Violence,Discrimination,Psychological Distress,and HIV Vulnerability Among Men Who Have Sex With Men in Memphis,Tennessee

Abstract

Gay, bisexual, and other men who have sex with men (MSM) are disproportionally impacted by HIV. Discrimination, violence, and psychological distress (PD) may influence engagement with HIV prevention services and amplify HIV vulnerability among this priority population. These dynamics are understudied in the Southern United States. Understanding how these relationships interact is critical to designing effective HIV programs. We examined associations between MSM-related discrimination, MSM-related violence, and severe PD with HIV status among 2017 National HIV Behavioral Surveillance study participants in Memphis, Tennessee. Eligible participants were aged ≥18 years, born and identified as male, and reported having sex with another man in their lifetime. Participants completed a Centers for Disease Control and Prevention–designed anonymous survey and self-reported discrimination and violence across their lifetime, and PD symptoms within the past month, scored on the Kessler-6 Scale. Optional HIV rapid tests were performed on-site. Logistic regressions examined the associations between the exposure variables and HIV antibody-positive results. Among 356 respondents, 66.9% were aged <35 years and 79.5% identified as non-Hispanic Black; 13.2% reported experiencing violence, 47.8% reported discrimination, and 10.7% experienced PD. Of the 297 participants who tested, 33.33% were living with HIV. Discrimination, violence, and PD were significantly associated with each other (p < .0001). HIV antibody-positive test results were associated with violence (p < .01). Memphis-based MSM face a complex array of social experiences, which may increase vulnerability to HIV. On-site testing at community-based organizations and clinical settings among MSM may be an opportunity to screen for violence and incorporate strategies when designing HIV programs.

Keywords

HIV/AIDS physiological and endocrine disorders violence behavioral issues discrimination sexual health sexuality mental health

Introduction

Gay, bisexual, and other men who have sex with men (MSM) may disproportionately experience violence, discrimination, and severe psychological distress (PD), which can amplify vulnerability to health conditions driven by social, economic, and community factors, such as HIV (Gupta et al., 2008). MSM are disproportionately impacted by HIV and are a priority population for HIV services, such as testing and pre-exposure prophylaxis (PrEP). In 2020, the Centers for Disease Control and Prevention (CDC) reported 71% of new HIV diagnoses in the United States were among MSM who did not inject drugs, the most common mode of transmission (Centers for Disease Control and Prevention, 2022a). Ending the HIV Epidemic in the US (EHE) is an initiative aimed to reduce 90% of new HIV diagnoses by 2030. One strategy of EHE is directing focus on jurisdictions with a greater incidence of transmission, such as the Southern United States, to employ more prevention and treatment tools (U.S. Department of Health and Human Services, 2022).

Historically, the Southern United States has been a high-priority region for ending the HIV epidemic, experiencing the highest rates of new diagnoses. In 2020, this region accounted for half of new HIV diagnoses among MSM (Centers for Disease Control and Prevention, 2022b). In the same year, the Memphis Metropolitan Statistical Area (MSA), which consists of eight counties across three Southern states (i.e., Tennessee, Mississippi, Arkansas), reported the third highest HIV diagnosis rate in the United States (20.7 per 100,000 persons; (Centers for Disease Control and Prevention, 2022b). More specifically, Shelby County, which includes Memphis city, reports the highest proportion of new HIV cases in the MSA. This disparity has most disproportionately affected non-Hispanic (NH) Black residents. In 2021, the racial makeup of the Shelby County population was reported as 54.6% NH Black, 40.4% NH White, and 6.9% Hispanic (U.S. Census Bureau, 2021). In the same year, NH Black individuals accounted for 83.2% of new HIV diagnoses compared with their NH White (9.1%) and Hispanic counterparts (6.0%; HIV Surveillance and Epidemiology Program, 2022).

