Conceptualizing the Effects of Continuous Traumatic Violence on HIV Continuum of Care Outcomes for Young Black Men Who Have Sex with Men in the United States.

Abstract

The United States (US) is on track to achieve the 90-90-90 targets set forth by UNAIDS and the National HIV/AIDS strategy, yet significant racial disparities in HIV care outcomes remain, particularly for young Black men who have sex with men (YBMSM). Research has demonstrated that various types of violence are key aspects of syndemics that contribute to disparities in HIV risk. However, little research has looked collectively at cumulative violent experiences and how those might affect HIV treatment and care outcomes. Drawing on extant literature and theoretical underpinnings of syndemics, we provide a conceptual model that highlights how continuous traumatic violence experienced by YBMSM may affect HIV outcomes and contribute to racial disparities in HIV outcomes. The findings of this focused review suggest a need for research on how continuous exposure to various types of violence influence HIV prevention and treatment outcomes for young Black MSM.

Introduction

The United States (US) is on track to achieve the 90-90-90 targets set forth by UNAIDS and the National HIV/AIDS strategy (90% of persons living with HIV know their status; 90% of persons with diagnosed infection prescribed antiretroviral therapy (ART); and 90% of those on ART virally suppressed).^1,2 Yet, this progress has been woefully unequal when considered by race, sexuality, and age.³ Black MSM continue to face the greatest burden of HIV. Data from 2018 suggest that 1 in 2 Black MSM are projected to acquire HIV in their lifetimes, compared to 1 in 11 white MSM.⁴ HIV diagnosis rates are between 22 and 33 times higher among Black individuals as compared to white.⁵ These disparities are more pronounced among young (aged 15-29 years old) Black MSM (YBMSM); nationally, these young men are three and five times more likely than their Latinx and white counterparts, respectively, to be living with HIV.⁶ Despite having fewer sex partners and less condomless sex than their white counterparts,^7,8 YBMSM account for nearly half of all HIV diagnoses among MSM aged 18-29, compared to 19% among white young MSM.⁹

Additionally, Black MSM fare worse on all dimensions of the HIV continuum of care outcomes (i.e., awareness of HIV status, initiation in care, retention in care, medication adherence, and viral load suppression) relative to their white MSM counterparts.^10,11 Research suggests that more Black MSM, compared to white or Latinx MSM, are infected but unaware of their HIV status.^12,13 Awareness of HIV infection is particularly low among MSM under the age of 30.¹⁴ Once diagnosed, estimates indicate that only approximately 53% of Black MSM living with HIV are retained in care,¹⁵ and Black people living with HIV are less likely to adhere to ART long enough to be virally suppressed compared to individuals of other races or ethnicities.^16–18 ART prescriptions among persons in HIV care increased overall from 89% in 2009 to 94% in 2013, yet fewer Blacks than Latinx or whites received ART prescriptions.^16,19 Among Black MSM in care, approximately 52% are virally suppressed (as compared to 59% and 67% of white MSM, respectively).¹⁵ Mirroring trends in HIV diagnosis, young Black MSM face worse outcomes along the HIV care continuum than any other age cohort.⁷ YBMSM are least likely to be retained in HIV care⁷ and are at particularly high risk of poor ART adherence and, thus, having a detectable viral load;^17,20 only about 45% of YBMSM are virally suppressed, compared to 60% of young white MSM.¹⁵

Syndemic Theory

These disparities in HIV prevention and treatment are likely attributable to syndemic factors, or the co-occurrence and interaction of social conditions and inequities,²¹ including violence, early-life adversities, substance use, depression, and homophobia.²² Syndemic theory demonstrates how health, social, and psychological conditions can co-occur and be mutually-reinforcing, ²³ to collectively increase disease burden for certain populations,^21,24 including HIV.²³ Singer (1996) proposed the SAVA syndemic to understand the mutually reinforcing nature of substance abuse, violence, and AIDS/HIV evident among low-income racial and ethnic minority men.^21,24 Researchers have continued to study how syndemic factors influence HIV risk among MSM. For example, in the EXPLORE study with a cohort of over 4,000 MSM, researchers demonstrated that accumulation of five syndemic factors (i.e., depression, alcohol, stimulant, and polydrug use, and childhood sexual abuse) predicts HIV seroconversion among MSM.²⁵ While most commonly applied to HIV risk^26–28 or incidence,^25,29 syndemics research has also examined the effects of syndemics on outcomes for people living with HIV. The overall effects of syndemics on HIV care outcomes has been found to increase with each additional syndemic factor, such that every increase in syndemic factors (polysubstance use, depression, violence, sexual risk) was associated with higher viral load.³⁰

