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. Author manuscript; available in PMC: 2024 Nov 1.
Published in final edited form as: Arch Sex Behav. 2023 Jun 28;52(8):3565–3575. doi: 10.1007/s10508-023-02642-2

Association Between Age of Anal Sex Debut and Adult Health Behaviors among Sexual Minoritized Men Living with HIV

José E Diaz 1, Elias Preciado 2, Mary Ann Chiasson 3,4, Sabina Hirshfield 1
PMCID: PMC11034742  NIHMSID: NIHMS1982394  PMID: 37378702

Abstract

Earlier age of anal sex debut (ASD) has been linked with contemporary and long-term health outcomes, including vulnerability to HIV acquisition. The goal of this study was to utilize a life course approach to examine associations between earlier ASD and recent health behaviors among sexual minoritized men (SMM) living with HIV. A total of 1,156 U.S. SMM living with HIV recruited from social and sexual networking apps and websites completed online surveys as part of a longitudinal eHealth intervention. Data from baseline surveys were analyzed to determine associations between age of ASD and adult health outcomes, including mental health, HIV viral load, and substance use. The median age of ASD among these participants was 17 years old, consistent with other work. Earlier ASD was significantly associated with a greater likelihood of past two-week anxiety (AOR = 1.45, 95% CI:1.07-1.97) and past three-month opioid use (AOR = 1.60, 95% CI:1.13-2.26); no significant associations were found for recent depression, HIV viral load, or stimulant use. Earlier ASD may function as an important proxy measure for deleterious health outcomes in adulthood, particularly recent anxiety and opioid use. Expansion of comprehensive and affirming sexual health education is critical to early engagement of individuals with a higher risk of HIV acquisition, with plausible downstream health benefits lasting into adulthood among SMM living with HIV.

Keywords: sexual debut, adult health outcomes, life course, sexual minoritized men, living with HIV, health disparities, substance use, adolescent health

Introduction

Sexual minoritized men (SMM) living with HIV are impacted by multiple overlapping health inequities, including high rates of depression, anxiety, and substance use (Brezing et al., 2015; Millar et al., 2017; O’Cleirigh et al., 2015; Remien et al., 2019; West et al., 2023). These health inequities complicate HIV treatment and care by contributing to reduced HIV care engagement, antiretroviral (ART) treatment adherence, and viral suppression (Blashill et al., 2015; Kuhns et al., 2016; Quinn et al., 2018; Satyanarayana et al., 2021). Further, social and structural stigma often function as drivers of the inequities experienced by SMM living with HIV (Flentje et al., 2020; Karver et al., 2022; Rendina et al., 2016), thereby challenging efforts to improve health equity. Mixed results across studies exploring health inequities among SMM living with HIV (Flentje et al., 2020) encourage additional research examining critical life events with plausible downstream health impacts among this key population.

Life course approaches encourage us to consider both the existence of critical life events and the stage of an individual’s life when those events occur, as they have potential to influence health behaviors and outcomes (Hammack et al., 2018; Liu et al., 2010; Shanahan et al., 2016). For example, health behaviors that occur earlier in adolescence may catalyze a series of cumulative risk factors that can increase health risks later in life, including HIV-related sexual behaviors, alcohol and drug use, and mental health concerns (Coker et al., 1994; Friedman et al., 2008; Lyons et al., 2012; Outlaw et al., 2011; Sanchez et al., 2020). By primarily centering on HIV acquisition risk (Lyons et al., 2012; Nelson et al., 2020; Outlaw et al., 2011), research exploring documented antecedents of disease burden often eschews the potential merit of life course-based understandings of HIV treatment among SMM living with HIV. Indeed, exploring HIV treatment and concurrent health conditions among SMM living with HIV through a life course approach may help to identify intervenable patterns in critical life events, including in adolescence, that impact adult health behaviors.

Anal sex debut (ASD) with another man represents a positive and normative stage of sexual development for SMM. While ASD among SMM has historically occurred in adulthood, generational shifts towards earlier experiences of anal sex encourage renewed attention (Sanchez et al., 2020). Earlier ASD has been associated with early onset of substance use, mental health disparities, sexual behaviors that may increase HIV or sexually transmitted infection (STI) acquisition, and engagement in sex work among adolescent SMM (Dewaele et al., 2017; Lombardi et al., 2008; Lowry et al., 2017; Lyons et al., 2012; Nelson et al., 2020; Outlaw et al., 2011); these patterns often persist into adulthood (Nelson et al., 2016; Sanchez et al., 2020). Further, ASD often occurs alongside sexual health education that is insensitive to the needs of adolescent SMM (Kubicek et al., 2010; Nelson et al., 2020), which is a missed opportunity to increase knowledge and reduce HIV acquisition and transmission. As a result, efforts to intervene upon the life course trajectories of SMM may benefit from additional insight into the long-term impact of earlier ASD on adult health outcomes, especially among SMM living with HIV.

