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.     

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.     

Systematic Review of Racial Disparities in Human Papillomavirus–Associated Anal Dysplasia and Anal Cancer Among Men Who Have Sex With Men

We systematically reviewed the literature on anal human papillomavirus (HPV) infection, dysplasia, and cancer among Black and White men who have sex with men (MSM) to determine if a racial disparity exists. We searched 4 databases for articles up to March 2014.Studies involving Black MSM are nearly absent from the literature. Of 25 eligible studies, 2 stratified by race and sexual behavior. Both reported an elevated rate of abnormal anal outcomes among Black MSM. White MSM had a 1.3 times lower prevalence of group-2 HPV (P < .01) and nearly 13% lower prevalence of anal dysplasia than did Black MSM.We were unable to determine factors driving the absence of Black MSM in this research and whether disparities in clinical care exist. Elevated rates of abnormal anal cytology among Black MSM in 2 studies indicate a need for future research in this population.Although it is relatively rare in the general US population, anal cancer and its precursors disproportionately affect men who have sex with men (MSM) and people living with HIV. Anal cancer rates have been found to be highest among HIV-infected MSM with an estimated anal cancer incidence of 131 per 100 000 for HIV-infected MSM, 46 per 100 000 for HIV-infected heterosexual men, and 30 per 100 000 in HIV-infected women.1 Furthermore, although the introduction of antiretroviral therapy has led to an increased life expectancy for HIV-infected individuals, a concomitant increase in anal cancer cases has occurred since 1996.2Anal intraepithelial neoplasia is the immediate precursor of anal cancer and presents as a low-grade squamous intraepithelial lesion or as a high-grade squamous intraepithelial lesion. Infection with human papillomavirus (HPV) is thought to cause the majority of anal intraepithelial neoplasia. Group-1 high-risk HPV types (HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59) are strongly carcinogenic; group-2 high-risk HPV types (HPV 26, 30, 34, 53, 66, 67, 68, 69, 70, 73, 82, 85, and 97) are weaker carcinogens and “probable” or “possible” causes of cancer.3 Although up to 90% of HPV infections are cleared within 2 years in the general population, HPV is much more likely to lead to anal cancer in HIV-infected individuals.4 Furthermore, rates of anal intraepithelial neoplasia have increased markedly among HIV-infected MSM.2Though MSM have been established as a group at high risk for anal cancer, no studies have been designed to study racial differences among MSM in anal HPV, dysplasia, and cancer. A focus on Black MSM is important in light of several factors that may have a differential impact on anal cancer risk in this population. First, oncogenic HPV subtypes have been found to be variably distributed across populations based upon race. For example, in 2 recent studies, Black women were found to have higher rates of HPV (such as 33, 35, 58, and 68) that are not included in the existing HPV vaccines.5,6 Second, transmission of HPV within sexual networks7 may propagate certain subtypes with variable oncogenic potential. Black communities, including Black MSM, are known to have more within-group sexual partners than Whites and other ethnic minorities who are more likely to have sexual mixing patterns involving individuals of other racial groups.7,8 Third, Black MSM have the highest HIV incidence rate compared with other MSM populations9 and thus will increasingly be at risk for anal cancer. Finally, marked disparities across access to care, prevention services, and health insurance10 put Black MSM at increased risk for preventable oncogenic anal HPV, dysplasia, and cancer.Previous reviews of anal HPV infection, dysplasia, and cancer have identified MSM as a high-risk group, highlighted an absence of young MSM from anal HPV studies, offered an explanation for the increase in anal cancer incidence, and explored cost-effectiveness of routine anal screening.11–14 We built upon previous work by comparing anal HPV infection, dysplasia, and cancer among MSM with data from past studies. We had 2 objectives with the systematic review. First, we aimed to determine if a racial disparity exists in anal HPV infection, dysplasia, and cancer screening. Second, we aimed to determine if a racial disparity exists in anal HPV infection, dysplasia, and cancer outcomes. We aimed to inform future research programs and the development of screening and care programs for Black MSM by identifying patterns in anal HPV infection, dysplasia, and cancer from the existing literature.     

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.     

Acceptable Interventions to Reduce Syphilis Transmission Among High-Risk Men Who Have Sex With Men in Los Angeles

