Syndemic Theory and HIV-Related Risk Among Young Transgender Women: The Role of Multiple,Co-Occurring Health Problems and Social Marginalization

Objectives. We assessed whether multiple psychosocial factors are additive in their relationship to sexual risk behavior and self-reported HIV status (i.e., can be characterized as a syndemic) among young transgender women and the relationship of indicators of social marginalization to psychosocial factors.Methods. Participants (n = 151) were aged 15 to 24 years and lived in Chicago or Los Angeles. We collected data on psychosocial factors (low self-esteem, polysubstance use, victimization related to transgender identity, and intimate partner violence) and social marginalization indicators (history of commercial sex work, homelessness, and incarceration) through an interviewer-administered survey.Results. Syndemic factors were positively and additively related to sexual risk behavior and self-reported HIV infection. In addition, our syndemic index was significantly related to 2 indicators of social marginalization: a history of sex work and previous incarceration.Conclusions. These findings provide evidence for a syndemic of co-occurring psychosocial and health problems in young transgender women, taking place in a context of social marginalization.Transgender women (i.e., male-to-female transgender persons) are individuals whose gender identities are discordant with the male gender they were assigned at birth. During the developmental period from early adolescence through young adulthood, many transgender women struggle to develop a coherent sense of self while addressing feelings of guilt and shame about their identities and pressures to conform to familial, peer, and gender norms. Many feel the need for secrecy, either to pass in their chosen gender or to hide their true feelings to avoid rejection and discrimination.1 Instead of support and understanding from family, friends, and other adults, these women often experience social rejection and marginalization because of their gender identity and expression, as well as perceived sexual orientation.2–4 Rejection and marginalization are particularly harmful during this period of developmental vulnerability and often result in severe consequences, as evidenced by high rates of homelessness, trading sexual intercourse for food and other basic needs, and incarceration.5–9 A growing body of literature suggests that the marginalization experienced by these young women contributes to a wide range of negative health outcomes, such as psychological distress, substance abuse, and victimization (e.g., from verbal, physical, and sexual abuse). All of these outcomes are related to sexual risk behavior and HIV infection.5–8The prevalence of HIV infection among transgender women is equal to or greater than that among other traditionally high-risk groups, such as men who have sex with men (MSM).10 In a review of 29 studies of HIV incidence, prevalence, and related risk behavior among transgender individuals completed between 1990 and 2003, the average laboratory-confirmed HIV prevalence for transgender women across age groups was 27.7% (4 studies), and the average self-reported HIV prevalence was 11.8% (18 studies that reported prevalence estimates).10 More recent data from local testing of more than 500 transgender women with no known previous positive HIV test results in Miami Beach, Florida, and San Francisco and Los Angeles, California, found a 12% HIV infection prevalence, which suggests a high percentage of unrecognized HIV infection in this population.11 In an analysis by age, the most new HIV infections, representing 45% of all cases, were detected among those aged 20 to 29 years.11Estimates of HIV prevalence among young transgender women are scarce and based on very small, nonprobability samples. A community-based study of ethnic minority transgender women (aged 16–24 years; n = 51) found 22% with self-reported HIV-positive status.6 A previous analysis of study data from young transgender women (aged 15–24 years; n = 151), found a comparable rate of 19% self-reported HIV infection.7 The higher rate of self-reported HIV infection among young transgender women than among transgender women more generally may result from relatively high rates of HIV testing. A total of 87% of young transgender women in this study had been tested for HIV infection at least once.7 However, self-reported prevalence of HIV infection among these young women is still likely to be underestimated in light of the evidence of unrecognized infection among those aged 20 to 29 years.11High rates of unprotected receptive anal intercourse among young transgender women10 place them at risk for both acquiring and transmitting HIV infection. In the review of 29 studies, 31.7% of transgender women reported multiple, primarily male, sexual partners, and 48.3% reported having sexual intercourse with casual partners.10 The average proportion of any unprotected receptive anal intercourse was 44.1%, and the proportion of unprotected insertive anal intercourse was 27.4% (assessed across various recall periods).10 In the community-based study of young transgender women (n = 51), 59% reported having unprotected anal intercourse (receptive or insertive) in the past 12 months.6Multiple psychosocial health problems, including psychological distress, substance use, violence, and victimization are common among transgender women. For example, community surveys suggest rates of depression and suicidality that are up to 3 times as high as in the general population.3,12–14 Evidence indicates that substance use is common (previous 30-day use of alcohol = 50% and of marijuana = 38%)15 and that sexual intercourse under the influence of drugs and alcohol is also highly prevalent.15–17 Studies of violence and victimization among transgender women estimate that 21% to 68% have experienced forced sexual intercourse,9,18 and between 37% and 65% have experienced physical abuse, as either a child or an adult.9,15,18Similarly, evidence suggests that psychosocial health problems are prevalent among young transgender women. Garofalo et al., in their community-based study of 51 ethnic minority young transgender women, found that although self-esteem and depression were within the normal range on average, both were independently associated with unprotected anal intercourse.5 In another study, past-year alcohol and marijuana use were reported by 65% and 71% of participants, respectively.6 Wilson et al. reported that more than 90% of young transgender women in their study sample had used substances in their lifetime (88% had used alcohol; 63%, marijuana; 30%, cocaine; 32%, ecstasy; and 30%, methamphetamine).7 Sexual intercourse under the influence of alcohol or drugs was reported to be 50% in one study5 and 53% in another8 and was significantly associated with unprotected anal intercourse.5 Garofalo et al. found that more than half of participants reported a history of forced sexual intercourse, which was significantly associated with sexual risk behavior.5 Reported fear of partner anger and rejection were also given as reasons young transgender women engaged in unsafe sexual intercourse.6Psychological distress and substance abuse, as well as frequent experiences of violence and other forms of victimization, may contribute to HIV risk in this population, potentially fueling heightened rates of HIV infection. In light of the high HIV prevalence rates and the complexity of risk factors associated with risk behaviors and HIV acquisition, a leading group of experts in transgender health has suggested examining HIV risk among young transgender women within the framework of syndemic theory.19 Singer and Snipes coined the term syndemic for the health crisis (co-occurrence of substance use, AIDS, and violence) among poor and underserved inner-city women in the early 1990s.20 As described by Singer, a syndemic involves

a set of enmeshed and mutually enhancing health problems that, working together in a context of deleterious social and physical conditions that increase vulnerability, significantly affect the overall disease status of a population.21^(p15)

Thus, a syndemic is more than the interaction of diseases; rather, it is the mutually reinforcing interaction of disease and social conditions.21–23 Singer and Clair describe syndemics as occurring in “noxious social conditions” and posits that they are often produced by “structural violence of social inequality.”22^(p434)Stall et al. applied syndemic theory to the study of HIV-related sexual risk among urban MSM. They found that increasing numbers of psychosocial health problems, polysubstance use, depression, partner violence, and childhood sexual abuse were significantly and positively associated with high-risk sexual behavior and HIV infection.24 Similarly, in an urban sample of ethnically diverse MSM aged 16 to 24 years, Mustanski et al. found that increasing numbers of psychosocial health problems, including binge drinking, street drug use, psychological distress, intimate partner violence, and sexual assault, increased the odds of multiple anal intercourse partners, unprotected anal intercourse, and HIV-positive status.25To our knowledge, syndemic theory has not previously been applied to the study of HIV risk among young transgender women; however, their marked social and economic marginalization and high prevalence of psychosocial health problems and HIV infection suggest that the principles underlying this theory may well apply. The syndemic model, therefore, served as a framework guiding our analysis. We chose specific psychosocial health problems for inclusion in our syndemic model—as the data would allow—that were similar to factors examined among both urban poor and underserved women and urban MSM and that reflected the life circumstances of young transgender women.We hypothesized that a syndemic of co-occurring health and psychosocial factors such as low self-esteem, polysubstance use, victimization related to transgender identity (e.g., verbal threats and insults, harrassment by chasing or following respondents or damaging their property, and physical assaults), and intimate partner violence (e.g., partner-controlling actions, verbal harassment, threats to physical safety, sexual violence, and pressure or coercion to hide female gender identity) are additive and associated with HIV infection and sexual risk for HIV infection. That is, the more psychosocial health problems reported, the greater the risk for both unsafe sexual behavior and HIV infection. In addition, Singer specified that a syndemic develops in a context of deleterious social conditions that increase vulnerability. Thus, we further tested indicators of social marginalization as correlates of this clustering of psychosocial factors. Our objectives were to (1) assess whether multiple psychosocial factors are additive in their relationship to sexual risk behavior and self-reported HIV status among young transgender women (i.e., could be characterized as a syndemic) and (2) assess the relationship of indicators of social marginalization, such as a history of commercial sex work, homelessness, and incarceration, to these psychosocial factors.     