Yet, since its introduction, syndemic theory has only minimally been applied to explain the HIV burden experienced by Black MSM.^31–33 In research with a large sample of Black MSM, greater syndemic burden (i.e., an additive index consisting of measures of depression, childhood sexual abuse, alcohol and drug use, and intimate partner violence) was associated with increased HIV risk behaviors and increased likelihood of HIV infection.²⁹ Additionally, data from the Multicenter AIDS Cohort Study demonstrate the interrelated nature of psychosocial health conditions among Black MSM including parental abuse, gay and non-gay related victimization, and internalized homophobia and their association with sexual risk behaviors.²⁶ Relatively little attention has been paid to the influence of syndemics on HIV prevention. Recently, Chandler and colleagues (2020) sought to fill this gap and found that, surprisingly, Black MSM who reported syndemic factors (e.g. substance use, depression) were more likely to report an HIV test in the previous 6 months, and more likely to report using PrEP, than Black MSM who reported no syndemic factors.^34,35 These findings suggest that individual-level factors (e.g. substance use) may be less relevant for understanding HIV disparities than social and structural syndemic conditions.³⁴

Violence syndemics

Violence has been identified as a critical, and still understudied, aspect of syndemics.³⁶ Violence is the intentional use of physical force or power, threatened or actual, that results in or has a high likelihood of resulting in injury, death, or psychological harm or maldevelopment.³⁷ Although included as part of Singer’s early syndemic research,²⁴ there continues to be a lack of understanding about how various types of violence influence HIV outcomes. Most research, for example, focuses on a specific type of violence exposure (e.g. childhood sexual abuse or intimate partner violence)^26,38,39 and its relationship to HIV outcomes, rather than looking collectively and interactively at several types of experiences of violence. Much of the research on violence as part of syndemics focuses on interpersonal violence, with less attention to the social and structural manifestations of violence, including police and neighborhood violence.⁴⁰ Additionally, there is little research on the ways in which various types of violence are co-occurring and reinforcing of one another, creating a syndemic of violence. Understanding the role of violence in syndemics among YBMSM is particularly needed, given that Black youth are significantly more likely to witness and be victims of violence than white or Latinx youth.⁴¹

Continuous traumatic violence

There is increasing recognition that individuals who are chronically exposed to violence, including social and structural forms of violence, may be particularly vulnerable to poor health outcomes.⁴² Similar to continuous traumatic stress, which includes chronic exposure to stressful life experiences,^43,44 continuous traumatic violence (also known as chronic violence exposure) refers to situations in which individuals repeatedly face violence or threats of violence in their everyday lives for prolonged periods of time. This violence can present as continuous danger or ongoing threats that can manifest as structural, economic, psychological, interpersonal and social violence.^44–46 An important characteristic of continuous traumatic violence is the existence of a current, ongoing threat rather than an isolated traumatic event or prior traumas in which the threat has ceased.⁴⁷ A small but growing body of literature has started to examine continuous traumatic violence and its effects on HIV risk and treatment outcomes.^48,49 Chronic exposure to violence has been found to be associated with condomless sex,^50,51 PTSD, and substance misuse⁴² among Black adolescent males. Although understudied, longitudinal research has demonstrated that the effects of violence and trauma on HIV prevention and treatment operate through a person’s overall level of exposure experienced over time, rather than a change observed within a confined timeframe,⁵² highlighting the importance of examining continuous traumatic violence across the lifespan. Continuous traumatic violence may play a key role in understanding racial disparities evident along the HIV care continuum.

