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. Author manuscript; available in PMC: 2022 May 1.
Published in final edited form as: AIDS Care. 2020 Oct 14;33(5):663–674. doi: 10.1080/09540121.2020.1828798

Associations of social capital resources and experiences of homophobia with HIV-related risk behaviors and HIV care continuum among men who have sex with men in Los Angeles

Sae Takada 1,2, Pamina Gorbach 3,4, Ron Brookmeyer 5, Steve Shoptaw 6,7
PMCID: PMC8044261  NIHMSID: NIHMS1637275  PMID: 33050712

Abstract

For men who have sex with men (MSM) in the US, the positive (access to resources within their social networks) and negative (experiences of homophobia) elements of social capital may explain their disproportionate burden of HIV infection. We analyzed data from 379 HIV seronegative and seropositive MSM in Los Angeles, collected between May 2017 and February 2018. Dependent variables were HIV transmission risk behaviors and care continuum outcomes. We used multivariable logistic regression to estimate the association between social capital resources and experiences of homophobia with dependent variables, adjusting for sociodemographic variables and drug use. Most participants were under age 40, and 41% identified as Black/African American and 36% as Latino/Hispanic. Social capital resources associated with likelihood of new sexually transmitted infections (−5.5% per standard deviation (SD) SD, 95%CI −10.3,0.7%) and HIV testing (5% per SD 95%CI 0.8,9.2%). Experiences of homophobia associated with likelihood of methamphetamine use during sex (10% per SD 95%CI 7,14%) and receiving (4.3% per SD, 95%CI 1.9,6.7%) and giving (7.2% per SD 95%CI 4.5,9.9%) exchange sex, and missed appointments (7.2% per SD 95%CI0.8,13.6%). Findings that elements of social capital consistently associated with HIV transmission risk behaviors and HIV testing suggest interventions to increase social capital resources would have great impact on the HIV-prevention continuum.

Keywords: men who have sex with men, social capital, homophobia, HIV care continuum, Risk behaviors

Introduction

In the United States, gay, bisexual, and other men who have sex with men (MSM) bear a disproportionate burden of HIV infection (Centers for Disease Control and Prevention, 2017; Purcell et al., 2012). Further, they fall below national goals for achieving HIV testing, linkage to and retention in care, and virologic suppression, collectively known as HIV care continuum (Singh, 2017). Individual-level risk behaviors (Beyrer et al., 2012) do not sufficiently explain persistent HIV disparities, particularly among racial and ethnic minorities, prompting examination of social and structural environments.

Social capital is a concept that encompasses the resources embedded in social relationships, such as expectations of reciprocity, trust, information and norms, that serve as resources for individuals and facilitate collective action (Coleman, 1988; Kawachi, Subramanian, & Kim, 2008; Moore & Kawachi, 2017; Putnam, 2001; Villalonga-Olives, Wind, & Kawachi, 2018). Social capital is associated with health benefits, including all-cause mortality (Kawachi, Kennedy, Lochner, & Prothrow-Stith, 1997). It links with mental health and substance use (De Silva, McKenzie, Harpham, & Huttly, 2005; Hikichi et al., 2017; Weitzman & Kawachi, 2000), and HIV outcomes (Yusuf Ransome et al., 2018), including linkage to and engagement in care, delayed diagnosis (Y. Ransome, Kawachi, & Dean, 2017), HIV-seroconversion (Hermanstyne et al., 2018), pre-exposure prophylaxis awareness (Yusuf Ransome, Zarwell, & Robinson, 2019), and transmission risk behaviors (Campbell, Williams, & Gilgen, 2002; Crosby, Holtgrave, DiClemente, Wingood, & Gayle, 2003).

While the literature largely focuses on its health benefits, social capital can also cause harm through the promotion of unhealthy norms and beliefs and the exclusion of those who do not conform (Coleman, 1988; Portes, 1998; Villalonga-Olives & Kawachi, 2017). This double-edged nature of social capital is demonstrated in experiences of homophobia among MSM, the verbal and physical insults from family, institutions, and community due to biases against their sexuality (Frye et al., 2014; Jeffries, Marks, Lauby, Murrill, & Millett, 2013; Kosciw, Greytak, Zongrone, Clark, & Truong, 2018; Quinn & Dickson-Gomez, 2016). MSM who describe religion and faith as important aspects of identity also report homophobia as prevalent within their faith communities (Diaz & Ayala, 1999; Quinn & Dickson-Gomez, 2016).