Research examining sexual debut among SMM often centers on any sexual debut, rather than ASD, and is framed by the lens of HIV prevention. To address these gaps, the current study utilized a life course approach to examine the links between earlier age of ASD and subsequent adult health outcomes, including mental health (i.e., depression, anxiety), HIV viral load, and substance use (i.e., stimulant use, opioid use) in a U.S. online sample of adult SMM living with HIV.

Method

Participants

Data used in this study were collected between 2015 and 2016 as part of a one-year, video-based randomized controlled trial, Sex Positive! [+]. This study aimed to reduce serodiscordant condomless anal sex among sexual minoritized men living with HIV who reported sub-optimal ART adherence and/or a detectable viral load (Hirshfield et al., 2019). Participants could receive up to a total of US $115 in Amazon.com gift cards (distributed electronically and via postal mail) depending on completion of study activities. More details on study design are described elsewhere (Hirshfield et al., 2016).

Inclusion criteria have been described elsewhere (De et al., 2018; Hirshfield et al., 2016; Walters et al., 2020). Briefly, potential participants who completed an online screener survey were eligible if they were: 1) age 18 or older; 2) cisgender male or gender queer; 3) non-Hispanic white, non-Hispanic Black, or Hispanic/Latinx; 4) U.S. residents; 5) living with HIV; 6) reported past 30-day suboptimal ART adherence and/or a past-year detectable viral load; and 7) reported condomless anal sex with an HIV-negative or unknown status male partner in the past 6 months. A total of 1,203 men completed the eligibility screener, consented to participate in the online study, and completed the baseline survey.

For present analyses, we excluded men with missing data on ASD (n = 6), on one or more outcomes examined (n = 15), and sociodemographic data (n = 26), resulting in an analytic sample of 1,156 SMM living with HIV.

Measures

Age of Anal Sex Debut

ASD was assessed by asking participants “How old were you the first time you had anal sex with a man?” Survey response options were ordinal, including whole numbers (11 through 19), “Younger than 10”, and “20 or Older”. Responses were split at the median into earlier ASD (17 or younger) and later ASD (18 or older), consistent with median ASD found in these data and other studies (Nelson et al., 2016; Sanchez et al., 2020).

Early Health History

Age of alcohol onset.

Age of alcohol onset was assessed by the following question: “How old were you when you first had a drink containing alcohol? (not counting sips)” (Grosso et al., 2019). Ordinal response options, including whole numbers, ranged from “Younger than 10” to “20 or older.” These data were operationalized based on their median values into dichotomous variables, with 16 or younger categorized as earlier and 17 or older categorized as later.

Years of living with HIV.

Years of living with HIV was assessed by subtracting the self-reported year of HIV diagnosis from participants’ birth year. We describe the sample based on years of living with HIV to explore its potential links with ASD, but do not include this indicator in subsequent models.

Adult Mental and Physical Health

Mental Health

Past two-week anxiety was assessed using the 2-item Generalized Anxiety Disorder (GAD2) scale, which examined generalized anxiety disorder symptoms in the past two weeks. Past two-week depression was assessed via the 2-item Patient Health Questionnaire (PHQ-2), which screens for symptoms of depressed mood in the past two weeks. Response options for each scale ranged from 0 (Not at all) to 3 (Nearly every day). Scores on the GAD2 were summed with totals of 3 or more classified as past two-week anxiety, while summed scores of 3 or more on the PHQ-2 were coded as past two-week depression (Kroenke et al., 2007; Lowe et al., 2005).

HIV Care.

Viral load was self-reported as: (1) “My viral load was undetectable, OR < 200 copies/ml,” (2) “My viral load was detectable, OR > 200 copies/ml,” (3) “I don’t know–but I think I was detectable,” and (4) “I don’t know–but I think I was undetectable;” responses were then dichotomized as detectable or unknown (2-3) or undetectable (1,4).

Substance Use

Past three-month opioid use.

Opioid use in the past three months includes the self-reported smoking, snorting, injection, or ingestion of heroin or painkillers (i.e., Percocet, Oxycontin, Vicodin).

Past three-month stimulant use.