These health disparities can be attributed to social and structural factors, such as stigma and discrimination, associated with the intersections of racial, ethnic, and sexual identity (Bowleg, 2013). The guiding concept of stigma is established as the deviation from societally accepted standards that result in the disqualification of social acceptance in identities (Goffman, 2009). Stigma can be enacted in many ways, potentially leading to the perpetuation of discrimination. Discrimination is, “a socially structured and sanctioned phenomenon, justified by ideology and expressed in interactions. . .intended to maintain privileges for members of dominant groups at the cost of deprivation for others” (Berkman & Kawachi, 2000, p. 41). Specifically, HIV-related and MSM-related stigma and discrimination pose a harmful threat to the health and well-being of MSM (Babel et al., 2021). HIV-related stigma reflects the negative views and attitudes aimed at those who are vulnerable to or living with HIV. HIV-related discrimination is the enactment of prejudice and unfair treatment of those vulnerable to or living with HIV because of their known or perceived status (Centers for Disease Control and Prevention, n.d.-b). While different, some overlap exists between HIV-related stigma and MSM-related stigma, which is the stigma connected to known or presumed sexual preferences and behaviors of MSM (Centers for Disease Control and Prevention, 2016a). MSM-related stigma is associated with the enactment of MSM-related discrimination, both of which can be harmful to MSM and increase sexual practices that allow for vulnerability to HIV (Balaji et al., 2017; Batchelder et al., 2020).

More extreme enactments of MSM-related discrimination can result in MSM-related violence, the experience of being attacked or injured by someone based on perceived or known sexual identity. The prevalence of intimate partner violence (IPV) and the relationship between IPV victimization and increased HIV vulnerability among MSM is established (Finneran & Stephenson, 2014; Wang et al., 2018). MSM and MSM of color experience MSM-related violence, both physical and sexual, at higher rates than other MSM because these subgroups are more likely to be affected by individual and structural issues, such as financial hardship, lower educational attainment, engagement in transactional sex, and decreased psychological resilience (Lampinen et al., 2008; Siconolfi et al., 2021). However, analyses disentangling experiences of MSM-related violence would be beneficial, particularly related to MSM-related discrimination and severe PD, as such investigations could inform interventional efforts to abate HIV vulnerability.

Numerous studies have examined the prevalence of severe PD symptoms, such as frequent hopelessness, sadness, or anxiousness, among MSM populations vulnerable to or living with HIV, because they disproportionately bear psychological health burdens, like mental distress and illness, which influence HIV health-seeking behaviors (Safren et al., 2010; Weiser et al., 2004). MSM were also more likely to present with suicidal behaviors, including ideation and attempts, compared with their heterosexual male counterparts (Luo et al., 2017). A systematic review published in 2022 identified social-structural factors, such as stigma, discrimination, and violence, suggest more pervasive mental illness symptomology (Operario et al., 2022). Examining the relationships between PD and these harmful elements may provide a valuable perspective on HIV vulnerability in this population.

MSM-related discrimination, MSM-related physical violence, and severe PD symptoms have all been separately examined; however, how these experiences interact with one another and with HIV status remains unclear. Experiencing MSM-related discrimination, violence, and severe PD may impact engagement with HIV services, including testing and PrEP use. The intersection of these events has the potential to increase HIV vulnerability. These dynamics are understudied in the Southern United States, which when investigated could inform current and future prevention and treatment services. The objective of the present study is to examine the experiences of MSM-related discrimination, MSM-related violence, severe PD symptoms, and HIV test results among a sample of MSM in the Memphis MSA.

Method

National HIV Behavioral Surveillance

National HIV Behavioral Surveillance (NHBS) is a CDC-funded network of 23 sites in the United States that conducts annual standardized, anonymous questionnaires rotating among three priority populations, including MSM, persons who inject drugs, and low-income, cisgender heterosexually active adults at an increased risk for HIV. The objective is to collect data on HIV-related topics and behaviors, such as HIV testing, PrEP use, sexual behaviors, and substance use, to understand local HIV transmission dynamics and guide service delivery (Centers for Disease Control and Prevention, 2016b). The NHBS site in the MSA conducts local operations through participant recruitment, data collection from a CDC-designed anonymous survey, and providing on-site testing for HIV, sexually transmitted infections (STIs), and hepatitis C virus (Kent & Marr, 2022). In 2017, NHBS Memphis collected data on its first MSM cycle, which was part of CDC’s fifth NHBS cycle, NHBS-MSM5.