Homophobia is a form of stigmatization, a process that makes an attribute “deeply discrediting” and reduces a person “to a tainted, discounted one” (p.3) (Goffman, 1963). Stigma operates at the interpersonal level, specific to the relationship between the stigmatized and the stigmatizer (Major & O’Brien, 2005; Takada et al., 2019; Yang & Kleinman, 2008). Experiences of homophobia have been associated with HIV transmission risk behaviors (Garcia et al., 2016; Jarama, Kennamer, Poppen, Hendricks, & Bradford, 2005; Mizuno et al., 2012), delayed HIV testing (Scott et al., 2014), and mental health and substance use (Hatzenbuehler, Nolen-Hoeksema, & Erickson, 2008; Li, Okafor, Gorbach, & Shoptaw, 2018; B. Mustanski, Andrews, & Puckett, 2016).

This study assessed the concurrent effects of the positive and negative aspects of social capital on HIV outcomes. The theory of fundamental causes posits that social context is a fundamental cause of health inequalities that influences multiple mechanistic pathways through shaping access to resources (Link & Phelan, 1995; Phelan, Link, & Tehranifar, 2010). Expanding upon this theory, we hypothesize that social capital is a fundamental cause of health for MSM by positively and negatively influencing HIV transmission risk behaviors and engagement in care continuum. We examine the association of social capital resources and experiences of homophobia with these outcomes in a cohort of highly diverse MSM in Los Angeles. We hypothesize that social capital resources are associated with fewer transmission risk behaviors and better achievement of care continuum milestones, while homophobia is associated with more transmission risk behaviors and worse achievement of care continuum milestones (Figure 1). We also hypothesize that social capital resources buffer the effects of homophobia on HIV-related behaviors and outcomes.

Figure 1.

Figure 1.

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Hypothesized relationship between social capital and HIV-transmission risk behaviors and care continuum milestones. Social capital resources and experiences of homophobia associate (dark arrows) with HIV-related outcomes, and social capital resources moderate (grey arrows) the relationship between experiences of homophobia and HIV-related outcomes.

Methods

Study population

Data were collected as part of the mSTUDY, an on-going epidemiological study examining a diverse cohort of MSM based in Los Angeles. The study recruited those identified as MSM and between ages 18 and 45 at the Los Angeles Lesbian Gay Bisexual Transgender Center and the UCLA Vine Street clinic. The cohort was recruited such that 50% were HIV seropositive, and that 50% reported substance use in the past 6 months. Computer-assisted self-interviews and biological samples are collected at baseline and every 6 months. This paper analyzes data collected between May 2017, when social capital questions were first introduced in the questionnaire, and February 2018, to allow for participation in at least in one cycle of the interview. The institutional review board at University of California, Los Angeles, approved this research (IRB#18-000876). All participants provided informed consent.

Dependent variables

Based on our hypothesis that social capital is a fundamental cause of health inequalities that affect multiple pathways, we collected nine dependent variables representing HIV transmission risk behaviors and HIV care continuum.

Of the five risk behaviors, four were self-reported: (1) engagement in heavy (6 or more) drinking during or just before sex with their main partner in the past 6 months; (2) methamphetamine use during or just before sex with their main partner in the past 6 months; (3) giving money, drugs, or a place to stay in exchange for sex in the past 3 months; (4) receiving money, drugs or a place to stay for sex in the past 3 months. The fifth was testing positive for syphilis, gonorrhea, or chlamydia at the time of interview.

Of the four care continuum measures, three were self-reported: (1) receipt of HIV test prior to the study; (2) missing a scheduled appointment with their HIV care provider in the past 6 months; (3) missing antiretroviral therapy (ART) in the past Saturday or Sunday. The fourth was virologic suppression at the time of interview, defined as less than or equal to 20 RNA copies/mL.

Independent variables

Our primary independent variables were social capital resources and experiences of homophobia. Social capital resources were measured using five items from the World Bank Integrated Questionnaire for the Measurement of Social Capital (SC-IQ) (Grootaert, 2004). The SC-IQ draws its items from survey studies demonstrating reliability, validity, and usefulness, and has been adapted to various settings (Farajzadegan, Jafari, Nazer, Keyvanara, & Zamani, 2013; Rimaz, Mohammad, Dastoorpoor, Jamshidi, & Majdzadeh, 2014; Sheingold & Sheingold, 2013). We used the following items: (1) “How many people do you think you can borrow $50 from today?” (2) ”About how many close friends do you have?” (3) “In the past 12 months, how many different people have you turned to for assistance when you had a personal problem?” (4) “If you suddenly faced a long-term emergency such as an illness or loss of income, how many people beyond your immediate household could you turn to who would be willing to assist you?”(5) “If you suddenly had to go away for a week or two, could you count on your neighbors to take care of your household?” We adapted the questions by specifying the monetary amount for the first item and changing “children” to “household” for the fifth item.