Relation of Childhood Sexual Abuse,Intimate Partner Violence,and Depression to Risk Factors for HIV Among Black Men Who Have Sex With Men in 6 US Cities

Objectives. We assessed the relation of childhood sexual abuse (CSA), intimate partner violence (IPV), and depression to HIV sexual risk behaviors among Black men who have sex with men (MSM).Methods. Participants were 1522 Black MSM recruited from 6 US cities between July 2009 and December 2011. Univariate and multivariable logistic regression models were used.Results. Participants reported sex before age 12 years with someone at least 5 years older (31.1%), unwanted sex when aged 12 to 16 years (30%), IPV (51.8%), and depression (43.8%). Experiencing CSA when aged 12 to 16 years was inversely associated with any receptive condomless anal sex with a male partner (adjusted odds ratio [AOR] = 0.50; 95% confidence interval [CI] = 0.29, 0.86). Pressured or forced sex was positively associated with any receptive anal sex (AOR = 2.24; 95% CI = 1.57, 3.20). Experiencing CSA when younger than 12 years, physical abuse, emotional abuse, having been stalked, and pressured or forced sex were positively associated with having more than 3 male partners in the past 6 months. Among HIV-positive MSM (n = 337), CSA between ages 12 and 16 years was positively associated with having more than 3 male partners in the past 6 months.Conclusions. Rates of CSA, IPV, and depression were high, but associations with HIV sexual risk outcomes were modest.Despite significant medical advances, the HIV epidemic remains a health crisis in Black communities. The Black population represents only 14% of the total US population but accounted for 44% of all new HIV infection (68.9 of 100 000) in 2010.1 Black men who have sex with men (MSM) are disproportionately impacted by HIV compared with other racial/ethnic groups of MSM.1,2 Male-to-male sexual contact accounted for 72% of new infections among all Black men.1 Young Black MSM (aged 13–24 years) have a greater number of new infections than any other age or racial group among MSM.1 Researchers have been challenged with developing HIV prevention strategies for Black MSM.3–7 Higher frequencies of sexual risk behaviors, substance use, and nondisclosure of sexual identities do not adequately explain this disparity.8,9 High rates of sexually transmitted infections (STIs), which facilitate HIV transmission, and undetected or late diagnosis of HIV infection only partially explain disproportionate HIV rates.8Researchers have begun to examine a constellation of health factors that may contribute to HIV among MSM. For example, syndemic theory or the interaction of epidemics synergistically, such as intimate partner violence (IPV) and depression, may help explain HIV-related sexual risk behaviors among Black MSM.9 Childhood sexual abuse (CSA), IPV, and mental health disorders including depression may comprise such a constellation and warrant further exploration.Experiences of CSA have been identified as being associated with negative sexual health outcomes, with MSM reporting higher CSA rates than the general male population.10–12 Men with CSA experiences are more likely than men without CSA experiences to engage in high-risk sexual behaviors,13–21 have more lifetime sexual partners,13–16 use condoms less frequently,13,14,16 and have higher rates of STIs,13,14,17 exchanging sex for drugs or money,13,14,17 HIV,13,14 alcohol and substance use,13–21 and depression.13–15,18,21 Such findings suggest that sexual risk reduction counseling may need to be tailored for MSM with CSA experiences.15Childhood sexual abuse histories have also been correlated with sexual revictimization, including IPV.22–24 One study with population-based estimates of CSA found that gay and bisexually identified men had higher odds of reporting CSA (9.5 and 12.8, respectively) compared with heterosexual men.25 For sexual minority men, CSA histories were associated with higher HIV and STI incidence.25 However, research examining CSA, revictimization, and sexual risk behaviors is lacking among Black MSM.In one existing study, Black and Latino MSM with CSA histories identified their trauma experiences as influencing their adult sexual decision-making.26 Among Black MSM in 2 additional studies, emotional distress and substance use were attributed to having CSA experiences (Leo Wilton, PhD, written communication, October 2, 2013).27 In an ethnically diverse sample of 456 HIV-positive MSM, CSA was associated with insertive and receptive condomless anal sex.19Similar to CSA, IPV has not been extensively examined among MSM or Black MSM,28 but may be associated with sexual risk behaviors. Intimate partner violence is defined as a pattern of controlling, abusive behavior within an intimate relationship that may include physical, psychological or emotional, verbal, or sexual abuse.29 Little research exists on IPV among same-sex couples despite incidence rates being comparable to or greater than that of heterosexual women.28,30–34 Important IPV information comes from the National Intimate Partner and Sexual Violence Survey, a nationally representative survey for experiences of sexual violence, stalking, and IPV among men and women in the United States.28 Among men who experienced rape, physical violence, or stalking by an intimate partner, perpetrator differences by gender were found among gay, bisexual, and heterosexual men; 78% of bisexual and 99.5% of heterosexual men reported having only female perpetrators, and 90.7% of gay men reported having only male perpetrators.28 Being slapped, pushed, or shoved by an intimate partner during their lifetime was reported by gay (24%), bisexual (27%), and heterosexual (26.3%) men.28Intimate partner violence has been linked to condomless anal sex, HIV infection, substance use, CSA, and depression.35–37 Being an HIV-positive MSM has been linked with becoming a victim of IPV.38,39 Welles et al. found that being an African American MSM who initially disclosed having male partners and early life sexual abuse experiences was associated with IPV victimization.39 Wilton found that a high percentage of Black MSM reported IPV histories: emotional abuse (48.3%), physical abuse (28.3%), sexual abuse (21.7%), and stalking abuse (29.2%; Leo Wilton, PhD, written communication, October 2, 2013). Such findings lend to the importance of exploring, both independently and together, the association of CSA and IPV with sexual risk behaviors.Some studies have reported the influence of mental health (e.g., depression) on sexual risk behaviors among MSM,9,40,41 whereas others have not corroborated such findings.42 Greater rates of depression among MSM than among non-MSM samples43–45 and elevated rates of depression and anxiety among Black MSM have been reported.46 The Urban Men’s Health Study, a cross-sectional sample of MSM in 4 US cities, did not find a significant relationship between high depressive symptoms and condomless anal sex.42 However, the EXPLORE study, a randomized behavioral intervention for MSM in 6 US cities, supported the association between moderate depressive symptoms and an increased risk for HIV infection.47 Moderate levels of depression and higher rates of sexual risk were also reported for HIV-infected MSM over time.48 Another study conducted with 197 Black MSM found that moderate depressive symptoms were associated with having condomless anal sex with a serodiscordant casual partner.49 These mixed findings support the need to better understand the relationship between the severity of depression (i.e., moderate vs severe) and HIV risk behaviors.The HIV Prevention Trials Network 061 study, also known as the BROTHERS (Broadening the Reach of Testing, Health Education, Resources, and Services) Project, was a multisite study to determine the feasibility and acceptability of a multicomponent intervention for Black MSM. The current analysis aims to assess the prevalence of CSA, IPV, and depressive symptomology, and examine the relationships between these factors and insertive and receptive condomless anal sex and number of sexual partners in a large cohort of Black MSM.     

Sexual Partner Selection and HIV Risk Reduction Among Black and White Men Who Have Sex With Men

Objectives. We examined differences in sexual partner selection between Black and White men who have sex with men (MSM) to better understand how HIV status of participants'' sexual partners and related psychosocial measures influence risk taking among these men.Methods. We collected cross-sectional surveys from self-reported HIV-negative Black MSM and White MSM attending a gay pride festival in Atlanta, Georgia.Results. HIV-negative White MSM were more likely than were HIV-negative Black MSM to report having unprotected anal intercourse with HIV-negative men, and HIV-negative Black MSM were more likely than were HIV-negative White MSM to report having unprotected anal intercourse with HIV status unknown partners. Furthermore, White MSM were more likely to endorse serosorting (limiting unprotected partners to those who have the same HIV status) beliefs and favorable HIV disclosure beliefs than were Black MSM.Conclusions. White MSM appear to use sexual partner–related risk reduction strategies to reduce the likelihood of HIV infection more than do Black MSM. Partner selection strategies have serious limitations; however, they may explain in part the disproportionate number of HIV infections among Black MSM.Men who have sex with men (MSM) continue to make up the majority of people who are HIV infected in the United States. About one third of US HIV infections among MSM occur in Black men¹; however, Black men account for only 13% of the US male population.² Several published reports of HIV risks that stratify risk behavior by race do not demonstrate elevated risk behavior among Black MSM as compared with White MSM.^3,4 For example, Black MSM overall report fewer sexual partners and similar rates of unprotected anal intercourse when compared with White MSM. Because rates of risk behaviors fail to explain the racial disparities in HIV infections, contextual factors may offer important information for explaining the disproportionate HIV infections. Alarming rates of HIV among Black MSM have led this group to be among the top priority HIV prevention populations in the United States.⁵ Thus, a comprehensive understanding of HIV risk factors relevant to this population is warranted.Multiple contextual factors potentially drive disparities in HIV/AIDS between Black MSM and White MSM. Perceived HIV prevention strategies such as selecting unprotected sexual partners thought to have the same HIV status, or serosorting, may play a role in explaining racial disparities in HIV infections. Many HIV-infected and non–HIV-infected men believe serosorting makes HIV transmission less likely and, thus, condom use unnecessary.^6,7 This relationship may stem from the tendency for people to dislike using condoms^8–10 and to practice alternative behaviors they believe are protective, such as serosorting. As a result, partner HIV serostatus is often a determining factor in sexual risk decision making.^11,12 Several studies have found that MSM commonly use serosorting in general, but less is known about serosorting among MSM of various ethnicities.^7,13–15Data on the effectiveness of serosorting are somewhat mixed, but it is known that serosorting can lead to HIV exposure.¹⁶ Although some studies have noted the potential for serosorting to reduce overall HIV rates,^17,18 limitations of this practice, including infrequent HIV testing, lack of open communication about HIV status, and acute HIV infection place MSM who serosort at risk for HIV transmission.^19,20There are at least 2 factors that directly influence whether or not an individual is motivated to serosort. First, individuals who serosort likely do so to lower their perceived risk for HIV infection, that is, to make them feel safe while not using condoms. In this sense, serosorting can reduce HIV transmission anxiety. Hence, the perception that serosorting makes unprotected sex safer is most likely driving sexual behavior risk taking. Notably, risk perceptions have been previously demonstrated to play an important role in predicting other health-related behaviors.^21–23 Second, serosorting requires explicit verbal discussion about HIV status. As such, those who engage in serosorting need to be capable of discussing their own and their partners'' HIV status.⁷ When serosorting, merely assuming the HIV status of a partner is often substituted for explicit disclosure²⁰; however, serosorting cannot be effective under these conditions.We sought to examine partner selection practices that potentially contribute to disparate HIV infection rates among Black MSM and White MSM. First, we examined the sexual behavior of Black MSM versus that of White MSM. On the basis of previous studies, we hypothesized that Black MSM and White MSM would report similar numbers of unprotected anal intercourse partners. However, because the HIV status of partners men choose may drive the differences in HIV infection rates, we hypothesized that Black MSM would report more partners of unknown or positive HIV status than would White MSM and that White MSM would report more partners of negative HIV status than would Black MSM. In keeping with these hypotheses, we also predicted that Black MSM would report less favorable beliefs about serosorting and HIV status disclosure. Finally, we predicted that Black MSM would report higher HIV perceived risk because of their choosing serodiscordant partners.     