Stimulant use includes the self-reported use of cocaine, crack cocaine, methamphetamine, ecstasy, or “uppers” in the past three months, including various methods of consumption (i.e., smoking, snorting, injection, or ingestion).

Social and Behavioral Correlates.

Sex work was assessed by asking participants if they “were given anything (money, drugs, a place to stay, etc.) in exchange for sex” in the past 3 months. We use the term sex work throughout in line with recent research (Hansen & Johansson, 2023). For smoking status, regular or occasional smokers were indicated based on responses to one question: “Which best describes your current cigarette (or e-cigarette) use?” Response options included: 0) I don’t smoke, 1) regular smoker, 2) occasional smoker, with combined respondents indicating 1 or 2 due to indicate current smoking behaviors. Cannabis use was assessed by asking participants if they had used marijuana in the past 3 months. Race/ethnicity was categorized as: non-Hispanic white, Hispanic/Latinx, or non-Hispanic Black. Education was dichotomized as some college or less vs. college graduate or more. Income was collapsed into four levels (Less than $20,000, $20,000-$39,999, $40,000-$59,999, $60,000+). City size was reported as: “a rural area, a small town, a suburb of a smaller urban area, a smaller urban area, a suburb of a big city, a big city” and was collapsed into three levels (Big city, urban/small, suburban/rural). Primary care provider (yes/no) data were obtained by asking study participants: “Is there one doctor, nurse, or another medical provider whom you consider to be in charge of your overall HIV health care now?”

Statistical Analyses

We examined univariate distributions of each factor of interest. We then conducted bivariate chi-square analyses to assess whether outcomes and social and behavioral correlates were associated with ASD. Reference group for all analyses was later ASD (18 or older), allowing us to model the potential associations between earlier ASD (17 or younger) and adult health outcomes. Next, we ran unadjusted and adjusted logistic regression models examining the association between ASD and each outcome (past two-week anxiety, past two-week depression, recent HIV viral load, past three-month opioid use, past three-month stimulant use). Adjusted models controlled for sociodemographic characteristics (i.e., age, race/ethnicity, education, income, city size, having a primary HIV care provider), adolescent behaviors (i.e., age of alcohol onset) and adult behavioral factors (i.e., smoking status, cannabis use, engagement in sex work). Analyses were conducted in Stata 17.0/SE (StataCorp, 2021).

Results

Baseline Characteristics

Sociodemographic and behavioral characteristics of the participants are presented in Table 1. Briefly, the median age of participants was 37 (range, 18 to 77). Sixty-two percent of the sample were non-Hispanic white, while non-Hispanic Black men and Hispanic men comprised 20.9% and 17% of the sample, respectively. More than half of the sample had less than a college education (55.1%), earned less than $40,000 annually (60.1%), and lived in a large city (52.3%). A large majority (89.7%) had someone they considered their primary HIV care provider. In terms of substance use, similar proportions reported use of marijuana (48.5%) and of stimulants (45.1%) in the past 3 months. Just over 1 in 5 reported anxiety (22.5%) and depression (23.1%) in the past 2 weeks. Descriptively, participants also had been living with HIV for an average of 8.7 years.

Table 1.

Sociodemographic and behavioral characteristics by age of anal sex debut among an online sample of MSM living with HIV (n = 1,156).

