to 10% at the last visit (p<0.001) and drug use disorder decreased from 38% at baseline to 31% at the last visit (p = 0.004). No changes occurred in proportion assessed with anxiety/depressive mood disorders (20% at baseline, 18% at last visit, p = 0.358) or alcohol use disorder (28% at baseline, 22% at the last visit, p = 0.106). During follow-up, participants reported significant less use of alcohol (p<0.001), nitrites (p<0.001) and ecstasy (p<0.001). We found no differences between daily and event-driven PrEP users. The development and recovery of disorders during follow-up were highly interrelated.

INTERPRETATION

Mental health disorders are prevalent among those initiating PrEP. We did not find increases in mental health disorders during PrEP use, but rather a decrease in sexual compulsivity and drug use disorders. The initial prevalence of mental health disorders in our study point at the continuous need to address mental health disorders within PrEP programs.

FUNDING

ZonMw, H-TEAM, Internal GGD research funds, Aidsfonds, Stichting AmsterdamDiner Foundation, Gilead Sciences, Janssen Pharmaceutica, M A C AIDS Fund, and ViiV Healthcare.

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.

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.

Child Sexual Abuse and Compulsive Sexual Behavior: A Systematic Literature Review

PURPOSE OF REVIEW

Information on potential risk factors and clinical correlates of compulsive sexual behavior (CSB) may help inform more effective prevention and treatment measures. Sexual victimization, specifically, child sexual abuse (CSA), has been associated with CSB.

RECENT FINDINGS

This systematic review describes 21 studies on the relationship between CSA and CSB. Most studies identified a significant association between CSA and CSB. However, variability in measurements, potential differences in links among community versus clinical samples, relevance of research among college samples, lack of support for gender-related differences, and the need for more longitudinal designs were identified.

SUMMARY

Research would benefit from more formalized assessments of CSB across different populations. Prevention efforts should be aimed toward individuals who experienced CSA and/or other abuse, particularly if they report engaging in risky sexual behavior. Individuals with CSB who have experienced sexual abuse may benefit from trauma-focused treatment.

Whither syndemics?: Trends in syndemics research, a review 2015-2019

As originally conceived, syndemics refers to complex epidemics involving two types of adverse interaction - the clustering and interactions of two or more diseases or health conditions (the biological-biological interface) and social environmental factors (the biological-social interface). The theory has been widely applied in the fields of medicine, public health and anthropology, but how the concept is conceptualised and investigated in new syndemics literature remains unclear. This paper offers a scoping review of recent syndemics literature aiming to address the question: Where have scholars taken the syndemics concept? Five bibliographic databases were searched for titles containing 'syndemic[s]' revealing 334 records. A total of 143 journal articles, 23 book chapters, 21 commentaries, 2 books and 5 dissertations were assessed. Citations were classified into five categories: syndemics (n = 22), potential syndemics (n = 34), socially determined heightened burden of disease (n = 29), harmful disease cluster (n = 32) and additive adverse conditions (n = 71). The limited number of citations meeting the definition of a syndemic arrangement highlights the challenges related to describing and empirically supporting the biological-biological and biological-social relationships. Nevertheless, there is value in retaining the original, holistic, biosocial meaning of syndemics to identify and detail the casual pathways and mechanisms of interactions.

Examining the Impact of a Psychosocial Syndemic on Past Six-Month HIV Screening Behavior of Black Men who have Sex with Men in the United States: Results from the POWER Study

Syndemic production theory has been used to explore HIV transmission risk or infections but has not been used to investigate prevention behavior, or with large samples of non-Whites. This analysis is the first to explore the impact of syndemic factors on previous six-month HIV screening behavior among US Black MSM. Data from Promoting Our Worth, Equality and Resilience (POWER) were analyzed from 3294 participants using syndemic variable counts and measures of interaction/synergy. Syndemic variables included: past three-month poly-drug use, depression, last year intimate partner violence, HIV risk and problematic binge drinking. BMSM reporting two syndemic factors were more likely to report screening (AOR = 1.37, 95% CI 1.04-1.80; p = 0.028) with no significant associations for three or more conditions. Measures of joint effect revealed that there were synergies among depression, problematic binge drinking and poly-drug use but these psychosocial factors cannot entirely explain testing patterns and excess disease burden among BMSM.

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.