STD Prevalence, Risky Sexual Behaviors, and Sex With Women in a National Sample of Chinese Men Who Have Sex With Men

We describe the behavioral characteristics and sexually transmitted disease (STD) prevalence of Chinese men who have sex with men (MSM) (n = 41) from a national probability sample of men (n = 1861). Most MSM were partnered with females (97%) and had a low rate of consistent condom use (7%). More MSM than heterosexual men self-reported a prior STD and risky sexual behaviors. MSM may act as a bridge for HIV transmission to female partners. Targeted interventions may help prevent a generalized HIV epidemic in China.In some parts of China, HIV prevalence has exceeded 1% of the general population.^1,2 Men who have sex with men (MSM) accounted for 7.3% of HIV infections³ and 11% of new HIV infections in 2007.⁴ The proportion of HIV infections among MSM is likely to grow, as studies have documented increasing HIV prevalence and high prevalence of risky sexual behaviors and of sexually transmitted diseases (STDs) among this population.^5–12MSM may serve as a bridge population for transmitting HIV to the general population. Empirical data have shown that a large proportion of Chinese MSM are either married or have female sex partners.^5,13 High-risk sexual behaviors with both male and female partners among MSM are also common. Surveys have documented extremely high rates of inconsistent condom use with female partners.^13–15 We report the sociodemographic and sexual behavioral characteristics and the STD prevalence of a national probability sample of Chinese heterosexual men and men who had homosexual experiences.     

Individual,Psychosocial, and Social Correlates of Unprotected Anal Intercourse in a New Generation of Young Men Who Have Sex With Men in New York City

Objectives. We examined associations of individual, psychosocial, and social factors with unprotected anal intercourse (UAI) among young men who have sex with men in New York City.Methods. Using baseline assessment data from 592 young men who have sex with men participating in an ongoing prospective cohort study, we conducted multivariable logistic regression analyses to examine the associations between covariates and likelihood of recently engaging in UAI with same-sex partners.Results. Nineteen percent reported recent UAI with a same-sex partner. In multivariable models, being in a current relationship with another man (adjusted odds ratio [AOR] = 4.87), an arrest history (AOR = 2.01), greater residential instability (AOR = 1.75), and unstable housing or homelessness (AOR = 3.10) was associated with recent UAI. Although high levels of gay community affinity and low internalized homophobia were associated with engaging in UAI in bivariate analyses, these associations did not persist in multivariable analyses.Conclusions. Associations of psychosocial and socially produced conditions with UAI among a new generation of young men who have sex with men warrant that HIV prevention programs and policies address structural factors that predispose sexual risk behaviors.Young men who have sex with men (MSM) continue to be at increased risk for the acquisition and transmission of HIV. Nationally, among those aged 13 to 24 years, the estimate of new HIV infections attributed to male-to-male sexual contact increased from 61% in 2006 to 71% in 2009.1 In New York City between 2001 and 2008, 73% of HIV diagnoses among male adolescents and young adults were among young MSM.2 These national and local surveillance data confirm that a third generation of MSM, a generation that did not witness the heightened morbidity and mortality of the early AIDS epidemic, continue to bear a disproportionate burden of HIV/AIDS. In addition to these epidemiological trends, adolescents and young adults are at heightened risk for HIV/AIDS because the periods of adolescence and young adulthood are marked by a higher prevalence of HIV-related risk behaviors such as unprotected sex and illicit drug use.3,4 Moreover, these periods are often characterized by significant transitions and challenges for young MSM, specifically around the formation of sexual identity as well as coming out to family members and peers that may all coalesce to increase vulnerability for HIV.To date, research related to HIV risk among MSM, and more specifically young MSM, has generally focused on understanding the influence of individual-level characteristics on risk-taking behaviors. For example, it is well established that factors such as educational attainment,5 race/ethnicity,6–8 sexual orientation,9 age at sexual onset,8,10 and relationship status11,12 are associated with sexual risk-taking behaviors, such as engaging in unprotected anal intercourse (UAI). In addition, previous research indicates that those with a history of arrest and incarceration are more likely to engage in greater sexual risk behaviors than are those without such a history.13,14More recently, research efforts have moved beyond examining individual-level characteristics by considering both protective and harmful psychosocial states that may either buffer against or exacerbate vulnerabilities that function as drivers of HIV-related sexual risk behaviors.15,16 For instance, experiences of homophobia can often lead to discomfort with one’s sexual identity and may act as a significant psychosocial stressor linked to increased sexual risk taking.17,18 Conversely, young MSM with positive attitudes about homosexuality are less likely to have multiple sex partners and may be less likely to engage in UAI.19 Finally, gay community affiliation may function to either protect against or exacerbate the risk for HIV transmission and acquisition.Exposure and access to gay neighborhoods with norms promoting safer sexual behaviors may lead to safer sexual practices, such as consistent condom use, among MSM20 as well as greater awareness about HIV education and services available to MSM.21 However, higher gay community affinity among a younger generation of MSM may be associated with greater sexual risk taking in the absence of norms promoting safer sexual behaviors.22Increasingly, empirical research has examined the impact of social factors for their association with sexual risk taking among MSM overall.23 For example, several studies have linked poverty and economic disadvantage as socially produced risk factors associated with sexual risk taking among MSM.24,25 These associations may be more pronounced among individuals with higher levels of residential or housing instability or homelessness because they may engage in sex work to secure vital material resources and therefore be at an increased risk for HIV transmission and acquistion.24,26–28 Because of the need to understand the effect of individual, psychosocial, and social factors on HIV risk among young MSM, we sought to characterize how these factors influence sexual risk behaviors, specifically UAI, in a sample of young MSM. These findings have the potential to inform novel HIV/AIDS-related prevention and intervention efforts for this new generation of men.     

Correlates of Sexual HIV Risk Among African American Men Who Have Sex With Men

Objectives. We examined correlates of condomless anal intercourse with nonmain sexual partners among African American men who have sex with men (MSM).Methods. We recruited social networks composed of 445 Black MSM from 2012 to 2014 in Milwaukee, Wisconsin; Cleveland, Ohio; and Miami Beach, Florida. Participants reported past-3-month sexual behavior, substance use, and background, psychosocial, and HIV-related characteristics.Results. Condomless anal intercourse outside main concordant partnerships, reported by 34.4% of MSM, was less likely in the case of no alcohol and marijuana use in the past 30 days, and higher risk-reduction behavioral intentions. High frequency of condomless anal intercourse acts with nonmain partners was associated with high gay community participation, weak risk-reduction intentions, safer sex not being perceived as a peer norm, low condom-use self-efficacy, and longer time since most recent HIV testing.Conclusions. Condomless anal intercourse with nonmain partners among Black MSM was primarily associated with gay community participation, alcohol and marijuana use, and risk-reduction behavioral intentions.HIV infection in the United States falls along sharp lines of disparity related to sexual orientation and race. Every year since HIV surveillance began, men who have sex with men (MSM) have accounted for the majority of the country’s HIV cases.1 The disease also disproportionately affects African Americans, who constitute 12% of the American population but carry 44% of its HIV infection burden.1 Yet, the starkest disparity emerges from the combined impact of race and sexual orientation. Black MSM represent only a fraction of a percent of the American population but accounted for more than 25% of the country’s new HIV infections in 2010,1 with HIV rates much higher among Black than White MSM.2 HIV incidence among racial-minority MSM in some cities ranges from 24% to 29%.3,4 Considerable attention is being given to biomedical strategies such as early initiation of antiretroviral therapy (ART) and preexposure ART prophylaxis for HIV prevention.5,6 However, the impact of these promising strategies will depend upon ART coverage and adherence, neither of which is likely to be quickly attained or complete. For this reason, integrated HIV prevention approaches are needed, including improved interventions to reduce risk behavior among racial-minority MSM.Previous research has examined but has generally failed to establish differences in individual-level risk practices between Black and White MSM.7–10 However, sexual network characteristics, high rates of undiagnosed and untreated HIV infection, high sexually transmitted infection (STI) prevalence, and unsuppressed viral load among HIV-positive African American MSM are believed to contribute to HIV disparities.9–16Black MSM are not a monolithic population,17–20 and multiple factors may influence extent of HIV vulnerability within the community of racial-minority MSM. These include risk-related sexual behavior norms, attitudes, and intentions21–25; substance use12,26–30; poverty and disadvantage19,20; and psychosocial domains including internalized homonegativity or homophobia,31–34 self-perceived masculinity,35,36 HIV conspiracy beliefs or mistrust,37,38 religiosity,39 and resilience.40,41 It is important to ascertain the relative importance of these and other factors to properly tailor HIV prevention interventions for racial-minority MSM.In this study, we recruited social networks of African American MSM and sought to determine the relationships of 4 types of factors with the riskiness of men’s sexual behavior practices: (1) social, economic, and demographic background characteristics; (2) substance use; (3) HIV risk–specific knowledge, attitudes, beliefs, and intentions; and (4) psychosocial domains including internalized homonegativity, self-ascribed masculinity, AIDS conspiracy beliefs, resilience, religiosity, and gay community participation. We examined HIV risk–specific characteristics because they are proximal to adopting protective actions according to many behavioral science theories.42–44 We examined psychosocial domains because broader personal and contextual life experiences may also potentiate risk. We sought to identify characteristics related not only to some men’s high-risk behavior but also the adoption of very safe behavior by other African American MSM, a strengths-based question that has been insufficiently explored.     

