Application of Syndemic Theory to Black Men Who Have Sex with Men in the Multicenter AIDS Cohort Study

Abstract

This study analyzed data from a large prospective epidemiologic cohort study among men who have sex with men (MSM), the Multicenter AIDS Cohort Study, to assess syndemic relationships among Black MSM in the cohort (N = 301). We hypothesized that multiple interconnections among psychosocial health conditions would be found among these men, defining syndemic conditions. Constituents of syndemic conditions measured included reported depression symptoms, sexual compulsiveness, substance use, intimate partner violence (IPV), and stress. We found significant evidence of syndemics among these Black men: depression symptoms were independently associated with sexual compulsiveness (odds ratios [OR]: 1.88, 95% CI = 1.1, 3.3) and stress (OR: 2.67, 95% CI = 1.5, 4.7); sexual compulsiveness was independently associated with stress (OR: 2.04, 95% CI = 1.2, 3.5); substance misuse was independently associated with IPV (OR: 2.57, 95% CI = 1.4, 4.8); stress independently was associated with depression symptoms (OR: 2.67, 95% CI = 1.5, 4.7), sexual compulsiveness (OR: 2.04, 95% CI = 1.2, 3.5) and IPV (OR: 2.84, 95% CI = 1.6, 4.9). Moreover, men who reported higher numbers of syndemic constituents (three or more conditions) reportedly engaged in more unprotected anal intercourse compared to men who had two or fewer health conditions (OR: 3.46, 95% CI = 1.4–8.3). Findings support the concept of syndemics in Black MSM and suggest that syndemic theory may help explain complexities that sustain HIV-related sexual transmission behaviors in this group.

Introduction

Growing up as a Black man who has sex with men (MSM) in the USA confers dual “minority” status based upon both one’s racial and sexual identities.^1,2 Many challenges to mental and physical health exist for members of this sexual and racial minority, including higher rates of HIV infection and mental health problems compared to either heterosexual men or non-Black MSM. The developmental exposure to multiple minority stressors contributing synergistically to excess burden of disease in a specific population is referred to as a “syndemic.”³ Syndemic theory has been used successfully to explain HIV risk-taking behaviors among mostly White MSM in the USA and HIV prevalence and incidence among MSM in Thailand.^4–6

Syndemic theory posits that a constellation of health problems, including depression, sexual compulsiveness, substance misuse, intimate partner violence (IPV) and stress, accrue across the lifespan and each condition can amplify the negative impact of one or more other health problems.^3,7 For Black MSM who face multiple and overlapping “isms” (e.g., racism, classism, and homonegativism), negative health impacts that correlate to being a dual minority may be even further exaggerated. While there is a limited but extremely influential body of research examining the impact of dual minority status on health risk,^7–12 few studies to date have done so utilizing well-validated retrospective measures of syndemic production across the life course of self-identified Black MSM.

This study analyzed data from a large-scale epidemiologic cohort study conducted among MSM, the Multicenter AIDS Cohort Study (MACS), to explore the extent to which syndemic relationships could be observed among Black MSM participants in the MACS. We hypothesized that multiple interconnections among psychosocial health conditions would be found among the men in the MACS and that occurrence of negative early life events would be associated with syndemic production.

Methods

Multicenter AIDS Cohort Study

The MACS is an ongoing, prospective cohort study of the natural history of HIV infection among MSM in the US. Men were enrolled in four cities: Baltimore, MD; Chicago, IL; Los Angeles, CA; and Pittsburgh, PA. The study design has been described previously^13–15 and only methods relevant to the present substudy are presented here. A total of 6,972 men have been enrolled since the study’s inception in April 1984. Participants return every 6 months for a detailed interview, physical examination, and collection of blood for laboratory testing and storage. The interview includes questions about physical health, medical treatments, and sexual and substance use behaviors. More information about the MACS study, including data collection instruments, can be found at the MACS website (http://www.statepi.jhsph.edu/macs/macs.html).