Chronic exposure to violence may be more detrimental to health and resiliency than episodic exposures,⁵³ resulting in hypervigilance,⁵⁴ chronic psychological dysregulation, and the undermining of health seeking or promoting behaviors.⁵³ Individual victimization of any of these types of violence is essential for understanding HIV disparities experienced by YBMSM, as they disproportionately experience such violence types.^55,56 But, of equal importance, is the continuous exposure over time experienced by some YBMSM to household violence, violence among peer networks, and neighborhood violence. In order to adequately understand the comprehensive and longitudinal impact of violence on the syndemics of HIV, we must consider continuous traumatic violence and the interconnected nature of multiple types of violence. Continuous traumatic violence for YBMSM is particularly salient in urban areas, which have long histories of place-based police and neighborhood violence coupled with health disparities due to racial segregation and disinvestment. Individuals living in resource-constrained communities of color in the US are disproportionately impacted by violence,⁵⁷ and Black youth are significantly more likely to witness and be victims of violence than other youth.⁴¹ In Chicago, for example, neighborhoods that have high violence rates often bear the disproportionate burden of high STI/HIV rates.⁵⁸ Greater exposure to community violence is associated with more sexual partners, inconsistent condom use^59,60 and increased sexual risk behaviors.^51,61 Additionally, race-based policing practices have been identified as a community-level HIV vulnerability,⁶² as perceived racism is a driver of sexual risk behaviors.^63,64 Black MSM report high rates of being stopped and questioned by police, which may increase vulnerability to HIV and poor HIV care outcomes via psychological distress, racial discrimination, and condom-carrying behaviors.⁶² Racial discrimination, for example, is a well-documented driver of sexual risk behavior.^63,64

An intersectional framework of syndemics

Researchers have suggested that syndemics experienced by Black men may be best approached in combination with an intersectional framework that accounts for the intersecting systems and oppressions that reinforce syndemics.^65,66 Developed by Black feminist scholars,^67–69 intersectionality examines how multiple social identities intersect and reflect intersecting social and structural inequities.^67,68 For example, young Black MSM’s experiences with violence and HIV may reflect interlocking systems of oppression and privilege due to racism, heterosexism, sexism, and ageism. Intersectionality can complement syndemic theory by drawing attention to the systems and structures that influence syndemic conditions. Syndemic conditions such as community and police violence, criminal justice involvement, substance use, and psychological distress are created and upheld by broader structures of power and systems of oppression.⁷⁰ Yet, syndemic research frequently examines individual-level conditions (e.g. interpersonal violence) without adequately considering the relevant social structures that reinforce those individual-level factors.^33,71 Accounting for the unique and varied experiences of young Black MSM, particularly those rooted in structural intersectional oppression, may provide a more comprehensive understanding of syndemics.

Continuous traumatic violence and HIV outcomes among YBMSM: A proposed model

Guided by extant literature and theoretical underpinnings of syndemics, the continuous traumatic violence and HIV outcomes model (Figure 1) highlights the relationship among various forms of violence and the relationship between continuous traumatic violence and HIV risk and care outcomes. While accumulating evidence demonstrates the relationship between HIV and violence, there remains a paucity of research on this topic with YBMSM and a lack of understanding about how violence contributes to HIV outcomes and the ways in which we can protect against these outcomes. We provide an overview of the empirical literature that examines the syndemic relationships between various types of violence and the ways in which violent experiences collectively contribute to HIV risk and care outcomes.

Figure 1.

Continuous traumatic violence and HIV outcomes among YBMSM model

The proposed model suggests that experiences of violence, consisting of neighborhood violence, police violence, enacted stigma and discrimination, intimate partner violence, and childhood sexual abuse, can be chronic, cumulative, and mutually reinforcing, creating a violence syndemic. Similarly, those cumulative experiences of violence can both directly and indirectly (via psychological distress, internalized stigma, and PTSD symptoms) influence HIV care outcomes. There are also likely several protective factors including resilience, future orientation, self-efficacy, and network affiliation that may buffer the effects of violence. This model builds on existing empirical literature, summarized below.

Continuous traumatic violence experienced by YBMSM: A review of the evidence

Literature search

This is a focused review of published scientific literature on various experiences of violence among young Black MSM in the US and the ways in which violence operates as a syndemic. In early 2020, we conducted a literature review using PubMed, JSTOR, and Psychinfo to identify articles on violence in association with HIV prevention, risk, and treatment. Keywords included “violence and HIV,” “chronic violence exposure and HIV,” “violence syndemic” and “violence and Black MSM.” We also searched for specific types of violence known to affect MSM and/or Black men: childhood sexual abuse, race- and sexuality-based stigma and discrimination, neighborhood violence, police violence, and intimate partner violence. Although our focus was specific to young Black MSM, given the paucity of research on chronic violence exposure and violence syndemics among this population, we reviewed literature on violence among MSM of all ages and races and ethnicities. All searches focused on articles published in English. We reviewed abstracts to eliminate any unrelated studies (e.g. studies not in the US or those with women). Relevant research included both witnessing and experiencing violence and the effects of violence along all steps on the HIV continuum of care, including HIV prevention and risk. However, given the lack of research on violence along each step of the care continuum for Black MSM, particularly with regard to syndemic conditions, we have organized our review by type of violence, summarizing existing literature.