Objectives. We examined perceptions of and attitudes toward existing and potential syphilis interventions, including case management and Web-based programs, to increase syphilis testing among high-risk men who have sex with men (MSM).Methods. Between October 2010 and June 2011, we conducted in-depth interviews with 19 MSM in Los Angeles, California, with repeat early syphilis infections (primary, secondary, and early latent syphilis) within the previous 5 years. We analyzed the interviews inductively to determine the most acceptable potential interventions.Results. Experiences with health department and community-based standard of care case management were generally positive. The most popular interventions among respondents included a Web site providing information on syphilis and syphilis testing, automated Web reminders to test, being paid to test, free online home testing kits, and preexposure prophylactic medication. Respondents’ beliefs that they would continue to practice high-risk sexual behaviors reinforced their reasons for wanting increased accessibility and convenient testing strategies.Conclusions. Public health officials should consider participant responses to potential interventions for syphilis, which suggest that high-risk MSM would consider testing more often or using other interventions.Cases of primary and secondary syphilis among men who have sex with men (MSM) in the United States increased from approximately 6400 in 2009 to more than 8700 in 2012,1 with Los Angeles County reporting the highest number of cases in the country.2 In Los Angeles County as well as in other US metropolitan areas, the majority of cases occur among MSM,3–5 and incidence rates have increased dramatically in recent years.1,5–7 Syphilis is particularly common among MSM coinfected with HIV,8 and can increase the transmissibility of HIV among those who are HIV positive and the susceptibility to HIV among those who are HIV negative.9–11The Centers for Disease Control and Prevention recommends annual screening for syphilis among sexually active MSM and more frequent testing for MSM who have multiple or anonymous partners.12 It has also been suggested that additional testing and other intervention efforts focused on high-risk MSM,13–16 who may be core transmitters of syphilis, are needed to reduce the current syphilis epidemic.14 One potential group of core transmitters may be MSM who have repeated syphilis infections,17,18 because repeat infections suggest continued practice of risky sexual behaviors or riskier sexual networks. Indeed, in Los Angeles County and other jurisdictions, between 6% and 12% of MSM experience a repeat primary or secondary syphilis infection within 2 years.18–20Efforts to curtail the rising syphilis epidemic include increased community screening, enhanced case management and partner notification,21,22 and several wide-scale social marketing campaigns.23,24 One of the primary efforts currently in place in Los Angeles County is syphilis case management and partner notification services, which is provided by public health investigators (PHIs) who are located at the public health department or are embedded within a community-based organization. As the primary promoters of syphilis intervention strategies in the county, PHI duties include locating, counseling, and referring infected individuals to treatment and locating and notifying sexual partners potentially exposed to syphilis. In addition to these standard public health practices of enhanced testing and case management, recent research has indicated that antibiotic prophylaxis for syphilis is potentially an acceptable prevention method for high-risk individuals,25 although evidence is limited and concerns regarding risk compensation (i.e., being less careful because of feeling more protected) and the development of antibiotic resistance have been noted.26 Overall, syphilis rates have continued to rise despite current efforts, suggesting that new and improved approaches are needed.14Although targeting interventions to MSM repeatedly infected with syphilis may have the potential for significant individual and public health impact, little is known about the acceptability of potential interventions to this group of men. We have presented suggestions for improving current standard of care public health practices, such as case management. In addition, we explored attitudes about and responses to numerous potential interventions to increase syphilis testing and reduce transmission among MSM with repeat syphilis infection in Los Angeles County.     

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.     

Lessons Learned From Use of Social Network Strategy in HIV Testing Programs Targeting African American Men Who Have Sex With Men