Substudy

During visit numbers 49 and 50 (April 1, 2008 to March 31, 2009), participants were asked to complete an additional survey that captured data about events throughout the life course that are hypothesized to be related to syndemic production.¹⁶ Participation in this substudy was voluntary and confidential and participants could opt out without impacting their involvement in the ongoing MACS. The substudy questionnaire took approximately 30–45 minutes to complete and participants received $10 compensation for their time. All study procedures, including the study instrument, were approved by the Institutional Review Board at each study site.

Of eligible participants, 87% opted to participate in the substudy. The substudy obtained 1,551 surveys from unique individuals. Of these men, 301 were Black men and comprise the analytic sample for these analyses.

For the current study we analyzed data from the sample of Black MSM (N = 301) to evaluate potential associations among sociodemographic, psychosocial, and behavioral health conditions (i.e., syndemic conditions) that may correspond with HIV status and unprotected anal intercourse.

Measures

Outcome Variables (Psychosocial Health Conditions)

Five health conditions were measured. (1) Depression symptoms; total CES-D score¹⁷ dichotomized as no/low reported depression symptoms (<16) or significant reported depression symptoms (16+).¹⁸ (2) Sexual compulsiveness; this 10-item scale (five-point Likert from “never” to “very frequently”) asked participants to indicate how often they felt symptoms of sexual compulsion over the past 5 years (e.g., had trouble controlling sexual urges, missed opportunities for productive and enhancing activities because of your sexual activity, etc.).¹⁹ (3) Substance use; defined as self-reported use of one or more of the following: (a) at least weekly use of poppers, crack, methamphetamine, cocaine, heroin, speedball, and/or ecstasy since last visit; (b) use of two or more of the above listed drugs since last visit; (c) binge drinking (six or more drinks on one occasion) since last visit. (4) Intimate partner violence; defined as any reported experience of physical, mental, or emotional abuse over the past 5 years perpetrated by a boyfriend or other male sexual partners.²⁰ (5) Stress; this 14-item scale asked participants to indicate level of stress (five-point Likert from “no stress” to “extreme stress”) over the past 12 months related to various daily tasks/conditions (e.g., job, finances, health, crime, etc.).²¹ The syndemic outcome variable was defined as the presence of two or more reported co-occurring health conditions in an individual (described above).

Predictor Variables

Predictor variables were self-reported adverse health conditions and events throughout the participant’s life course from childhood to the present. For each scaled item, and unless otherwise noted, participants were defined to experience each form of adversity if their mean score for the scale was in the highest tertile. Reliability analyses were conducted and for the most part yielded high Cronbach’s Alphas (≥0.70), indicating high internal consistency of the scales used in the study.

Early Life (<18 Years of Age)

Variables describing adverse early life events are described below. (1) Childhood satisfaction; this six-item scale asked participants to indicate their level of agreement regarding happiness/satisfaction before the age of 10 (e.g., “I was a happy kid,” “I was part of a happy family,” etc.), Cronbach’s Alpha = 0.910. (2) Parental substance abuse; defined as a positive response to a single item indicating a parent/guardian had a drug or alcohol problem before the participant was 18 years old. (3) Parental domestic violence; defined as a positive response to a single item indicating witnessing physical violence between parents/guardians before the participant was 18 years old. (4) Physical abuse; defined as a positive response to a single item indicating a parent/guardian hit or beat the participant before the age of 18. (5) Childhood sexual assault; participant indicated that a person had “forced or frightened [him] into doing something sexually that [he] did not want to do” prior to the age of 18. (6) Childhood victimization; this five-item scale asked participants to indicate frequency of various forms of victimization (verbal, physical, emotional) during Jr. High/Middle School (ages 13–15). Response options ranged from “never” to “about once a week or more.” Responses for all five items were combined to create an overall victimization score that ranged from 0 to 4.20. (7) Gay-related victimization; coded positive for participants who indicated one of the forms of childhood victimization happened because they were, or were thought to be, gay or bisexual.²² (8) Aggressive environment; five questions regarding frequency of witnessing various forms of victimization (verbal, physical, emotional) during Jr. High/Middle School (ages 13–15). Response options ranged from “never” to “about once a week or more.” Responses for all five items were combined to create an overall aggressive environment score.²² (9) Homophobic environment; coded positive for participants who indicated witnessing one of the forms of victimization measured by the aggressive environment questions and stated that the victimization happened because the victim was, or was thought to be, gay or bisexual.²² (10) Masculinity attainment; this 22-item scale asked participants to indicate their self-perception of attainment of masculinity norms during high school (ages 16–19).²³ Participants indicated the frequency of feeling the various items (e.g., “Try to cover up or conceal your mannerisms because you thought they were feminine or girl-like,” etc.) from “never” to “very frequently,” Cronbach’s Alpha = 0.80. (11) Social connectedness; this 20-item scale asked participants to indicate their perceived level of social connectedness during high school (e.g., “I felt like an outsider,” “I was able to relate to my peers,” etc.), Cronbach’s Alpha = 0.85.²⁴