A Syndemic of Psychosocial Health Disparities and Associations With Risk for Attempting Suicide Among Young Sexual Minority Men

Objectives. We examined a syndemic of psychosocial health issues among young men who have sex with men (MSM), with men and women (MSMW), and with women (MSW). We examined hypothesized drivers of syndemic production and effects on suicide attempts.Methods. Using a pooled data set of 2005 and 2007 Youth Risk Behavior Surveys from 11 jurisdictions, we used structural equation modeling to model a latent syndemic factor of depression symptoms, substance use, risky sex, and intimate partner violence. Multigroup models examined relations between victimization and bullying experiences, syndemic health issues, and serious suicide attempts.Results. We found experiences of victimization to increase syndemic burden among all male youths, especially MSMW and MSM compared with MSW (variance explained = 44%, 38%, and 10%, respectively). The syndemic factor was shown to increase the odds of reporting a serious suicide attempt, particularly for MSM (odds ratio [OR] = 5.75; 95% confidence interval [CI] = 1.36, 24.39; P < .001) and MSMW (OR = 5.08; 95% CI = 2.14, 12.28; P < .001) compared with MSW (OR = 3.47; 95% CI = 2.50, 4.83; P < .001).Conclusions. Interventions addressing multiple psychosocial health outcomes should be developed and tested to better meet the needs of young MSM and MSMW.Substantial evidence has been accumulating over the past several decades to suggest that men who have sex with men (MSM) experience substantial disparities in many facets of health.1 An important characteristic of these disparities is that they tend to arise early in the life course. For example, meta-analyses have shown that by adolescence and young adulthood MSM experience significantly higher rates of depression,2 substance use,3 HIV sexual risk behaviors,4 and suicidality2 than do their heterosexual peers. Little research has been conducted on the health of young men who have sex with men and women (MSMW). The few empirical studies separating adolescent MSM from adolescent MSMW have shown that adolescent MSMW report significantly higher rates of substance use, including tobacco use, than do their heterosexual3 and MSM5–9 counterparts. Additionally, MSMW have been found to be more likely to report HIV sexual risk behaviors than are their heterosexual peers.9One theoretical explanation for these disparities is syndemics.10–12 Syndemic theory posits that as individuals are confronted with adversity across the life course, particularly in the forms of social marginalization and victimization, they develop psychosocial health problems such as low self-image, depression, and substance use.13 These conditions tend to co-occur, which has a snowballing effect on overall health. In fact, several studies have demonstrated that as the number of psychosocial conditions within an individual increases, so does their risk of major negative health outcomes.10–12,14 It follows from this argument that young MSM, who experience far greater levels of adversity than do heterosexual youths,15–18 would also experience greater rates of syndemics and higher rates of the resulting negative health outcomes.We examined syndemic production in a population-based sample of young men and its association with serious suicide attempts. By looking at syndemics in a large enough sample that could be broken into MSM, MSMW, and men who have sex with women (MSW), we sought to determine whether syndemics are a general human phenomenon or whether they exist and are associated with negative health outcomes only for certain socially marginalized populations.10,11,19 We also examined the structure of the syndemic construct by testing for measurement invariance using multigroup confirmatory factor analysis (CFA),20 which, essentially, asks whether the meaning of the syndemic construct is the same across groups. Next we examined the relation between experienced adversity and syndemic production to see whether this association exists for all groups of young men, and if so, to what degree. Finally, we tested the relationship between syndemics and a serious adverse health outcome—making a life-threatening suicide attempt—and whether the negative effects were the same across groups.     

Correlates of Sexual Risk Among Sexual Minority and Heterosexual South African Youths

We explored psychosocial correlates of sexual risk among heterosexual and sexual minority youths (SMYs) in Johannesburg, South Africa. Young people 16 to 18 years old (n = 822) were administered surveys assessing demographic characteristics, sexual behaviors, mental health, and parent–child communication. Adjusted multivariate regressions examining correlates of sexual risk revealed that SMYs had more sexual partners than heterosexual youths (B = 3.90; SE = 0.95; P < .001) and were more likely to engage in sex trading (OR = 3.11; CI = 1.12-8.62; P < .05). South African SMYs are at increased risk relative to their heterosexual peers.South Africa has the highest burden of HIV in the world; 9.2% of young persons aged 15 to 19 years living in the country are infected with HIV.1,2 Few studies have examined multilevel sexual risk factors (e.g., individual, partner, family) among sexual minority youths (SMYs)3 in South Africa, despite their increased vulnerability.4–8 Research has shown that rates of sexual risk behavior are high among adult men who have sex with men (MSM) in sub-Saharan Africa,5,9 and South African SMYs may be especially vulnerable given the transitional nature of adolescence, fear of discrimination, and lack of cultural acceptance of homosexuality.4,7,10Our analyses were guided by theories of syndemics (i.e., collective risk or co-occurring epidemics)11–13 and minority group stress.14 These theories posit that young MSM experience psychosocial disparities in numerous areas (substance use, abuse and victimization, mental health problems, risk taking)15–18 and that SMYs are at increased risk for poor mental health, sexual vulnerability, substance use, and violence.19,20 Moreover, stigma creates stressful environments, another cause of mental health problems among SMYs.14 This situation is especially salient in South Africa, where same-sex behavior is so highly stigmatized that even normative adolescent sexual exploration would likely be denounced.7We hypothesized that South African SMYs would be at increased sexual risk relative to heterosexual youths. To our knowledge, this is one of the first investigations to examine risk and protective factors associated with sexual risk in this population.     

Drug Use and High-Risk Sexual Behaviors Among African American Men Who Have Sex With Men and Men Who Have Sex With Women

Objectives. We investigated covariates related to risky sexual behaviors among young African American men enrolled at historically Black colleges and universities (HBCUs).Methods. Analyses were based on data gathered from 1837 male freshmen enrolled at 34 HBCUs who participated in the 2001 HBCU Substance Use Survey. The covariates of risky sexual behavior assessed included condom nonuse, engaging in sexual activity with multiple partners, and history of a sexually transmitted disease.Results. Young Black men who had sex with men were more likely to engage in risky sexual behaviors than were young men who had sex with women. Two additional factors, early onset of sexual activity and consumption of alcohol or drugs before sexual activity, were independently associated with modestly higher odds of sexual risk behaviors.Conclusions. Services focusing on prevention of sexually transmitted diseases should be provided to all male college students, regardless of the gender of their sexual partners. Such a general approach should also address drug and alcohol use before sexual activity.Sexually transmitted diseases (STDs) threaten the sexual and reproductive health of adolescents and young adults, as indicated by the fact that an estimated half of the STD cases reported in 2000 occurred among those aged 15 to 24 years.¹ African Americans and men who have sex with men (MSM) are disproportionately affected by HIV/AIDS and other STDs. ^2–7 Moreover, although previous research indicates that Black MSM are no more likely than other MSM to engage in sexual risk behaviors,⁸ this group has been particularly affected by the HIV/AIDS epidemic.⁹Few studies have compared Black men who have same-gender and opposite-gender sexual partners. Thus, it is unclear whether Black MSM and Black men who have sex with women (MSW) differ in terms of their sexual risk behaviors. In addition, although a number of large studies have collected data from populations of young MSM,^10–14 few analyses have focused specifically on college populations.¹⁵In general, sexual risk-taking behaviors have received less attention among college students than among other groups; however, concerns regarding HIV/AIDS in this population were heightened by the rise in the number of HIV/AIDS diagnoses among male college students, particularly Black MSM, in North Carolina from 2001 to 2003.¹⁶ The majority of college students are sexually active, with prevalence estimates of lifetime sexual activity ranging from 74%¹⁵ to 86.1%.¹⁷ Less is known regarding students enrolled in historically Black colleges and universities (HBCUs). In one study of students enrolled at 8 HBCUs, 82% of the respondents reported a history of sexual intercourse and 59.6% reported that they had used a condom during their most recent intercourse.¹⁸Studies have identified risk and protective factors for sexual risk taking, including early onset of sexual activity,^19–21 substance use and early initiation of use,^22–25 and academic achievement.²⁶ Although the relation of other factors to risky sexual behaviors is less clear, some studies have shown that adolescents and college students with higher levels of religiosity are less likely to report a history of sexual activity.^27–29 However, findings regarding condom use are inconsistent,^28,30 and in 1 study individuals'' religiosity during adolescence was not related to their likelihood of contracting a sexually transmitted infection 6 years later.²⁶ Among college students, living situation may also be an important factor to consider, given previous research indicating that undergraduates who live with their parents are less likely than those who do not to use marijuana and alcohol.³¹We examined covariates of risky sexual behaviors, including inconsistent condom use, engaging in sexual activity with multiple partners, and history of STD infection (the latter as a proxy for risky behavior), among Black MSM and Black MSW attending HBCUs. In addition to the association between risky sexual behaviors and partner gender, we investigated relations between risky behaviors and early onset of sexual activity, substance use in conjunction with sexual activity, religiosity, and living situation.     