Neighborhood violence

The intersections of neighborhood violence, urban poverty, and HIV incidence are well documented among MSM.^25,26,72,73 In particular, an extensive literature review has documented that neighborhood violence exposures, including victimization and witnessing violence, are correlated with increased HIV risk behaviors among Black youth including early sexual debut, having sex while under the influence of drugs or alcohol, and having sex without a condom.^48,74 In research in Chicago, nearly 60% of adult participants reported lifetime exposure to neighborhood violence, and neighborhood violence was associated with HIV sexual risk behaviors among Black youth.^50–74–78 Similarly, longitudinal research with YBMSM has shown that having a close friend or neighbor who was robbed or attacked is associated with more fragmented social network ties, which is in turn associated with higher reports of using drugs while having sex.⁷⁹ Less research has examined how community violence exposure influences engagement in care, ART adherence, or viral suppression among YBMSM. However, some research has shown that neighborhood violence is positively associated with greater psychological distress, hard drug use, use of marijuana to facilitate sex, and condomless anal intercourse and negatively associated with ART adherence among YBMSM living with HIV.^80,81

Police violence

There is clear evidence that communities that experience high rates of neighborhood violence also experience elevated levels of police violence.^82,83 Continued police violence among Black men and the recent rise in support for the Black Lives Matter movement in response to the death of George Floyd,⁸⁴ have thrust issues of racism and police violence into the forefront. Little research has examined the effects of police violence on HIV outcomes for YBMSM. Predominantly Black communities experience a higher burden of policing, arrests, and violent interactions with police, which may disproportionately affect Black MSM.^85,86 Residential segregation is one of the most robust indicators associated with racial disparities in police shootings of unarmed victims.⁸⁷ States with higher levels of structural racism (measured by segregation, economic, employment, education, and incarceration indices), have significantly higher Black-white disparities in rates of police shootings of unarmed victims.^87,88 In a recent analysis of police violence, lifetime prevalence of police violence among Black individuals was nearly 18% for physical violence, 31% for psychological violence, and 29% for neglect, rates significantly higher than experienced by white and Latinx individuals.⁸⁹ Another study of excessive police violence estimated that Black men were 21 times more likely to be killed by police than white men.⁹⁰ Experience with police violence has also been found to be associated with greater odds of psychotic experiences and suicidal ideation and attempts among urban residents.⁸⁹ In another recent study,⁵⁴ among those who had ever been stopped by police, stops that met the criterion for being a traumatic event (participants who thought their lives were in danger or that they would be seriously injured) were associated with high levels of psychological distress. Notably, police violence had nearly twice the effect on psychological distress than exposure to other forms of neighborhood violence.⁵⁴

Yet, there is a dearth of research on the effects of police violence on YBMSM, or Black MSM living with HIV. Reported experiences of police violence are highest among communities of color and individuals who identified as gay or transgender.⁸⁹ In one of the only studies examining incarceration history and involvement with police among Black MSM, researchers found that police and law enforcement discrimination was associated with greater psychological distress and lower willingness to use HIV pre-exposure prophylaxis (PrEP) and incarceration and recent arrest were associated with greater sexual risk.⁹¹ Repeated arrests and episodes of incarceration can exacerbate the structural disadvantage that Black MSM experience by reducing access to housing, employment, medical care, and social services, which can create barriers along the entire HIV care continuum.^62,92,93 Furthermore, incarceration can be a particularly violent experience for Black MSM, who face higher likelihood of sexual victimization from staff and other inmates while in prison.⁹⁴ Importantly, data on police violence also provide some evidence of a violence syndemic, highlighting the association between police and other types of violence. For example, among a large urban sample, individuals who reported intimate partner violence or adverse childhood experiences (including child abuse) were significantly more likely to be exposed to all subtypes of police violence.⁸⁹

