Substance use, intimate partner violence, history of incarceration and vulnerability to HIV among young Black men who have sex with men in a Southern USA city

Abstract

In this longitudinal qualitative study we explored the lived experiences of young Black men who have sex with men in Dallas, Texas in relationship to methamphetamine use, intimate partner violence and a history of incarceration as syndemic conditions that may contribute to their risk of transmitting or acquiring HIV. We conducted a total of 106 interviews (four repeat interviews every six months) with a cohort of 30 participants. Some reported condomless sex, and no discussion about condom use or HIV status with sexual partners. Fifteen participants reported that they were living with HIV. Methamphetamine use contributed to participants’ unstable housing, job loss, destructive relationships and HIV risk. One third of participants reported a history of intimate partner violence. About half had a history of incarceration resulting from IPV, substance use/dealing and/or other activities. Post-release, having a criminal record limited job opportunities and impacted their financial stability. Consequently, some engaged in survival work involving HIV risk (sex work, organising/participating in sex parties). Methamphetamine use, IPV and incarceration may constitute syndemic conditions that increase young Black men who have sex with men’s risk for HIV acquisition and transmission. HIV prevention interventions must address syndemics and include structural factors and the wider social environment.

Introduction

The HIV epidemic in the USA remains primarily concentrated among men who have sex with men. HIV disproportionally affects Black men who have sex with men (Lieb et al. 2011; CDC 2019), and particularly young Black men who have sex with men (Koblin et al. 2013). Estimates indicate that the lifetime risk of acquiring HIV is one in two for Black men who have sex with men, compared with one in four for Latino and one in 11 for white men who have sex with men (CDC 2016). Moreover, in 2016 36% of Black men who have sex with men diagnosed with HIV were 13–24 years old, and 39% were 25–34 (CDC 2019).

A disproportionate number of USA HIV cases (49%) are located in the southern states (Reif, Whetten and Wilson 2014). In 2015, Texas, where this study was conducted, ranked third among the 50 states in the number of HIV diagnoses, with only 57% of those diagnosed with HIV estimated to be virally suppressed (CDC 2019), and an overrepresentation of Black men who have sex with men and young Black men who have sex with men in particular among new infections (Texas Department Health Services 2018). A study of young Black men who have sex with men in Dallas and Houston found that condomless sex was associated with experiences of racism, homophobia and socioeconomic distress (Huebner, Kegeles and Rebchook 2014). Related findings showed that 30% of the men with an HIV negative/unknown status reported a history of incarceration, while 51% reported condomless sex in the past two months (Scott et al. 2014).

While individual and structural factors may explain Black men who have sex with men’s high HIV rates (Mayer et al. 2014), these men report similar or lower rates of sexual risk behaviour than other men who have sex with men. However, Black men who have sex with men are more likely to be affected by poverty, underutilisation of health services and barriers to HIV care compared to other men who have sex with men (Millett et al. 2012). Having sex with other men within sexual networks of Black men, in which some men living with HIV may not be diagnosed with HIV and/or are not virally suppressed, also likely increases HIV acquisition risk (Peterson et al. 2009).

A combination of structural and individual factors such as substance use, intimate partner violence and a history of incarceration in the lives of Black men who have sex with men may also affect their vulnerability to HIV. Some of these men may be part of social networks characterised by high rates of substance use and dealing, and therefore with high rates of incarceration and recidivism (Halkitis and Jerome 2008; Lim et al. 2011). Intimate partner violence is prevalent among men who have sex with men, with significant associations with substance use, and condomless sex (Buller et al. 2014). Among Black men who have sex with men, research has found multiple associations between intimate partner violence, substance use, including methamphetamine and HIV risk (Wu et al. 2015; Wu, El-Bassel and Gilbert 2018), with receptive condomless sex, number of sex partners and intimate partner violence as correlates of HIV infection among Black men who have sex with men testing for HIV (Beymer et al. 2017). Research has also shown an association between a history of incarceration among Black men who have sex with men and their HIV risk (Brewer et al. 2014). These factors may work in concert to produce vulnerability to HIV for Black men who have sex with men, but the literature on how they contribute to sexual risk is underdeveloped.