NHBS-MSM5 cycle respondents were recruited through venue-based sampling, which included screening and recruiting participants at locations and events those eligible may frequent, such as bars, nightclubs, and Pride festivals (Centers for Disease Control and Prevention, 2016b). Following recruitment, potential respondents were screened for eligibility by Memphis NHBS staff. Eligible participants were aged ≥18 years, born and identified as cisgender male, reported having a sexual encounter with another male in their lifetime, and never contributed to a previous NHBS cycle. Participants completed an informed consent prior to the survey, which was administrated by a trained interviewer. Consent was also obtained for optional on-site testing for HIV, and STIs, including chlamydia and gonorrhea, by way of blood testing and urinalysis. Due to the sensitivity of the topics addressed, verbal consent was obtained to maintain participant anonymity per CDC protocol (Centers for Disease Control and Prevention, 2016b). A blank consent form was provided to all participants. The trained interviewer recorded consent on a tablet tracking form by indicating consent was verbally given, providing an interviewer signature, and date of consent. Participants were compensated for their time via a US $50 Visa gift card following survey completion. Participants were given an additional US $25 Visa gift card if they completed the optional on-site HIV testing. The Tennessee Department of Health Institutional Review Board approved this study (IRB Number: FWA00000379).

Measures

Measures are developed or gathered by CDC to create a standardized, anonymous survey format. CDC-developed measures are thoroughly critiqued through expert opinion. MSM-related discrimination and MSM-related violence measures were administered for multiyear, multisite NHBS questionnaires. Participants self-reported experiences of nonphysical discrimination based on known or perceived sexual identity across their lifetime (Table 1). Nonphysical, MSM-related discrimination items were binary and included verbal discrimination (“Were you called names or insulted because someone knew or assumed you were attracted to men?”), poor service (“Did you receive poorer service than other people in restaurants, other businesses, or agencies because someone knew or assumed you were attracted to men?”), mistreatment at work or school (“Were you treated unfairly at work or school because someone knew or assumed you were attracted to men?”), and poor health care (“Were you denied or given lower quality health care because someone knew or assumed you were attracted to men?”; Centers for Disease Control and Prevention, 2016b). One or more reported experiences of MSM-related discrimination were combined into a composite score and coded as a binary variable (yes, experienced MSM-related discrimination/no, did not experience MSM-related discrimination).

Table 1.

Measures Used to Examine Self-Reported Experiences of NHBS-MSM5 Cycle Respondents

Measure	Survey question(s)	Response categories	Timing of measure	Variable type	Method of variable coding	Bivariate models combinations analyzed	Multivariable model combinations analyzed
MSM-related discrimination	Verbal—“Were you called names or insulted because someone knew or assumed you were attracted to men?” Poor service—“Did you receive poorer service than other people in restaurants, other businesses, or agencies because someone knew or assumed you were attracted to men?” Work/school—“Were you treated unfairly at work or school because someone knew or assumed you were attracted to men?” Health care—“Were you denied or given lower quality health care because someone knew or assumed you were attracted to men?”	Yes, No, Don’t know	Across lifetime	Categorical	Yes/no - Yes, ≥1 reported experience indicates MSM-related discrimination	Relationships examined from different combinations of: sample demographics, MSM-related violence, severe PD, and HIV antibody test results	Model testing: MSM-related discrimination, MSM-related violence, severe PD, age group, race/ethnicity, insurance status, and HIV antibody test results
MSM-related violence	Violence—“Were you physically attacked or injured because someone knew or assumed you were attracted to men?”	Yes, No, Don’t know	Across lifetime	Categorical	Yes/no - Yes indicates experience of MSM-related violence	Relationships examined from different combinations of: sample demographics, MSM-related discrimination, severe PD, and HIV antibody test results	Model testing: MSM-related discrimination, MSM-related violence, severe PD, age group, race/ethnicity, insurance status, and HIV antibody test results
Severe PD	Nervousness—“During the past 30 days, how often did you feel nervous?” Restlessness—“During the past 30 days, how often did you feel restless or fidgety?” Hopelessness—“During the past 30 days, how often did you feel hopeless?” Sadness/depressed—“During the past 30 days, how often did you feel so sad or depressed that nothing could cheer you up?” Everything was an effort—“During the past 30 days, how often did you feel that everything was an effort?”	All of the time, Most of the time, Some of the time, A little of the time, None of the time, Don’t know	In the 30 days prior to the formative assessment	Categorical	Yes/no - Each item scored 0-4, summation of responses were scored 0-24, with 0 suggesting lowest level of PD and 24 suggesting the most severe. Yes, a score ≥ 13 indicates severe, non-specific PD	Relationships examined from different combinations of: sample demographics, MSM-related discrimination, MSM-related violence, and HIV antibody test results	Model testing: MSM-related discrimination, MSM-related violence, severe PD, age group, race/ethnicity, insurance status, and HIV antibody test results
HIV antibody testing	N/A	N/A	Rapid, on-site testing following the formative assessment	Categorical	PLWH/person not living with HIV -HIV antibody positive indicating PLWH, HIV antibody negative indicating the person is not living with HIV	Relationships examined from different combinations of: sample demographics, MSM-related discrimination, MSM-related violence, and severe PD	Model testing: MSM-related discrimination, MSM-related violence, severe PD, age group, race/ethnicity, insurance status, and HIV antibody test results