Experiences of homophobia were measured using five questions from the Lifetime Victimization scale used in Aging with Pride: National Health, Aging, and Sexuality/Gender Study (Fredriksen-Goldsen & Kim, 2017). The dichotomous questions asked whether, in the past 12 months, the respondent experienced the following because they were or thought to be gay or bisexual: (1) verbally insulted; (2) threatened with physical violence; (3) had an object thrown at them; (4) was punched, kicked or beaten; (5) and threatened with a knife, gun, or another weapon.

Covariates

We collected sociodemographic variables: age at the time of interview; race and ethnicity categorized as Black/African American, Hispanic/Latino, White, and other; educational attainment as years of schooling completed; annual income categorized by $10,000 per year. We collected self-reported substance use in the past 6 months, dichotomized into any use and no use, as substance use has been correlated with risk behaviors and poor HIV outcomes (Goodman-Meza et al., 2019; Knox, Reddy, Lane, Hasin, & Sandfort, 2017). We measured internalized homophobia, the intrapersonal experience of shame and guilt surrounding one’s sexual identitiy and practices, using the 9-item Internalized Homophobia Scale (Herek, Cogan, Gillis, & Glunt, 1998). Internalized homophobia has been correlated with HIV transmission risk behaviors (Diaz & Ayala, 1999; Garcia et al., 2016; Jarama et al., 2005). We rescaled the raw score, ranging from 9 (lowest) to 45 (highest) (Cronbach alpha 0.94), to a mean of 0 and a standard deviation (SD) of 1, with higher values indicating higher levels of internalized homohobia.

Statistical analysis

Exploratory factor analyses (Pett, Lackey, & Sullivan, 2003) to determine the psychometric properties of the sets of questions for social capital resources and experiences of homophobia identified one major factor for each set. Each set was averaged and rescaled to yield composite scores with a mean of 0 and a SD of 1, with higher values indicating more social capital resources (Cronbach alpha 0.80) and greater experiences of homophobia (Cronbach alpha 0.82). (See Appendix for details.) The correlation coefficient between social capital resources and experiences of homophobia was 0.002.

We conducted bivariate logistic regression analyses to estimate the pairwise associations between each of the dependent variables and the independent variables and covariates described above. We subsequently specified nine multivariable logistic regression models in which each of the nine dependent variables were specified as a function of both social capital resources and experiences of homophobia, adjusting for sociodemographics, internalized homophobia, and drug use. We estimated marginal effects (Ai & Norton, 2003), defined as the effect of a small change in social capital resources and experiences of homophobia on the probability of engaging in HIV transmission risk behaviors or achieving HIV care continuum (Norton & Dowd, 2018). Finally, we specified nine multivariable logistic regression models in which each of the dependent variables were specified as a function of social capital resources, experiences of homophobia, and its interaction, social capital resources * experiences of homophobia, adjusting for covariates, to estimate the moderating effect of social capital resources on the relationship between the experiences of homophobia and all dependent variables.

The regression models were fitted to complete-case data; after removing observations with missing data from the 379 unique participants (including 18 missing for methamphetamine use, 15 for alcohol use, 23 for exchange sex, 22 for missed medication, 15 for missed appointments), 351 to 361 observations remained for the estimation samples for models relevant to all participants (substance use with sex, exchange sex, STI, HIV testing), and 190 to 211 observations for the estimation samples for models relevant to participants living with HIV (missed appointments, missed medication, viral load). Statistical analyses were conducted using STATA v15.0 (R. Williams, 2012).

Results

The demographic and socioeconomic characteristics of the sample of 379 MSM are reported in table 1. Most of participants were under 40, with a majority equally comprised of MSM who identified as Black/African American or as Latino/Hispanic. Most (89%) completed high school, over half (63%) earned less than $20,000 annually, and most (88%) of all participants and nearly all (97%) of HIV-seropositive participants had health insurance. Most (77%) participants reported drug use in the past 6 months. Over half (216, 57%) of the participants were living with HIV. The mean internalized homophobia score was 16.27 (SD 8.99).