The Interaction of Sexual Identity With Sexual Behavior and Its Influence on HIV Risk Among Latino Men: Results of a Community Survey in Northern San Diego County,California

Objectives. We examined the sexual behavior, sexual identities, and HIV risk factors of a community sample of Latino men to inform efforts to reduce Latinos'' HIV risk.Methods. In 2005 and 2006, 680 Latino men in San Diego County, California, in randomly selected, targeted community venues, completed an anonymous, self-administered survey.Results. Most (92.3%) respondents self-identified as heterosexual, with 2.2%, 4.9%, and 0.6% self-identifying as bisexual, gay, or other orientation, respectively. Overall, 4.8% of heterosexually identified men had a lifetime history of anal intercourse with other men. Compared with behaviorally heterosexual men, heterosexually identified men who had sex with both men and women were more likely to have had a sexually transmitted infection, to have unprotected sexual intercourse with female partners, and to report having sex while under the influence of alcohol or other drugs. Bisexually identified men who had sex with men and women did not differ from behaviorally heterosexual men in these risk factors.Conclusions. Latino men who have a heterosexual identity and bisexual practices are at greater risk of HIV infection, and efforts to reduce HIV risk among Latinos should target this group.Latinos and sexual minorities are disproportionately affected by HIV/AIDS. Latinos represented 14% of the US population in 2005,¹ but they accounted for 18% of HIV/AIDS cases diagnosed in 2006.² Although an estimated 6% to 9% of the US population has a lifetime history of homosexual sex,^3,4 men who have sex with men accounted for 49% of all HIV/AIDS cases diagnosed in the United States in 2006.² Sexual risk for HIV varies considerably by sexual orientation, with gay-identified and bisexually identified men generally at greater risk.^5,6 However, a person''s self-identified sexual orientation frequently does not correspond to his or her sexual behavior.^7–9Within Latino culture, it is possible for a man to have sex with men while maintaining a heterosexual identity and protecting his sense of masculinity.^10–13 For Latino men, sexual identity appears to be contingent upon certain behavioral and contextual factors, such as whether they have female sexual partners, are primarily attracted to women, adopt an insertive role in sexual practices, have sex with effeminate men, or have sex with men when under the influence of alcohol or drugs. Homophobia, social stigma attached to same-sex practices, and sexual conservatism are commonly found throughout Latino culture and may inhibit Latino men who have sex with men from self-identifying as gay or bisexual.^9,10,14–16 Research suggests that Latino men are more likely than are White men to engage in bisexual behavior (i.e., to have sex with both men and women)^8,17,18 but are less likely than are White men to disclose a nonheterosexual orientation.^16,19,20Among men, bisexual behavior appears to be more prevalent than bisexual identity. Although approximately 1% to 2% of the US male population identifies as bisexual,^3,4 rates of male bisexual behavior in national samples have ranged from 1% to 5%.^4,21,22 However, these estimates are questionable because of differences in sampling methods and varying definitions of bisexuality.²³ Recent research conducted in the United States suggests that men who have sex with men and women (MSMW) are at greater risk of HIV infection than men who have sex with men (MSM) exclusively and men who have sex with women (MSW) exclusively.^24–26 By contrast, investigators in Mexico have found that MSMW who self-identify as bisexual practice less risky sexual behaviors with their male partners than do exclusively gay men.⁶It has been difficult to quantify the population of heterosexually identified Latino MSMW because of the secretive nature of their sexual practices. In a homophobic cultural context, the fear of social rejection encourages people to hide their same-sex sexual behavior and lead a double life.¹⁰ A study involving a large population of HIV-positive MSM found that 15% of the Latino sample identified as heterosexual had a history of same-sex intercourse,²⁷ whereas a survey of 455 men recruited from gay-oriented publications and venues in 12 US cities found that 17% (n = 26) of Hispanic respondents (as per terminology used in the original survey) reported being “on the down low”.⁹ Although these results may not generalize to community-based US samples of Latino men, they suggest that a substantial proportion of heterosexually identified Latino men have a history of sex with men. Similarly, a household probability survey in Mexico City found that 73% of men with a lifetime history of bisexual practices identified as heterosexual, as did 29% of those with a lifetime history of having sex only with men.⁶Men''s nondisclosure of sexual practices with men has implications for the health of their female sexual partners.^8,17 In the United States in 2006, Latinas accounted for 23.7% of HIV infections among Hispanics; of these, an estimated 51.7% were infected through heterosexual contact.² Although most cases of heterosexual transmission to Latinas are related to sex with injection drug users,²⁸ women who have unprotected sex with heterosexually identified MSMW are also at risk and are likely a subset of this population.Although there is some evidence of greater HIV risk among MSMW than among MSM or MSW,^24–26 previous research has not examined the roles that both sexual behavior and sexual identity play in HIV risk among Latino men in particular. Sexual identity may influence HIV risk among Latino MSMW because a man who identifies as heterosexual may perceive that he is at lower risk of sexually transmitted infections (STIs) than are gay or bisexual men and may thus take fewer measures to protect himself or his partner. MSMW who identify as heterosexual may also be more likely to resort to substance use to reduce sexual inhibition, thus increasing the likelihood that they will engage in unsafe sex.²⁹Our goal was to learn more about the sexual practices of Latino men and to better understand the interactions among sexual behaviors and sexual identities in this population so as to inform efforts to reduce HIV risk among Latinos. Using survey data, we examined the sexual behavior of a community sample of Latino men; determined the proportions of MSM, MSW, and MSMW among them; elicited any discrepancies between their sexual behavior and their sexual identity; and searched for differences in HIV risk by sexual orientation.     

Posttraumatic stress disorder and HIV risk among poor, inner-city women receiving care in an emergency department

Objectives. We examined the associations between posttraumatic stress disorder (PTSD) and HIV risk behaviors among a random sample of 241 low-income women receiving care in an urban emergency department.Methods. We recruited participants from the emergency department waiting room during randomly selected 6-hour blocks of time. Multivariate analyses and propensity score weighting were used to examine the associations between PTSD and HIV risk after adjustment for potentially confounding sociodemographic variables, substance use, childhood sexual abuse, and intimate partner violence.Results. A large majority of the sample self-identified as Latina (49%) or African American (44%). Almost one third (29%) of the participants met PTSD criteria. Women who exhibited symptoms in 1 or more PTSD symptom clusters were more likely than women who did not to report having had sex with multiple sexual partners, having had sex with a risky partner, and having experienced partner violence related to condom use in the preceding 6 months.Conclusions. The high rate of PTSD found in this sample and the significant associations between PTSD symptom clusters and partner-related risk behaviors highlight the need to take PTSD into account when designing HIV prevention interventions for low-income, urban women.The relationship between posttraumatic stress disorder (PTSD) and HIV risk behaviors remains relatively underresearched. However, several studies have shown that PTSD is associated with sexual HIV risk behaviors and HIV seropositive status.^1–3 Emergency departments have been identified as the first and primary source of medical treatment of many women infected with or at high risk for HIV^4–6 and for those with high rates of interpersonal violence and trauma, including those suffering from PSTD.^7–11Hutton et al. found that, after adjustment for potentially confounding factors, a PTSD diagnosis was associated with engaging in anal intercourse and exchanging sex for money or drugs in a sample of 177 female inmates.¹² High rates of PTSD have also been found among HIV-positive women,^3,13,14 many of whom have experienced repeated traumas associated with PTSD, such as childhood sexual abuse and intimate partner violence (IPV).^3,13,14 In a study of HIV-positive women, 35% of those with a trauma history met the criteria for PTSD,¹⁵ a rate far exceeding both the lifetime PTSD rate (10.4%) among women in the general population¹⁶ and the PTSD rate (4.6%) in a nationally representative sample of female crime victims.¹⁷The relationship between PTSD and HIV risk behaviors has been found to vary according to the presence of different PTSD symptoms (avoidance, hyperarousal, and reexperiencing trauma). In their study of 64 HIV-positive women and men, Gore-Felton and Koopman found that moderate to severe reexperiencing symptoms were associated with multiple sexual partners and unprotected sex during the preceding 3 months.¹⁸ Individuals with avoidant symptoms were less likely to have engaged in unprotected sex, possibly as a result of deficits in establishing and maintaining intimate partnerships.¹⁸ The presence of hyperarousal symptoms may trigger individuals to seek sexual stimulation and engage in riskier sex, and they may experience difficulty in problem solving and negotiating safe sex.¹⁹The research just described highlights mechanisms of how different PTSD symptom clusters may increase the likelihood of engaging in HIV risks. However, it should also be acknowledged that the relationship may be bidirectional: a traumatic experience (e.g., forced unprotected sex) associated with a risk of HIV may lead to PTSD.Furthermore, research suggests that the relationship between PTSD and HIV risk may be mediated by several factors, including childhood sexual abuse, IPV, and substance abuse. Those who have experienced childhood sexual abuse are at increased risk of developing PTSD,^20–22 engaging in subsequent sexual HIV risk behaviors, and HIV transmission.^3,23 Similarly, IPV has been found to increase the risk of both developing PTSD and engaging in a range of HIV risk behaviors, including unprotected sex,^24–38 sexual practices leading to a high risk of sexually transmitted infections,^6,32,39–42 sex with multiple partners,^31,32,43 trading of sex for money or drugs,^40,44 sex with risky partners,^38,45 and sex with HIV-positive partners.³⁸ Finally, substantial research indicates that drug and alcohol dependencies are associated with both PTSD^46,47 and engaging in a range of HIV risk behaviors.^48–51We examined the relationship between PTSD (and the symptom clusters of avoidance, reexperiencing trauma, and hyperarousal) and sexual HIV risk behaviors in a random sample of 241 women attending an emergency department in a low-income neighborhood of the Bronx, New York. We hypothesized that women who met the criteria for PTSD and the symptom clusters of hyperarousal, reexperiencing trauma, or avoidance would be more likely than women who did not meet these criteria to engage in sexual HIV risk behaviors after adjustment and matching for potentially confounding factors such as sociodemographic characteristics, childhood sexual abuse, substance abuse, and IPV.     