Objectives. We report lessons derived from implementation of the Social Network Strategy (SNS) into existing HIV counseling, testing, and referral services targeting 18- to 64-year-old Black gay, bisexual, and other men who have sex with men (MSM).Methods. The SNS procedures used in this study were adapted from a Centers for Disease Control and Prevention–funded, 2-year demonstration project involving 9 community-based organizations (CBOs) in 7 cities. Under the SNS, HIV-positive and HIV-negative men at high risk for HIV (recruiters) were enlisted to identify and recruit persons from their social, sexual, or drug-using networks (network associates) for HIV testing. Sites maintained records of modified study protocols for ascertaining lessons learned. The study was conducted between April 2008 and May 2010 at CBOs in Washington, DC, and New York, New York, and at a health department in Baltimore, Maryland.Results. Several common lessons regarding development of the plan, staffing, training, and use of incentives were identified across the sites. Collectively, these lessons indicate use of SNS is resource-intensive, requiring a detailed plan, dedicated staff, and continual input from clients and staff for successful implementation.Conclusions. SNS may provide a strategy for identifying and targeting clusters of high-risk Black MSM for HIV testing. Given the resources needed to implement the strategy, additional studies using an experimental design are needed to determine the cost-effectiveness of SNS compared with other testing strategies.Approximately 1.1 million people are living with HIV in the United States and about 50 000 new infections occur each year.1 Gay, bisexual, and other men who have sex with men (MSM) remain the most affected subpopulation. Although constituting approximately 2% of the US population,2 MSM accounted for 63% of all new infections in 2010,3 61% of HIV diagnoses among men in 2010,4 and represent approximately 48% of people living with HIV.4Among MSM, Black MSM are disproportionately affected. Young (aged 13–24 years) Black MSM accounted for 55% of new infections among young MSM in 2010.3 There are more new HIV infections among 13- to 24-year-old Black MSM than among any other subgroup by race/ethnicity, age, and gender in the United States.3The available literature suggests that myriad individual, social, and contextual factors contribute to the HIV rates among young, Black MSM.5–13 These factors include a higher background prevalence of HIV in the community leading to a greater chance of exposure to an infected partner despite less risky behavior5–8; a higher prevalence of other sexually transmitted infections, like syphilis and gonorrhea, that might facilitate the acquisition and transmission of HIV5–8; limited access to treatment and health care6; stigma, homophobia, discrimination12; partner characteristics and risk behaviors5,9–11; and lack of awareness of individual or partner’s HIV status.5,11Awareness of HIV status is a critical step in addressing the HIV epidemic among young, Black MSM. Centers for Disease Control and Prevention (CDC) estimates that approximately 18% of the people living with HIV have not been diagnosed.14 Furthermore, of those living with HIV in 2009, 66% are linked to care, 37% retained in care, and 25% have a suppressed viral load.14 Individuals with consistently suppressed viral load experience reduced HIV-related morbidity and mortality and have a lower probability of transmitting the virus to others.14 Although Blacks are more likely to have ever been tested for HIV than other racial/ethnic groups in the United States, 2 in 5 have never been tested.15Additionally, many test too late in the course of their infection to receive maximum benefits from treatment.6 In 2008, more than one third of Blacks who were diagnosed with HIV were also diagnosed with AIDS within 1 year.15These data underscore the need for strategies to identify undiagnosed HIV positive, young, Black MSM. This paper presents results from a multisite study designed to evaluate the relative effectiveness of 3 strategies—alternate venue testing (AVT), the Social Network Strategy (SNS), and partner counseling and referral services (PCRS; now known as Partner Services)—for reaching and motivating previously undiagnosed, 18- to 64-year-old Black MSM to be tested for HIV and linked to medical care and prevention services. Applicants were required to meet the following eligibility criteria for funding: (1) conduct the study in a city with a Black population of at least 100 000 based on 2000 US Census data; (2) have an HIV counseling and testing program (CTR) that had been in existence for at least 3 years (prior to 2006) and that historically and currently provided services to Black men, including MSM; and (3) conduct PCRS or have a written agreement with the local health department to obtain aggregate PCRS data for Black MSM. Each of the funded sites had existing AVT programs that were expanded for this study to focus on Black MSM. All of the sites received SNS training and implemented this strategy into their existing CTR programs. The purpose of this article is to report common, cross-site lessons learned from implementation of SNS into existing HIV CTR services in New York City, New York; Baltimore, Maryland; and Washington, DC.     

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.     

Preparing for Rectal Microbicides: Sociocultural Factors Affecting Product Uptake Among Potential South American Users

Objectives. We examined views on rectal microbicides (RMs), a potential HIV prevention option, among men who have sex with men and transgender women in 3 South American cities.Methods. During September 2009 to September 2010, we conducted 10 focus groups and 36 in-depth interviews (n = 140) in Lima and Iquitos, Peru, and Guayaquil, Ecuador, to examine 5 RM domains: knowledge, thoughts and opinions about RM as an HIV prevention tool, use, condoms, and social concerns. We coded emergent themes in recorded and transcribed data sets and extracted representative quotes. We collected sociodemographic information with a self-administered questionnaire.Results. RM issues identified included limited knowledge; concerns regarding plausibility, side effects, and efficacy; impact on condom use; target users (insertive vs receptive partners); and access concerns.Conclusions. Understanding the sociocultural issues affecting RMs is critical to their uptake and should be addressed prior to product launch.The first phase 2 clinical trial of a rectal microbicide (RM) candidate—a tenofovir-based, reduced-glycerin variant of the vaginal gel evaluated in CAPRISA-0041—is under way in men who have sex with men (MSM) and transgender women (TGW) at 5 international sites.2 If this product is found to be safe and acceptable, efficacy trials could begin by 2015,3 leading to a new prevention option for people at risk for HIV infection during unprotected receptive anal intercourse. Especially for MSM and TGW, an HIV prevention option specifically for this type of intercourse is urgently needed. Despite a worldwide decrease in new HIV infections,4 the epidemic continues to expand in MSM across all income levels globally,5 and a recent meta-analysis placed the odds ratio for TGW being infected with HIV relative to all adults of reproductive age at 48.8.6In addition to myriad social, cultural, and political factors that make MSM and TGW more vulnerable to HIV infection,7 unprotected receptive anal intercourse itself is 10% to 20% riskier than unprotected vaginal intercourse.8,9 As Beyrer et al. note, if the transmission probability of unprotected receptive anal intercourse were similar to that of unprotected vaginal intercourse, the 5-year cumulative HIV incidence in MSM would drop by 80% to 90%.5 Even partially efficacious RMs could play an important role in preventing new HIV infections,10 but their effectiveness will rely on users finding such products acceptable and using them correctly and consistently.11,12 Thus a body of acceptability research has emerged to examine the factors that may affect RM use, such as different product formulations (e.g., gels and lubricants,13–16 suppositories,17 and douches18–20), the maximum volume of rectally applied product that users find tolerable,21 frequency of use, cost effectiveness, and side effects.22Overall, acceptability research has demonstrated interest in a safe and effective RM among MSM and TGW22–25; however, knowledge gaps remain. Particularly important to understand is how potential users see themselves interacting with RMs, including social, cultural, and political factors, all of which may affect the adoption of an HIV prevention technology.26 We examined views of RMs among potential users in 3 South American cities to understand the sociocultural issues that could affect their uptake.     