Table 1:

Demographic characteristics of study respondents (N = 379)

Variable N or mean % or SD
Age
18 – 20 5 1%
21 – 30 147 39%
31 – 40 163 43%
41 – 50 64 17%
Race
Black/African American 153 41%
Latino/Hispanic 137 36%
White 52 14%
Other 36 9%
Educational attainment
Did not complete high school 41 11%
Completed high school but no college 122 33%
Some college or 2-year college 121 32%
Completed 4-year college 69 19%
More than college 19 5%
Annual income
Less than $10,000 144 38%
$10,000 – $19,999 94 25%
$20,000 – $29,999 50 13%
$30,000 – $39,999 33 9%
$40,000 – $49,999 20 5%
$50,000 – $59,999 16 4%
$60,000 or greater 19 5%
Drug use in past 6 months
Yes (including marijuana) 290 77%
No 89 23%
Marijuana only 43 11%
Internalized homophobia 16.3 8.99
HIV serostatus
Positive 216 57%
Negative 163 43%
Social capital resources
Borrow $50 4.99 12.78
Long-term emergency 3.64 10.23
Personal problem 2.36 3.03
Close friend 4.90 10.55
Count on neighbor (dichotomous) 0.42 0.49
Experiences of homophobia
Verbally insulted 0.33 0.47
Threatened w violence 0.20 0.40
Had object thrown at 0.13 0.34
Punched, kicked, beaten 0.10 0.30
Threated w weapon 0.09 0.29
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SD = standard deviation

Table 2 shows the distribution of each of the nine dependent variables and mean social capital resources and experiences of homophobia for each variable. A minority of participants reported HIV transmission risk behaviors, with one-fifth reporting substance use during sex. Fewer reported exchange sex and had a new STI diagnosis. Most (93%, 352) had prior HIV testing. Among those with HIV, 88% (191) had received care in the past 6 months, 41% (88) had missed an appointment, 31% (67) had missed medication in the past weekend, and 60% (130) had achieved virologic suppression.

Table 2.

Frequency of HIV-related risk behaviors and HIV care continuum among participants, and mean scores for social capital resources and experiences of homophobia (N = 379) †

Variables N Social capital resources Experiences of homophobia
Mean (SD) Mean (SD)
HIV-Related Risk Behavior
Heavy alcohol use during sex in the past 6 months
Yes 78 0.06 (1.06) 0.20 (1.11)
No 283 0.00(0.97) −0.05 (0.97)
Methamphetamine use during sex in the past 6 months
Yes 86 −0.22 (0.93) 0.53 (1.22)
No 278 0.11 (1.01) −0.17 (0.85)
Received money/drugs for sex in the past 3 months
Yes 55 −0.11 (0.94) 0.75 (1.30)
No 301 0.07 (1.01) −0.14 (0.86)
Gave money/drugs for sex in the past 3 months
Yes 33 −0.20 (0.81) 0.78 (1.33)
No 323 0.06 (1.01) −0.08 (0.92)
New STI diagnosis since last visit
Yes 65 −0.22 (0.85) −0.04 (0.87)
No 305 0.04 (1.03) 0.01 (1.03)
HIV Care Continuum
Ever tested for HIV prior to study
Yes 352 0.05 (0.99) 0.00 (1.00)
No 20 −0.73 (0.71) −0.05 (1.06)
Missed medication in the past Saturday or Sunday
Yes 67 −0.19 (0.97) 0.07 (1.05)
No 127 0.01 (0.95) −0.03 (0.97)
Missed a scheduled appointment with HIV care provider in the past 6 months
Yes 88 −0.03 (0.94) 0.23 (1.15)
No 113 0.06 (0.97) −0.14 (0.86)
Viral suppression ≤ 20
Yes 130 −0.04 (0.95) −0.08 (0.92)
No 85 −0.03 (0.98) 0.15 (1.12)
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†

“Missed medication in the past Saturday or Sunday,” “Received health care in the past 6 months,” “Missed a scheduled appointment with HIV care provider are for the past 6 months,” and virologic suppression are among participants living with HIV. Other measures are among all participants.

SD = standard deviation

In bivariate analyses, we found that social capital resources were associated with lower probability of methamphetamine use during sex and higher probability of prior HIV testing (Table 3). Experiences of homophobia were associated with higher probability of methamphetamine use during sex, giving or receiving money or drugs for sex, and missed appointments.

Table 3.

Average Marginal Effects for bivariate and multivariable logistic regression models describing the association between social capital resources and experiences of homophobia with and HIV-related risk behaviors and HIV care continuum, adjusting for covariates

