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Syndemic Health Disparities and Sexually Transmitted Infection Burden Among Black Men Who Have Sex with Men Engaged in Sex Work in the U.S.

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Abstract

Black men who have sex with men (MSM) engaged in sex work (BMSM-SW) experience elevated HIV and sexually transmitted infection (STI) prevalence. Further, BMSM-SW have been shown to have higher rates of syndemic psychosocial health conditions which contribute to HIV risk behavior and incidence, and poorer care outcomes than other groups of men who have sex with men. However, syndemic perspectives have not been applied to understanding past-year STI burden among BMSM-SW in the U.S. Sexually active Black MSM ≥ 18 years old were recruited from Black Pride events in six U.S. cities (n = 4421) between 2014 and 2017. Multivariable logistic regressions assessed correlates of past-year sex work engagement; whether BMSM-SW had higher odds of syndemic conditions; and whether BMSM-SW had higher odds of self-reported, past-year STI diagnoses. Structural equation models assessed relationships between sex work engagement, syndemic conditions, and STI controlled for sociodemographics and number of sexual partners. A total of 254 (5.7%) Black MSM reported past-year sex work, of whom 45.3% were HIV positive. BMSM-SW were significantly more likely to be Hispanic, to report past-year bisexual behavior, and to report annual income < $10,000. In multivariable models, BMSM-SW were significantly more likely to report intimate partner violence, assault victimization, polydrug use, and depression symptoms; they were also more likely to report past-year gonorrhea, chlamydia, and syphilis. Syndemic conditions mediated the relationship between past-year sex work and past-year STI burden, constituting a significant indirect effect. BMSM-SW in the U.S. face severe biopsychosocial health disparities. Interventions developed for BMSM engaged in sex work are lacking. Our results suggest that interventions containing safer sex work education and sex-positive biobehavioral HIV/STI prevention alongside substance use, mental health, employment, and education components will be most effective.

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Acknowledgements

We thank the Center for Black Equity and local Black Pride organizations for partnering with us to implement POWER, the community-based organizations who performed onsite HIV testing on the study’s behalf, the thousands of study participants who volunteered their time to contribute to this research, and members of the POWER Study Team who made data collection possible. The local Black Pride organizations are as follows: D.C. Black Pride, Detroit’s Hotter than July, Houston Splash, In the Life Atlanta, Memphis Black Pride, and Philadelphia Black Pride. The community-based organizations who performed onsite HIV testing are as follows: Atlanta: AID Atlanta, AIDS Health Care Foundation, NAESM; Detroit: Community Health Awareness Group, Horizons Project, Unified; Houston: Avenue 360, Houston AIDS Foundation, Positive Efforts; Memphis: Friends for Life; Philadelphia: Access Matters, Philadelphia FIGHT; Washington, D.C.: Us Helping Us. An earlier version of this manuscript was presented at the 2018 International Academy of Sex Research meeting (Madrid, Spain).

Funding

This study was partially supported by National Institutes of Health Grant R01NR013865 and analysis was partially supported by NIMH training Grant 5-T32MH094174-09.

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Authors and Affiliations

  1. Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, 130 De Soto Street, Pittsburgh, PA, 15261, USA

    Cristian J. Chandler & M. Reuel Friedman

  2. Center for LGBT Health Research, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA

    Cristian J. Chandler, Elí Andrade, Leigh A. Bukowski, Ronald D. Stall & M. Reuel Friedman

  3. Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA

    Étienne Meunier

  4. Department of Human Development and Family Sciences, University of Connecticut, Storrs, CT, USA

    Lisa A. Eaton

  5. Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA

    Elí Andrade, Leigh A. Bukowski & Ronald D. Stall

  6. Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA

    Derrick D. Matthews

  7. Department of Biostatistics and Epidemiology, School of Public Health, Rutgers University, Piscataway, NJ, USA

    Henry F. Raymond

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Appendices

Appendix 1

See Table 5.

Table 5 Direct, indirect, and total effects of relationships between past-year sex work (predictor), syndemic psychosocial conditions (mediator), and past-year STI diagnoses (outcome) among Black MSM in POWER, 2014–2017 (n = 4421)
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Appendix 2

See Figure 2.

Fig. 2
figure 2

Structural equation model showing total and indirect effects pathways between past-year sex work, syndemic psychosocial conditions, and STI burden among sexually active Black men in the POWER study, 2014—2017. ***p < .001. Path coefficients and standard errors (parenthesized) are shown for total effects pathways. Italicized path coefficients and standard errors (parenthesized) are shown for indirect effects pathways. Model adjusted for year, city, income, bisexual behavior, Hispanic ethnicity, HIV positive status, bisexual behavior, and age ≥ 40. Covariate paths are suppressed for interpretability. Fit statistics are as follows: SRMR = 0.034; RMSEA = 0.049 (95% CI 0.046, 0.052); CFI = 0.928; TLI = 0.902

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Appendix 3

See Table 6.

Table 6 Total and indirect path coefficients and standard errors in pathways between sex work engagement and psychosocial health syndemic among Black MSM in the POWER study, 2014–2017 (n = 4421)
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Chandler, C.J., Meunier, É., Eaton, L.A. et al. Syndemic Health Disparities and Sexually Transmitted Infection Burden Among Black Men Who Have Sex with Men Engaged in Sex Work in the U.S.. Arch Sex Behav 50, 1627–1640 (2021). https://doi.org/10.1007/s10508-020-01828-2

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