Age of Anal Sex Debut
Overall n (%) 18 or older 17 or younger χ2
Age
29 and younger 281 (24.3) 95 (17.9) 186 (29.8) 34.81***
30-39 355 (30.7) 153 (28.8) 202 (32.4)
40-49 306 (26.5) 161 (30.3) 145 (23.2)
50+ 214 (18.5) 123 (23.1) 91 (14.6)
Race/ethnicity
Non-Hispanic White 718 (62.1) 382 (71.8) 336 (53.9) 44.47***
Non-Hispanic Black 241 (20.9) 78 (14.7) 163 (26.1)
Hispanic 197 (17.0) 72 (13.5) 125 (20.0)
Education
Less than college 637 (55.1) 244 (45.9) 393 (63.0) 35.98***
College degree or more 519 (44.9) 288 (54.1) 231 (37.0)
Income
up to 20k 403 (34.9) 158 (29.7) 245 (39.3) 17.86***
20k-39k 291 (25.2) 134 (25.2) 157 (25.2)
40-59k 180 (15.6) 93 (17.5) 87 (13.9)
60k+ 282 (24.4) 147 (27.6) 135 (21.6)
City Size
Rural/Suburban 200 (17.3) 91 (17.1) 109 (17.5) 0.19
Urban/Small city 352 (30.5) 165 (31) 187 (30.0)
Large City 604 (52.3) 276 (51.9) 328 (52.6)
Primary HIV Care Provider, yes 1,037 (89.7) 484 (91.0) 553 (88.6) 2.08
Engage in sex work, past 3 months 214 (18.5) 79 (14.9) 135 (21.6) 7.77**
Regular or occasional smoker (vs. none) 438 (37.9) 164 (30.8) 274 (43.9) 19.11***
Age of alcohol onset 16 or younger 657 (56.8) 263 (49.4) 394 (63.1) 19.06***
Cannabis use, past 3 months 561 (48.5) 232 (43.6) 329 (52.7) 10.69***
Anxiety, past 2 weeks 260 (22.5) 96 (18.1) 164 (26.3) 11.54***
Depression, past 2 weeks 267 (23.1) 111 (20.9) 156 (25.0) 2.49***
Recent HIV viral load
Detectable or unknown 337 (29.2) 134 (25.2) 203 (32.5) 6.35*
Opioid use, past 3 months 198 (17.1) 70 (13.2) 128 (20.5) 11.21**
Stimulant use, past 3 months 521 (45.1) 222 (41.7) 299 (47.9) 4.07*
Mean (SE) t, p-value
Years since HIV diagnosis 8.68 (0.24) 8.39 (0.34) 8.93 (0.33) −1.13
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SE=Standard error.

*

p<0.05,

**

p<0.01,

***

p<0.001.

Engaging in sex work was defined as being “given anything (money, drugs, a place to stay, etc.) in exchange for sex”.

Sociodemographic Characteristics by Age of Anal Sex Debut

Compared to participants with an older ASD age (18 or older), those with earlier ASD (17 or younger) were significantly more likely to report an earlier age of alcohol initiation (younger: 63.1% vs. older: 49.4%) in their youth. In addition, participants with earlier age of ASD were more likely than those with later ASD to report engaging in transactional sex in the past 3 months (younger: 21.6% vs. older: 14.9%), be a regular or occasional smoker (43.9% vs. 30.8%), have a detectable or unknown HIV viral load (32.5% vs. 25.2%), report past two-week anxiety (26.3% vs. 18.1%) and depression (25.0% vs. 20.9%), and indicate the use of marijuana (52.7% vs. 43.6%), opioids (20.5% vs.13.2%), and stimulants (47.9% vs. 41.7%) in the past three months.

Tables 2 (unadjusted) and 3 (adjusted) report estimates from logistic regression models examining associations between earlier ASD, behavioral and sociodemographic correlates, and our outcomes of interest: past two-week anxiety, past two-week depression, recent HIV viral load, past three-month opioid use, and past three-month stimulant use. For clarity, we report here only the adjusted models from Table 3.

Table 2.

Unadjusted logistic regression models examining associations between age of anal sex debut, sociodemographic, and behavioral factors with adult health outcomes (n = 1,156).