Although qualitative studies have emphasised the social contexts influencing substance use, mental health and HIV vulnerability among Black men who have sex with men (Bowleg 2013; Follings and Lassiter 2016; Johnson 2016; Wilson, Valera et al. 2016), little is known about how the interaction of psychosocial and structural factors relate to their HIV risk. In this longitudinal qualitative study, we use syndemic theory as a framework to explore the lived experiences of young Black men who have sex with men in Dallas, Texas, in relationship to methamphetamine use, intimate partner violence and a history of incarceration as syndemic conditions that may influence how they navigate their lives and combine to contribute to their risk of transmitting or acquiring HIV.

Syndemic theory refers to the synergy of co-existing biological and socio-structural factors that interact with and amplify each other to produce an additive or cumulative effect over and above the effect that any of those factors would create by themselves, resulting in an excess burden of disease in a population (Singer 1994; Stall, Friedman and Catania 2007). The concept of syndemics provides a framework to understand the drivers of the HIV epidemic and how the interaction of social/structural and individual factors exacerbates the burden of disease (Lancet 2017).

Methods

Data and sample

We conducted in-depth, semi-structured interviews every six months with a convenience sample of 30 young Black men who have sex with men who participated for two years (2013–2015) in a longitudinal cohort (total of 106 interviews). We attempted to interview each individual four times. By following a diverse sample of these men for two years, we were able to document how the conditions and social processes that affected their lives influenced their vulnerability to HIV.

Men were eligible to participate if they self-identified as African American or Black, were 18–29 years old, had sex with other men, resided and intended to remain in Dallas for two years. We directly recruited participants through an HIV prevention intervention programme that was being evaluated as part of this investigation, and through conducting participant observation at clubs and community events. We sampled purposively to include a variety of experiences regarding involvement in the HIV prevention programme, and also used snowball sampling to build the sample, asking participants to refer friends and acquaintances that might qualify. Our ethnographer, who also conducted the interviews, screened potential participants in a private area at the HIV programme space or at community venues. Men interested in participating and/or being referred by other participants could also contact the ethnographer through social media and were screened by telephone.

Interviews were conducted in a confidential space at the University of Texas Southwestern. Participants provided information (phone numbers, email addresses, Facebook aliases) that we used to contact them over time. Of the original cohort of 30 participants enrolled at baseline, we retained 25 (83%) throughout the study. After the first or second interview, two participants moved from Texas, two were incarcerated and one was lost to contact. Participants provided written informed consent before the first interview and received an incentive of $50 at each interview. Institutional Review Boards at the University of California San Francisco and the University of Texas Southwestern approved the study.

Interviews focused on education, employment, relationships, social networks, self-esteem, sexual life/sexual risk behaviours, HIV testing and treatment, substance use and perceptions of HIV prevention programmes and HIV-related norms. Interviews lasted 90–180 minutes, were audio-recorded and transcribed verbatim. The third author, a white man and ethnographer at the University of Texas Southwestern with experience working with marginalised communities in Dallas, conducted all the interviews.

Analysis

We used an inductive-deductive approach based on thematic analysis (Rubin and Rubin 2005). Four researchers, including the interviewer, analysed the data. We developed a set of broad codes based on the study objectives and interview guides, such as HIV-Related Risk, Romantic Relationships and Experiences Growing-Up Gay. An initial line-by-line analysis of selected transcripts produced emergent themes, such as Incarceration History, Limited Employment Opportunities, Unstable Housing and Violence Experiences, which we incorporated into the larger coding scheme and applied to all transcripts. Coding differences were noted and explored during regular meetings, with memos written up to generate theory and to set guidelines for code application. The team compared coding to build inter-rater reliability (assessing percent agreement in the coding of selected interviews at the outset, mid-point and end of the coding process) reaching a threshold of 90% coder agreement. The participants’ ages are what they reported at the first interview. We identify participants using pseudonyms to protect anonymity and confidentiality.

