HIV Care Continuum Disparities Among Black Bisexual Men and the Mediating Effect of Psychosocial Comorbidities

Abstract

Introduction: Differences across the HIV care continuum between men who have sex with men and women (MSMW) and men who have sex with men only (MSMO) are emerging in recent literature but have not been comprehensively documented among black MSM. Although MSMW have lower HIV prevalence than MSMO, they are more likely to be HIV-positive unaware and be virally unsuppressed. Explanatory factors for these differences have not previously been assessed.

Methods: Between 2014 and 2016, we surveyed sexually active black MSM 18 years or older at Black Gay Pride events in 6 U.S. cities (n = 3881), 1229 of whom either self-reported HIV-positive status or tested HIV-positive onsite. We compared HIV-positive MSMW (n = 196) with HIV-positive MSMO (n = 1033) by HIV-positive unaware status, HIV care uptake, and viral load suppression. We conducted multivariable logistic regressions and built a structural equation model assessing mediating effects of psychosocial comorbidities (violence victimization, depression, and polydrug use) on the relationship between MSMW status and unsuppressed virus.

Results: MSMW were more likely than MSMO to be HIV-positive unaware [adjusted odds ratio (aOR) = 2.17; 95% confidence interval (CI): 1.58 to 3.00]. Among those who were HIV-positive aware (n = 720), MSMW were more likely to report never receiving HIV care (aOR = 2.74; 95% CI: 1.05 to 7.16) and to report detectable viral loads (aOR = 2.34; 95% CI: 1.31 to 4.19). Psychosocial comorbidities significantly mediated (P = 0.01) the relationship between MSMW status and unsuppressed virus.

Discussion: Black MSMW were less likely than black MSMO to uptake biomedical care and secondary prevention. Biobehavioral intervention development specific to HIV-positive black MSMW will be most successful if psychosocial comorbidities are also addressed.

Figure 1

Total and indirect path coefficients between bisexual behavior, psychosocial morbidity, socioeconomic status, and detectable viral load among HIV-positive aware men in POWER, 2014—2106 (n=720). ***=p<.001; **=p<.01; *=p<.05; t=p<.10. Solid lines represent significant total effects pathways at p<.05. Dashed lines represent marginally significant total effects pathways at p<.10. Plain text represents total effects path coefficients; italicized text represents indirect effects path coefficients. Pathways show beta-coefficients and observed information matrix standard errors (parenthesized). Effects for covariates (age, year, city, Hispanic ethnicity, socioeconomic status) suppressed from figure for interpretability. SRMR=.027.