There is a marked racial disparity observed in HIV in the United States with black men who have sex with men (MSM) experiencing the greatest burden of infection compared with other racial/ethnic groups. In 2015, two-thirds of all new HIV diagnoses in the United States occurred among MSM, with black MSM (41.4%) accounting for the plurality of these diagnoses followed by white MSM (30.4%) and Hispanic MSM (28.2%).1 During the period of 2010–2014, the Centers for Disease Control and Prevention (CDC) reported differential trends in HIV diagnoses by race and ethnicity: White MSM saw an 11% decline, black MSM experienced a 1% increase, and Hispanic MSM saw a 14% increase in the rate of new HIV diagnoses.1 Furthermore, more than one-third of new diagnoses in 2014 occurred among young MSM (YMSM; aged 13–29 years).1 Should these disparities persist, the US CDC predicts 1 in 2 black MSM, 1 in 5 Hispanic MSM, and 1 in 11 white MSM will become infected with HIV during their lifetime.2 To inform research on disparities, the National Institute of Minority Health and Health Disparities has developed a multilevel research framework that is applicable across a broad range of health conditions, including HIV.3 We drew from this framework, which encourages consideration of how biological, behavioral, and sociocultural factors at multiple levels of influence (individual, social, and systems) impact health outcomes, to identify putative driving factors for observed racial disparities in HIV among YMSM.
Meta-analyses of research on individual HIV-risk behaviors among MSM have demonstrated few racial differences, leading to hypotheses that network and social determinants may be explanatory.4 However, to date, there have been few studies of YMSM with the multilevel and network data and diverse participants required to test these hypotheses. For example, black YMSM, compared with YMSM of other racial/ethnic groups, have been found to have more homophilous networks5,6 with one study suggesting they are 3 times more likely to have a same-race sexual partner compared with other YMSM.7 Findings such as these highlight how ongoing disparities can be supported by inherent network structures. Homophilous networks act as feedback loops where black YMSM become infected with HIV, the network environment facilitates the spread of the virus primarily to other black YMSM, and the process repeats. Beyond homophily, more dense networks have also been shown to potentiate spread of sexually transmitted infections (STIs).8 Here too, black YMSM, compared with white YMSM, are particularly vulnerable, as they enter and participate in sexual networks characterized by high density and racial homogeneity.5 These types of network environments and sexual mixing patterns facilitate transmission of HIV and STIs among black YMSM; developing a more nuanced understanding of their network environments is key to disrupting future HIV infections and reducing racial disparities among YMSM.
Beyond networks, other social determinants of health have been implicated in racial disparities in HIV.9 Sexual minority youth have been shown to experience disproportionately high rates of stress and stigma related to their sexual minority status.10 Similar to network structures, these types of stigma have been found to vary by race and ethnicity with black and Hispanic YMSM having higher rates of both perceived and internalized stigma compared with white YMSM.10 Past research has also shown that internalized stigma related to, or as a result of, one's sexual orientation is associated with a lack of access to needed health care resources, particularly those related to mental health11, and HIV care and treatment.12 One recent study noted that nearly half of the black MSM went without health coverage sometime in the preceding 2-year period and that those who experienced greater health provider–related stigma had longer gaps between medical visits.12 Differences in health care access can drive disparities by increasing rates of undiagnosed or untreated HIV and STIs; HIV treatment reduces the likelihood of future transmission13 and STIs increase infection risk.14
Although more recent work has begun to focus on network drivers of HIV among MSM in general, little work has characterized how network characteristics and measures related to stress and stigma may impact HIV, specifically among YMSM. By examining these characteristics, we can gain a better understanding of the drivers of persistent racial disparities in HIV. To address this, we analyze biological, self-report, and network data from YMSM in Chicago to: (1) compare how sexual network characteristics may differ by race and ethnicity; (2) assess how measures related to stress and stigma—such as victimization and trauma—may be drivers of racial disparities in HIV infection; and (3) develop a better understanding of how health care services are utilized among YMSM and whether these differ by race and ethnicity.