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.     

HIV Prevalence and Awareness of Positive Serostatus Among Men Who Have Sex With Men and Transgender Women in Bogotá, Colombia

Objectives. We estimated HIV prevalence among men who have sex with men (MSM) and transgender women in Bogotá, Colombia, and explored differences between HIV-positive individuals who are aware and unaware of their serostatus.Methods. In this cross-sectional 2011 study, we used respondent-driven sampling (RDS) to recruit 1000 MSM and transgender women, who completed a computerized questionnaire and received an HIV test.Results. The RDS-adjusted prevalence was 12.1% (95% confidence interval [CI] = 8.7, 15.8), comparable to a previous RDS-derived estimate. Among HIV-positive participants, 39.7% (95% CI = 25.0, 54.8) were aware of their serostatus and 60.3% (95% CI = 45.2, 75.5) were unaware before this study. HIV-positive–unaware individuals were more likely to report inadequate insurance coverage, exchange sex (i.e., sexual intercourse in exchange for money, goods, or services), and substance use than other participants. HIV-positive–aware participants were least likely to have had condomless anal intercourse in the previous 3 months. Regardless of awareness, HIV-positive participants reported more violence and forced relocation experiences than HIV-negative participants.Conclusions. There is an urgent need to increase HIV detection among MSM and transgender women in Bogotá. HIV-positive–unaware group characteristics suggest an important role for structural, social, and individual interventions.Colombia ranks second among countries in Latin America in HIV prevalence, with estimates ranging from 0.7% to 1.1% of the adult population.1 Men who have sex with men (MSM) represent the group most strongly affected, with prevalence of 18% to 20% based on venue-based convenience samples2,3 and 15% based on respondent-driven sampling (RDS).4 Colombia has a long history of armed conflict, and the pervasive conditions of violence, internal displacement, and poverty can be relevant to HIV transmission.5 “Social cleansing” by armed groups has been aimed at MSM and transgender women, as well as people living with HIV,5 and the stigma associated with homosexuality and HIV is widespread and inherent in structural inequalities in Colombia.6,7 Social epidemiological models posit that HIV is influenced by such structural (e.g., civil unrest, migration) and social factors (e.g., social networks, community attitudes), as well as individual characteristics (e.g., psychological characteristics, behavior).8Public health efforts emphasize the importance of detecting and treating undiagnosed HIV as a means of reducing HIV incidence.9–11 In the United States, approximately 20% of HIV-positive individuals are thought to be unaware of their infection, but this group is estimated to be responsible for nearly half of new transmissions.12 There is limited research concerning awareness of serostatus in Latin America. Undiagnosed infection was found to be 89% among HIV-positive MSM sampled in Peru in 2011,13 and rates are likely to be high in Colombia because of low levels of testing,6 including among MSM.4,14 Recent studies of MSM in France, Peru, and the United States have found associations between undiagnosed infection and demographic characteristics such as age, income, and education13,15,16; risk behaviors14,17,18; family or intimate partner violence19; and health insurance coverage.20 We also examined awareness in relation to violence and forced relocation, conditions specific to the Colombian context.Respondent-driven sampling was developed as a means of obtaining unbiased estimates from hidden populations,21–23 and it has been shown to capture a more diverse24,25 and hidden26 group of MSM than time–location or snowball sampling. Research has suggested, however, that biases can occur.27–29Our current study and a study conducted by the United Nations Population Fund and the Colombian Ministry of Health and Social Protection (UNFPA/MSPS) were independently funded at approximately the same time to address the limited information about behavioral risk and HIV prevalence among Colombian MSM. Comparison of findings from the 2 studies provides evidence concerning reliability of the RDS-derived prevalence estimates. We estimated HIV prevalence among MSM and transgender women in Bogotá, Colombia, examined reliability of RDS-derived estimates in relation to the UNFPA/MSPS study,4 and investigated the role of the social and structural context of Colombia in both prevalence and awareness of positive serostatus.     