Participants also reported experiences of physical violence, not specific to intimate partner violence (IPV), because of perceived or known sexual identity across their lifetime, MSM-related violence (“Were you physically attacked or injured because someone knew or assumed you were attracted to men?”; Centers for Disease Control and Prevention, 2016). This variable was also characterized as binary (yes, experienced MSM-related violence/no, did not experience MSM-related violence), omitting any missingness.

Severe PD was measured via the Kessler-6 scale, a six-item condensed measure of the Kessler-10 scale with varying symptoms experienced in the past 30 days, including nervousness (“During the past 30 days, how often did you feel nervous?”), hopelessness (“How often did you feel hopeless?”), restlessness (“How often did you feel restless or fidgety?”), sadness or depression (“How often did you feel so sad or depressed that nothing could cheer you up?”), everything was effortful (“How often did you feel that everything was an effort?”), and worthlessness (“How often did you feel down on yourself, no good or worthless?”; (Kessler et al., 2002). The PD items were measured by the frequency of symptoms experienced (i.e., “All of the time,” “Most of the time,” “Some of the time,” “A little of the time,” and “None of the time”). The Kessler-6 scale demonstrates excellent internal consistency reliability (α = .89–.92; Kessler et al., 2002). Answer choices were scored from 0 to 4 for each of the six items. The range for summed responses was 0 to 24, with 0 suggesting the lowest level of PD experienced and 24 suggesting the highest level. Cumulative answer frequencies of 13 or higher were considered nonspecific severe PD, which were dichotomized, based on the validated cut-point, into a binary variable for analysis (Oliver et al., 2020).

On-site rapid HIV testing was performed via fingerstick using a 20-min OraQuick HIV-1/2 antibody test. Optional testing was offered to all NHBS participants and remained anonymous when participants were informed of their antibody test results. Preliminary HIV antibody-positive results were confirmed via lab-based testing at the Tennessee Department of Health State Laboratory in Shelby County. Testing was offered regardless of the self-reported status provided by the respondent. For this analysis, the HIV antibody test result was classified as person living with HIV (PLWH; or HIV antibody positive) or person not living with HIV (HIV antibody negative).

Analyses

The analysis comprised a stepwise approach with summary statistics of the sociodemographic characteristics and exposure variables, bivariate and multivariable logistic regression modeling, and subsequent associations between the exposure and outcome variables. All analyses were performed using SAS Enterprise Guide software, Version 8.3 (SAS Enterprise Guide 8.3, 2020).

Summary Statistics

The analysis began by running variable frequency tables and chi-square tests to review and evaluate substantial counts and percentages from the sociodemographic characteristics of the sample, including age group, race/ethnicity, sexual identity, educational attainment, annual income, insurance status, being unhoused in the past 12 months, and employment status. The same testing was used to establish estimates and compare the descriptive sample characteristics to experiences of MSM-related discrimination, MSM-related violence, severe PD, and HIV antibody-positive test results.

Bivariate Regressions and Associations

The relationships were examined between different combinations of variables by conducting bivariate analyses to establish preliminary associations and inform a multivariable logistic regression with on-site HIV antibody test results. First, the relationships were tested between each of the sociodemographic characteristics separately with MSM-related discrimination, MSM-related violence, and severe PD to form any significant associations and identify potential covariates. Next, an examination of the associations was entered across the exposure variables to review and detect multicollinearity for the multivariable model. Then, a review of the associations between HIV antibody-positive test results and the exposure variables was conducted.