Period of Coming Out

Internalized homophobia was measured with a nine-item scale, where participants indicated their level of agreement with statements about sexuality (e.g., tried to stop being attracted to men in general, etc.) during the period they were coming out, Cronbach’s Alpha = 0.76.²⁵ Internalized homophobia was coded as positive if participants “agreed” or “strongly agreed” with any of the items.

Adulthood

Adulthood variables included the following: (1) Sexual assault; measured using a single item indicating that “someone forced or frightened [him] into doing something sexually that [he] did not want to do” after the age of 18. (2) Discrimination; a 10-item scale that may have happened due to discrimination at any point since the age of 18 (e.g., fired from a job, prevented from buying/renting a home).²⁶ (3) Urban affiliation; this eight-item scale addressed participants’ perceptions of living in an urban environment, Cronbach’s Alpha = 0.91.

Past 5 Years

Current Discrimination was measured using a 9-item scale addressing discrimination and marginalization in the past 12 months (e.g., “You were treated with less courtesy than other people,” “You were called names or insulted,” etc.), Cronbach’s Alpha = 0.93;²⁷Internalized Homophobia is identical to the scale described previously, except being specific to the last 12 months, Cronbach’s Alpha = 0.71;²⁵Life Satisfaction was measured using the same scale as the Childhood Satisfaction adapted to be relevant to current perceptions of satisfaction (e.g., “I am a happy person,” “I have many friends,” etc.), Cronbach’s Alpha = 0.85.

Sociodemographic Covariates

Educational status was categorized as high school or less, some college, college graduate, and at least some postgraduate education. Income was based on annual earnings categorized as less than $20,000, $20,000–39,999, $40,000–59,999, and $60,000 and above. HIV serostatus was determined by an enzyme-linked immunosorbent assay with confirmatory Western blot.

Statistical Analysis

Only MSM who identified themselves as Black or African American were included in these analyses. The presence of a syndemic was defined as two or more co-occurring health conditions within an individual; therefore, we calculated count scores based on the number of health conditions for each participant. To evaluate the differences in demographic and life course experiences between participants with and without a syndemic condition, an independent sample t test with homogenous variances was used for continuous variables (e.g., age) and Pearson’s chi-square tests and Fisher’s exact tests were used for categorical variables.

Bivariate analyses were used to correlate the predictors with syndemic versus no syndemic conditions. We used multivariable logistic regression models to create separate profiles for MSM who reported high levels of depression, sexual compulsiveness, substance use, IPV, and stress. Each model included the same demographic and behavioral predictor variables. We ran the same logistic model for each psychosocial health condition (depression, sexual compulsiveness, etc.) but excluded measures of a given health condition for the logistic model predicting that particular condition. The models yielded odds ratios (ORs) and associated 95% confidence intervals (CIs) for each of the psychosocial health conditions that were adjusted for demographic variables previously identified as being significant in the bivariate analysis. Lastly, we conducted an analysis examining whether there was an additive effect of the number of health conditions and greater sexual risk taking behavior among the men in the study. All statistical analyses were conducted using PASW Statistics 18, Release Version 18.0.0.²⁸

Results

Demographic Characteristics

Mean age of the sample was 47 years. The majority of men in the sample graduated from college and had an annual income of less than $40,000. Seventy percent of the men were HIV positive. Twenty-two percent reported use of stimulant drugs since last visit, with the majority reporting use of crack cocaine (16%). Slightly more than half the sample (54%) reported having two of more co-occurring health conditions, indicating a syndemic.