Findings

Participant characteristics

Participants were 19–29 years old. Many participants had not completed high school and had limited employment skills; few had stable jobs throughout the study duration. Some participated in the sex economy (street/online sex work, sex parties, porn industry), and in informal street economies (odd jobs, dealing drugs, shoplifting, selling stolen merchandise). They lived in different parts of Dallas by themselves, with family or roommates or in unstable situations (inexpensive motels where sex work or drug use occurs, “couch surfing,” staying with friends or were homeless). Although some participants had family members as positive role models, many had grown up in unstable family environments. Some had strained or no relationships with their biological families, particularly with parents unable to raise them because of their own substance use or incarceration. Most participants identified as gay and participated to different extents in the gay Black community. Their sex lives were in the context of casual encounters or serial boyfriend relationships, mostly with other young Black men. Some reported condomless sex and not having discussed condom use or HIV status with sex partners. Six participants reported being contacted either by the local Health Department’s Partner Services or their sex partners about potential exposure to HIV/STI. No participants were taking Pre-Exposure Prophylaxis, and few could describe its purpose. All participants reported to know their HIV status. Ten participants stated that they were living with HIV at their first interview, and five others reported in subsequent interviews that they had seroconverted (50% of the 30 participants reported living with HIV during the study). Throughout the results, we thread participants’ stories to examine how methamphetamine use, intimate partner violence and having a history of incarceration interact in the lives of our participants to create vulnerability points related to their risk of transmitting or acquiring HIV.

Methamphetamine use and its consequences

While most participants referred to drinking alcohol and smoking marijuana as a normal, everyday activity, they reported the use of methamphetamine to be problematic and widespread among young Black men who have sex with men. A participant noted: ‘Crystal, Tina, Ice¹, that’s the most popular. Weed [marijuana] is number one because it’s easy to get, it’s really not harmful. But meth is number two ‘cause I’m hearing a lot of young attractive people doing that.’ Participants told of different experiences related to methamphetamine, whether administered orally, nasally or intravenously, and its potentially deleterious impact on relationships, sexual risk and living with HIV. Two participants had stopped being in relationships because of their boyfriends’ use of methamphetamine. One of them explained:

His drug of choice [methamphetamine] I couldn’t deal with. That’s the type of drug that messes with your mind. He was like, ‘I’ll stop for you, I promise, da, da.’ [Then] we got into our first argument. And the first thing [he did was he] bought more meth [methamphetamine]. I knew it was going to be a pattern. I didn’t want to be in that relationship.

Several participants talked about friends who were living with HIV and out of care and using methamphetamine as a means of coping with their HIV status: ‘to forget about it, to try to deal with the situation [living with HIV], which is the total opposite of what they need to be doing.’

John (age 29) reported a history of methamphetamine use intertwined with intimate partner violence, incarceration, and risk of transmitting HIV. At the time of his first interview, John had been diagnosed with HIV for nine years but was not receiving HIV care and had been using methamphetamine for the last five. Referring to previous jobs, he said: ‘I lost [my job] doing drugs, now I’m trying to get back on track.’ He had a misdemeanour criminal charge for the physical assault of an ex-boyfriend, unpaid traffic tickets, had been raped, lived in his car with a friend with whom he had sex, managed that friend’s sex work engagements and did sex work himself. John related methamphetamine use to HIV risk behaviours in the context of sex parties and ‘party and play’, the recreational use of drugs that facilitate sexual activities:

There’s too many sex parties. Dallas’ gay community used to be stronger on powder [cocaine] but now… everybody is doing Tina. Like party and play. Bring your own drugs. It [methamphetamine] turn you into ‘Who is that big prostitute?’ That’s the number one [activity] spreading it [HIV].