Stigma and discrimination

We conceptualize stigma associated with race, sexuality, or HIV status as a form of structural violence,⁹⁵ which may manifest as discrimination, marginalization, and physical violence. This conceptualization reflects the ways in which stigma is embedded in political, social and economic systems in the US to fuel inequity, injustice, and harm.⁹⁶ Given the prevalence and intersection of racism, homophobia, and HIV-stigma, Black MSM may frequently contend with stigma and discrimination.⁹⁷ For example, studies have identified high frequencies of reported discrimination based on race (40%), HIV status (38%) and sexual identity (33%) among Black men living with HIV, and further found that greater perceived discrimination was associated with lower ART adherence, increased AIDS symptoms, and lower likelihood of having an undetectable viral load.^98,99 Among Black MSM living with HIV, researchers have found that individuals who reside in neighborhoods with higher rates of poverty experience more frequent hate crimes related to their sexual identity. Additionally, neighborhood-related stressors are related to more frequent discrimination based on race, sexuality, and HIV status.¹⁰⁰

HIV-related discrimination has also been associated with lower ART adherence among people living with HIV.^99,101 Similarly, exposure to crime and experiences of sexual and physical trauma are associated with greater perceived HIV stigma and concerns about initiating ART.¹⁰² There is also evidence that stigma and discrimination from health care providers can influence HIV care outcomes. Among Black MSM, perceived stigma or mistreatment due to sexual identity or race from health care providers is associated with longer elapsed time since last appointment with an HIV provider.¹⁰³ These experiences of stigma can increase stress, limit social support, and increase sexual and drug-related risk behaviors among young MSM.^104–106

Intimate partner violence (IPV)

Rates of lifetime IPV among MSM range from 15.4% to 51%,¹⁰⁷ yet the relationship between IPV and HIV outcomes are still not well understood. Among Black MSM, receptive condomless anal intercourse at last sexual encounter, greater number of sexual partners in the last 30 days, and IPV were significantly associated with HIV prevalence and incidence.¹⁰⁸ A meta-analysis demonstrated that being a survivor of IPV was associated with increased risk of alcohol or drug use, depressive symptoms, condomless anal sex, and being HIV positive.¹⁰⁹ The relationship between IPV and sexual behaviors may be more complex for YBMSM, who are more likely to have older sexual partners and less experience negotiating safer sex than older MSM.¹¹⁰ Among young MSM, previous studies have found IPV to be associated with an increase in sexual risk behaviors.^111,112 However, research by Chandler and colleagues found that among Black MSM, syndemic conditions may actually increase HIV prevention efforts. In their research, men with one or more syndemic factors (including IPV, substance use, and depression), were more likely to have had an HIV screening within the past 6 months.³⁴ Similarly, syndemic conditions (IPV, substance use, and depression) were associated with increased likelihood to use HIV preexposure prophylaxis (PrEP).³⁵

Among MSM living with HIV, IPV may lead to disruptions in care. IPV has been associated with a higher rate of clinically relevant interruptions in care, including an increased rate of HIV-related hospitalizations after diagnosis.¹¹³ Similarly, among a diverse sample of MSM in Miami, researchers found that greater syndemic burden (including IPV), was associated with ART non-adherence and lower odds of viral suppression.¹¹⁴

Childhood sexual abuse (CSA)

Childhood sexual abuse (CSA) is forced or unwanted sex before the age of 18 with someone five or more years older.¹¹⁵ Experiences of CSA can have significant emotional and behavioral effects for MSM. Research has shown that the prevalence of CSA among MSM is higher than among men in the general population.¹¹⁶ A number of studies have shown a strong and positive relationship between CSA and higher rates of HIV risk behaviors¹¹⁷ and infections among MSM,¹¹⁸ and poorer HIV continuum of care outcomes.¹¹⁷ Among Black MSM living with HIV, experiences of CSA are associated with greater number of sexual partners.¹¹⁹ CSA is also closely linked with other syndemic factors. For example, individuals reporting CSA are significantly more likely to have symptoms of depression and to report using nonprescription drugs.^120–122 Substance use and psychological distress have been common pathways linking CSA to sexual behaviors.¹²⁰ Related to other experiences of violence, CSA is associated with adult IPV,¹²³ further compounding the effects of CSA and IPV. Studies have identified elevated rates of CSA and IPV among Black MSM, where CSA was associated with multiple HIV sexual risk behaviors.^39,119 Black MSM who have experienced CSA also report high levels of PTSD and substance use.¹²²

Continuous traumatic violence and the HIV care continuum

Given the stark disparities YBMSM face along the HIV care continuum, it is imperative to identify factors that reinforce violence syndemics to contribute to HIV disparities. A deeper understanding of how these multiple dimensions of violence may interact and influence HIV risk, engagement in care, and ART adherence among YBMSM is needed.