Table 1 presents bivariate associations of co-occurring health conditions with demographics and life course events. Men in the syndemic group (mean (M) age = 45.7, standard deviation (SD) = 8.7) were significantly younger than those in the no-syndemic group (M = 48.6, SD = 9.2); t = 2.9, p < 0.01. No differences were observed between syndemic and no-syndemic conditions by education level or HIV status.

Table 1.

Demographic characteristics, life course experiences and syndemic conditions among black MSM (N = 301)

Variables	Total	No syndemic	Syndemic	P valuec
	N = 301	N = 138	N = 163
	% (n)	% (n)	% (n)
Age, yeard	47.1 (9.0)	48.6 (9.2)	45.7 (8.7)	0.004
Education
HS or less	17.3 (52)	18.1 (25)	16.6 (27)	0.82
Some college	26.6 (80)	25.4 (35)	27.6 (45)
College graduate	24.9 (75)	23.2 (32)	26.4 (43)
Postgraduate	31.2 (94)	33.3 (46)	29.4 (48)
Income
Less than $20,000	28.9 (87)	29.0 (40)	28.8 (47)	0.33
$20,000–39,999	25.9 (78)	22.5 (31)	28.8 (47)
$40,000–59,999	17.9 (54)	16.7 (23)	19.0 (31)
Over $60,000	27.2 (82)	31.9 (44)	23.3 (38)
HIV status
Positive	69.8 (210)	70.3 (97)	69.3 (113)	0.86
Drug use
Crack	16.3 (49)	3.6 (5)	27.0 (44)	<0.001
Other coke	5.3 (16)	4.3 (6)	6.1 (10)	0.49
Amphetamine	3.0 (9)	0.0 (0)	5.5 (9)	0.004
Ecstasy	2.0 (6)	1.4 (2)	2.5 (4)	0.69
Any stimulanta	21.9 (66)	8.0 (11)	33.7 (55)	<0.001
Sex riskb
ARI partner	45.5 (137)	40.6 (56)	49.7 (81)	0.11
AII partner	44.2 (133)	45.7 (63)	42.9 (70)	0.64
UARI partner	18.3 (55)	13.8 (19)	22.1 (36)	0.06
UAII partner	23.6 (71)	19.6 (27)	27.0 (44)	0.13
Early life events (<age 18)
Childhood satisfaction	1.9 (0.9)	1.9 (1.0)	2.0 (0.9)	0.66
Parental substance abuse	39.7 (114)	36.0 (49)	43.0 (65)	0.23
Parental domestic violence	36.6 (104)	34.3 (46)	38.7 (58)	0.45
Physical abuse	50.9 (146)	45.5 (60)	55.5 (86)	0.09
Sexual assault	29.9 (90)	31.9 (44)	28.2 (46)	0.49
Childhood victimization	27.4 (80)	20.3 (27)	33.3 (53)	0.013
Aggressive environmentd	1.3 (1.2)	1.2 (1.1)	1.4 (1.2)	0.11
Homophobic environment	13.3 (40)	11.6 (16)	14.7 (24)	0.43
Gay-related victimization	26.2 (79)	19.6 (27)	31.9 (52)	0.015
Masculinity attainmentd	2.4 (1.2)	2.1 (1.0)	2.7 (1.2)	<0.001
Social connectednessd	3.0 (0.9)	2.8 (1.0)	3.2 (0.9)	0.001
Period of coming out
Internalized homophobiad	2.7 (1.1)	2.4 (1.0)	3.0 (1.1)	<0.001
Adulthood (≥age 18)
Sexual assault	11.7 (33)	9.2 (12)	13.8 (21)	0.22
Discrimination	69.8 (210)	65.2 (90)	73.6 (120)	0.11
Urban affiliationd	19.4 (5.2)	2.4 (0.8)	2.5 (0.5)	0.23
Last 5 years
Gay community connection
Attituded	2.6 (0.7)	2.6 (0.8)	2.7 (0.7)	0.73
Behaviord	3.3 (0.8)	3.3 (0.8)	3.3 (0.9)	0.49
Discrimination	61.3 (182)	44.1 (60)	75.8 (122)	<0.001
Internalized homophobiad	2.1 (1.1)	1.9 (1.0)	2.3 (1.1)	0.001
Life satisfactiond	2.0 (0.7)	1.8 (0.7)	2.2 (0.7)	<0.001