Multivariable Regressions and Associations

After identifying potential covariates and other associations with bivariate models, a multivariable model was executed between MSM-related discrimination, MSM-related violence, and severe PD, including the covariates of age group, race/ethnicity, and insurance status to distinguish any confounding relationships. This was tested against the outcome variable of HIV antibody-positive test results, to examine if experiences of discrimination, violence, and severe PD are an indicator that MSM in the MSA have a higher likelihood to be living with HIV, barring any other variables that may confound the relationship.

Results

Summary Statistics

Of the 851 participants approached, 509 were screened, and 356 met the eligibility criteria to complete the survey (Table 2). Among the 356 MSM, the mean age was 29 years, with 66.9% (n = 238) aged <35 years, and 79.5% (n = 283) identifying as NH Black. Most of the sample reported some college or more (n = 217; 61%), having health insurance (n = 263; 73.9%), and being employed (n = 268; 75.3%). Nearly half of the respondents reported earning less than $20,000 USD per year (n = 159; 44.7%). Thirty participants reported being unhoused in the past 12 months (8.4%).

Table 2.

Sample Characteristics: Categorical Variables, Prevalence, and Significance Levels of Severe Psychological Distress (PD), Experiences of Violence, and MSM-Related Discrimination; N = 356^a

Characteristic	Sample descriptives, n (%)	Severe psychological distress in past 30 days(score ≥ 13), n (%)	p	Experience of MSM-related violence in lifetime, n (%)	p	Experience of MSM-related discrimination in lifetime, n (%)	p	Positive HIV test results^b, n (%)	p
Age			.66		.45		.14		<.0001*****
18–24	102 (28.7)	10 (9.8)		12 (11.8)		52 (51.0)		16 (15.7)
25–34	136 (38.2)	14 (10.3)		20 (14.7)		69 (50.7)		38 (27.9)
35–44	49 (13.8)	5 (10.2)		2 (4.1)		19 (38.8)		14 (28.6)
45+	69 (19.4)	9 (13.0)		13 (18.8)		30 (43.5)		31 (44.9)
Race/ethnicity			.19		.6		.57		.02***
Non-Hispanic Black	283 (79.5)	27 (9.5)		36 (12.7)		131 (46.3)		90 (31.8)
Non-Hispanic White	55 (15.4)	8 (14.5)		8 (14.5)		29 (52.7)		5 (9.1)
Hispanic	14 (3.9)	2 (14.3)		2 (14.3)		7 (50.0)		3 (21.4)
Non-Hispanic Other	4 (1.1)	1 (25.0)		1 (25.0)		3 (75.0)		1 (25.0)
Sexual identity			.34		.22		.44		.08
Gay	263 (73.9)	25 (9.5)		33 (12.5)		122 (46.4)		80 (30.4)
Bisexual	85 (23.9)	12 (14.1)		14 (16.5)		44 (51.8)		17 (20.0)
Heterosexual	6 (1.7)	1 (16.7)		0 (0)		3 (50.0)		2 (33.3)
Educational attainment			.003***		.04***		.28		.9
High school, GED or less	139 (39)	23 (16.5)		24 (17.3)		68 (48.9)		38 (27.3)
Some college	148 (41.6)	11 (7.4)		16 (10.8)		72 (48.6)		43 (29.1)
College graduate or higher	69 (19.4)	4 (5.8)		7 (10.1)		30 (43.5)		18 (26.1)
Annual incomes (Quartiles)			.007***		.004***		.81		.007***
$ 0–9,999	72 (20.7)	16 (22.2)		11 (15.3)		31 (43.1)		24 (33.3)
10,000–19,999	87 (24.8)	8 (9.2)		21 (24.1)		49 (56.3)		36 (41.4)
20,000–39,999	98 (27.9)	5 (5.1)		9 (9.2)		45 (45.9)		19 (19.4)
40,000+ per year	94 (26.8)	9 (9.6)		6 (6.4)		42 (44.7)		20 (21.3)
Insurance status			.11		.09		.39		.003***
Currently insured	263 (73.9)	24 (9.1)		30 (11.4)		122 (46.4)		84 (31.9)
Not insured	93 (26.1)	14 (15.1)		17 (18.3)		48 (51.6)		15 (16.1)
Experienced homelessness in the past 12 Months			< .0001*****		.004***		.16		.2
Yes	30 (8.4)	10 (33.3)		9 (30.0)		18 (60.0)		12 (40.0)
No	326 (91.6)	28 (8.6)		38 (11.6)		152 (46.6)		87 (26.7)
Employment status			.006***		.02***		.24		.004***
Employed	268 (75.3)	23 (8.6)		31 (11.6)		125 (45.9)		64 (23.9)
Unable to work or unemployed	65 (18.3)	13 (20.0)		12 (18.5)		33 (50.8)		29 (44.6)
Other	23 (6.5)	2 (8.7)		4 (17.4)		12 (52.2)		6 (26.1)