Variables Heavy alcohol use during sex (n = 353) Methamphetamine use during sex (n = 356) Give money, drugs, or a place to stay for sex (n = 348) Receive money, drugs, or a place to stay for sex (n = 348) New diagnosis of STI since last visit (n = 358)
Bivariate Multivariable Bivariate Multivariable Bivariate Multivariable Bivariate Multivariable Bivariate Multivariable
AME (95% CI) AME (95%CI) AME (95% CI) AME (95%CI) AME (95% CI) AME (95%CI) AME (95% CI) AME (95% CI) AME (95% CI) AME (95% CI)
Social capital resources 0.01 (−0.03, 0.05) 0.03 (−0.02, 0.07) −0.06 (−0.11, −0.02)** −0.04 (−0.09, 0.00) −0.02 (−0.06, 0.01) −0.02 (−0.06, 0.02) −0.02 (−0.06, 0.02) −0.02 (−0.06, 0.02) −0.04 (−0.08, 0.00) −0.05 (−0.10, −0.01)*
Experiences of homophobia 0.04 (0.00, 0.08) 0.03 (−0.01, 0.07) 0.10 (0.07, 0.14)*** 0.09 (0.05, 0.12)*** 0.05 (0.03, 0.07)*** 0.04 (0.02, 0.07)*** 0.08 (0.06, 0.11)*** 0.07 (0.04, 0.10)*** −0.01 (−0.05, 0.03) −0.02 (−0.06, 0.02)
Age 0.00 (−0.01, 0.01) 0.00 (−0.01, 0.01) 0.01 (0.00, 0.01) 0.00 (0.00, 0.01) 0.00 (0.00, 0.01) 0.00 (0.00, 0.01) 0.00 (−0.01, 0.00) 0.00 (−0.01, 0.00) −0.01 (−0.01, 0.00) −0.01 (−0.01, 0.00)*
Race/ethnicity
Black −0.02 (−0.17, 0.12) −0.01 (−0.15, 0.13) −0.15 (−0.27, −0.02)* −0.12 (−0.24, −0.01)* −0.03 (−0.13, 0.08) −0.01 (−0.12, 0.10) −0.02 (−0.16, 0.11) 0.02 (−0.12, 0.15) −0.07 (−0.19, 0.06) −0.04 (−0.17, 0.09)
Hispanic −0.04 (−0.18, 0.10) −0.03 (−0.17, 0.11) −0.08 (−0.21, 0.05) −0.09 (−0.20, 0.02) 0.02 (−0.09, 0.13) 0.02 (−0.09, 0.14) 0.00 (−0.14, 0.13) 0.00 (−0.13, 0.13) −0.03 (−0.16, 0.09) −0.01 (−0.14, 0.13)
White −0.05 (−0.20, 0.10) −0.03 (−0.19, 0.13) −0.13 (−0.25, −0.01)* −0.13 (−0.24, −0.02)* 0.01 (−0.13, 0.14) 0.04 (−0.11, 0.19) 0.06 (−0.12, 0.24) 0.11 (−0.08, 0.30) −0.06 (−0.19, 0.07) −0.02 (−0.17, 0.14)
Educational Attainment (year) 0.00 (−0.01, 0.02) −0.01 (−0.02, 0.01) −0.01 (−0.03, 0.00) 0.00 (−0.02, 0.01) 0.01 (0.00, 0.02) 0.01 (0.00, 0.02) 0.01 (0.00, 0.02) 0.01 (0.00, 0.02) 0.01 (−0.01, 0.02) 0.01 (0.00, 0.03)
HIV Positive −0.01 (−0.03, 0.01) −0.01 (−0.04, 0.02) 0.16 (0.08, 0.25)*** 0.14 (0.06, 0.22)*** 0.00 (−0.06, 0.06) −0.01 (−0.07, 0.06) 0.04 (−0.04, 0.11) 0.05 (−0.02, 0.13) −0.01 (−0.09, 0.06) 0.02 (−0.06, 0.11)
Annual income (per $10) −0.01 (−0.03, 0.01) −0.01 (−0.04, 0.02) 0.05 (−0.08, −0.02)*** −0.03 (−0.05, 0.00) −0.02 (−0.04, 0.01) −0.01 (−0.03, 0.01) −0.02 (−0.05, 0.00) −0.01 (−0.04, 0.01) 0.00 (−0.03, 0.02) 0.00 (−0.03, 0.02)
