Partner Violence: A Significant Part of a Syndemic Among Black Men Who Have Sex With Men 24 July 2018 22nd International AIDS Conference Elwin Wu, Nabila El-Bassel, Louisa Gilbert http://sig.columbia.edu

Disclosure Funding National Institute on Drug Abuse (NIDA), Grant # R01DA030296 (“Couple-Based HIV/STI Prevention for Drug-Involved, African American MSM”) No conflicts of interest with respect to commercial, financial, or other relationships

State of Affairs for HIV Among MSM in the U.S. Some MSM are losing ground more than others Male-to-male sexual contact represents the largest transmission category HIV by Risk & Gender, 2014: https://www.cdc.gov/hiv/library/slideSets/index.html File under heading “HIV Surveillance—Epidemiology of HIV Infection (through 2015)” with direct link at https://www.cdc.gov/hiv/ppt/library/slidesets/cdc-hiv-surveillance-genepi.pptx MSM by race ethnicity 2005-2014: http://www.cdc.gov/nchhstp/newsroom/images/2015/hiv-data-trends-figure3.jpg (referring page is http://www.cdc.gov/nchhstp/newsroom/2015/nhpc.html#TrendGraphics) MSM are roughly 2% of the U.S. population (http://www.cdc.gov/hiv/group/msm/bmsm.html) Lifetime risk graphs from CROI 2016 https://www.cdc.gov/nchhstp/newsroom/2016/croi-2016.html#Graphics February 24, 2016 - Conference on Retroviruses and Opportunistic Infections Figures from February 24, 2016 - Conference on Retroviruses and Opportunistic Infections

HIV: Part of a Syndemic Introduction to Syndemics published in 2009 Unequal Opportunity published in 2007 Lancet (04 March 2017): Syndemic understanding/approach getting greater awareness and application Criteria for a syndemic ≥2 diseases/health conditions affecting a poplulation Health burden is more than the sum of the parts Contextual factors/social forces drive the co-occurrence and/or synergy Other syndemics (other than SAVA) HIV & TB HIV, malnutrition, & food insecurity [in Sub-Saharan Africa] violence, immigration, depression, type 2 diabetes, & abuse (VIDDA) [among Mexican immigrant women in US] Hepatitis C [HCV infection], alcohol use, & hepatocelllar carcinoma “Syndemics involve the adverse interaction of diseases of all types (eg, infections, chronic non-communicable diseases, mental health problems, behavioural conditions, toxic exposure, and malnutrition).”-Singer et al. (2017) Lancet article

PV & the Syndemic Among MSM Mimiaga, M. J. et al. (2015). The effect of psychosocial syndemic production on 4-year HIV incidence and risk behavior in a large cohort of sexually active men who have sex with men. JAIDS, 68, 329-336. Stall, R. et al. (2003). Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. American Journal of Public Health, 93, 939-942. Mustanski, B. et al. (2017). Prospective effects of a syndemic on HIV and STI incidence and risk behaviors in a cohort of young men who have sex with men. AIDS & Behavior, 21, 845-857. Dyer, T. P. et al. (2012). Application of syndemic theory to black men who have sex with men in the Multicenter AIDS Cohort Study. Journal of Urban Health, 89, 697-708. Herrick, A., Stall, R., Egan, J., Schrager, S. & Kipke, M. (2014). Pathways towards risk: Syndemic conditions mediate the effect of adversity on HIV risk behaviors among young men who have sex with men (YMSM). Journal of Urban Health, 91, 969-982. Parsons, J. T. et al. (2017). Syndemic conditions and HIV transmission risk behavior among HIV-negative gay and bisexual men in a U.S. national sample. Health Psychology 36, 695-703.

Primary Research Questions What is the prevalence of PV among a large sample of black MSM? Is PV associated with other syndemic outcomes—HIV risk indicators, substance use—among this sample of black MSM?

Connect ’N Unite (CNU): HIV Prevention for At-Risk Black MSM Couples Main Inclusion Criteria—Men who: Report having a male “main partner” operationalized as: a male with whom he has had an ongoing sexual relationship over the prior 90 days, and a male with whom the participant has an emotional relationship/bond more than any person; Self-identify as Black/African American*; Report illicit substance at least 1 time in past 90 days*; Report at least 1 unprotected act of anal intercourse in the prior 90 days with a male who is not the main partner*; and Identify each other as their main partner *or has male main partner who meets this criterion

Sample Black men who have sex with men (MSM) Cis-man ≥ 18 years old Identifies as Black/African American Had sex with a man in the past 3 months 1,271 individuals recruited and completed screening Subsample of respondents who met the above criteria N=1,043

CNU Screening: Measures Sociodemographics Gender, Race/ethnicity, Age Experienced partner violence (PV) Revised conflict tactics scale (CTS2) Excluded minor psychological abuse “Gay-related”: threatened and/or actually outed as gay “HIV-related”: threatened and/or actually outed as HIV+ HIV risk indicators (past 90 days) HIV status (self-reported) # of male sexual partners # of acts of condomless anal intercourse (CAI) with men Substance use (past 90 days) NIDA Risk Behavior Assessment

Analyses Prevalence of PV among this sample of Black MSM Form: psychological, physical, sexual, injurious, gay- related, HIV-related “Directionality”: experiencing, perpetrating Timeframe: ever, current (past 30 days) Hypothesis Testing: PV will be associated with greater likelihood of adversity to wellbeing/health Multivariate regression Linear, binary logistic, multinomial depending on nature of the outcome variable Covariance adjustment: age, HIV status (except for HIV status as dependent variable)

Results and Conclusions Prevalence estimates: PV is a significant public health concern for Black MSM Hypothesis testing: Support for PV as a central factor in the syndemic among Black MSM Behavioral aspects of combination prevention need to address PV among Black MSM in the U.S. Addressing PV among Black MSM may confer benefits with respect to prevention of HIV transmission. Need to attend to forms of PV that are specific or more unique to sexual minority populations

Thank you! NIDA Co-Investigators CNU Team Community collaborators/colleagues & volunteers Study participants Nabila El-Bassel Louisa Gilbert Patrick Baker Natalie Bareis Atrina Brill Channon Greenfield Justin Hashimoto Leona Hess Y.G. Lee Justin Manusov Allen Montes Omar Martinez John Page Rocio Pena Kimberlyn Shirrells