Early Sexual Experiences, Mental Health, and Risk Behavior among Black Non-Hispanic and Hispanic / Latino Men Who Have Sex with Men (MSM)

Black and Latino men who have sex with men (MSM) are disproportionately affected by childhood sexual abuse (CSA). Investigating these histories is often confounded by underreporting and varied definitions of abuse. Unrecognized abuse may manifest in unhealthy ways, specifically psychological distress, substance use, and high-risk sexual behaviors. Black and Hispanic/Latino MSM in New York City discussed formative sexual experiences in in-person interviews. Eligible men reported a sexual experience occurring before age 16 with a man or woman 18 or older at the time. Among interviewees (n = 61), men living with HIV were significantly younger at the time of their first sexual experience with a male partner compared to HIV-negative men. Approximately half of interviewees (47.5%) scored at or above the diagnostic cutoff for post-traumatic stress disorder (PTSD). Hispanic/Latino men had increased odds of scoring at or above the diagnostic cutoff for PTSD compared to Black non-Hispanic men. Further, nearly half of interviewees (46%) scored at or above the diagnostic cutoff for harmful drug use or possible drug dependence. Study findings have implications for future research using an indirect approach to uncovering potential sexual abuse during childhood, and associations with adult health outcomes.

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.

Psychosocial Syndemic Risks Surrounding Physical Health Conditions Among Sexual and Gender Minority Individuals

Purpose: The high prevalence of physical health conditions among sexual and gender minority (SGM) individuals could be explained, in part, by SGM individuals' disparate exposure to interconnected psychosocial syndemic risks, including substance use, depression, posttraumatic stress disorder, intimate partner violence, and sexual assault. We utilized a syndemic framework to understand the overlapping and potentially synergistic association between psychosocial syndemic risks and physical health conditions among SGM adults. Methods: A sample of 298 self-identified SGM adults (M age = 28.03, SD = 9.86; 47.0% racial/ethnic minority, 41.6% transgender or gender nonconforming) completed an online survey from May 2016 through May 2017. Results: Three (1.0%) participants reported no syndemic risks, 19 (6.4%) reported one, 52 (17.4%) reported two, 85 (28.5%) reported three, 89 (29.9%) reported four, and 50 (16.8%) reported all five syndemic risks. The number of psychosocial syndemic risks was positively associated with the number of physical health conditions and synergistically (i.e., more than additively) increased the overall health burden on SGM individuals. Conclusion: We found evidence for psychosocial syndemic risks as predictors of SGM individuals' physical health. This study is novel in providing evidence for syndemics surrounding a comprehensive set of physical health outcomes among individuals identifying along a full spectrum of SGM identities. The study controlled for HIV to examine syndemic conditions surrounding physical health outcomes beyond this well-established syndemically determined condition. Comprehensive intervention and policy efforts that address co-occurring psychosocial risks for physical health conditions are needed to reduce health disparities affecting SGM populations.

A Psychosocial Risk Model of Potentially Traumatic Events And Sexual Risk Behavior Among LGBTQ Individuals

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals face heightened risk of potentially traumatic events (PTEs) exposure, including hate crimes and childhood abuse. Past research demonstrates associations between PTEs exposure and sexual risk behavior; however, examining the indirect effect of PTEs on sexual risk behavior remains understudied among LGBTQ individuals. This study tested a path analysis model to inform interventions targeted to reduce sexual risk behavior, as conceptualized by condomless sex with casual partners without knowing the person's HIV or sexually transmitted infection (STI) status, among LGBTQ individuals with PTEs exposure. Participants completed an online one-time survey and included 207 LGBTQ adults who experienced at least one PTE during the past year. Indirect effect results indicated that PTEs exposure was related to sexual risk behavior through serial associations between shame, loneliness, and substance use. Direct effect estimates indicated that greater PTEs exposure was associated with greater shame, loneliness, substance use, and sexual risk behavior. Greater shame was associated with greater loneliness, which was associated with greater substance use. Also, greater substance use was associated with greater sexual risk behavior. This study adds to the burgeoning body of literature on the relationship between PTEs exposure and sexual risk behavior among LGBTQ individuals. Clinical and counseling interventions for LGBTQ individuals with PTEs exposure should work to address modifiable psychosocial risk factors associated with sexual risk behavior.

Relationship functioning and substance use in same-sex male couples

BACKGROUND

Research suggests that substance use among partnered sexual minority men will be inversely associated with the quality of dyadic functioning. We tested whether dimensions of relationship functioning implied within Couples Interdependence Theory (e.g., rewards, costs, barriers, alternatives, investment, and comparison to an ideal) predicted drug use and problematic alcohol use consistent with this hypothesis.

METHODS

This study utilized baseline data from a sample of 70 couples recruited in the New York City area. All participants were cis-gender male and 18 or older. In each couple, at least one partner reported recent drug use, at least one was aged 18 to 29, and at least one was HIV negative. Participants provided demographic information; completed measures of relationship functioning and problematic alcohol use; and reported recent (past 30 day) drug use.

RESULTS

Actor-partner interdependence models were calculated. The use of miscellaneous recreational drugs (excluding marijuana) was positively associated with participants' perception of rewards, costs, and barriers to leaving and negatively associated with comparisons to an ideal, alternatives, and investment. In addition, partner perceptions of rewards were positively associated with this outcome. AUDIT scores were negatively associated with comparison to an ideal; and positively associated with partner perceptions of alternatives. Relationship functioning was unrelated to marijuana use.

