Psychosocial associations of biobehavioral HIV prevention among Black men who have sex with men in the United States

Black men who have sex with men (BMSM) experience the highest HIV incidence among at-risk groups; therefore, understanding the unique circumstances of BMSM is essential to addressing this significant public health issue. The theory of syndemic production, or the effect of co-occurring epidemics, was used to explore the result of psychosocial issues (substance use, intimate partner violence, sexual risk and depression) on HIV prevention and care outcomes. This dissertation analyzed data from the Promoting Our Worth, Equality and Resilience (POWER) study to explore the impact of individual-level syndemics on past six-month screening behavior, PrEP use and HIV care continuum outcomes among BMSM. In the first analysis, BMSM under 30 were more likely to have been screened than BMSM aged 40 and older (AOR = 2.18, 95% CI: 1.74, 2.72). Further, despite the presence of a syndemic, men with two psychosocial issues were significantly more likely to report being screened for HIV compared to men who reported no psychosocial issues (AOR = 1.37, 95% CI: 1.04, 1.80). The second analysis explored differences among BMSM who reported PrEP-eligible HIV risk and BMSM who reported using PrEP. The analysis found that those with a college education (AOR = 0.39, 95% CI: 0.28 – 0.55) and graduate education (AOR = 0.50, 95% CI: 0.32, 0.79) were significantly less likely than men with a high school or less education to report PrEP use. Additionally, compared to men who reported no psychosocial issues, BMSM were significantly more likely to report PrEP use when experiencing three (AOR = 5.65, 95% CI: 3.17, 10.08) or four psychosocial issues (AOR = 18.34, 95% CI: 5.01, 67.20). The third analysis focused on HIV-positive BMSM found that BMSM without insurance were less likely to report being in HIV care (AOR = 0.13, 95% CI: 0.05, 0.36) or using ART (AOR = 0.33, 95% CI: 0.20, 0.54). There were no significant associations between syndemic variables and HIV care outcomes. The results of these analyses suggest that individual factors cannot entirely explain disparities in HIV incidence and demonstrate the need to model the social and structural ecology of BMSM contributing to excess disease burden