Study Design and Recruitment
Data were from the baseline visit of RADAR, a longitudinal cohort study of YMSM living in the Chicago metropolitan area (N = 1015). The primary objective of this cohort study is to apply a multilevel perspective to a syndemic of health issues associated with HIV among diverse YMSM. Diverse methods for participant recruitment have been previously described6 and were selected to achieve the multiple cohort, accelerated longitudinal design. First, a subset of participants from 2 cohorts of YMSM, Project Q2 (n = 65) and Crew 450 (n = 162), who were first recruited in 2007 and 2010, respectively, enrolled in the cohort. In 2015, a third cohort of YMSM (n = 468) was recruited. At the time of enrollment into their original respective cohorts, all participants were between 16 and 20 years of age, assigned male at birth, spoke English, and had a sexual encounter with a man in the previous year or identified as gay, bisexual, or transgender. Next, the RADAR cohort was expanded through an iterative process where serious romantic partners were recruited at each visit, thereby creating a dynamic dyadic network. All serious romantic partners who were assigned male at birth were eligible for enrollment into the cohort, regardless of current gender identity or sexual orientation. Romantic partners who were assigned female at birth or were older than 29 years completed a study visit but were not enrolled in the cohort. Finally, cohort members were allowed to refer a maximum of 3 YMSM peers for enrollment into the study, as long as they were between 16 and 29 years of age. Demographic characteristics of the sample are shown in Table 1.
Network data were captured using a touchscreen-based interview-assisted network inventory developed for the RADAR study.15 Network members were elicited via 5 “name-generator” questions asking the participant to indicate close social ties, drug-use partners, and sexual partners. After the list of names of alters was generated, demographic characteristics (age, race, gender, perceived sexual identity, and neighborhood of residence), characteristics of the relationship (frequency of contact, strength of relationship, and relationship type), and behaviors with that alter were obtained. Given the focus of the current article, we included data from network members who were named as sexual partners in the 6 months before the interview. Detailed sexual behavior (first and last date of sexual contact, type of sexual contact, frequency of sexual contact, and condom use) was obtained about these sexual partners.
In addition to capturing data about network members, data were also captured about the perceived relationships between network members. Therefore, it was possible to calculate a number of key network characteristics that expose dynamics important to disease spread. Within each network interview, we calculate 2 different measures of sexual connectedness—density and transitivity. The density of each YMSM sexual network was calculated by summing the number of sexual connections observed between all network members (including the participant) and then dividing the sum by the total number of possible pairs, given the number of YMSM in the sexual network. The transitivity was measured using the number of sexual ties of an ego's YMSM alters, calculated by summing the total number of sexual connections between other nominated YMSM and dividing the sum by the number of other nominated YMSM. Homophily was measured using the assortativity coefficient, a commonly used statistic to measure the extent of mixing within a network. In the current case, this measure ranges from 1, indicating only same-race sexual partnerships, to −1, indicating only different-race sexual partnerships. Multiplexity was also calculated using the quadratic assignment procedure correlation function by determining the extent of overlap between a participant's sex, support, and drug networks. Finally, the number of concurrent sexual partners was calculated using the start and end date of sexual contact.
Psychological and Behavioral Measures
Social and behavioral measures included items assessing mental health, stigma, substance use, and sexual risk–taking behaviors. Mental health was measured by the PROMIS Depression Scale16 and 3 items that measured suicidal ideation, suicidal planning, and suicide attempts over the prior 6 months.17 Substance use was measured by the Alcohol Use Disorders Identification Test (AUDIT)18 and the Cannabis Use Disorders Identification Test (CUDIT).19 Sexual risk–taking was captured within the network interview through the total number of sexual partners, the total number of condomless anal sex (CAS) partners, and the total number of CAS acts over the prior 6 months. Stigma was measured by 2 scales, one that measured internalized stigma using an adapted 8-item measure20 and one that measured externalized stigma using an adapted 7-item measure.20
NAAT testing for gonorrhea and chlamydia, through self-administered rectal swabs, was completed for all participants regardless of HIV status. In addition, for HIV-positive individuals, viral load was captured through blood samples from which plasma was extracted and testing was performed using Abbot RealTime HIV-1 RNA PCR with a sensitivity of 40 copies/mL.