CONCLUSIONS

These findings provide support for the hypothesis that relationship functioning and substance use are related. Couples Interdependence Theory implies such an assumption and it underlies many couples-based approaches to drug use intervention. These findings point to the potential utility of integrating relationship skill building into substance use interventions for partnered sexual minority men.

Antiretroviral Medications for the Prevention of HIV Infection: A Clinical Approach to Preexposure Prophylaxis, Postexposure Prophylaxis, and Treatment as Prevention

Preventing new human immunodeficiency virus (HIV) infections is essential to halting the global pandemic. HIV prevention strategies include integrating both nonpharmacologic (eg, safe sexual counseling, circumcision) and pharmacologic approaches. Several pharmacologic HIV prevention strategies are increasingly used globally and include postexposure prophylaxis, preexposure prophylaxis, and treatment as prevention. These prevention modalities have enormous clinical and public health appeal, as they effectively reduce HIV acquisition in individuals and also may lower HIV incidence in communities when integrated and implemented broadly. Efforts are now underway to scale HIV prevention programs using these techniques in both high- and low-resource settings.

Syndemic Experiences, Protective Factors, and HIV Vulnerabilities Among Lesbian, Gay, Bisexual and Transgender Persons in Jamaica

Syndemics approaches explore the convergence of psychosocial factors that elevate HIV vulnerabilities. Less research has explored syndemics among lesbian, gay, bisexual and transgender (LGBT) persons in contexts where criminalization has downstream impacts on LGBT discrimination, such as Jamaica. We implemented a cross-sectional survey with LGBT persons (n = 911) in Jamaica. We conducted structural equation modeling to examine direct and indirect effects of a latent syndemics construct (binge drinking, depressive symptoms, childhood/adult abuse) on HIV vulnerabilities (lifetime sex partners, perceived HIV risk, condom self-efficacy) and the mediating role of protective factors (social support, resilient coping). Direct paths from syndemics to lifetime sex partners, perceived HIV risk, and condom self-efficacy were significant. Resilient coping and social support partially mediated the association between syndemics and condom use self-efficacy. Resilient coping partially mediated the relationship between syndemics and lifetime sex partners. Interventions can target syndemic issues to reduce HIV vulnerabilities among Jamaican LGBT persons.

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.

Transcendendo: A Cohort Study of HIV-Infected and Uninfected Transgender Women in Rio de Janeiro, Brazil

Purpose: Worldwide, the burden of adverse health conditions is substantial among travestis and transgender women (trans women). Transcendendo, the first trans-specific cohort in a low- or middle-income country, is an open cohort established in August 2015 to longitudinally evaluate the health aspects of trans women aged ≥18 years in Rio de Janeiro, Brazil.

Methods: Study visits occur on an annual basis. Data on sociodemographics, behavioral, gender transition, affirmation procedures, hormone use, discrimination, violence, clinical and mental health, HIV prevention, and care (for those HIV-infected) are collected. Physical examination, anthropometric measurements, and laboratory tests are performed.

Results: As of July 2017, 322 trans women were enrolled in the cohort with a median age of 31.5 years (interquartile range 25.7–39.5), of whom 174 (54%) were HIV-infected. The Transcendendo baseline information reinforces the scenario of marginalization and deprivation surrounding trans women. Most participants had low income (62.0% were living with below US$ 10.00/day), showed a very high engagement in sex work (78.6%), and reported increased occurrence of sexual (46.3%) and physical (54.0%) violence. Pre-exposure peophylaxis (PReP) was used by 18.8% of the HIV-uninfected trans women, only through research participation. Positive screening for depression (57.8%) and problematic use of tobacco (56.6%), cannabis (28.9%), cocaine (23.8%), and alcohol (21.5%) were high. Almost all participants (94.8%) reported hormone use at some point, mostly without medical supervision (78.7%).

Conclusion: Our results describe a context of exclusion experienced by trans women, exposing vulnerabilities of this population in a middle-income country, with poor access to trans-specific care, HIV prevention and care, and mental health care. Addressing transgender experiences and needs can help the development of strategies to diminish stigma, improve health care environment, guide future research on trans morbidities, substance use, and trans-specific interventions to support health-related recommendations. Ultimately, it contributes to close the gaps concerning transgender health and reinforces that trans care cannot be disentangled from the social environment that surrounds trans women.