Psychological distress

Psychological distress, including depression, anxiety, and PTSD are hypothesized to be major mediating pathways linking various dimensions of continuous traumatic violence to poorer engagement and retention in HIV care for YBMSM. Rates of depression, anxiety, internalized stigma, and other psychological barriers are high among youth living with HIV.¹²⁴ YBMSM who have experienced greater neighborhood violence had nearly five times the odds of psychological distress compared to those experiencing less neighborhood violence.¹²⁵ Prior research has also found that YBMSM who experienced IPV were more likely to have greater psychological distress including suicidal ideation, where CSA was positively associated with the number of suicide attempts.¹²⁶

Internalized stigma

Internalized stigma refers to the internalization or acceptance of prejudice, stereotypes, and negative views as a product of social bias.¹²⁷ Internalized stigma can contribute to feelings of shame and lower self-worth, exacerbating the effects of violence on HIV disparities.^128–130 For example, several studies have shown that internalized HIV stigma was associated with greater depressive symptoms, longer gaps in HIV medical care, and lower likelihood of anti-retroviral (ART) medication initiation and adherence.^131–133 Internalized HIV stigma has also been linked to psychosocial outcomes and lower antiretroviral medication adherence;¹³⁴ persons living with HIV with internalized HIV stigma may face concerns about being seen taking HIV medications, subsequently reducing adherence.¹³⁵ Among YBMSM, internalized HIV stigma has been linked to greater psychological distress,¹⁰⁴ which can negatively influence decisions to seek medical care.¹³⁶

Racial and sexuality-related stigmas may have cumulative effects. Recent research has demonstrated that, among Black MSM, higher levels of internalized racial and sexuality-related stigma were associated with greater HIV/STI internalized stigma following diagnosis of HIV or an STI.¹³⁷ The extant research on internalized stigma has tended to focus exclusively on a single type of stigma (e.g., HIV stigma),^133,138,139 leading to an incomplete understanding of the ways in which stigma contributes to disparities in HIV outcomes. This is particularly problematic in understanding the HIV epidemic among Black MSM, as they are often exposed to high levels of multiple stigmas at the same time, including HIV status, socioeconomic status, sexual identity, and race.^32,140–142 Additional research is needed to understand intersectional internalized stigmas and their collective effects on HIV outcomes especially for YBMSM.

Posttraumatic stress disorder (PTSD)

Post-traumatic stress disorder (PTSD) is a lasting mental health condition associated with exposure to a traumatic life event. PTSD symptoms, including re-experiencing (e.g. nightmares), avoidance, and arousal (e.g. overly alert or easily startled),¹⁴³ may emerge in response to continued exposure to various forms of violence and stigma.⁶⁴ Although understudied among Black MSM, PTSD symptoms and traumatic stress have been found to contribute to poorer physical and cognitive functioning among people living with HIV.¹⁴⁴ Additionally, HIV-related discrimination is significantly associated with PTSD symptoms, as it may be a reminder of prior trauma (particularly hate crimes) and serve as a form of revictimization, aggravating PTSD symptoms.⁹⁹ Research has demonstrated that racial discrimination is associated with PTSD among Black men, increasing risk for contracting HIV^.145 Yet, relatively little work has teased out how PTSD symptoms may influence HIV outcomes for people living with HIV who have extensive histories of violence.

Protective factors

In addition to understanding the pathways by which violence may influence HIV outcomes, it is equally important to identify potential protective factors that could serve as points of intervention.

Resilience

Despite exposure to syndemic conditions, many YBMSM exhibit resilience,¹⁴⁶ or the ability to overcome the negative effects of adversity to successfully cope with trauma.¹⁴⁷ Meyer (2015) described two types of resilience: individual-based resilience (i.e., personal agency) and community-based resilience (i.e., connectedness to community and social resources).¹⁴⁸ The majority of research on resilience focuses on individual-level resilience and has a tendency to place responsibility on overcoming adversity on stigmatized individuals, without adequate consideration of one’s environment or resources.¹⁴⁹ In contrast, community-level resilience resources (e.g., access to community organizations) are seen as mitigating factors that are external to the individual and have the potential to help individuals overcome adversity.¹⁵⁰ Community-level resilience reflects a community’s capacity to empower marginalized individuals via affirming social norms and values, inclusive policies, and safe and inclusive community spaces and health centers.¹⁵¹