Anxiety, past 2 weeks Depression, past 2 weeks Recent HIV Viral Load Opioid use, past 3 months Stimulant use, past 3 months
UORa (95% CIb) UOR (95% CI) UOR (95% CI) UOR (95% CI) UOR (95% CI)
Age of Anal Sex Debut [18 or older]
17 or younger 1.62 (1.22-2.15) 1.26 (0.96-1.67) 1.43 (1.11-1.85) 1.70 (1.24-2.34) 1.28 (1.02-1.62)
Engage in sex work, yes 2.21 (1.60-3.05) 1.74 (1.25-2.41) 1.85 (1.36-2.52) 2.65 (1.88-3.74) 3.61 (2.62-4.97)
Smoking Status [non-smoker]
Regular or occasional 1.32 (1.00-1.75) 1.44 (1.09-1.90) 1.43 (1.10-1.85) 1.78 (1.31-2.42) 2.33 (1.83-2.97)
Age of Alcohol Onset [17 or older]
16 or younger 1.28 (0.97-1.70) 1.23 (0.93-1.62) 1.06 (0.82-1.37) 1.89 (1.36-2.62) 1.91 (1.51-2.43)
Cannabis, past 3 months 1.71 (1.29-2.26) 1.52 (1.15-2.00) 1.06 (0.82-1.37) 2.00 (1.46-2.74) 2.45 (1.93-3.11)
Age [18-29]
30-39 1.49 (1.04-2.15) 1.15 (0.79-1.65) 0.74 (0.53-1.02) 2.22 (1.43-3.45) 1.56 (1.14-2.14)
40-49 0.88 (0.59-1.31) 1.08 (0.74-1.58) 0.50 (0.35-0.72) 1.43 (0.89-2.30) 1.18 (0.85-1.64)
50 and older 0.71 (0.45-1.12) 0.67 (0.43-1.06) 0.34 (0.22-0.51) 1.47 (0.88-2.45) 0.79 (0.55-1.14)
Race/Ethnicity [non-Hispanic White]
Non-Hispanic Black 0.84 (0.59-1.21) 0.69 (0.48-1.00) 1.81 (1.33-2.47) 0.79 (0.53-1.18) 0.48 (0.35-0.65)
Hispanic 1.09 (0.75-1.57) 1.00 (0.69-1.44) 1.51 (1.07-2.12) 0.69 (0.44-1.08) 1.03 (0.75-1.41)
Education [Some college or less]
College degree or more 0.65 (0.49-0.87) 0.61 (0.46-0.80) 0.58 (0.45-0.76) 0.89 (0.65-1.21) 0.89 (0.71-1.13)
Income [<19,999]
20-39k 0.66 (0.47-0.95) 0.53 (0.38-0.75) 0.63 (0.45-0.87) 0.86 (0.59-1.27) 0.59 (0.44-0.81)
40-59 0.67 (0.44-1.02) 0.35 (0.22-0.55) 0.60 (0.41-0.88) 0.83 (0.52-1.31) 0.52 (0.37-0.75)
60k+ 0.49 (0.33-0.72) 0.34 (0.23-0.51) 0.42 (0.29-0.60) 0.55 (0.35-0.84) 0.51 (0.37-0.70)
City Size [Suburban/rural]
Urban/small city 0.95 (0.64-1.41) 0.90 (0.60-1.33) 1.07 (0.74-1.57) 0.98 (0.64-1.51) 1.28 (0.90-1.83)
Big city 0.71 (0.49-1.03) 0.75 (0.52-1.08) 0.88 (0.62-1.26) 0.64 (0.43-0.97) 1.51 (1.09-2.09)
Primary HIV care provider, yes 0.67 (0.44-1.01) 0.84 (0.54-1.29) 0.22 (0.15-0.32) 1.10 (0.66-1.84) 0.99 (0.67-1.44)
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Italicized brackets indicate reference categories. UOR = unadjusted odds ratio. CI = confidence interval. Bold estimates indicate significance at p<0.05.

Table 3.

Multivariable logistic regression models examining associations between age of anal sex debut with adult health outcomes, adjusting for sociodemographic and behavioral factors (n=1,156).

Anxiety, past 2 weeks Depression, past 2 weeks Recent HIV Viral Load Opioid use, past 3 months Stimulant use, past 3 months
AORa (95% CIb) AOR (95% CI) AOR (95% CI) AOR (95% CI) AOR (95% CI)
Age of Anal Sex Debut [18 or older]
17 or younger 1.45 (1.07-1.97) 1.14 (0.84-1.54) 1.12 (0.84-1.49) 1.60 (1.13-2.26) 1.09 (0.83-1.43)
Engage in sex work, yes 1.78 (1.26-2.51) 1.30 (0.92-1.85) 1.39 (0.99-1.95) 2.38 (1.63-3.46) 2.97 (2.09-4.21)
Smoking Status [non-smoker/former smoker]
Regular or occasional 0.97 (0.71-1.32) 1.10 (0.81-1.49) 1.12 (0.84-1.50) 1.32 (0.94-1.85) 2.00 (1.52-2.65)
Age of Alcohol Onset [17 or older]
16 or younger 1.07 (0.79-1.46) 1.00 (0.74-1.35) 1.03 (0.78-1.37) 1.57 (1.10-2.23) 1.47 (1.12-1.92)
Cannabis, past 3 months 1.55 (1.15-2.08) 1.40 (1.04-1.88) 0.88 (0.67-1.16) 1.71 (1.22-2.39) 2.21 (1.70-2.87)
Age [18-29]
30-39 1.69 (1.15-2.48) 1.24 (0.84-1.83) 0.95 (0.67-1.34) 2.53 (1.59-4.02) 1.57 (1.10-2.26)
40-49 1.09 (0.71-1.68) 1.25 (0.82-1.89) 0.72 (0.49-1.06) 1.66 (0.99-2.76) 1.11 (0.76-1.63)
50 and older 0.93 (0.56-1.54) 0.85 (0.52-1.40) 0.56 (0.35-0.89) 1.78 (1.01-3.13) 0.80 (0.52-1.24)
Race/Ethnicity [non-Hispanic White]
Non-Hispanic Black 0.70 (0.48-1.04) 0.54 (0.37-0.81) 1.53 (1.08-2.15) 0.76 (0.49-1.17) 0.35 (0.24-0.50)
Hispanic 0.94 (0.63-1.40) 0.92 (0.62-1.37) 1.25 (0.86-1.81) 0.66 (0.40-1.07) 0.91 (0.64-1.30)
Education [Some college or less]
College degree or more 0.85 (0.62-1.17) 0.84 (0.61-1.16) 0.78 (0.57-1.05) 1.18 (0.82-1.69) 1.26 (0.95-1.68)
Income [<19,999]
20-39k 0.75 (0.51-1.09) 0.56 (0.39-0.81) 0.65 (0.46-0.92) 1.09 (0.72-1.66) 0.64 (0.46-0.91)
40-59 0.81 (0.52-1.26) 0.38 (0.23-0.61) 0.74 (0.49-1.13) 1.04 (0.63-1.72) 0.54 (0.36-0.82)
60k+ 0.63 (0.41-0.97) 0.39 (0.25-0.60) 0.64 (0.42-0.95) 0.64 (0.39-1.06) 0.57 (0.39-0.83)
City Size [Suburban/rural]
Urban/small city 1.06 (0.70-1.62) 1.06 (0.70-1.61) 1.23 (0.82-1.84) 1.07 (0.67-1.70) 1.43 (0.96-2.15)
Big city 0.75 (0.51-1.12) 0.87 (0.59-1.28) 0.96 (0.66-1.39) 0.67 (0.43-1.04) 1.77 (1.22-2.58)
Primary HIV care provider, yes 0.75 (0.48-1.18) 0.95 (0.60-1.51) 0.25 (0.16-0.38) 1.34 (0.77-2.34) 1.40 (0.90-2.18)
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Italicized brackets indicate reference categories.

