Psychosocial Factors and HIV Prevention for Gay, Bisexual, and Other Men Who Have Sex with Men

Syndemic Theory and Its Use in Developing Health Interventions and Programming: A Scoping Review

PURPOSE OF REVIEW

The central tenet of syndemics theory is that disease interactions are driven by social factors, and that these factors have to be understood in order to reduce the health burdens of local populations. Without an understanding of the theory and how it is being put into practice, there is a strong possibility of losing the potential for syndemic theory to positively impact change at community and individual level.

METHODS

Following an initial database search that produced 921 articles, we developed a multi-stage scoping review process identifying invention studies that employ syndemic theory. Inclusion was defined as the presence of healthcare interventions examining multiple social-biological outcomes, refering to a specific (local) at risk population, developing or attempting to develop interventions impacting upon multiple health and/or social targets, and explicit employment of syndemic theory in developing the intervention.

RESULTS

A total of 45 articles contained a substantial engagement with syndemic theory and an original healthcare intervention. However, only eleven studies out of all 921 articles met the inclusion criteria.

DISCUSSION/CONCLUSION

It is strongly suggested that when employing syndemic theory researchers focus close attention to demonstrating disease interactions, providing evidence of the social drivers of these disease interactions, and constructing interventions grounded in these analytical findings. We conclude that although frequently referred to, syndemic theory is rarely employed in its entirety and recommend that interventions be developed using a more thorough grounding in this important and powerful theory.

"I Think That I Have a Good Understanding of How to Protect Myself": A Qualitative Study About HIV Risk Perceptions Among Men and Gender Diverse Individuals Who Have Sex With Men

This qualitative study aimed to determine how men and gender diverse individuals who have sex with men describe their perceived risk of HIV and what factors influence this risk assessment. We conducted in-depth, virtual interviews with 18 HIV-negative individuals from Philadelphia, eligible for or taking PrEP. The interviews assessed the participants' understanding of their HIV risk, using thematic analysis to deductively code and extract themes. Three themes emerged: (1) participants expressed both deliberative and affective risk perception before and after sexual encounters; (2) participants linked HIV knowledge to risk perception and stigma; (3) participants connected intrinsic and extrinsic factors to risk perception differently. Participants endorsed low overall risk perception, while also describing moments of high affective risk perception after sexual encounters in which they were not able to implement their preferred prevention strategies. Future research should explore helping individuals transform affective risk perception into empowerment around sexual health.

Lifetime Prevalence and Sociodemographic Correlates of Multifactorial Discrimination Among Middle-Aged and Older Adult Men Who Have Sex with Men

This study describes multifactorial discrimination (discrimination attributed to multiple social identities) among middle-aged and older adult MSM. MSM aged 40+ years (N = 1,193) enrolled in the Multicenter AIDS Cohort Study completed behavioral surveys ascertaining experiences of discrimination and their social identity attributions. Non-proportional odds regressions assessed multifactorial discrimination by age, race/ethnicity, HIV status, and covariates. Twenty-seven percent of participants reported multifactorial discrimination. Adjusted models indicated that middle-aged men were more likely to report multifactorial discrimination compared to older adult men. Racial/ethnic minorities were more likely to report multifactorial discrimination compared to non-Hispanic white participants. These same patterns emerged among the sub-sample of participants living with HIV. To our knowledge, this is the first assessment of multifactorial discrimination in middle-aged and older MSM. Our findings support the deleterious association between multiple-marginalization and multifactorial discrimination. Multilevel interventions targeting interconnected experiences of stigma may improve the health of MSM in transition to older age.

A Systematic Review and Meta-Analysis of Combination Behavioral Interventions Co-Targeting Psychosocial Syndemics and HIV-Related Health Behaviors for Sexual Minority Men

In the U.S., sexual minority men (SMM) are disproportionately affected by HIV. Interventions are needed to increase HIV prevention and treatment behaviors, especially among syndemically exposed SMM. In recent years, researchers have created and tested combination behavioral interventions co-targeting syndemics and HIV-related health behaviors. We evaluated that literature via systematic review and meta-analysis, identifying 44 trials targeting mental health symptoms, alcohol use, and drug use, as well as sexual risk behavior, antiretroviral adherence, and healthcare engagement. For the randomized controlled trials, we computed between-group, pre-post effect sizes and tested them via random-effects models. Results supported the efficacy of combined interventions with significant, small, positive effects for improving mental health and reducing substance use (d = .20, CIs: 0.12, .29), and reducing sexual risk behavior and improving antiretroviral adherence (d = .16, CIs: .03, .30). Stratification analyses indicate that longer (9+ sessions) and individual (vs. group) interventions resulted in stronger effects on syndemic but not health behavior outcomes. Intervention developers should attend to intervention intensity and format. More evidence is needed about the importance of additional factors, such as novel intervention targets and cultural tailoring, as well as broadening the focus to multi-level interventions to address both interpersonal and structural mechanisms of change.