In an exploratory study with Black MSM living with HIV, researchers found evidence that HIV-related stigma was associated with a range of interruptions in health care, and that resilience was associated with positive HIV care outcomes.¹⁵² Another study explored resilience processes in young MSM living with HIV and found that relationships with healthcare organizations and groups were a key strategy in managing their HIV, especially community-based support groups for youth who were recently diagnosed and those that were peer-led.¹⁵³

Finally, although we conceptualize stigma and discrimination as a form of violence, there is also evidence that resilience processes in response to intersectional stigma may buffer the effects of stigma and discrimination for Black MSM living with HIV.^154,155 Supportive social networks of YBMSM have been found to improve coping with intersectional discrimination and stigma and foster empowerment through role-modeling, self-advocacy, and encouragement.¹⁵⁵ Additionally, research has found that coping strategies Black MSM living with HIV use to cope with racism may be adapted to cope with homophobia or HIV-related stigma.¹⁵⁶ Interventions that support coping and response to intersectional stigma and discrimination may be important in improving HIV care outcomes for YBMSM living with HIV.¹⁵⁷

Future orientation and self-efficacy

Future orientation is related to positive development in adolescence and may be a critical aspect of resilience as adolescents make choices and pathways to develop their personal and professional identities.¹⁵⁸ Similarly, self-efficacy has recently been situated within resilience theory when examining risk behaviors among adolescents, as positive self-efficacy may buffer the negative forces or stressors of daily life.¹⁵⁹ Several studies have documented that high future orientation (i.e., the ability to see a future self and forecast goals) and self-efficacy consistently mitigated the negative effects of neighborhood violence, interpersonal violence and family distress on HIV-related risk behaviors; further, high future orientation was correlated with more health seeking behaviors among YBMSM residing in highly economically disadvantaged and racially segregated Chicago neighborhoods.^160–164

Network affiliation and linkages

Historically, urban gay communities and nonprofits developed out of overwhelmingly white gay networks.¹³⁶ Thus, LGBTQ spaces that promote resilience in response to homonegativity may at the same time be a source of racism for MSM of color.⁷² In response, LGBTQ spaces designed by and for Black MSM have emerged to create safe spaces that reflect the needs of the Black LGBTQ community. Network affiliations (i.e., number and strength of connections to Black and gay communities) are also associated with differing HIV related risk and health promoting behaviors.¹⁶⁵ Additionally, gay community involvement among Black MSM may have protective effects.¹³⁵ The house and ball communities, for example, have served as important resources, particularly for YBMSM, providing supportive resources and an extended family network.⁷⁵

Community ties to the Black community may be particularly salient for YBMSM. Research in Chicago, which has a high racial segregation index,^166,167 has demonstrated that YBMSM were more likely to live in Black neighborhoods, had mostly same race friends and sexual partners¹⁶⁸ and experienced racism in the gay community and wider society.¹⁶⁹ Other research has shown that closeness with the mainstream gay community is associated with increased odds of living with HIV, higher rates of transactional sex, and increased sex under the influence of substances.¹⁶⁵ In contrast, strong connections to the Black community is associated with lower odds of living with HIV.¹⁶⁵ Accordingly, there is a need to understand how various social network ties and characteristics may influence the relationship between violence syndemics and HIV among YBMSM.¹⁷⁰

Methodological challenges and future research directions

In order to guide and support future research that would empirically test this proposed conceptual model for YBMSM, we highlight several important methodological challenges and areas for future research. Prior studies have only assessed limited types of violence, which might lead to an overestimation of the effects of a particular type of violence exposure given that many of these forms of violence tend to co-occur. Police and neighborhood violence tend to co-occur,⁵⁴ as do CSA and IPV.^123,171 Such overestimations might impede a more precise estimation of salient correlates, which can hamper effective assessment and intervention efforts. Additionally, as highlighted throughout this review, there is a significant lack of research on the experiences of violence among YBMSM. Inferences are made based on research with white MSM or older Black MSM, but the intersecting stigma and oppression facing many young Black MSM create unique experiences with violence that require additional attention. The presence of race-based violence, and the ways in which race underpins the broader social and political systems in the US, creates experiences that cannot be gleaned from syndemic research with white MSM.¹⁷² While some existing research on trauma and resilience can more broadly provide some insights into how violence may influence HIV prevention and treatment among YBMSM, we lack a clear understanding of which types of violence contribute to various behaviors, negatively impacting our ability to design and administer appropriate interventions.