HIV Testing Preferences Among Young Men of Color Who Have Sex With Men

Objectives. We assessed awareness of and preferences for rapid HIV testing among young, urban men of color who have sex with men and are engaged in high-risk behaviors for HIV.Methods. A cross-sectional survey was conducted in New York City among 177 young men who have sex with men (MSM).Results. Among the 85% of the participants who had previously undergone HIV testing, 43% reported rapid testing at their most recent test. In terms of future tests, 64% would seek rapid testing, as compared with 36% who preferred traditional testing. Those who preferred rapid testing were significantly more likely to have attended at least some college, to have discussed HIV testing with a sexual partner, to be aware of rapid testing, and to have had a previous HIV test.Conclusions. In general, young MSM of color seem aware of rapid testing. However, our results indicate the need to carefully consider the unique needs of those who are particularly disenfranchised or engaged in high-risk behaviors and who may need concerted efforts around HIV counseling and testing. Likewise, our findings point to a need for more effective education and social marketing strategies.According to recent Centers for Disease Control and Prevention (CDC) surveillance data, HIV infection rates in the United States remain high among men who have sex with men (MSM). In 2005, MSM accounted for more than half (53%) of all HIV/AIDS diagnoses and 71% of reported adult male and adolescent HIV infections.¹ Racial disparities have emerged within the MSM population as the AIDS epidemic has shifted increasingly toward minorities. Despite representing only 13% of the US population in 2000, Blacks accounted for 49% of cumulative HIV/AIDS diagnoses in 2005, with same-sex contact the primary mode of infection transmission.²At the same time, young adult members of minority groups have also exhibited greater rates of HIV infection. In 2006, Black young adults accounted for 60% of HIV/AIDS diagnoses among adolescents and young adults aged 13 to 24 years. Although Black adolescents make up only 16% of the US adolescent population, they accounted for 69% of new AIDS cases reported for that age group in 2006.³Research has shown that young minority MSM are at particular risk for infection, with consistent reports of risky sexual behaviors⁴ reflected in high rates of HIV prevalence, incidence, and undiagnosed infections.^5–7 Nationally, 52% of new infections among Black MSM occur among those aged 13 to 29 years, as compared with 25% among their White MSM counterparts.⁸ A study analyzing data from the CDC''s Young Men''s Survey, a cross-sectional survey of MSM aged 15 to 22 years in Baltimore, Maryland, and New York City, New York, revealed HIV prevalence to be 10 times higher among Blacks (17.7%) than among Whites (1.7%).⁹Although HIV incidence and prevalence are high among young minority MSM, many are unaware of their status² and unknowingly expose their partners to HIV.⁷ CDC guidelines recommend at minimum annual HIV testing for sexually active MSM,⁵ especially younger MSM and those from minority groups.¹⁰ Despite these recommendations, however, testing frequency remains low. In a study assessing HIV testing behaviors among MSM, the CDC analyzed data from 5 cities participating in the National HIV Behavioral Surveillance System. Results showed that nearly half (48%) of those found to be HIV positive were unaware of their infections, with the proportions highest among MSM aged 18 to 30 years and minority MSM. In fact, 64% of those with unrecognized infections were Black, and 58% had not taken an HIV test in the preceding year.²Another study analyzing data from the Young Men''s Survey revealed similar results among participating MSM aged 15 to 29 years. The odds of having an unrecognized HIV infection were nearly 7 times greater among Black MSM than they were among White MSM. Fifty-five percent of those with unrecognized infections had not undergone an HIV test during the preceding year.⁷To advance HIV prevention efforts in the United States, prevention programs must reduce unrecognized infection among young MSM by increasing the demand for and availability of HIV testing.⁷ In an effort to increase testing rates, the CDC announced in 2003 a set of new prevention strategies. A main component of this initiative is to expand HIV testing to increase the numbers of HIV-infected individuals who are aware of their status.¹¹ New HIV testing technologies have made it possible to reach and test a larger, more diverse population in nontraditional venues. The OraQuick (Orasure Technologies, Bethlehem, PA) rapid HIV test, approved by the Food and Drug Administration, allows for presumptive diagnoses of HIV infection within 20 minutes, and the test can be performed outside clinical settings with either finger-stick whole blood or oral swabs.In a 2007 literature review summarizing the available research on rapid HIV testing, Roberts et al. found considerable variation in clients'' rates of acceptance of rapid testing, ranging from 14.1% to 98%.¹² Several studies assessing acceptance rates for rapid testing technology have revealed rates upwards of 65%.^13–15 Focus group data from Black adults showed that although the rapid test was preferred over traditional HIV testing as a result of the shorter turnaround time for results, concerns were raised about the test''s accuracy.¹⁶Another study conducted with MSM, injection drug users, and high-risk heterosexuals revealed that only 13% of the participants were aware of rapid HIV tests and that, among those who were aware, only 14% had actually been tested via this modality. Preference for the standard test was reported as a primary reason for not undergoing rapid testing.¹⁷ Studies with Black young adults aged 18 to 24 years have produced similar findings. Although a majority of respondents report a preference for receiving results in 1 session, many continue to express concern about the accuracy of the test.^18,19HIV testing preferences have been well-documented among older MSM, who have shown an inclination toward anonymous over confidential testing,^20,21 as well as a preference for testing at sex clubs over clinic settings.²² Not being of minority race or ethnicity, having completed more years of schooling, and having access to testing services have been found to be factors associated with increased likelihood of testing among MSM.²³ Reasons for avoiding or delaying HIV tests include fear of positive test results and concern that others might learn about the results.²³The need to increase rates of acceptance of HIV testing among populations of color is clear, particularly among young MSM. However, relatively little is known about the factors that influence their decision to test or the circumstances that prevent them from being tested. Although 1 recent study attempted to assess the correlates of HIV testing among young minority MSM,²³ it did not explore preferences with respect to HIV testing method, which could potentially have a large impact on HIV testing rates. The researchers did find that awareness of a comfortable testing site and greater perceived social support concerning HIV were strongly associated with HIV testing among their sample.²³Given the high rates of unrecognized infection and the potential to reach greater numbers of affected individuals through rapid HIV testing, it is important to understand the awareness and acceptability of this testing modality among young minority MSM. We attempted to fill the gaps in the available literature by assessing awareness of and preferences for rapid HIV testing among a sample of young MSM of color engaged in high-risk behaviors for HIV.     