Internalized homophobia 0.02 (−0.02, 0.06) 0.02 (−0.03, 0.06) 0.04 (0.00, 0.08)* 0.02 (−0.02, 0.06) 0.01 (−0.01, 0.04) 0.01 (−0.02, 0.04) 0.02 (−0.02, 0.06) 0.01 (−0.02, 0.05) 0.01 (−0.03, 0.05) 0.00 (−0.04, 0.04)
Drug use in past 6 months
Yes 0.11 (0.02, 0.20)* 0.11 (0.02, 0.20)* 0.27 (0.21, 0.34)*** 0.26 (0.19, 0.32)*** 0.07 (0.02, 0.13)** 0.06 (0.00, 0.12) 0.14 (0.07, 0.20)*** 0.11 (0.03, 0.18)** 0.06 (−0.02, 0.15) 0.05 (−0.04, 0.14)
No
Variables Testing for HIV prior to study (N = 362) Missed appointments in 6 months (n = 196) Missed medications last weekend (n = 189) Virologic suppression (n = 209)
Bivariate Multivariable Bivariate Multivariable Bivariate Multivariable Bivariate Multivariable
AME (95% CI) AME (95%CI) AME (95% CI) AME (95%CI) AME (95% CI) AME (95%CI) AME (95% CI) AME (95% CI)
Social capital resources 0.06 (0.02, 0.10)** 0.05 (0.01, 0.09)* −0.03 (−0.10, 0.05) 0.01 (−0.06, 0.08) −0.05 (−0.12, 0.02) −0.03 (−0.11, 0.04) 0.00 (−0.07, 0.07) −0.03 (−0.10, 0.04)
Experiences of homophobia 0.00 (−0.02, 0.03) 0.00 (−0.02, 0.02) 0.09 (0.03, 0.15)** 0.07 (0.01, 0.14)* 0.02 (−0.04, 0.09) 0.01 (−0.05, 0.08) −0.05 (−0.12, 0.01) −0.06 (−0.12, 0.01)
Age 0.00 (0.00, 0.00) 0.00 (0.00, 0.00) −0.01 (−0.02, 0.00) −0.01 (−0.02, 0.00) 0.00 (−0.01, 0.01) 0.00 (−0.01, 0.01) −0.01 (−0.02, 0.00) 0.00 (−0.01, 0.01)
Race/Ethnicity
 Black −0.01 (−0.09, 0.07) −0.02 (−0.10, 0.06) −0.20 (−0.44, 0.04) −0.20 (−0.43, 0.03) −0.03 (−0.27, 0.21) −0.05 (−0.27, 0.18) −0.03 (−0.27, 0.22) −0.03 (−0.27, 0.21)
 Hispanic 0.01 (−0.07, 0.09) 0.00 (−0.08, 0.08) −0.11 (−0.36, 0.13) −0.13 (−0.35, 0.10) −0.10 (−0.33, 0.14) −0.12 (−0.33, 0.10) 0.12 (−0.11, 0.36) 0.14 (−0.09, 0.36)
 White 0.02 (−0.06, 0.10) 0.01 (−0.08, 0.09) −0.02 (−0.30, 0.27) −0.02 (−0.29, 0.25) −0.09 (−0.34, 0.15) −0.12 (−0.35, 0.10) 0.07 (−0.19, 0.33) 0.10 (−0.15, 0.34)
Education (years) 0.00 (0.00, 0.01) 0.00 (−0.01, 0.01) −0.02 (−0.04, 0.01) 0.00 (−0.03, 0.02) −0.02 (−0.05, 0.00)* −0.02 (−0.04, 0.00) 0.01 (−0.01, 0.04) 0.01 (−0.01, 0.04)
Income (per $10,000) 0.00 (−0.04, 0.05) 0.02 (−0.03, 0.07) −0.07 (−0.11, −0.03)*** −0.07 (−0.11, −0.03)*** −0.04 (−0.08, 0.00) −0.03 (−0.07, 0.02) 0.05 (0.01, 0.09) 0.04 (0.00, 0.09)*
Internalized homophobia −0.01 (−0.03, 0.01) 0.01 (−0.02, 0.03) 0.06 (−0.01, 0.12) 0.04 (−0.03, 0.10) 0.02 (−0.04, 0.09) −0.01 (−0.08, 0.06) −0.03 (−0.09, 0.04) −0.02 (−0.08, 0.05)
Drug use in past 6 months
 Yes 0.05 (−0.01, 0.12) 0.03 (−0.03, 0.09) 0.09 (−0.07, 0.25) 0.04 (−0.12, 0.20) 0.24 (0.11, 0.37)*** 0.26 (0.13, 0.39)*** −0.11 (−0.26, 0.04) −0.10 (−0.25, 0.05)
 No (ref)
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*