These challenges also highlight the need to apply an intersectional lens to syndemics research.⁶⁵ Syndemics research too frequently focuses on individual exposures to violence without adequate recognition of the importance of oppression and power and the ways experiences of violence can vary based on the intersection at which an individual exists (e.g. race, sexuality, ability, socioeconomic status). Future research must continue to contextualize experiences of violence or syndemics experienced by YBMSM and contribute to interventions that are systemic or multi-level in nature, rather than focused at marginalized individuals. Additionally, an intersectional lens will help researchers consider the diversity within Black MSM populations, including sexual orientation, sexual identity, skin tone, socioeconomic status, and ability/disability. In our review, few studies explored or acknowledged this diversity. Thus, much of our existing literature refers to YBMSM as a single, monolithic group.

To advance the proposed conceptual model, qualitative formative research is needed to clarify, refine, and expand existing and proposed metrics and measures of violence syndemics. Qualitative data can be used to trace the trajectories of violence exposures and their intersectional impact on participants’ HIV history and continuum of care engagement. Qualitative data would also provide important insights into how individual and social types of resilience might help moderate the impact of violence syndemics on HIV continuum of care outcomes. For example, while community connections are typically understood to be protective, the reality may be more complicated for individuals who face racism and homonegativity from within communities to which they belong.

Finally, longitudinal research is also warranted to understand various dimensions of violence, their interactions and how they accumulate, and their impacts on each step of the HIV care continuum. Most of the research studies we highlight in this paper are cross sectional studies, limiting their ability to uncover intersecting and developmental effects on YBMSM. Longitudinal studies are needed to assess the short- and long-term effects of exposures to violence, the variation in cumulative violence effects, and violence syndemics effects on prevention, engagement and retention in care, ART adherence, viral load suppression. Longitudinal research must also apply methods that help identify syndemics and how they might evolve over time. For example, latent transition analysis (LTA), has demonstrated success in identifying various profiles of syndemics, changes in syndemic factors over time, and the ways in which protective factors (i.e. social support) may attenuate the effects of syndemic conditions for different individuals.¹⁷² Additionally, latent class analysis (LCA) has been used to identify patterns of HIV prevention and treatment and can help capture typically unmeasured patterns of concentration and interaction of syndemic factors.^173,174

In addition, large enough representative sample sizes are needed so that various permutations of violence and their individual and additive effects can be ascertained. Respondent driven sampling (RDS) approaches can be very useful to address the challenge of sampling hard to reach populations.¹⁷⁵ Similarly, studies have also recruited longitudinal community cohorts through a variety of community-based online and in-person strategies,^39,175,176 including venue-based sampling, which can be particularly useful in reaching typically underrepresented samples.¹⁷⁷

Limitations

This was not a systematic review and thus, our review may not have included all relevant literature. However, we are addressing significant gaps in the literature by proposing a conceptual model based on the available empirical literature that explores how violence syndemics might impact the HIV care continuum and factors that may influence those relationships. A more robust systematic review or meta-analysis is warranted. An empirical test of the conceptual model would help to identify more precise relationships between violence syndemics and specific HIV care continuum outcomes. There are certain areas of the literature that have received considerably less empirical attention and thus, the ways in which violence interacts with other syndemic conditions and effects each step of the care continuum remains unclear. Further, this review focused specifically on YBMSM in the US and thus, literature on the effects of violence on HIV care with populations outside of the US were not included. Violence is systematic in nature, influenced by social and political environments. Thus, the experiences of men in other countries may not apply to the experiences of YBMSM in urban communities in the US. Where possible, we identified the specific point in the HIV continuum affected by factors, however, an empirical test of the conceptual model would help to identify measurable relationships between violence syndemics and specific HIV care continuum outcomes. Even with these limitations, we are advancing scholarly understanding by proposing a conceptual model based on the available empirical literature that examines how violence syndemics might impact the HIV care continuum and the factors that may influence that relationship.

Conclusion

The proposed conceptual model advances our understanding of HIV disparities, especially the role of multiple dimensions of violence, to evaluate violence syndemics and their independent and interactive correlation with engagement and retention in care, HIV medication adherence, and viral suppression. There is a need to identify the most salient aspects of violence associated with engagement and retention in care and ART adherence among YBMSM, which can inform actionable public health strategies to reduce HIV disparities.