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.     

Project HOPE: Online Social Network Changes in an HIV Prevention Randomized Controlled Trial for African American and Latino Men Who Have Sex With Men

Objectives. We examined whether and how an HIV prevention diffusion-based intervention spread throughout participants’ online social networks and whether changes in social network ties were associated with increased HIV prevention and testing behaviors.Methods. We randomly assigned 112 primarily racial/ethnic minority men who have sex with men (MSM) to receive peer-delivered HIV (intervention) or general health (control) information over 12 weeks through closed Facebook groups. We recorded participants’ public Facebook friend networks at baseline (September 2010) and follow-up (February 2011), and assessed whether changes in network growth were associated with changes in health engagement and HIV testing.Results. Within-group ties increased in both conditions from baseline to follow-up. Among the intervention group, we found a significant positive relation between increased network ties and using social media to discuss sexual behaviors. We found a positive trending relationship between increased network ties and likelihood of HIV testing, follow-up for test results, and participation in online community discussions. No significant differences were seen within control groups.Conclusions. Among high-risk MSM, peer-led social media HIV prevention interventions can increase community cohesion. These changes appear to be associated with increased HIV prevention and testing behaviors.African American and Latino individuals are at high risk for contracting HIV.1 In Los Angeles County, California, most of these cases are attributable to men who have sex with men (MSM), who currently account for more than 75% of all HIV cases.2,3 Researchers, and MSM themselves, have suggested use of novel approaches to increase HIV prevention and testing among at-risk populations.4,5Peer leader interventions, based on diffusion theories, are community-based interventions that train community peers to spread HIV prevention information and change HIV prevention-related social norms.6–9 Successful peer-led interventions have resulted in decreasing anal intercourse up to 25% and increasing condom use up to 16%, with sustained behavior change up to 3 years later.10–12 Peer-delivered interventions have been found to be acceptable among MSM populations.13 Social network interventions have shown that information can rapidly diffuse throughout social networks to change health behaviors,14,15 suggesting that peer-delivered HIV interventions also might diffuse throughout social networks.Growth in social media allows these technologies to be used for peer-led HIV testing interventions,4 and research supports that peer-led interventions delivered via social media can increase HIV testing.16 Social networking technologies, such as Facebook, allow users to connect and communicate with other network users by sharing pictures, messages, Web site links, and other multimedia information.17 High rates of online social networking, especially among groups disproportionately affected by HIV (e.g., MSM),18 make it important to evaluate whether and how interventions might diffuse throughout online social networks. Although social media can be used to increase HIV prevention,16,19,20a and health behaviors of (offline) social ties influence our own health behaviors20b, no known research has studied changes in social network ties during the course of an online social media community HIV intervention or whether and how HIV prevention information and behaviors might spread among group participants in a social media–based HIV testing intervention that is designed for network diffusion.The Harnessing Online Peer Education (HOPE) intervention was a 12-week randomized controlled HIV prevention intervention designed to use peer-led Facebook groups to diffuse HIV information to increase testing among African American and Latino MSM. The study found that participants in the HIV intervention groups were more likely to request an HIV test than were those in the control groups,16 but whether changes in social network ties (i.e., participants within each group becoming Facebook friends with one another) played a role in these effects among intervention group participants is unknown. The current study used data from the HOPE study and was designed to evaluate the association between changes in online social network structure and HIV prevention and testing among HOPE network participants. Specifically, we have (1) described the change from baseline to follow-up in network ties among HOPE participants as a result of the intervention, (2) presented network visualizations to illustrate changes in network connections among intervention and control group participants, and (3) determined whether changes in social network ties from baseline to follow-up were associated with online community engagement, discussions about HIV prevention, and rates of HIV testing.     