^aAny stimulant use include use of crack, other coke, amphetamine, and ecstasy since last visit

^bSex risk is defined by having one or more anal receptive intercourse partner (ARI), anal insertive intercourse partner (AII), unprotected anal receptive intercourse partner (UARI), unprotected anal insertive intercourse partner (UAII) since the last visit

^cFisher’s exact test was used when cells had expected count less than five

^dData are reported as mean (standard deviation) for continuous variables

Men in the syndemic group were significantly more likely than those in the no-syndemic group to report stimulant use, (x² = 28.99, p < 0.001), particularly crack cocaine use, (x² = 29.95, p < 0.001). Men in the syndemic group were more likely to report having been the target of gay (x² = 5.88, p = 0.02) and non-gay-related victimization (x² = 6.22, p = 0.01) during junior high/middle school years; having significantly higher perception of both masculinity attainment (t = 4.27, p < 0.001) and social connectedness (t = 3.52, p = 0.001) during high school years. During the period of coming out, men in the syndemic group reported more internalized homophobia (M = 3.02, SD = 1.10), compared to men in the no-syndemic group (M = 2.37, SD = 1.01; t = 5.21, p < 0.001). In adulthood, men in the syndemic group reported more discrimination, (x² = 31.1, p < 0.001) and more internalized homophobia (t = 3.36, p = 0.001); however, they also reported more current satisfaction with life (t = 5.73, p < 0.001), than men in the no-syndemic group.

Table 2 presents the results of the five multivariable logistic regression models showing independent associations of depression symptoms, sexual compulsiveness, substance use, IPV, and stress among Black MSM. Most evident from this table is that each of the psychosocial health conditions is independently associated with at least one other psychosocial health condition, which is in accordance with syndemic theory. Depression symptoms were independently associated with sexual compulsiveness and stress; sexual compulsiveness was also independently associated with stress; substance use was independently associated with IPV; stress was independently associated with depression symptoms, sexual compulsiveness, and IPV.

Table 2.

Multivariable logistic regression predicting intersecting psychosocial health conditions among black MSM (N = 301)

Variables	Depression	Sexual compulsiveness	Substance abuse	Intimate partner violence (IPV)	Stress
	OR(95% CI)	OR(95% CI)	OR(95% CI)	OR(95% CI)	OR(95% CI)
Age	0.98 (0.95, 1.01)	0.99 (0.96, 1.02)	0.99 (0.96, 1.03)	0.98 (0.95, 1.02)	0.97 (0.94, 0.99)*
Education
HS or less	Reference	Reference	Reference	Reference	Reference
Some college	1.69 (0.70, 4.09)	2.02 (0.89, 4.60)	0.58 (0.22, 1.52)	1.40 (0.63, 3.11)	0.67 (0.30, 1.50)
College graduate	1.60 (0.61, 4.18)	2.15 (0.88, 5.24)	2.30 (0.87, 6.05)	0.84 (0.34, 2.05)	0.88 (0.37, 2.10)
Post graduate	2.23 (0.86, 5.75)	1.60 (0.65, 3.93)	0.70 (0.25, 1.99)	0.86 (0.35, 2.12)	0.76 (0.32, 1.80)
Income
Less than $20,000	Reference	Reference	Reference	Reference	Reference
$20,000–39,999	0.61 (0.29, 1.30)	1.10 (0.55, 2.21)	0.71 (0.31, 1.63)	1.46 (0.73, 2.93)	0.87 (0.43, 1.75)
$40,000–59,999	0.63 (0.27, 1.50)	0.76 (0.34, 1.72)	0.78 (0.30, 2.05)	0.77 (0.33, 1.78)	1.37 (0.61, 3.10)
Over $60,000	1.17 (0.52, 2.65)	0.45 (0.20, 1.00)*	1.15 (0.45, 2.91)	0.58 (0.25, 1.35)	0.80 (0.36, 1.74)
HIV status
Negative	Reference	Reference	Reference	Reference	Reference
Positive	1.03 (0.58, 1.83)	0.57 (0.33, 1.00)*	1.19 (0.61, 2.30)	1.60 (0.89, 2.87)	0.93 (0.53, 1.64)
High risk sexa
No	Reference	Reference	Reference	Reference	Reference
Yes	1.12 (0.63, 2.00)	2.42 (1.40, 4.17)**	2.07 (1.12, 3.82)*	1.14 (0.64, 2.02)	0.66 (0.37, 1.16)
Psychosocial health conditions
Depression	–	1.88 (1.08, 3.26)*	1.38 (0.73, 2.61)	1.01 (0.57, 1.80)	2.67 (1.52, 4.67)***
Sexual compulsiveness	1.86 (1.06, 3.26)*	–	1.35 (0.72, 2.53)	1.17 (0.67, 2.05)	2.04 (1.19, 3.50)**
Substance use	1.38 (0.73, 2.60)	1.36 (0.73, 2.53)	–	2.57 (1.38, 4.78)**	1.31 (0.69, 2.49)
IPV	0.96 (0.54, 1.72)	1.16 (0.67, 2.03)	2.63 (1.41, 4.89)**	–	2.84 (1.64, 4.90)***
Stress	2.72 (1.54, 4.79)***	2.06 (1.20, 3.55)**	1.28 (0.67, 2.43)	2.82 (1.63, 4.86)***	–