The Prevalence and Correlates of Sexual Arrangements in a National Cohort of HIV-Negative Gay and Bisexual Men in the United States

Sexual agreements have received considerable attention as an aspect of dyadic functioning associated with HIV risk. To date, this research has primarily utilized convenience samples which overrepresented men from large urban areas and with higher HIV risk. The current study utilized a national cohort of 1061 HIV-negative gay and bisexual men recruited to be geographically diverse within the U.S. The sample included 531 (50.0%) men who identified as single. Of the 530 partnered men, 240 (45.3%) were monogamous; 238 (44.9%) were in open relationships (where sex with outside partners was permitted); and 52 (9.8%) were in monogamish relationships (where sex with outside partners was limited to instances where both primary partners were present). Regardless of urban (vs. non-urban) residence, men in monogamous relationships engaged in less anal sex generally and condomless anal sex (CAS) specifically with casual partners. Single men reported significantly more frequent anal sex with casual partners compared to open and monogamish men; however, there were no significant differences among these three groups with respect to CAS with casual partners. In multivariable models, monogamish men reported significantly more frequent marijuana use and alcohol consumption compared to all other groups. Urban (vs. non-urban) residence moderated associations between sexual arrangements and depression as well as the use of illicit drugs other than marijuana. These findings point to the need to better examine the potentially unique mechanisms which confer risk and resilience for gay male couples in urban versus non-urban settings. The observed association between sexual arrangements and substance use suggests interventions which facilitate the negotiation of sexual agreements may present an opportunity to engage in dyadic substance use intervention.

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.

Childhood sexual abuse among Black men who have sex with men: A cornerstone of a syndemic?

Background

The sequelae of childhood sexual abuse (CSA) includes HIV infection, engagement in HIV risk behaviors, substance misuse, and intimate partner violence (IPV). Although Black men who have sex with men (MSM) are disproportionately infected with HIV in the U.S.—especially in urban locations such as New York City—there is limited research with larger samples of Black MSM of varied HIV status regarding the prevalence of CSA and the potential negative consequence with respect to a “syndemic,” i.e., the co-occurrence of adverse conditions such as HIVrisk, substance misuse, and IPV.

Methods

Black MSM (N = 1,002) recruited in New York City from 2009–2015 completed a screening assessment eliciting self-reported data on age, CSA, self-reported HIV status, number of male sexual partners, number of acts of condomless anal intercourse (CAI), substance misuse, and IPV. Hypothesis testing utilized logistic and linear regression models with self-reported data on CSA (independent variable) and indicators of the following syndemic factors: HIV risk, substance misuse, and IPV.

Results

More than one-fourth (28.1%) met criteria for experiencing CSA. CSA was associated with significantly greater odds of being HIV-positive (AOR = 1.5; 95% CI = 1.1–2.0); number of male sexual partners (b = 2.0, SE = 0.5, p = .002) and condomless acts of anal intercourse (b = 4.3, SE = 1.6, p = .007); odds of binge drinking (AOR = 1.5; 95% CI = 1.1–2.0) and illicit substance use (AOR = 1.5; 95% CI = 1.1–2.0); and odds of experiencing current IPV (AOR = 1.7; 95% CI = 1.2–2.3). CSA was associated with significantly greater odds of concurrently experiencing 2 or more syndemic factors (AOR = 2.0, 95% CI = 1.4–2.9, p < .001); concurrently experiencing 2 or more syndemic factors was significantly associated with having a riskier HIV status (for being HIV-positive: AOR = 1.5, 95% CI = 1.1–2.1, p = .02; for having an unknown HIV status: AOR = 3.7, 95% CI = 1.9–12.9, p = .04).

Conclusions

Among Black MSM, CSA is a prevalent problem and is a significant antecedent to HIV, substance misuse, and IPV indicators and risk. Addressing CSA may be a valuable approach to remedy the syndemic of HIV, substance misuse, and violence that has burdened MSM, especially Black MSM, in the U.S.

TransAction: A homegrown, theory-based, HIV risk reduction intervention for transgender women experiencing multiple health disparities

HIV vulnerability among transgender women is symptomatic of numerous syndemic psychosocial and structural co-factors that attribute to and exacerbate HIV risk. From February 2010 to December 2017, 514 transgender women enrolled in a 'homegrown' theory-based, HIV risk reduction program, TransAction, specifically designed to intervene with trans women who experience numerous co-occurring health disparities. Increased attendance in TransAction intervention sessions was associated with significant reductions in the number of male sexual partners (coef. = -0.20), anonymous male sexual partners (-0.30), exchange male sexual partners (-0.25), engagement in drug/alcohol use (-0.37), engagement in injection drug use (-0.20), engagement in unmonitored injection hormone use (-0.55), engagement in sex while high (-0.23), and engagement in sex work (-0.20; all coefficient estimates p ≤ 0.05). Results demonstrated that the homegrown HIV risk reduction intervention was successful in working with transgender women who experience multiple co-occurring syndemic conditions. Given that there has been a dearth of evidence-based interventions for this population that are designed to be delivered in resource limited settings, TransAction can serve as a model HIV risk reduction program for guiding public health departments and community-based organizations.