As described by various participants, groups of 10–20 Black men attended the sex parties, usually held at hotels, mentioned by John. Condoms might or might not be available at these events. The organisers would collect $20 entrance fees (drinks included), bartend, socialise, and/or participate in sex. At least three participants organised those parties for income.

Whether to cope with HIV or other issues, methamphetamine use seemed central in John’s life and a potential factor in his transmitting HIV. John reflected on the consequences of methamphetamine use in his life, while stating that it was not for him:

Meth has been helping mask my problems. It’s not the road I want to go. I made myself homeless, [I] did what they do [steal, sex in exchange] to get high. At first it was cool. Not eating, a quiet world [because of using methamphetamine] but then it started consuming me.

John’s circumstances remained the same at the fourth interview two years later. He procured money in the street or online (persuading men at hook-up sites to send him money with a promise of sex), injected methamphetamine, knew he had hepatitis but not what type and his HIV care was sporadic. He reported that not having a car, after the police had seized his, made it hard for him to keep medical appointments. While at odds with his life situation at the time and perhaps encumbered by his methamphetamine use, he still stated his need to get back on track, expunge a legal charge, avoid activities that may lead to prison and not add any extra burden to being Black and gay, two of his social identities:

My [criminal] background is starting to hurt me again, but to get it [legal record] expunged it’s $500 to $1000. My main focus [is] to have my own business…. I need to have a clean underbelly and nobody can pull nothing up [a criminal record], ‘Oh you did this,’ because that can hurt you when they run a background [check]. I don’t believe in the Fed [prison]. That’s the devil. I’m Black and gay and I don’t need nothing extra to bring me down.

Intimate partner violence, methamphetamine use, incarceration, and vulnerability to HIV

Approximately one third of the participants reported a history of physical intimate partner violence in their present or past romantic relationships, sometimes resulting in serious injuries. While none of them reported sexual violence as part of those relationships, other forms of violence were a feature of many participants’ social context. Those included domestic violence and brutal deaths (a father murdered, a brother killed by the police) in their families. They also included participants’ fights with relatives associated with families’ lack of acceptance of their being gay; at school, the armed forces or correctional facilities in the context of bullying and homophobia; or in venues such as clubs in the context of alcohol use.

Participants reported jealousy or cheating as reasons for intimate partner violence. Some qualified their accounts of intimate partner violence by saying it was a consequence of being young, ‘stupid’, using drugs or alcohol or lack of experience being in a relationship. At times, it was hard to discern the role of aggressor or victim from those violence-related statements.

At his first interview, Damon (age 24) referred to the regular physical fights, power struggles and economic imbalances within a context of drug use as part of the relationship with his ex-boyfriend:

It was pretty much a fast [falling] in love. That’s when all the bullshit started as far as the power… I got fired, drug usage caused me to be not dependable, got another job. I hated that job [and quit]. By this time, he started back the illegal stuff [fraud], he was supporting me. He paid the down payment for me to get another car. [Then] I found out he cheated on me. And me being angry … we got into a fight. That was the first time [it got physical], I kind of shrugged it away like it wasn’t nothing…. he hit me on the mouth, he busted my leg. Part of me was almost like I had to deal with certain things to afford this lifestyle [being supported financially].

Damon acknowledged that his strategy to avoid fighting was to encourage his boyfriend to stay on methamphetamine: ‘Definitely, [we fight] once a month, sometimes more frequent. It always seems to be when he’s sobering up. A lot of times I would try to keep him high to avoid it [violence].’ A fight before breaking up resulted in Damon being incarcerated for assault charges, and having no economic resources left: ‘I came out to having nothing, nor a vehicle or a place to stay. I went through a bad depression, a depressed state.’