= p< 0.05,

**

= p< 0.01,

***

= p<0.001

AME = Average Marginal Effects

In multivariable analyses adjusting for sociodemographics, internalized homophobia, and drug use, social capital resources were associated with lower probability of methamphetamine use during sex, lower probability of new STI diagnosis, and higher probability of prior HIV testing (Table 3 and Figure 2a). Experiences of homophobia were associated with higher probability of methamphetamine use during sex, giving or receiving money or drugs for sex, and missed appointments (Table 3 and Figure 2b).

Figure 2a.

Figure 2a.

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Forest plot of average marginal effects of social capital resources (% change per standard deviation change) with HIV-related risk behaviors and HIV care continuum, adjusted for experiences of homophobia and covariates

Figure 2b.

Figure 2b.

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Forest plot of average marginal effects of experiences of homophobia (% change per standard deviation change) with HIV-related risk behaviors and HIV care continuum, adjusted for social capital resources and covariates

In adjusted multivariable regression models containing the interaction variable between social capital resources and experiences of homophobia, the interaction variable was not statistically significant at the level of p<0.05 for any of the models (results not shown).

Discussion

In our cross-sectional study among a diverse group of MSM in Los Angeles, social capital resources and experiences of homophobia – beneficial and harmful aspects of social capital – were significantly associated with HIV transmission risk behaviors, STIs, and HIV testing. Findings underscore the potential for social capital interventions to prevent HIV acquisition.

Consistent with prior research (Mizuno, Borkowf, Ayala, Carballo-Dieguez, & Millett, 2015; Sen, Aguilar, & Goldbach, 2010), social capital resources were associated with lower probability of engaging in HIV transmission risk behaviors. In particular, social capital resources were associated with lower likelihood of acquiring STIs, suggesting that they may be less likely to acquire or transmit HIV. Finally, social capital resources were significantly associated with having tested for HIV prior to study, similar to studies that showed supportive social relationships, at individual and ecological levels, associated with HIV testing among MSM (Y. Ransome et al., 2017; Scott et al., 2014). This may reflect connections to other MSM increasing access to information and norms on HIV prevention, testing, and social support (B. S. Mustanski, Newcomb, Du Bois, Garcia, & Grov, 2011), such as the peer support systems (“gay families”) among MSM (Quinn & Dickson-Gomez, 2016).

Reported experiences of homophobia associated with higher probability of HIV transmission risk behaviors, consistent with prior literature that showed that MSM who reported experiences of homophobia were more likely to engage in risky sex (Jarama et al., 2005; Jeffries et al., 2013; Mizuno et al., 2012). An ethnographic study describes one pathway between experiences of homophobia, subsequent loss of social capital resources, and engagement in risk behavior: rejected from families and religious institutions for their sexuality, MSM engaged in risky sex to dull the pain, and used exchange sex as a means of obtaining food, housing and economic security (Garcia et al., 2016).

Social capital was not significantly associated with HIV care continuum, with the exception of the association between experiences of homophobia and missed appointments. This is consistent with a recent review showing lack of association between social capital and HIV care outcomes in the majority of studies (Yusuf Ransome et al., 2018; Webel et al., 2012). One explanation is that other resources, such as structural resources, may be more relevant than social capital resources for accessing and sustaining care. Alternatively, this may reflect the nature of HIV care in Los Angeles, where care is available independent of insurance status, and once a person is referred to care, he or she is also connected to resources within the care delivery system, potentially alleviating the disparity between those who have and do not have resources embedded within friends, families, and neighborhoods. Such HIV care delivery models that integrate case management, community health workers (Walton et al., 2004) and peer navigation (Cunningham et al., 2018) into medical care were fought for by advocacy communities, and have improved HIV care outcomes for the most vulnerable patients.

Social capital resources did not moderate associations between experiences of homophobia and HIV-related outcomes. A prior study similarly showed that social integration, a concept that often falls under the construct of social capital (Kawachi et al., 2008), did not link with reported homophobic experiences and risky sexual behavior among MSM (Jeffries et al., 2013).

Our study was subject to several limitations. First, data on behaviors, engagement in care, and ART adherence are self-reported, and therefore subject to the challenges inherent to all studies based on self-reported data. While interviews were conducted in a confidential manner, data may be biased with respect to the participants’ willingness to report risk behaviors or poor engagement with care. Second, our data were collected from a diverse, at-risk population of MSM in Los Angeles, and our findings may not be generalizable to other populations and settings. Our data are cross-sectional and limits our ability to make causal claims. Based on the fundamental causes theory, we specified nine multiple regression models, and acknowledge the probability of incorrectly rejecting the null hypothesis. Finally, we adapted questions from a larger social capital survey rather than use a validated scale of social capital (e.g. (Crosby et al., 2003; Y. Ransome et al., 2017)), because its questions were relevant to our study population who experience high rates of poverty, housing insecurity, and incarceration (Li et al., 2018; Okafor, Gorbach, Ragsdale, Quinn, & Shoptaw, 2017), and who may not identify with particular communities or organizations often referred to by validated tools.

Our results suggest that social capital resources may reduce HIV disparities for MSM. Interventions on social capital can target individuals, communities or both; they can build or strengthen social capital, or use it to leverage its effects (Villalonga-Olives et al., 2018). For example, providers may strengthen social capital at the individual level by assessing their patient’s important relationships, as recommended by the National Academy of Medicine (Gold et al., 2018; Institute of Medicine, 2014); they may leverage social capital by discussing how norms and resources in those relationships may contribute to health and risk for HIV. At the community level, public health practitioners can leverage the effects of social capital through engaging formal and informal organizations such as MSM social networks, LGBTQ community organizations, and faith-based organizations to disseminate healthy behaviors, promote HIV testing, and address stigma (Derose et al., 2016; Tobin et al., 2018; M. V. Williams et al., 2016).