Adversity and Syndemic Production Among Men Participating in the Multicenter AIDS Cohort Study: A Life-Course Approach

Objectives. We tested a theory of syndemic production among men who have sex with men (MSM) using data from a large cohort study.Methods. Participants were 1551 men from the Multicenter AIDS Cohort Study enrolled at 4 study sites: Baltimore, Maryland–Washington, DC; Chicago, Illinois; Los Angeles, California; and Pittsburgh, Pennsylvania. Participants who attended semiannual visits from April 1, 2008, to March 31, 2009, completed an additional survey that captured data about events throughout their life course thought to be related to syndemic production.Results. Using multivariate analysis, we found that the majority of life-course predictor variables (e.g., victimization, internalized homophobia) were significantly associated with both the syndemic condition and the component psychosocial health outcomes (depressive symptoms, stress, stimulant use, sexual compulsivity, intimate partner violence). A nested negative binomial analysis showed that the overall life course significantly explained variability in the syndemic outcomes (χ² = 247.94; P < .001; df = 22).Conclusions. We identified life-course events and conditions related to syndemic production that may help to inform innovative interventions that will effectively disentangle interconnecting health problems and promote health among MSM.A growing number of epidemiological studies have detected significant health-related disparities among men who have sex with men (MSM) for many dangerous health conditions, ranging from psychosocial problems1, 2 to infectious and chronic diseases.3–6 A notable feature of these seemingly distinct public health epidemics is that they are often interconnected and manifest themselves among MSM in ways to suggest that they are mutually reinforcing, thereby creating a syndemic.7–11 A syndemic, as defined by the Centers for Disease Control and Prevention, is “two or more afflictions, interacting synergistically, contributing to excess burden of disease in a population.”12 Syndemic conditions have been hypothesized to be a driving force for HIV transmission among MSM in the United States and abroad.7, 9 However, relatively little is known about the underlying pathways that explain the production and maintenance of syndemics among populations of MSM.We tested a theory of syndemic production among MSM using data from a large cohort study, the Multicenter AIDS Cohort Study (MACS).13 The syndemic theory we investigated takes a life-course perspective on syndemic production among MSM and proposes that experiences of social marginalization, often starting at a very early age, place these men at greater risk for a combination of psychosocial health problems (i.e., depression, partner violence, stimulant use) that subsequently intertwine to drive risks related to HIV and other negative health outcomes.7 An empirically tested theory of syndemic production offers an explanation for the existence of syndemic conditions among MSM and may inform the development of innovative interventions to lower rates of psychosocial health problems and subsequent risk of HIV transmission.     

Sexual Risk Behaviors Among HIV-Positive Black Men Who Have Sex With Women, With Men, or With Men and Women: Implications for Intervention Development

Objectives. We compared demographics and sexual and drug risk behaviors among HIV-positive Black men who have sex with women only, with men only, or with men and women to assess differences among and between these groups.Methods. We analyzed cross-sectional data from the Supplement to HIV and AIDS Surveillance Project for 2038 HIV-positive Black men who reported being sexually active. We classified the participants by their reported sexual behaviors in the past year: intercourse with women (n = 1186), with men (n = 741), or with men and women (n = 111).Results. Respondents whose sexual partners were both men and women reported more noninjection drug use, sexual exchange, and sexual partners than did the other 2 groups. Bisexual respondents were also more likely than were heterosexuals to report unprotected intercourse with a steady female partner and were more likely than were both other groups to report having steady partners of unknown HIV serostatus and using drugs during their last sexual episode.Conclusions. HIV-positive Black men with both male and female sexual partners engaged in more sexual and drug risk behaviors than did their heterosexual and homosexual peers. More information concerning the prevention needs of behaviorally bisexual HIV-positive Black men is needed.Epidemiological studies consistently show that Black men are disproportionately affected by HIV/AIDS.¹ Although non-Hispanic Black men composed approximately 6% of the US population, they accounted for 29.2% of the estimated number of adults and adolescents living with HIV/AIDS at the end of 2005.^1,2 Surveillance data show that unprotected male–male sexual intercourse and injection drug use are the primary modes of HIV transmission among Black men. Behavioral studies examining sexual risk show that some HIV-positive persons, including HIV-positive Black men, continue to engage in unprotected sexual intercourse with male and female partners of negative and unknown HIV serostatus.^3–8Considerable research has examined sexual and drug risk behaviors, partner characteristics, and sociodemographics of HIV-positive men. Factors such as use of alcohol or drugs during last episode of sexual intercourse,^9–12 partnership status (steady or nonsteady),^13,14 number of partners,¹⁵ partner''s HIV status (negative, positive, or unknown),^16–18 poverty,¹⁹ and sexual exchange (paying or receiving goods or money for sexual intercourse)^20,21 have all been associated with high-risk sexual behaviors among HIV-positive persons. Many of these studies included relatively few Black men, or Black homosexual and bisexual men were combined into 1 group, or Black men were compared with high-risk men of other race/ethnicity. Although all of these studies have produced pieces of a puzzle for understanding issues associated with HIV transmission among Black men living with HIV/AIDS, they have not specifically focused on behaviorally different groups of HIV-positive Black men.Rates of HIV seropositivity are high among Black men, and HIV infections are spreading throughout Black communities. We therefore sought to examine differences in self-reported sexual behavior between HIV-positive Black men who have sex with men (MSM), with women (MSW), or with men and women (MSMW) without regard to self-reported sexual orientation. In particular, we examined differences in sexual risk behavior between MSW and MSMW and between MSM and MSMW in the past year. Our data may identify factors contributing to the spread of HIV in Black communities, assist researchers to develop interventions to reduce and eliminate high-risk behaviors in these populations, and ultimately help reduce and prevent the transmission of HIV.     

The Role of Stigma and Medical Mistrust in the Routine Health Care Engagement of Black Men Who Have Sex With Men

Objectives. We assessed how health care–related stigma, global medical mistrust, and personal trust in one’s health care provider relate to engaging in medical care among Black men who have sex with men (MSM).Methods. In 2012, we surveyed 544 Black MSM attending a community event. We completed generalized linear modeling and mediation analyses in 2013.Results. Twenty-nine percent of participants reported experiencing racial and sexual orientation stigma from heath care providers and 48% reported mistrust of medical establishments. We found that, among HIV-negative Black MSM, those who experienced greater stigma and global medical mistrust had longer gaps in time since their last medical exam. Furthermore, global medical mistrust mediated the relationship between stigma and engagement in care. Among HIV-positive Black MSM, experiencing stigma from health care providers was associated with longer gaps in time since last HIV care appointment.Conclusions. Interventions focusing on health care settings that support the development of greater awareness of stigma and mistrust are urgently needed. Failure to address psychosocial deterrents will stymie progress in biomedical prevention and cripple the ability to implement effective prevention and treatment strategies.The HIV epidemic is one of the most critical public health issues facing the United States today. Although HIV infections are documented among all racial/ethnic and sexual risk groups, Black men who have sex with men (Black MSM) are the most affected by HIV in the United States.1 Forty-four percent of new HIV infections are among Blacks, and the rate of HIV infection among this group is 7.9 times higher than is the rate of HIV infections among Whites. Black MSM, in particular, are diagnosed with HIV at a rate 6.0 times higher than that of White MSM, and they are 3.8 times more likely to be living with HIV than are White MSM.2 The remarkable HIV-related race/ethnicity and sexual orientation disparities observed among Black MSM require urgent attention.Although surveillance regarding HIV infection highlights increases in HIV transmission among Black MSM, in particular young Black MSM, there is considerable promise in emerging and available HIV prevention and treatment options (e.g., microbicides,3 preexposure prophylaxis,4 and treatment as prevention5). However, these approaches to HIV prevention require engagement in routine medical care and HIV treatment–related care. The use of biomedical technologies in preventing the spread of HIV will fail if those in need are not connected to care that can facilitate access to and monitor the use of these strategies.6,7Within the current HIV prevention and treatment health care landscape, it is well understood that HIV-positive Black MSM who are without engagement in care suffer worse morbidities and greater mortality than do those in care and that overall rates of engagement in care must be improved.8–10 Likewise, we know very little about the routine health care of HIV-negative Black MSM.11,12 Limited previous research has found that Black MSM describe their experiences of engaging in health care as fragmented and their health care services offered as subpar.13 The inadequate screening and treatment of sexually transmitted infection and HIV are observed even for routine sexually transmitted infection and HIV care among HIV-negative Black MSM.14 Consequently, failure to engage HIV-negative Black MSM in care results in missed opportunities to provide them with prevention options.Theoretically, there are multiple factors to consider when examining the limited retention to care that we observe among Black MSM.15–18 Notably, being uninsured or underinsured, limitations because of location and transportation, and lack of available qualified health professionals are factors directly related to access.19 However, psychosocial deterrents to care are equally important and impede health care access as well.20–23 For instance, stigma, described as the social devaluation or discrediting associated with a specific characteristic or attribute,24 and trust in health care providers and medical establishments are linked to health care behaviors.25 We focused on these psychosocial factors.Research in the area of psychosocial-related deterrents to seeking health care has highlighted the need to better understand the role of stigma in health care access26–28—in particular, the role of enacted stigma (or experiences of discrimination) in health care settings. Institutions that are mandated to protect the well-being of Black MSM are in many instances perceived as threatening to them as a result of experiencing health care provider sexual-orientation and HIV-status discrimination.29,30 Furthermore, in a review of stigma and the HIV epidemic, Mahajan et al. highlight the lack of data on measuring the effects of overlapping stigmas (in the case of Black MSM, being part of a racial and sexual orientation minority) on accessing health care.25 Not only can stigma undermine access to care, but it is also associated with longer breaks in care among those who have been linked.6,9,10 Therefore, previous research warrants an assessment of the extent to which Black MSM experience enacted stigmas and how these experiences are related to accessing medical care.Medical mistrust among Black adults has also been identified as a barrier to engaging in routine health care. Beliefs regarding mistrust in the treatment of HIV in particular are especially damaging to clinicians’ abilities to engage those in need of care.31,32 Trust in health care providers has been directly linked to health outcomes such as antiretroviral adherence and good mental health.32 However, few studies have investigated the role of medical mistrust among MSM, and limited data on Black MSM exist on this topic.33 The available literature generally presents 2 focus assessments when assessing medical mistrust: (1) a system focus assessment, that is, general trust in medical establishments; and (2) an individual focus assessment, that is, trust in a provider’s ability to offer adequate care.34–37 These concepts are thought to affect one’s likelihood of seeking out (system focus) and staying in (individual focus) care. However, research on these areas is limited and exploratory in nature.We sought to understand how experiences of health care–enacted stigma relate to accessing routine medical care among HIV-negative and HIV-positive Black MSM attending a community event in Atlanta, Georgia. Furthermore, we examined the association of this relationship with global medical mistrust and personal trust in one’s health care provider. We hypothesized that experiences of enacted health care stigma would predict routine care and that this relationship would be mediated by perceptions of medical mistrust among HIV-positive and -negative Black MSM.     