At Damon’s third interview, in a sometimes-confusing timeline of events characteristic of his interviews, he had not picked up his HIV test results due to fear of being diagnosed with HIV. He had been HIV tested after the Health Department’s Partner Services contacted him for potential exposure to HIV and learning that his ex-boyfriend had been hospitalised possibly for HIV-related symptoms. Based on his reports, both intimate partner violence and methamphetamine use resulted in criminal charges and incarceration. At the fourth interview, he was unemployed and couch surfing. He had not slept for several days. He stated that he was HIV negative but acknowledged not always using clean syringes when injecting methamphetamine. He recounted new criminal charges for possession of substances and public intoxication when the police found methamphetamine in a motel room where he was staying with friends. His circumstances still constituted a downward spiral, and methamphetamine use, the consequences of incarceration and HIV risk were still apparent in his life. Similar to other participants, he seemed powerless regarding how to proceed with his recent legal charges related to drug possession, appeared not to understand the specifics of his legal situation and had no resources to hire a lawyer.

Incarceration and its social and financial consequences

Approximately half our participants had a criminal record, with a history of short or long-term incarceration. Some had multiple criminal charges. Reasons for incarceration included arms or drug possession/dealing, physical assault, prostitution, identity theft/credit card use, forgery and/or association with partners or friends’ illegal activities. None of the participants with a history of incarceration reported HIV seroconversion while incarcerated. Most of them reported having few economic resources and little financial stability upon release, and that having a criminal record curbed their options for employment and housing. One participant provided examples of how astuteness as well as luck might help him pass background checks to secure gainful employment despite having a criminal record. Luck involved employers’ lax policies regarding criminal records. Astuteness meant, for example, switching digits of one’s social security number in background check forms hoping it would go unnoticed.

Peter (age 25) illustrates the risk of transmitting HIV through sex, the mixed health and financial outcomes related to incarceration and fears of criminalisation based on HIV status. At the first interview, he reported owning a small business, had a felony charge and was out of HIV care. He referred to his risk of transmitting HIV to men willing to have condomless sex with him as not being his responsibility: ‘[Being HIV positive] really didn’t have that much of a consequence to those who really was interested in having sex with me… most people don’t care.’

At his second interview six months later, Peter reported that he had spent three months in jail under a new charge, had lost his business and car because of financial debt and was living with family. Consistent with the report from another previously incarcerated participant, time in a correctional facility provided him an opportunity to reengage in HIV care and become virally suppressed. Referring to living with HIV, and to the fact that he previously had been out of HIV care, he said: ‘Until recently I didn’t look at the drawbacks of being positive… how people can become sick. [But] friends started dropping off [dying] because of it and I was like, okay, this is serious.’ Concerned about laws criminalising HIV transmission, Peter explained that he started having protected sex only when he realised that living with HIV and not using condoms could be a criminal offence and a reason for incarceration: ‘I’m afraid. I don’t want to get into any trouble. I’m done with the law and jail.’ Unfortunately, Peter moved to a different state after his second interview and was lost to follow-up.

A few previously incarcerated participants engaged in sex work to earn money when legal employment and housing opportunities were limited due to having a criminal record. At the first interview, Danny (age 29) supplemented his restaurant work by engaging in condomless sex for money. His roommates paid his rent. Like other participants, he acknowledged the impact of his criminal record, the result of activities committed when younger: ‘I can find jobs–but it’s housing. If I do get something it’s slummy, infested with roaches. That [robbery] was a mistake when I was younger. I’m tryin’ to get over it. But it’s always there.’ At the fourth interview, despite his statements about employment not being an issue, Danny was still unemployed and his roommates still covered his rent. He had recently been jailed for evasion of public transportation fare. He had some income from organising sex parties, at which he also engaged in condomless sex.

Tobias (age 23), on the other hand, presented a story of personal redemption. At the first interview, he reported having different criminal charges, and experiencing IPV as part of a bad breakup when he described himself as ‘a person I didn’t like.’ He had a history of recurrent STIs, indicating condomless sex. Incarcerated male relatives had been his role models, but his grandfather was a guiding figure who was helping him stay out of trouble and out of jail: ‘[grandfather’s] guidance basically to not mess up no more cuz I don’t want to go to the pen [jail or prison] again.’ He explained that because of his self-determination, learning from past mistakes and his family support he was changing and learning to be a better person:

Everybody I knew growin’ up was on probation. I wanted to get on probation as crazy as that sounds because that’s how friends, [and] all the males in my family, except for my pops [were]. I haven’t always been on the straight and narrow course. I did things my way and I always rebelled. And [now] I’m gettin’ settled. It’s helping me [probation] become a better person.