^aHigh risk sex is defined as having unprotected anal intercourse, both insertive and receptive, since the last visit

*p ≤ 0.05, ** p ≤ 0.01, *** p ≤ 0.001

Subsequently, we examined whether the interconnection of health conditions amplifies the likelihood of engaging unprotected anal intercourse and more specifically, likelihood of engaging in unprotected insertive and/or receptive anal intercourse. Examination of the association between the number of health conditions and the prevalence of high-risk sexual behaviors revealed that as the number of health conditions increased so did the odds of engaging in UAI (OR: 1.33, 95% CI = 1.1–1.6). The analysis examining whether there is an additive effect of the number of health conditions and greater sexual risk-taking behavior indicated that men who had three or more health conditions engaged in more unprotected anal intercourse with their partners compared to men who had two or fewer health conditions, and consequently may be at greater risk for HIV transmission and acquisition (OR: 3.46, 95% CI = 1.4–8.3).

Discussion

Confirming our hypothesis, we found that a set of psychosocial health conditions are inter-related among Black MSM, and that this cluster of psychosocial health conditions is related to HIV risk-taking behavior in this population. In addition, the majority of men in the cohort reported negative early life events that significantly predicted the presence of syndemic conditions in adulthood. These data provide preliminary evidence to support the concept that many Black MSM experience health impacts of a syndemic, which is related to various and related early negative life events. Findings of this study explain the existence of co-occurring conditions among Black MSM and offer contributory factors which could be used to guide development of a set of innovative interventions to abate psychosocial health problems, and in the process, lower risk for HIV transmission in this population.

Findings showed that gay-specific childhood and adolescent stressors correspond with negative psychosocial conditions in adulthood and support syndemic theory, which represents a significant contribution to the interplay between negative life events and HIV risks for Black MSM in the USA. Moreover, our findings that Black MSM who reported having at least three conditions engaged in more HIV risk, provide some understanding of how social, cultural, and environmental contexts specific to Black men affect HIV risks over time. More specifically, these data show that for men who had multiple and significant negative life events particularly involving parental abuse, gay, and non-gay-related victimization, masculinity attainment, and internalized homophobia corresponded with risk and affect their sexual behaviors. While not causal, these findings do provide rich developmental contextual information that may help explain the greater likelihood to accept increased risks in their sexual behaviors as adults.

Our finding that substance use only correlated with IPV may be a finding that is specific to this sample of Black MSM. The Black men in the MACS substudy sample have been followed up to 10 years. Thus, report of substance use is relatively low, compared to other community-based samples of MSM, as they may have been in treatment or resolved their substance use behavior. It could also be that HIV risk behaviors may be less strongly associated with substance use among Black MSM, which aligns with other studies of Black MSM.^8,9

Additionally, the association of stress with other health conditions, except substance use, may indicate that at least among Black participants in the MACS, substance use was not primarily used to cope with stress, but that stress itself was a mechanism that impacts the sexual risk behavior.

