Abstract and Introduction
Abstract
Introduction: Men who have sex with men and women (MSMW) have been shown in cross-sectional studies to suffer HIV-related health disparities above and beyond those found among men who have sex with men only (MSMO). We conducted a secondary data analysis over a 7-year time frame of participants in the Multicenter AIDS Cohort Study, a long-standing prospective cohort study, to examine whether MSMW had persistently higher rates of depression symptoms, polydrug use, and (among HIV-positive men who have sex with men) HIV viral load levels compared with MSMO.
Methods: Men were behaviorally defined as bisexual if they reported sexual activity with at least 1 male and 1 female partner between study waves 38 and 50. We used generalized mixed modeling with repeated measures to test differences in CES-D score, polydrug use, and viral load between sexually active MSMO (n = 1514) and MSMW (n = 111), adjusting for age, income, race/ethnicity, and recent seroconversion.
Results: MSMW were significantly more likely than MSMO to have higher CES-D scores, polydrug use, and viral load levels (all P < 0.01). Outcome trajectories did not differ significantly over time between these groups. Black and Hispanic HIV-positive MSMW had higher viral load levels relative to white HIV-positive MSMW (P < 0.01).
Discussion: Compared with MSMO, MSMW in the Multicenter AIDS Cohort Study suffer from profound and persistent HIV-related health disparities across biological, behavioral, and psychosocial domains. Further qualitative and quantitative research contextualizing the pathways underlying these disparities is recommended for intervention development targeting MSMW at risk for HIV acquisition and transmission.
Introduction
Men who have sex with men (MSM) account for 61% of new HIV cases in the United States, with annual incidence rates estimated at 2.39%, leading to HIV prevalence rates approaching 40% by the time one reaches age 40. Syndemics theory posits that MSM suffer a set of psychosocial health disparities, such as depression and substance use, which are influenced by the stress of enduring sexuality-related marginalization and violence as synergistic epidemics that work together to increase HIV risk. To date, this theory has pooled 2 potentially distinct groups of MSM: men who have sex with men only (MSMO) and men who have sex with both men and women (MSMW). A newly emergent, largely cross-sectional, formative literature is beginning to indicate that men who identify and/or behave bisexually endure psychosocial health disparities and HIV risk behavior in ways distinct from other MSM: they may be more likely to be depressed and/or suicidal; to engage in substance use and abuse; to suffer violence victimization; and to report higher levels of internalized homophobia. These within-MSM differences suggest that MSMW may experience syndemics at a higher rate than MSMO and that, if syndemics function as drivers of HIV acquisition and transmission risk among MSM, they may drive risk among MSMW as well. Little research has been conducted on hypothetical mechanisms of syndemic production among MSMW. However, a growing body of descriptive research demonstrates that bisexuals report low levels of gay/lesbian community attachment; their access to minority community strengths may be impeded by high internalized homophobia, feelings of perceived and endured biphobia and cultural invisibility, and disconnectedness from traditional minority social support structures.
MSMW have been found to be less likely to be HIV positive aware than MSMO; their comparatively lower uptake of HIV testing has been linked to higher rates of internalized homonegativity, and they are less likely to disclose their same-gender sexual behaviors to health care providers. Although several studies report on psychosocial health risks among HIV-positive MSMW, we are not aware of any research that has attempted to differentiate the trajectories of viral load suppression among HIV-positive MSMW and MSMO. Given that MSMO and MSMW are conflated in 1 risk group (MSM) in Centers for Disease Control and Prevention–supported HIV care data collection and reporting mechanisms, these data do not exist on a national level. Though several studies have conducted longitudinal analyses of bisexual behavior among men and/or women, we are not aware of previous research that reports on HIV-related health risks among bisexually behaving people over time.
This study will explore the psychosocial factors, including depression and substance use, related to longitudinal trajectories of viral load suppression among HIV-positive MSMW and MSMO. To address these research questions, we conducted a secondary data analysis of behavioral, psychosocial, and biomedical data from participants in the Multicenter AIDS Cohort Study (MACS).