Equally important is reducing homophobia, the negative aspect of social capital, in families, institutions, and faith-based communities to allow MSM to disclose their sexual identity, prevent experiences of discrimination (Frye et al., 2014; Quinn & Dickson-Gomez, 2016), and coalesce sources of identity and financial stability (B. S. Mustanski et al., 2011). Studies have shown that stigma erodes social capital resources through the exclusion of stigmatized persons and the threat of exclusion for those associated with them (Gilmore & Somerville, 1994; Lee, Chan, Chau, Kwok, & Kleinman, 2005; Takada et al., 2014; Yang et al., 2007). While evidence-based interventions to reduce homophobia in communities is limited, a community-based social marketing campaign was shown to reduce homophobia (Hull et al., 2017).

Finally, interventions must address broader structural inequalities that shape social capital (Crosby et al., 2003; Y. Ransome et al., 2017) through investments in housing and infrastructure, access to public services, and examining policies that perpetuate residential segregation (Kawachi et al., 2008). Building healthy communities through creating social capital resources and reducing stigma offer promise for improving chronic disease outcomes among populations with complex medical and social conditions.

Conclusion

Among a diverse group of MSM in Los Angeles, social capital resources and experiences of homophobia associated significantly with a range of HIV transmission risk behaviors, STIs, and HIV testing. To reduce the HIV burden among MSM, interventions are needed to increase social capital resources and decrease experiences of homophobia.

Acknowledgements

We would like to thank our study participants and our research assistants and coordinators.

Funding details

This work was supported by the National Institute on Drug Abuse grant U01DA036267, the MStudy (PI: Gorbach,Shoptaw). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The authors acknowledge salary support by the VA Office of Academic Affiliations through the National Clinician Scholars Program. The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government

Appendix

We conducted exploratory factor analysis to determine the psychometric properties of the social capital resources and experiences of homophobia scales. We used a matrix of tetrachoric correlation for dichotomous questions. We iterated principal axis factor as the method of extraction, and a varimax orthogonal rotation (Pett, Lackey, & Sullivan, 2003). We then calculated Cronbach alpha coefficients for the responses within each factor as a measure of internal consistency reliability.

  • 1. Construction of social capital resources composite score

The table below shows the distribution of the 5 items

Social Capital item Mean Median SD Min 25% 75% 99% max
1. From whom can you borrow $50 4.99 2 12.78 0 1 5 100 150
2. To whom can you turn to in case of a long-term emergency 3.64 2 10.23 0 0 4 25 150
3. To whom have you turned to for a personal problem in the past year 2.36 2 3.03 0 0 3 15 30
4. Close friends 4.9 2 10.55 0 2 5 50 150
5. Can you count on your neighbors if you had to go away for a week or two? 0.42 0 0.49 0 0 1 1 1
Open in a new tab

For each of the items 1 – 4, 1 to 5% of respondents responded with values that were greater than an order of magnitude above the median. As a result, these small minority of respondents were raising the mean and standard deviation. Based on the distribution of the responses, we designated 10 as the maximum possible value, and assigned all values above 10 as 10.

Factor analysis of the five social capital resource questions identified one major factor (examination of Scree plot and eigenvalue >1). All items were rescaled to a mean of 0 and a SD of 1, then averaged. The result was rescaled to yield a composite social capital resource score with a mean of 0 and a SD of 1, with higher values indicating more social capital resources (Cronbach alpha 0.80).

  • 2. Construction of composite score for experiences of homophobia

Below shows the distribution of the original 5 items

Mean Median SD Min 25% 75% max
1. Verbally insulted 0.33 0 0.47 0 0 1 1
2. Threatened with physical violence 0.20 0 0.40 0 0 0 1
3. Had an object thrown at them 0.13 0 0.34 0 0 0 1
4. was punched, kicked, or beaten 0.10 0 0.30 0 0 0 1
5. threatened with a knife, gun, or weapon 0.09 0 0.29 0 0 0 1
Open in a new tab

The items were added, and then rescaled to a mean of 0 and standard deviation of 1, with higher values indicating greater experiences of homophobia (Cronbach alpha 0.82).

  • 3. Construction of internalized homonegativity score

Below is the distribution of the original score. The score was rescaled for a mean of 0 and standard deviation of 1.

mean Median SD Min 25% 75% max
homonegativity 16.27 12 8.99 9 9 21 45
Open in a new tab

Footnotes

Disclosure Statement

The authors have nothing to disclose.

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