Bridging the Divide: HIV Prevention Research and Black Men Who Have Sex With Men

Objectives. We obtained contextual information regarding documented barriers to HIV clinical trial participation among Black men who have sex with men (MSM), and explored current preventive HIV clinical trial attitudes, beliefs, and perceptions among Black MSM leaders in the United States.Methods. We conducted 2 focus groups with Black MSM leaders attending an annual African American MSM Leadership Conference on HIV/AIDS. Focus group questions explored biomedical research perceptions and attitudes, barriers to participation in biomedical prevention research, and steps that need to be taken to address these barriers. A feedback and member checking (participants presented with final themes to provide feedback and guidance) session was also held at the 2012 conference.Results. Three distinct themes emerged regarding Black MSM engagement and participation in HIV vaccine research: (1) community-based organizations as true partners, (2) investment in the Black gay community, and (3) true efforts to inform and educate the community.Conclusions. A key focus for improving efforts to engage the Black MSM community in preventive HIV clinical trials is building and maintaining equitable and reciprocal partnerships among research institutions, Black-led AIDS service organizations and community-based organizations, and community members.Black men who have sex with men (MSM) represent 1 in 500 US citizens and 9% of all MSM in the United States,1 yet they accounted for 38% of new HIV infections among MSM and 70% of new HIV infections among Black males in 2010.2 Nationally, MSM represent about 4% of the male population, yet they account for 52% of all people living with HIV.3 HIV prevalence among Black MSM is roughly double the prevalence among White MSM.2 The impact of HIV on the Black MSM community has dramatically increased over time. From 2006 to 2009 the annual number of new HIV infections among MSM rose by 20% and new infections among young MSM (aged 13 to 29 years) during this same period increased dramatically (48%).4 For Black MSM the HIV disease burden is experienced throughout the lifetime. Among young men (aged 13–24 years), Black MSM are 14 times more likely to test HIV-positive than are White MSM.5 As a result, many Black MSM are infected with HIV as they enter adulthood. Like other racial and ethnic groups, Black MSM are more likely to date other Black MSM.6,7 This practice, known as assortative mixing, combined with higher HIV prevalence within Black MSM communities, may contribute to the dramatic increase in the odds of becoming infected for Black MSM as they age. By the time Black MSM reach age 25 years, 1 in 4 are already infected with HIV and by age 40, 60% are living with HIV.8Published data regarding HIV trial participation has focused on the larger Black community and has shown that overall US Blacks take part in HIV vaccine trials at the same rate as Whites.9,10 From 1988 to 2002, Black individuals represented 10% of the volunteers enrolled in US preventive HIV vaccine trials.11 Unpublished data through March 2013 indicate that 22% of all HIV vaccine trial participants identified as Black or African American and, of these participants, 8% identified as Black MSM (e-mail communication from Alicia Sato, Statistical Center for HIV/AIDS Research and Prevention, March 27, 2013). Although there has been a marked increase in the proportion of racial/ethnic minority participants in the United States in phase I and phase II preventive HIV vaccine trials across National Institute of Allergy and Infectious Diseases (NIAID)-funded networks, these numbers do not reflect the HIV epidemic’s impact on Black MSM in the United States.The inclusion of Black MSM in HIV vaccine research is necessary for 2 main reasons. First, it is plausible that a vaccine may have variable efficacy in different racial/ethnic groups12,13 and underrepresentation may have implications for generalizability of clinical trials results in these populations. Insufficient numbers of participants of color in the first HIV vaccine efficacy trial14 made it difficult to interpret subgroup analyses of minority populations. This is of particular interest because there were fewer infections among Black and Asian vaccinees compared with Black and Asian placebo recipients in that trial, but the numbers of Black and Asian participants were so small that it was impossible to know whether this was an actual sign of vaccine efficacy or a result of random chance. Second, participation in HIV vaccine clinical trials may help ensure increased acceptability when a licensed vaccine becomes available.In general, major medical, clinical, and behavioral research studies have limited numbers of Black individuals involved as research participants. Much of the literature on the relative absence of Blacks in research points to the mistrust of researchers for many reasons including historical and current racial discriminatory practices directed at African Americans.15–17 Several studies have explored barriers to participation specific to HIV vaccine trials experienced by the larger African American community. The most commonly cited causes of poor participation by Blacks in HIV vaccine trials are mistrust or fear, stigma, and misinformation.18,19 Survey data have found that many Black individuals believe that a cure for AIDS exists and is being withheld from the poor20 or kept a secret.21 For many Black people, the term “medical research” is associated with being lied to, used, and treated like guinea pigs.22 Additional barriers to participation include lack of information and understanding as well as limited knowledge of the nature of research.22–25Few studies have explored the barriers to HIV vaccine research participation faced by Black MSM. Social stigmatization of HIV and AIDS is a persistent concern for Black individuals in the United States.26 Black MSM often experience being labeled as “high risk” in the larger gay community and the fear of strengthening this stereotype may prevent participation in an HIV vaccine trial. In one study of MSM, participants identified the stigma of trial enrollment and the fear of being viewed by intimate partners as high risk or promiscuous as a significant barrier to enrollment.27Recent efforts by the HIV Vaccine Trials Network (HVTN) and other NIAID-funded networks to improve preventive HIV clinical trial participation among Black, Latino(a), and MSM communities have focused on partnering with community and faith-based organizations to increase awareness of the need for an HIV vaccine, and to improve public knowledge and attitudes about HIV vaccine research. These efforts have included developing research-based HIV vaccine–related messages; identifying, establishing, and sustaining partnerships with organizations and key opinion leaders who are part of the priority audiences and who would disseminate the key messages; and identifying other effective communication channels and strategies for stakeholder engagement and dissemination of HIV vaccine research–related information.We report the findings of a focus group study of Black MSM key opinion leaders examining attitudes and perceptions of HIV prevention research and the NIAID HIV Vaccine Research Education Initiative (NHVREI) in the Black MSM community. The objectives were to (1) obtain important contextual information regarding documented barriers to HIV clinical trial participation among Black MSM, and (2) explore current HIV vaccine clinical trial attitudes, beliefs, and perceptions among Black MSM in the United States who had been involved in NHVREI to ascertain if exposure to NHVREI made a difference in the way Black MSM key opinion leaders viewed biomedical interventions. NHVREI’s logic model focused on including community leaders to reach key populations. As such, the researchers hypothesized that those MSM leaders with a history of involvement with NHVREI activities would indicate more support for MSM participation in preventive HIV vaccine trials specifically and biomedical research generally.     