This study has important implications for future research agendas and public health practice. Several studies have demonstrated a relationship between the presence of a syndemic and HIV seroprevalence,^3,4,7 but to date, the origins of syndemics have only been suggested theoretically¹⁶ and typically within samples of predominately white MSM.^3,4,7,29 This study also identified several variables that are associated with syndemic, findings that reinforce the need to devote some attention to social and familial problems related to growing up as a Black MSM to slow the disproportionate rate of HIV infections. This seems particularly apt given our finding of additive effects of syndemic conditions with greater risks for HIV via unprotected anal sex in Black MSM.

This study also provides innovative methodologies for pursuing syndemic research among Black MSM. In this study, most scales had only previously been validated among non-Black MSM. While we found that many of these measures were reliable, several measures were marginally so (Cronbach Alpha ≤ 0.70) and were removed from the analysis. This highlights the need for researchers in this area to develop measures that are culturally relevant to Black MSM in order to better examine HIV and other health disparities. This is especially salient when considering community connectedness for Black MSM. Community of origin and gay community connectedness may represent two non-intersecting dimensions for Black MSM.^30,31 Thus, researchers need to address the multidimensional psychosocial problems and needs of Black MSM by first developing methods to address these different dimensions of social, cultural, and gay-community connectedness.³²

There are limitations to the study. One is that we lacked specific information related to being a Black man in America from a sociocultural perspective, so it is impossible to attribute findings to Black MSM and not to Black men of any sexual orientation. For instance, measures of spirituality or community connectedness may have provided a better understanding of connectedness within the community, from a cultural perspective. Further, measures of cultural connectedness may provide insight into the ways that Black MSM orient themselves in terms of their cultural and/or their sexual orientation. Another limitation is the reliance on retrospective self-reports of syndemic production early life stressors, which may be subject to social desirability and/or recall bias. However, several studies utilizing these substudy data have found the test/retest reliability to be very high when participants completed the survey twice. Moreover, the psychosocial health conditions that comprise the syndemic outcome variables were evaluated using several different time frames. For example, CES-D questions were asked for the past 6 months, but IPV questions were for the past 5 years, whereas sexual risk was measured since last visit (also last 6 months for most participants). Also, participants in this study are survivors from a convenience sample therefore, conclusions regarding generalizability may be somewhat conservative. Additionally, the study does not assess questions relating to sexual (and gender) fluidity and diversity over time. For example, men in the sample may self-identify as heterosexual, yet behaviorally, be bisexual, which for Black MSM may be an important distinction. That said, this is a very important group that does have sex with men but do not perceive themselves to be gay/bisexual, which is important for tailoring interventions. Finally, Black MSM participants in the MACS substudy represent a different cohort of Black MSM, compared to other community-based studies of Black MSM. Participants in our study are better resourced (i.e., educated, higher income status, have regular and frequent contact with medical professionals, care and support) and have more social support than Black MSM sampled in other community-based assessments, further affecting the extent to which findings can be generalized to all Black MSM.

Despite these limitations, there are strong implications that can be derived from this study that may inform and require modification of current public health infrastructure when responding to the HIV prevention needs of Black MSM. Using a life course approach means that interventions, either behavioral or structural, need to start at a young age, and most importantly, need to be specific to the sociocultural contexts of Black men. A current program to prevent gay-related violence and victimization among youth is the “It Gets Better” campaign.³³ While important in its message, this may not speak to young Black MSM who are experiencing multiple life stressors that are specific to being both a racial and sexual minority.

To address the needs of Black men who have sex with men, structural changes need to be addressed, which focus on the need for social, cultural and gay community connectedness and its import to men who face multiple structural barriers in addition to life stressors. Then, and only then, can innovative interventions that not only focus on reducing HIV risk-taking behaviors, but improve the overall quality of life for Black MSM, including mental and physical health and well-being, untangle the intertwining epidemics faced by these men.