By the time of the fourth interview, Tobias lived with family, had held a job for more than a year and was back at school. With his mother’s support, he had learned how to protect himself sexually and avoid STIs. While he did not know whether his record could be expunged after his probation ended, when asked how having a felony had affected him, he answered: ‘It takes a lot to stop me. I know what I want and I am going to get it regardless. I’ll find a way.’

Discussion

Understanding the experiences of young Black men who have sex with men and the social contexts of their lives is the first step in developing comprehensive HIV prevention interventions with them (Dillon and Basu 2014). These qualitative narratives illuminate how substance use, intimate partner violence and the consequences of incarceration constitute syndemic conditions that interact in young Black men who have sex with men’s lives, particularly in the USA South, to increase their HIV vulnerability.

Similar to other findings from qualitative narratives with young Black men who have sex with men (Nation, Waters and Dawson-Rose 2018), methamphetamine use among our participants was associated with HIV risk in the context of party and play and sex parties. For some young Black men who have sex with men living with HIV such as John, methamphetamine may serve as a way of coping with the hardships of life, including an HIV diagnosis, instead of seeking HIV care, as well as a potential factor in his transmitting HIV to others. Based on participants’ stories, intimate partner violence may be related to methamphetamine use, and reflect lack of communication skills to navigate the power dynamics and sexual arrangements in their romantic relationships. Unable to steer interpersonal conflict, and because of economic dependency or fear of further violence (Cruz 2003), young Black men who have sex with men like Damon may remain in unhealthy relationships characterised by intimate partner violence and substance use that increase their chances of incarceration and their vulnerability for HIV.

For many participants, intimate partner violence, drug possession/dealing or other illegal behaviours resulted in a history of incarceration, illustrating the interaction of syndemic conditions as some of them, despite their young age, cycled through correctional settings and accumulated criminal records which prevented them from successfully gaining formal employment. The precarious financial situations of our participants often drove risk behaviours. The large number of participants in our cohort with a history of incarceration corresponds to other findings among young Black men who have sex with men in Houston and Dallas for whom, incarceration was associated with condomless sex, HIV/STI diagnosis, binge drinking, stimulant use, homelessness and unemployment (Kegeles et al. 2015). Other research findings also suggest that substance use, mental health issues and unstable housing influence the rates of incarceration among young Black men who have sex with men with participation in social and sexual networks with criminal justice involvement (Schneider, Lancki and Schumm 2017).

Many participants faced challenging structural issues; their financial situation varied between interviews in a downward spiral, and HIV risk was apparent in their lives. Some tried to improve their circumstances over time through legal means, but those became closed off due to their having few skills that would make them employable, limited access to economic opportunities and a history of incarceration. For others, these factors seemed to exacerbate pre-existing socioeconomic conditions within a social context of poverty and marginalisation and resulted in the belief that only illegal income generating activities would be successful. Through the two years of this study, support from associates or their own personal agency helped a few previously incarcerated participants, like Danny and John, engage in means of survival where HIV risk may occur, such as sex work or organising and participating in sex parties. Conversely, for men like Tobias, personal agency and family support may help protect them from HIV, overcome the negative consequences of their own incarceration and blunt the deleterious impact of considering incarcerated relatives as role models to emulate (Miller 2006). Similar to other research (Rowell-Cunsolo, El-Bassel and Hart 2016; Schneider et al. 2017), we found that for at least some participants living with HIV, incarceration could make a difference in helping them achieve HIV viral suppression. Ironically, this may be a consequence of individual and structural barriers to accessing health care in the community. Different from our findings, access to medical care in carceral settings may vary, negatively affecting HIV care engagement and contributing to correctional facilities becoming syndemic nodes that help re-create synergistic social conditions that contribute to produce an excess burden of disease among incarcerated Black men (McCarthy et al. 2016).