Differences in the social networks of African American men who have sex with men only and those who have sex with men and women

Objectives. We compared social network characteristics of African American men who have sex with men only (MSMO) with social network characteristics of African American men who have sex with men and women (MSMW).Methods. Study participants were 234 African American men who have sex with men who completed a baseline social network assessment for a pilot behavioral HIV prevention intervention in Baltimore, Maryland, from 2006 through 2009. We surveyed the men to elicit the characteristics of their social networks, and we used logistic regression models to assess differences in network characteristics.Results. MSMO were significantly more likely than were MSMW to be HIV-positive (52% vs 31%). We found no differences between MSMO and MSMW in the size of kin networks or emotional and material support networks. MSMW had denser sexual networks, reported more concurrent and exchange partners, used condoms with more sexual partners, and reported interaction with a larger number of sexual partners at least once a week.Conclusions. Although there were many similarities in the social and sexual network characteristics of MSMO and MSMW, differences did exist. HIV prevention interventions should address the unique needs of African American MSMW.Recent epidemiological data suggest that the highest rates of HIV infection in the United States are found among African American men who have sex with men (MSM).¹ According to the National HIV Behavioral Surveillance survey in 2004–2005, among 5 cities studied, Baltimore, Maryland, had the highest HIV rates among African American MSM, with a prevalence of 51% and an estimated incidence rate of 8% per year.² African American MSM are also more likely than are MSM of other racial/ethnic groups to report bisexual identity.^3–9Some studies have focused on men who have sex with men and women (MSMW) as a potential bridge group to heterosexual transmission.^10,11 Several investigators have found that MSMW have lower HIV rates than do men who have sex with men only (MSMO).^11–13 Some studies have found that MSMW report more sexual partners than do MSMO,^11,14 although another has found that not to be true.¹⁵Social network factors have been linked to transmission of HIV and other sexually transmitted infections.^16–18 Indeed, there is evidence that network structural characteristics, such as network density (the extent to which social network members know one another) and partner concurrency, may lead to high rates of sexually transmitted infectious diseases.^19–21 Network dynamics have also been used to explain the greater burden of HIV and AIDS among African Americans compared with other racial groups in the United States.²² Network characteristics such as network size, composition, and density have been found to be associated with HIV risk behaviors, such as sharing injection equipment,^23–27 having multiple partners, engaging in unprotected sex, and exchanging sex for money or drugs.^28–31Social network analysis is a useful method to assess amounts, types, and sources of emotional and instrumental social support³² without assuming that social support is derived from specific role relationships, such as spouse, coworker, main sexual partner, or friend. In different populations, specific role relationships may not exist, or the same role may provide different types of social support. Few studies have examined the social networks of MSM,^33,34 and there is even less information on the social networks of African American MSM. Miller et al.³⁵ conducted in-depth interviews with 21 African American MSM and inquired about the composition of their social networks. They found that African American MSM listed twice as many non-MSM male friends as MSM friends. Few listed MSM friends with whom they did not have sex. A study of HIV-positive men and women reported that African American MSM received more social support from friends and health care providers than they did from family members.³⁶ It has been suggested that some African American MSM perceive that their community consists of their social network members rather than a physical location.³⁷We examined differences in social network composition between African American MSMO and African American MSMW. Examining social network composition is critical not only for assessing the dynamics of transmission of HIV but also for assessing the social and economic support available to people with HIV. Support issues are especially important among impoverished urban populations. Understanding social network composition is also critical for developing and sustaining appropriate HIV prevention and care programs. In these analyses we were specifically interested in examining the sources and functions of social support within participants'' social networks, the sexual risk behaviors participants engaged in with network members, and the overlap between social support networks and sexual networks. We anticipated that MSMO would report more dense social networks than MSMW but less social support.     

Learning From Successful Interventions: A Culturally Congruent HIV Risk�CReduction Intervention for African American Men Who Have Sex With Men and Women

Few HIV prevention interventions have been developed for African American men who have sex with men or who have sex with both men and women. Many interventions neglect the historical, structural or institutional, and sociocultural factors that hinder or support risk reduction in this high-risk group.We examined ways to incorporate these factors into Men of African American Legacy Empowering Self, a culturally congruent HIV intervention targeting African American men who have sex with men and women.We also studied how to apply key elements from successful interventions to future efforts. These elements include having gender specificity, a target population, a theoretical foundation, cultural and historical congruence, skill-building components, and well-defined goals.AFRICAN AMERICAN MEN WHO have sex with men (MSM) or who have sex with both men and women (MSMW) have the highest HIV prevalence among African Americans and among other racial/ethnic groups of MSM.^1–3 However, HIV risk behaviors alone do not explain the disproportionate HIV rates among African American MSM.^4,5 Attention to the sociocultural challenges facing African American MSM is needed.Only 1 published HIV behavioral intervention targets African American MSM⁶; none specifically target African American MSMW. Inclusion of culture is believed to improve the ability of public health programs to meet members'' needs.^7–9 However, inherent abstractness and a lack of operationalized definitions and cultural competency pose challenges for those designing and implementing interventions.^10–14 Understanding the experiences of African American MSM requires attention to definitions of what it means to be African American and of male sexuality that are rooted in African American history and culture. Choices regarding identification with gay or bisexual labels and disclosure of Black same-gender sexual activities must be contextualized within African American communities.^15–17Health improvement among African American MSM requires attention to racism; gender role expectations; connection to partners, families, and communities; and HIV-related stigma.^18–22 Double minority status is made worse by high HIV rates and perceived responsibility for spreading HIV.^23–25 Even if family and community provide social support, homophobia and racism can deter African American MSM from disclosing their sexuality and seeking HIV prevention and care.²⁶ Interventions must engage protective factors and address structural or institutional and sociocultural barriers to prevention.     

Hombres Sanos: evaluation of a social marketing campaign for heterosexually identified Latino men who have sex with men and women

Objectives. We evaluated the effectiveness of Hombres Sanos [Healthy Men] a social marketing campaign to increase condom use and HIV testing among heterosexually identified Latino men, especially among heterosexually identified Latino men who have sex with men and women (MSMW).Methods. Hombres Sanos was implemented in northern San Diego County, California, from June 2006 through December 2006. Every other month we conducted cross-sectional surveys with independent samples of heterosexually identified Latino men before (n = 626), during (n = 752), and after (n = 385) the campaign. Respondents were randomly selected from 12 targeted community venues to complete an anonymous, self-administered survey on sexual practices and testing for HIV and other sexually transmitted infections. About 5.6% of respondents (n = 98) were heterosexually identified Latino MSMW.Results. The intervention was associated with reduced rates of recent unprotected sex with both females and males among heterosexually identified Latino MSMW. The campaign was also associated with increases in perception of HIV risk, knowledge of testing locations, and condom carrying among heterosexual Latinos.Conclusions. Social marketing represents a promising approach for abating HIV transmission among heterosexually identified Latinos, particularly for heterosexually identified Latino MSMW. Given the scarcity of evidence-based HIV prevention interventions for these populations, this prevention strategy warrants further investigation.In the United States, adult and adolescent Latino males represent 5.6% of the total population¹ but 18.7% of HIV/AIDS cases.² Low rates of condom use^3–5 and limited HIV testing^5–7 likely contribute to the risk for infection and transmission among Latinos.Sex between men continues to account for the majority of new HIV infections in the United States.² HIV prevention efforts have traditionally targeted gay and bisexual men. However, individuals’ self-identified sexual orientation frequently does not correspond to their sexual behavior,^8–12 and recent research has been focused on men who self-identify as heterosexual but have sex with men. The results of studies on men who have sex with both men and women (MSMW) suggest that, regardless of sexual identity, this population is at greater risk for HIV than are men who exclusively have sex with men; likewise, MSMW are at greater risk than are men who exclusively have sex with women (MSW).^11,13–16 Reasons for greater risk among MSMW may include lower rates of condom use^11,16 and having sexual partners who engage in high-risk sexual practices.¹¹Previous studies have suggested that Latino men are more likely than are White men to engage in bisexual sexual behavior^9,11,17,18 but less likely than are White men to self-identify as gay or bisexual or to disclose their sexual orientation.^19–23 Cultural factors such as homophobia, social stigma related to same-sex practices, and sexual conservatism may inhibit Latino men from self-identifying as homosexual or bisexual.^{10,13,23–26} The degree to which Latinos integrate same-sex sexual practices into their sexual identities may influence their risk for HIV infection.²⁷ Latino MSMW who identify as heterosexual may perceive that they are at lower risk for sexually transmitted infections (STIs) than are gay or bisexual men, and Latino MSMW may thus be less likely to use condoms to protect themselves or their partners. Latino MSMW who identify as heterosexual may also be more likely to resort to substance use to reduce sexual inhibition, thus increasing the likelihood that they will engage in unsafe sex.^19,27Nondisclosure of same-sex sexual practices among MSMW also has significant implications for the health of their female sexual partners.^9,17 More than 70% of Latinas living with HIV/AIDS in the United States were infected via heterosexual contact.² Most cases of heterosexual transmission to Latinas are related to sex with partners who use injection drugs,²⁸ but unprotected sex with men who have multiple partners, including MSMW, has likely contributed to a subset of HIV cases among Latina women.^2,29Social marketing involves applying the principles and techniques of commercial marketing to the promotion of behavioral change for the good of a target audience.^30,31 Social marketing has been successfully used for HIV prevention with gay and bisexual males,^32,33 racial and ethnic minorities,³⁴ and youths.^35–38 Interventions using social marketing have been associated with improvements in HIV/STI testing^32,34 and condom use.^36,37,39,40 To our knowledge, no social marketing campaigns have been designed to reduce HIV risk among heterosexually identified Latino MSMW. Because of the secrecy of their sexual practices and the perceived association of HIV infection with homosexuality,^24,41,42 heterosexually identified Latino MSMW are difficult to reach with HIV prevention efforts. This population is not likely to be exposed to prevention messages or programs targeted to the gay and bisexual communities.¹⁸ Moreover, interventions requiring active recruitment of heterosexually identified MSMW may fail to reach sufficient numbers or may not reach those who are most secretive about their same-sex sexual practices.⁴¹ We sought to evaluate the effectiveness of a social marketing campaign to increase condom use and HIV testing among heterosexual Latino men in northern San Diego County, California, with a special emphasis on heterosexually identified Latino MSMW.     