The Impact of Pre-Exposure Prophylaxis on Sexual Communication and Sexual Behavior of Urban Gay and Bisexual Men

Pre-exposure prophylaxis (PrEP) has altered the public health landscape for gay, bisexual, and other men who have sex with men (GBM) by significantly increasing protection against HIV infection. Early epidemiologic data showed GBM generally used PrEP as prescribed, i.e., as an additional protective tool over and above barrier protection, although subsequent reports have been equivocal. Irrespective of population-level trends, some GBM appear to have reevaluated their HIV risk tolerance and changed their interactions with sex partners. Scant published data have focused on factors that influence PrEP-using GBM's decisions about sexual behavior-including condom use as well as sex with HIV-positive partners-and sexual communication practices. Thus, in this study, we investigated those research concerns qualitatively via content analysis of individual interviews conducted with 103 GBM in New York City (M age 32.5 years, 50% White, 64% on PrEP > 6 months). Emergent themes reflect (1) participants' strong HIV knowledge; (2) changing GBM community norms about condom use on PrEP; (3) increased focus on risk tolerance with individual differences in post-PrEP condom use; (4) appreciation for routine sexually transmitted infection (STI) screening in PrEP care concomitant with some STI knowledge deficits; (5) decreased stigma concerning, and greater comfort with, HIV-positive sex partners; and (6) increased confidence discussing HIV status and condom use preferences with partners. Findings have implications for future research as well as for clinical practice, such as enhanced STI education and provider-initiated discussions about risk compensation, serosorting, and sexual communication skills.

Autism and Adult Sex Education: A Literature Review using the Information-Motivation-Behavioral Skills Framework

Adults on the autism spectrum report comparable levels of desire for sex and sexual satisfaction as adults who are not on the spectrum. However, there has been little empirical focus on the need for sexual and relationship-oriented education for youth on the spectrum as they transition to adulthood. In this review, we use the Information-Motivation-Behavioral Skills Model of sexual health behavior change as a lens through which to understand the experiences of adults on the autism spectrum. We present those insights infused with emerging data and best practices in the field. Overall, it appears clear from the extant literature that providers need to recognize the specific characteristics of autism when developing sexual education curricula. Specifically, the social communication and sensory profile of people on the autism spectrum appears to interact with access to information, motivation to engage in healthy sexual activities, and the development of skills needed to engage in healthy sexual behavior. Finally, the voice of adults on the spectrum is essential to guide the emerging understanding of healthy sexuality.

Experiences of Stigma by Gay and Bisexual Men in Rural Oklahoma

Purpose: The unique experiences of men who have sex with men (MSM) residing in culturally conservative rural areas are not well represented in the scientific literature. The human immunodeficiency virus (HIV) epidemic in the United States has shifted toward rural areas where populations are dispersed and health care resources are limited. Methods: We recruited 40 sexual minority men, ages 22-66, residing in rural Oklahoma for in-depth, qualitative sexual health interviews that sought to understand how cultural and social environments impacted health behaviors. Findings: Participants described a stigmatizing social environment and less access to quality, sexual minority medical care within rural communities and perceived these as substantial barriers to enhancing health. Structural issues, including lack of sexual minority-affirming policies, institutional practices, and hostile cultural norms, were noted. Conclusions: Results indicate the need to develop greater awareness of stigma as an etiologic factor that contributes to the health of rural sexual minority populations, specifically when it relates to provision of culturally appropriate care.

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.

Syndemic Indicators Predict Poor Medication Adherence and Increased Health Care Utilization for Urban HIV-Positive Men Who Have Sex with Men

Research on men who have sex with men (MSM) has uncovered psychosocial factors (syndemic indicators) that are associated additively with poor health. To test these relations in a sample of HIV-positive MSM, we enrolled 166 patients from two HIV clinics. We investigated relations between syndemic indicators and outcomes including medication nonadherence, condomless anal sex (CAS), and healthcare utilization. A large proportion of participants reported each syndemic indicator: polysubstance use 43%, suicide attempt 28%, childhood sexual abuse 39%, partner abuse 64%. Analyses confirmed an additive effect, whereby endorsing 1+ indicator was associated with increased odds of medication nonadherence and medical hospitalization.