a

AOR = unadjusted odds ratio.

b

CI = confidence interval. Bold estimates indicate significance at p<0.05.

Mental Health: Past Two-Week Anxiety

In multivariable models, earlier ASD was associated with a greater odds of past two-week anxiety [adjusted odds ratio (AOR = 1.45, 95% confidence interval (CI): 1.07-1.97). Moreover, engaging in past three-month transactional sex (AOR = 1.78, 95% CI: 1.26-2.51), reporting past three-month marijuana use (AOR=1.55, 95% CI: 1.15-2.08), and being aged 30-39 (vs. 18-29, AOR=1.69, 95% CI: 1.15-2.48) were each associated with a greater odds of past two-week anxiety. Compared to an income of less than $20,000, reporting an income of $60,000 or more (AOR= 0.63, 95% CI: 0.41-0.97) was associated with a lower odds of past two-week anxiety.

Mental Health: Past Two-Week Depression

ASD was not significantly associated with past two-week depression. However, past three-month cannabis use (AOR=1.52, 95% CI:1.15-2.00) was associated with a greater odds of past two-week depression, while earning an income between $20,000-$39,999 (AOR = 0.56, 95% CI: 0.39-0.81), $40,000-$59,999 (AOR=0.38, 95% CI:0.23-0.61), or $60,000 or more (AOR = 0.39, 95% CI: 0.25-0.60) compared to earning less than $20,000, were each associated with a lower odds of past two-week depression.

HIV Viral Load

In adjusted models, ASD was not significantly associated with adult HIV viral load, though earning $20,000 or more per year ($20,000-$39,999 AOR=0.65, 95% CI:0.46-0.92; $60,000+ AOR = 0.64, 95% CI: 0.42-0.95) and having a primary HIV care provider (AOR = 0.25, 95% CI: 0.16-0.38) were associated with a lower likelihood of having a detectable or unknown viral load. Additionally, non-Hispanic Black men were more likely to have a detectable or unknown HIV viral load compared to non-Hispanic white men (AOR = 1.53, 95% CI: 1.08-2.15), while no difference was found between Hispanic/Latinx men and non-Hispanic white men.

Substance Use: Past Three-Month Opioid Use

Earlier ASD was associated with a greater likelihood of reporting opioid use in the past three months (AOR = 1.60, 95% CI: 1.13-2.26). Other predictors of recent opioid use included transactional sex (AOR = 2.38, 95% CI: 1.63-3.46), as was having an earlier age of alcohol initiation in youth (≤16 vs. 17 years old, AOR = 1.57, 95% CI: 1.10-2.23), and reporting past three-month marijuana use (AOR = 2.00, 95% CI: 1.46-2.74), and currently being aged 30-39 (AOR = 2.53, 95% CI: 1.59-4.02) and age 50 or older (AOR = 1.78, 95% CI: 1.01-3.13), relative to men under age 30.