Off-Premise Alcohol Sales Policies, Drinking, and Sexual Risk Among People Living With HIV

Drinking among HIV-positive individuals increases risks of disease progression and possibly sexual transmission. We examined whether state alcohol sales policies are associated with drinking and sexual risk among people living with HIV. In a multivariate analysis combining national survey and state policy data, we found that HIV-positive residents of states allowing liquor sales in drug and grocery stores had 70% to 88% greater odds of drinking, daily drinking, and binge drinking than did HIV-positive residents of other states. High-risk sexual activity was more prevalent in states permitting longer sales hours (7% greater odds for each additional hour). Restrictive alcohol sales policies may reduce drinking and transmission risk in HIV-positive individuals.More than 1 million people in the United States are living with HIV,¹ and about 56 000 people are newly infected each year.² Approximately one half of those who have had positive test results for HIV drink alcohol; about 1 in 6 regularly binge drinks.³ Drinking in this population is associated with poor treatment adherence,^4,5 disease progression,^6–8 and spread of the virus through risky sexual activity.^9–12Thus, reducing drinking and problem drinking among HIV-positive individuals is an important public health goal. Alcohol sales policies may be 1 tool for accomplishing this. Research has linked geographic variations in off-premise alcohol sales practices (e.g., regulations regarding the sale of alcohol in stores) to drinking and drinking problems in the general population.¹³ Other types of alcohol regulation have been linked to sexual health.^14–16 Sales policies may influence drinking and sexual activity by making purchases inconvenient or affecting where and when people drink.^17–20 We investigated (1) whether findings linking off-premise sales policies to drinking extend to those living with HIV (who have unique demographic characteristics, drinking patterns, and life circumstances) and (2) whether off-premise sales policies predict sexual risk behavior in this group.     

HIV Prevention for Black Men Who Have Sex With Men in the United States

The HIV/AIDS epidemic has exacted a devastating toll upon Black men who have sex with men (MSM) in the United States, and there is a tremendous need to escalate HIV-prevention efforts for this population.The social context in which Black MSM experience the impact of racism and heterosexism strongly affects their risk for HIV infection; thus, HIV-prevention research focused on Black MSM should focus on contextual and structural factors. There is a pronounced lack of community-level HIV-intervention research for Black MSM, but effective preliminary strategies involve adapting existing effective models and tailoring them to the needs of Black MSM.Future research should develop new, innovative approaches, especially structural interventions, that are specifically targeted toward HIV prevention among Black MSM.FOR MORE THAN 20 YEARS, the HIV/AIDS epidemic has been a tremendous burden on Black men who have sex with men (MSM) in the United States. Black MSM account for an increasingly large proportion of AIDS cases and have the highest rates of AIDS mortality among MSM.^1–4 HIV prevalence and incidence rates are disproportionately high among Black MSM compared to other racial/ethnic groups of MSM, including both younger (aged 15–22 years) and older (aged 23–49 years) Black MSM.^5–10 Moreover, rates of unrecognized HIV infection and sexually transmitted infections are higher among Black MSM than among other MSM.^11–13 Black MSM in the United States now experience rates of HIV infection that rival those among the general population in the developing world.^9,11The extremely high risk of HIV infection for Black MSM portends further devastation unless prevention efforts among this population become much more successful. There is a need for community-level risk-reduction interventions with proven efficacy among this population. However, few such interventions have been developed or adapted for Black MSM. In addition, there are salient contextual factors in the lives of Black MSM—especially racism and sexual prejudice—that can diminish their access to resources needed to protect them from HIV transmission, thus presenting formidable barriers to prevention. These barriers have not been well described in the literature because HIV prevention research has typically not focused on minority men within the general MSM population. When non-White MSM were considered, the pervasive influence of social context was not well delineated.To remedy this previous omission, we offer a detailed review of the social contextual factors that influence HIV risks in the lives of Black MSM. Then we describe the paucity of community-level HIV-prevention interventions specifically designed and implemented for Black MSM in the United States. We conclude with suggestions for a social–contextual approach for future intervention research among this population.MSM are not a homogenous population; the category includes all homosexually active and bisexually active men, regardless of their sexual identity.¹⁴ In this article, we use the term MSM as inclusive of all men who have sex with men, regardless of their sexual orientation, except for those studies that explicitly state that their participants'' sexual identity is homosexual, gay, or bisexual.     

Pregnancy as a Window of Opportunity for HIV Prevention: Effects of an HIV Intervention Delivered Within Prenatal Care

Objectives. We sought to determine whether an HIV prevention program bundled with group prenatal care reduced sexually transmitted infection (STI) incidence, repeat pregnancy, sexual risk behavior, and psychosocial risks.Methods. We conducted a randomized controlled trial at 2 prenatal clinics. We assigned pregnant women aged 14 to 25 years (N = 1047) to individual care, attention-matched group care, and group care with an integrated HIV component. We conducted structured interviews at baseline (second trimester), third trimester, and 6 and 12 months postpartum.Results. Mean age of participants was 20.4 years; 80% were African American. According to intent-to-treat analyses, women assigned to the HIV-prevention group intervention were significantly less likely to have repeat pregnancy at 6 months postpartum than individual-care and attention-matched controls; they demonstrated increased condom use and decreased unprotected sexual intercourse compared with individual-care and attention-matched controls. Subanalyses showed that being in the HIV-prevention group reduced STI incidence among the subgroup of adolescents.Conclusion. HIV prevention integrated with prenatal care resulted in reduced biological, behavioral, and psychosocial risks for HIV.Young pregnant women are at high risk for HIV and sexually transmitted infections (STIs).¹ In a systematic review of sexual risk behavior among pregnant or mothering adolescents, 19% to 39% had an STI during pregnancy, and 14% to 39% had an STI 6 to 10 months postpartum. Furthermore, young pregnant women were 5 times less likely to use condoms compared with nulliparous women.²Despite the risks of STI and HIV infection among women of reproductive age, few HIV interventions have specifically targeted pregnant women. The Children''s Health and Responsible Mothering project (Project CHARM), a school-based intervention of pregnant and mothering adolescents, found increases in condom-use intentions, but no difference in number of unprotected acts of sexual intercourse compared with a general health promotion control group.³ Another study found that pregnant women given a 4-session HIV intervention had moderate increases in knowledge and safer sexual behaviors that were sustained 6 months after the intervention.⁴Although few studies of HIV and STI interventions have targeted pregnant women, some have focused on women attending primary care clinics.^5–8 Interventions for STI clinic patients documented significant declines in STI incidence.^8,9 However, most HIV interventions are limited because they do not integrate HIV prevention with the provision of other services,^10,11 and are not theory based.^12–14Pregnancy offers a unique opportunity for intervention as it is a time when women engage in high-risk behaviors, make behavioral changes, and have frequent contact with health care professionals.^15–18 Finally, interventions integrated with existing care systems (e.g., prenatal care) can be sustained because care is reimbursable by insurance.¹⁹The bundling of HIV prevention with existing systems can increase the accessibility of HIV prevention by providing opportunities to reach individuals who may not have the motivation or time to attend stand-alone HIV prevention sessions.¹⁹ HIV and STI prevention programs have been successfully integrated in care settings such as psychiatric, drug treatment, and palliative medicine.^20–22 We developed an HIV intervention that was integrated with a model of prenatal care.CenteringPregnancy group prenatal care^23,24 has been shown to reduce preterm birth and increase prenatal care satisfaction.^23,25 We created a modified program, CenteringPregnancy Plus, by integrating HIV prevention with the group prenatal care model. The purpose of this study was to evaluate the effects of this integrated HIV prevention program on biological outcomes (STI, repeat pregnancy), sexual risk behaviors (condom use, unprotected sexual intercourse), and psychosocial variables (communication, perceived risk, self-efficacy).