Following Singer’s model for overlapping syndemics of substance use, violence and HIV/AIDS (2006), our findings suggest that methamphetamine use, intimate partner violence and a history of incarceration may constitute syndemic conditions that cluster, synergise and intertwine inseparably in the lives of the men in our study and may contribute to their vulnerability of acquiring or transmitting HIV. Syndemic theory emphasises the significance and dialectical interactions between structural and individual factors that exacerbate the burden of HIV disease (Baer, Singer and Susser 2013). The synergy of disease concentration, disease interaction and the cumulative impact of social forces conducive to disease inherent in syndemic theory’s biosocial approach (Tsai et al. 2017) provides a different paradigm to conceptualise the HIV epidemic among young Black men who have sex with men (Wilson et al.2014).

Quantitative studies have found evidence that syndemic conditions increase HIV vulnerability among men who have sex with men in general (Mimiaga et al. 2015; Santos et al. 2014), and among Black men who have sex with men (Dyer et al. 2012; Williams et al. 2015; Nelson et al. 2016). Few qualitative studies have examined HIV risk from the perspective of syndemics among men who have sex with men (Adam et al. 2017), and among Black men who have sex with men’s HIV care engagement (Quinn et al. 2018) in particular. While so far limited, the contribution of qualitative research to a syndemics approach may be to provide urgently needed empirical evidence and narratives (Tsai 2018) that explore the societal contexts, structural factors, environments and individual risk behaviours conducive to the existence of syndemic conditions. Qualitative research may also highlight the need for more comprehensive approaches to HIV prevention and care for achieving better health outcomes.

Consistent with qualitative methods, while our findings cannot be generalised, they suggest the synergistic interaction of substance use, intimate partner violence and a history of incarceration with HIV risk among young Black men who have sex with men. The presence and interaction of these factors as syndemic conditions in the lives of young Black men who have sex with men, particularly in the USA South, deserve further examination, together with the pathways of causality between the socio-structural, biological and psychological factors that may interact to produce HIV infection and be considered syndemics (Tsai et al. 2017). The involvement of young Black men who have sex with men in the sex economy, party and play and the impact of the intersecting stigmas of substance use, IPV, incarceration, fear of HIV testing, living with HIV and engaging in HIV care (Calton, Cattaneo and Gebhard 2016; Room 2005; Western and Wildeman 2009; Swan 2016) that may affect them deserve attention separately as specific themes.

Implications for HIV prevention and care

It is time to act to prevent new HIV infections among young Black men who have sex with men and facilitate their engagement in care among if living with HIV. While further research is needed on how to address syndemic conditions through multidisciplinary interventions (Douglas-Vail 2016), interventions must also address protective factors, such as optimism and education (O’Leary et al. 2014), resilience, supportive relationships and gay community involvement (Reed and Miller 2016) that may help young Black men who have sex with men navigate oppressive social structures and/or counteract syndemics (Wilson, Meyer et al. 2016).

Such interventions also need to include assessment of psychosocial issues and leverage culturally appropriate mental health and substance use services (Mimiaga et al. 2015), explore young Black men who have sex with men’s images of masculinity, sexual stereotypes, power relations and sexual arrangements (Essack et al. 2019) and the impact of racism, homophobia and stigma (Arnold, Rebchook and Kegeles 2014). Interventions also need to examine the implicit function of sex in men’s lives (e.g. “raw sex” in spaces such as sex parties and/or in the context of party and play) as an expression of their sexual desire and potential resistance to heteronormative and homonormative sexualities (Bailey 2016; Rhodes et al. 2011). These much needed interventions may help change the life experiences and HIV vulnerability of young Black men who have sex with men, and norms in the Black gay community and Black communities at large.