Substance Use: Past Three-Month Stimulant Use

While earlier ASD was associated with past three-month opioid use, it was not significantly associated with past three-month stimulant use. However, engaging in transactional sex (AOR = 2.97, 95% CI: 2.09-4.21), being a regular or occasional smoker (AOR = 2.00, 95% CI: 1.52-2.65), reporting past three-month marijuana use (AOR = 2.21, 95% CI: 1.70-2.87), being aged 30-39 (vs. 18-29; AOR = 1.57, 95% CI: 1.10-2.26), and living in a large city (vs. suburban/rural; AOR = 1.77, 95% CI: 1.22-2.58) were each associated with past three-month stimulant use. Relative to those reporting an annual income of $19,999 or less, reporting a higher income was associated with a lower likelihood of past three-month stimulant use, including among those earning $20,000-$39,999 (AOR = 0.64, 95% CI: 0.46-0.91), $40,000-$59,999 (AOR = 0.54, 95% CI: 0.36-0.83), or $60,000 or more (AOR = 0.57, 95% CI: 0.39-0.83).

Discussion

The life course framework is key to studying life events and HIV-related health trajectories among SMM (Hammack et al., 2018). Using this framework, we examined patterns of associations between earlier age of ASD and adult health outcomes, including mental health, HIV viral load, and substance use among a national online sample of SMM living with HIV. Earlier ASD was significantly associated with recent anxiety symptoms and opioid use but not other examined health outcomes. Conversely, we found that exchange sex in adulthood, which itself has been linked in adolescence with earlier age of ASD (Outlaw et al., 2011), was highly correlated with most adult health outcomes examined. These combined findings depict early adolescence as a critical developmental stage for sexual health interventions to educate, inform, and model health behaviors that can positively impact the trajectory towards improved adult health outcomes among SMM living with HIV (Diaz et al., 2022; Schnall et al., 2022).

In the current study, we found that earlier age of ASD was associated with adult anxiety among SMM living with HIV. SMM living with HIV are disproportionately burdened by anxiety compared the US population (Brandt et al., 2017), in part due to trauma and the multiple intersecting forms of discrimination they experience during certain milestones in their life course (Brown et al., 2015; Quinn et al., 2018; Willie et al., 2016). Earlier age of ASD has also been linked to structural forms of stigma, including policies that allow for either abstinence-only or heteronormative sexual health education (Bible et al., 2020; Tabaac et al., 2021, 2022). Comprehensive sex education is evidence-based and has demonstrated increased HIV prevention efforts among adolescents (Fonner et al., 2014), which may help reduce mental health concerns and substance use (Jackson et al., 2012). Interventions that provide affirming sexual health education to sexual minoritized adolescents, while scant, may reduce HIV acquisition vulnerability (Schnall et al., 2022), including those with earlier ASD. Where structural barriers prevent sexual health education, stigma-reduction interventions that empower parents to have inclusive sexual health conversations with their adolescent sons may prove vital (Bond et al., 2022; Flores et al., 2019). Importantly, these findings should not be interpreted as a call for abstinence-centered sexual health education, which has shown limited success (Santelli et al., 2017; Underhill et al., 2007) and may further stigmatize LGBTQ+ populations (Bible et al., 2020).

Disparities in anxiety and other mental health symptoms experienced by adult SMM living with HIV warrant structural interventions. For example, in the U.S., less than 13% of all mental health care providers offer culturally competent services for sexual minoritized groups (Williams & Fish, 2020). Care that is either disaffirming or ill-equipped to properly treat the needs of sexual minoritized groups threatens to perpetuate the life course trajectories that foster disparities in anxiety among adult SMM living with HIV (Pachankis, 2018; Rees et al., 2021). For example, the co-location of HIV treatment with other service provision (e.g., mental health treatment, substance use treatment) may reduce barriers to affirming mental health treatment utilization SMM living with HIV (Mizuno et al., 2019). Additional research is needed to examine whether co-located treatment may help reduce the prevalence and burden of anxiety among SMM living with HIV, including those with earlier ASD.