Structural measures included experiences of violence and trauma, living in a high disadvantage neighborhood, and access to prevention and treatment services. Experiences of violence and trauma were measured by a 6-item measure of lesbian, gay, bisexual, or transgender (LGBT)-related victimization and harassment,21 the Traumatic Events Experiences Scale,22 a measure of Intimate Partner Violence for those currently engaged in serious relationships,23 and a measure of childhood sexual abuse.24 Access to prevention services was measured by an item assessing HIV-testing history and an item assessing the use of pre-exposure prophylaxis (PrEP) over the past 6 months. For those who were HIV-positive, treatment access was measured by an item assessing whether antiretroviral therapy medication doses were missed in the past week and an item assessing the number of visits to a health care provider.
To describe differences by race, continuous variables were analyzed using t tests and categorical variables using χ2 tests. To test the significance of differences among means for multiple groups, analyses of variance were used.
There were significant racial differences in self-reports of depressive symptoms, with white YMSM reporting the highest rates (16.69) and black YMSM (14.31) reporting the lowest levels (Table 2; P < 0.001). Similar to depression, there were significant racial differences across alcohol (P < 0.001) and cannabis use (P = 0.034). Black YMSM were significantly more likely to report hazardous marijuana use, whereas white YMSM were significantly more likely to report high levels of alcohol problems. Similarly, there were significant racial differences in sexual risk–taking (P < 0.001), where black YMSM reported the lowest number of sexual partners and the lowest number of CAS partners. Unlike most other hypothesized social and behavioral drivers of HIV, black YMSM reported significantly higher externalized (P < 0.001) and internalized (P < 0.001) stigma, compared with both white and Latino MSM.
Racial differences were found in rectal STI prevalence (combined gonorrhea or chlamydia; Table 2), with black YMSM being more likely to test positive (P < 0.001). In addition, among HIV-positive individuals, black YMSM were significantly more likely to have a detectable viral load (P = 0.01).
Significant racial differences were observed across experiences of violence and trauma (Table 2), with black YMSM reporting the greatest victimization (P = 0.0370), trauma (P < 0.001), and childhood sexual abuse (P < 0.001). There were no significant differences regarding intimate partner violence. Black YMSM reported significantly greater numbers of lifetime HIV tests (P < 0.001); however, no differences were observed when examining PrEP use in the past 6 months. In addition, among those who were HIV-positive, there were no observed racial differences when examining either the number of missed antiretroviral medication doses in the past week or the number of visits to a health care provider.
Sexual Partner and Network Characteristics
Racial differences were found across all sexual partner characteristics (Table 3). Black YMSM were significantly more likely to have nonmale and nongay sexual partners (P < 0.001). Black YMSM were also the least likely to report having a very close relationship and most likely to report being not close at all with their sexual partners (P < 0.001). Examining network characteristics (Table 4), black YMSM also had the lowest transitivity among all sex ties (P < 0.001), whereas white YMSM had the highest. Black YMSM also had the highest density among all sex ties (P < 0.001), the highest racial homophily (P < 0.001), and the lowest number of concurrent partners (P = 0.029). No significant racial differences were observed when measuring multiplexity.
In a large and diverse sample of YMSM in Chicago, we found that black YMSM had a higher prevalence of both HIV and rectal STIs while observing no significant differences in PrEP use. Black YMSM reported lower rates of HIV transmission risk practices compared with all other YMSM and a greater number of lifetime HIV tests; however, HIV-positive black YMSM were significantly less likely to achieve viral suppression. Black YMSM reported the highest rate of cannabis use and greater levels of stigma, victimization, trauma, and childhood sexual abuse. White YMSM, meanwhile, reported higher rates of depression and the highest rates of alcohol use. In network analyses, black YMSM reported a greater number of sexual partners identifying as nonmale and nongay, and reported more HIV-positive sexual partners. Significant differences existed across network characteristics with black YMSM having the lowest transitivity, the highest density, and the lowest number of concurrent partners among YMSM. Finally, no significant differences were observed in access to health care treatment, including missed HIV medication doses in the past week and number of visits to a health care provider.