Human Papillomavirus Vaccination Among Young Adult Gay and Bisexual Men in the United States

Objectives. We examined human papillomavirus (HPV) vaccination among gay and bisexual men, a population with high rates of HPV infection and HPV-related disease.Methods. A national sample of gay and bisexual men aged 18 to 26 years (n = 428) completed online surveys in fall 2013. We identified correlates of HPV vaccination using multivariate logistic regression.Results. Overall, 13% of participants had received any doses of the HPV vaccine. About 83% who had received a health care provider recommendation for vaccination were vaccinated, compared with only 5% without a recommendation (P < .001). Vaccination was lower among participants who perceived greater barriers to getting vaccinated (odds ratio [OR] = 0.46; 95% confidence interval [CI] = 0.27, 0.78). Vaccination was higher among participants with higher levels of worry about getting HPV-related disease (OR = 1.54; 95% CI =  1.05, 2.27) or perceived positive social norms of HPV vaccination (OR = 1.57; 95% CI =  1.02, 2.43).Conclusions. HPV vaccine coverage is low among gay and bisexual men in the United States. Future efforts should focus on increasing provider recommendation for vaccination and should target other modifiable factors.Oncogenic human papillomavirus (HPV) types (mainly types 16 and 18) cause an estimated 93% of anal cancers, 63% of oropharyngeal cancers, and 36% of penile cancers among men in the United States.1 Nononcogenic HPV types 6 and 11 cause almost all anogenital warts.2 Gay and bisexual men have high rates of HPV infection and HPV-related disease. A recent review suggests that more than 50% of HIV-negative gay and bisexual men have an anogenital HPV infection.3 About 7% of gay and bisexual men report a history of genital warts.4 Anal cancer is also of great concern, with incidence among HIV-negative gay and bisexual men estimated to be 35 cases per 100 000 population.5 The anal cancer incidence rate among all men in the United States is just 1.6 cases per 100 000 population.6US guidelines began including the quadrivalent HPV vaccine (against HPV types 6, 11, 16, and 18) for males in October 2009.7 The Advisory Committee on Immunization Practices (ACIP) first provided a permissive recommendation that allowed the HPV vaccine to be given to males aged 9 to 26 years but did not include the vaccine in their routine vaccination schedule.7 In October 2011, the ACIP began recommending routine vaccination for boys aged 11 to 12 years with catch-up vaccination for males aged 13 to 21 years.8 Importantly, the ACIP recommends HPV vaccination for men who have sex with men through age 26 years.8The HPV vaccine series consists of 3 doses, with the second dose administered 1 to 2 months after the first dose, and the third dose is administered 6 months after the first dose.7 The quadrivalent HPV vaccine is currently approved to protect males against genital warts and anal cancer.9 Despite recommendations, recent data suggest that fewer than 21% of males in the United States have received any doses of the HPV vaccine.10–14Although several HPV-related disparities exist among gay and bisexual men, little research has addressed HPV vaccination among this population. Past studies have shown that knowledge about HPV and the HPV vaccine tends to be modest among gay and bisexual men.15–19 Many gay and bisexual men have indicated their willingness to get the HPV vaccine, with estimates ranging from 36% to 86%.16,18–20 Data on actual HPV vaccine coverage are sparse; a past study found only 7% of 68 young adult gay and bisexual men had received any doses of the HPV vaccine.11 This study was, however, conducted before the ACIP recommendation for routine vaccination of males.We built on this past research by examining HPV vaccination among a national sample of young adult gay and bisexual men in the recommended age range for HPV vaccination (18–26 years). We identified correlates of vaccination and why young adult gay and bisexual men are not getting the HPV vaccine. These data will help inform future programs for increasing HPV vaccination among this high-risk population.     

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.     

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.