Earlier ASD has also been linked to substance use among SMM, with unclear evidence surrounding opioid use (Outlaw et al., 2011). In this study, we found supportive evidence that earlier age of ASD debut was associated with a greater likelihood of adult opioid use, including heroin use and nonmedical use of prescription opioids (e.g., use outside of a doctor’s guidance). Fatal and non-fatal overdoses among people who use opioids represent a severe public health crisis, in part due to the continued proliferation of fentanyl in drug supplies (Irvine et al., 2022). Because earlier age of ASD is linked with concurrent substance use and a greater likelihood of sex under the influence of substances (Lyons et al., 2012; Outlaw et al., 2011), age-appropriate education and interventions that empower sexually active adolescent SMM to find pleasure without substance use may help to reduce potential vulnerability to substance use disorders.

Neither HIV viral load nor current stimulant use were associated with earlier ASD in multivariable models, despite significant bivariate associations. The resurgent stimulant use epidemic and its impact on HIV care outcomes may partly underlie these results. We found similarly high proportions of SMM living with HIV who reported recent stimulant use, regardless of earlier (47.9%) or later (41.7%) age of ASD. SMM who use stimulants, particularly methamphetamine, are less likely to be engaged in HIV care or have durable viral suppression (Goodman-Meza et al., 2019; Petrova et al., 2022). Additional research exploring potential pathways between earlier ASD and stimulant use are warranted to reduce barriers to HIV treatment as part of efforts to end the HIV epidemic.

Research has identified a link between earlier ASD and greater likelihood of engaging in sex work in adolescence (Outlaw et al., 2011). We extend this research by finding earlier ASD is associated with engagement in sex work in adulthood. Further, we found that recent engagement in sex work was associated with recent anxiety, opioid use, and stimulant use. Engagement in sex work across the lifespan likely exposes SMM to abuse and stigma, which may lead to heightened substance use and psychological distress, thereby increasing vulnerability to HIV acquisition (Oldenburg et al., 2015). Comprehensive stigma-reduction and sexual health-focused interventions may improve the preparedness of adolescent SMM for sexual behaviors, thereby reducing a contemporary and long-term pathway to engagement in sex work. While beyond the scope of present study, interventions aimed at resilience and skills building may improve the lived experiences of SMM currently engaged in, or who may consider engaging in, sex work (Chandler et al., 2020; Meanley et al., 2022; Nelson et al., 2022).

Limitations

This study represents an effort to better understand age of anal sex debut and adult health outcomes among SMM living with HIV using a life course perspective. However, limitations deserve mention. Participants were recruited through social networking sites and dating apps; thus, these data may not be generalizable to all SMM (specifically, SMM living with HIV) that do not use these virtual spaces for meeting other SMM. Analyses relied upon recall about ASD and is therefore subject to bias; however, population-based research has found low levels of recall bias when recounting first sexual experiences (Liang & Chikritzhs, 2013). Additionally, retrospective cross-sectional analyses may not capture the full breadth of pathways between early ASD and adult health outcomes, as many confounders in adolescence were unmeasured. Lastly, we were unable to control for the nature of early sexual relationships (e.g., coercive), which may have contributed to differences in health outcomes among those with earlier ASD (Downing et al., 2020). Still, examining potential links between age of ASD and health outcomes among SMM living with HIV provides additional insight into future research and plausibly intervenable pathways.

Conclusions

Significant life events have been linked to subsequent health outcomes across populations, including SMM living with HIV. Earlier ASD may function as an important proxy measure for deleterious health outcomes in adulthood, particularly recent anxiety and opioid use. Future research should continue to address early adolescence as a critical life course intervention time point in HIV prevention. Indeed, adolescence represents an often-missed opportunity to enact comprehensively protective interventions that help to reduce HIV and the overlapping burdens that can persist across the life course among SMM, including mental health, substance use, and socioeconomic hardships leading to engagement in sex work. Lastly, this study reflects the potential benefits of expanding sexual health education that is affirming to SMM to help reduce potential downstream impacts of early ASD, which may net a positive health effect on their life course trajectory.

Acknowledgements:

José E. Diaz and Elias Preciado contributed equally to this work.

Funding:

This research was supported by a grant from the NIMH (R01-MH100973) to Sabina Hirshfield, principal investigator.

Footnotes

Ethical Considerations: The Institutional Review Board at Public Health Solutions approved all study procedures. A Data and Safety Monitoring Board (DSMB), comprised of experts in trial designs, Internet research, web design, and populations living with HIV met three times (approximately once every six months) during active study recruitment to discuss issues related to participant safety, study validity, and data integrity. A Certificate of Confidentiality was also obtained from the National Institute of Mental Health (NIMH) to provide additional privacy protections for participants enrolled in this study.

Conflicts of Interest: The authors declare that they have no conflicts of interest.

Availability of data and material:

Not applicable.

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