The composition of one's risk environment, including sexual network characteristics (eg, density, homophily, etc), and the characteristics of an individual's sexual partners have previously been hypothesized to play a role in HIV disparities.4,5,25 In this cohort, black YMSM had the lowest transitivity, lowest number of concurrent partners, highest network density, and highest homophily among all participants. Transitivity—a measure of the extent to which 3 individuals are all connected, representing the smallest cyclic structure in a network—has previously been associated with increased HIV transmission because of individuals in transitive triads having potential to be exposed to the virus from multiple sources.26 Density, meanwhile, is a measure of the degree to which all possible relationships between individuals are observed, with past research finding an inverse relationship between network density and number of sexual partners.25 It is therefore interesting that, in this cohort, black YMSM experience the lowest overall transitivity but the highest density, suggesting that black YMSM are exposed to HIV through fewer pathways while also participating in a greater number of sexual relationships with network members. In other words, although there are a higher percentage of sexual partnerships between black YMSM themselves, there are a lower number of total partnerships.
Data such as these have the potential to yield novel HIV interventions aimed at reducing racial disparities in diagnosis rates. For example, it has proven possible to use network interventions to more accurately trace past partners of those newly diagnosed with HIV.27 Furthermore, network interventions are also likely to grow more sophisticated as traditional network data, such as those used in the current study, are increasingly integrated with other sources of network data such as from partner services programs and molecular surveillance.28 In addition, network data identifying differences in the composition of sexual partners can also be leveraged to better understand the long-term impact of prevention activities on racial disparities29 and improve targeting of influential members of sexual networks.30 Future research should aim to develop a better understanding of the dynamic nature of these networks over time and use diverse data sources to develop novel HIV network interventions.
Beyond differences in network composition and structure, black YMSM were observed to experience greater levels of stigma, victimization, trauma, and childhood sexual abuse. And, although they reported the lowest rates of suicide ideation, they also reported the second highest rate of suicide-planning and the highest rate of suicide attempts. As noted in one recent review and content analysis,31 there is a dearth of research on suicidality among black YMSM. In fact, the analysis noted that across 4 articles addressing the issue among this population, 3 used the same data set. This lack of research is surprising given the high level of suicidality observed in this cohort, particularly among black YMSM. Future research should be dedicated toward better understanding of mental health and suicidality outcomes among this population, as they may prove to be an important factor in reducing health disparities.
While historically the diagnosis rate of HIV among Hispanic MSM has fallen between those of white and black MSM, Hispanic YMSM are the only racial/ethnic group to experience an increase in rate of diagnoses in the most recent CDC report.1 Regarding their engagement in HIV-risk behaviors, mental health outcomes, and network characteristics, Hispanic YMSM in this cohort were found, with few exceptions, to consistently fall between black and white YMSM. They were, however, found to experience the lowest rates of externalized stigma, PrEP use, network homophily, and number of visits to a health care provider. These data suggest that we should expect the rate of new HIV diagnoses among Hispanic YMSM to fall between those of white and black YMSM; however, as previously mentioned, the rate is increasing among Hispanic YMSM.1 This pattern was predicted by a recent simulation of the HIV epidemic among YMSM informed by network data.32 Taken together, further research is required to better understand the rising HIV diagnosis rates among Hispanic YMSM in the United States and to avoid widening disparities among this population.
Results must be interpreted in the context of study limitations. First, this sample was a community sample rather than a probability sample and, as such, findings may not generalize to the larger population of YMSM. Second, some data were self-reported, including network characteristics of alters and the relationships between alters themselves. Errors in the reporting of this information by the participant may result in changes to our findings. Finally, reflecting the demographics of the HIV epidemic, we had few HIV-positive white YMSM in the sample, who limited the precision of our estimates of the proportion with a detectable viral load.
In summary, we found significant differences across several domains that may explain why HIV disparities persist across race/ethnicities among YMSM. Compared to other YMSM in the cohort, black YMSM had the highest network density and the highest concurrency among YMSM alters. They also reported higher rates of stigma, victimization, trauma, and childhood sexual abuse. And, although no significant differences were observed regarding health care treatment access, black YMSM did report a greater number of lifetime HIV tests and a lower proportion of viral suppression. This suggests current efforts to increase engagement in HIV prevention with black YMSM may be taking hold. Future research should focus on developing interventions that target social determinants of HIV such as stigma, victimization, and trauma, and that these HIV prevention and care interventions may be benefit from understanding the structure of YMSM sexual networks.
The authors thank the entire RADAR research team, particularly Dr. Thomas Remble and Antonia Clifford for overseeing the project and Daniel T. Ryan for data management. The authors also thank the RADAR participants for sharing their experiences with them.
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