Numbers may not sum up to 356 due to missing responses. ^bExcludes all missing/unknown results; n = 99.

***

p < .05. ****p < .001. *****p < .0001.

MSM-related violence was reported by 13.2% (n = 47) of participants (Table 2). MSM-related discrimination was reported by 47.8% (n = 170), and 10.7% (n = 38) experienced severe PD. Thirty (17.6%) out of the 170 participants who reported experiences of MSM-related discrimination also reported severe PD. Among those who reported severe PD symptoms, 15 (39.5%) also reported experiencing MSM-related violence during their life. Of those who reported experiences of MSM-related discrimination (n = 170), 26.5% (n = 45) also reported experiences of MSM-related physical violence. Among the 356 respondents, 297 (83.4%) consented and completed the HIV antibody testing provided on-site by NHBS Memphis. Test results showed that 33.3% (n = 99) were PLWH, or HIV antibody positive; 66.7% (n = 198) were not PLWH, or HIV antibody negative. Participants who identified as NH Black accounted for 30.3% (n = 90) of HIV antibody-positive results among those who tested (n = 297). Fifteen (39.5%) of the 38 who reported severe PD symptoms were also living with HIV. PLWH accounted for 42.6% (n = 20) of those who experienced MSM-related violence (n = 47) and 28.2% (n = 48) of those who experienced MSM-related discrimination (n = 170).

Bivariate Regressions and Associations

Several key pairs were examined for bivariate associations, which were later adjusted by other covariates for the multivariable model. These findings suggest that annual income (t = −2.71, p = .00701), educational attainment (t = −2.95, p = .003), employment status (t = 2.78, p = .006), and being unhoused in the past 12 months (t = 4.3, p < .0001) were all associated with severe PD. MSM-related violence was significantly associated with annual income (t = −2.92, p = .004), educational attainment (t = −2.09, p = .037), employment status (t = 2.25, p = .025), and being unhoused in the past 12 months (t = 2.86, p = .004; Table 2). MSM-related discrimination was not significantly related to any demographic factors. Severe PD and MSM-related violence were not associated with age group, race/ethnicity, and insurance status. Reported experiences of severe PD, MSM-related violence, and MSM-related discrimination were substantially interrelated (Table 3). Severe PD was associated with MSM-related violence (t = 7.60, p < .0001) and MSM-related discrimination (t = 4.16, p < .0001). Correspondingly, MSM-related violence was associated, as was MSM-related discrimination (t = 7.60, p < .0001).

Table 3.

Interactions Between Experiences of Severe PD, MSM-Related Discrimination, MSM-Related Violence, and HIV Status; N = 356^a

Individual social-level factors	Sample descriptives, n (%)	Severe psychological distress(score ≥ 13), n (%)	p	Experience of MSM-related violence, n (%)	p	Experience of MSM-related discrimination in lifetime, n (%)	p
Psychological distress
Reported experiences of PD in the past 30 days			.		< .0001*****		.
Yes	38 (10.7)	.		15 (39.5)		.
No	318 (89.3)	.		32 (10.1)		.
MSM-related discrimination
Reported experiences of MSM-related discrimination in lifetime			< .0001*****		< .0001*****		.
Yes	170 (47.8)	30 (17.6)		45 (26.5)		.
No	186 (52.3)	8 (4.3)		2 (1.1)		.
MSM-related violence
Reported experiences of MSM-related violence in lifetime
Yes	47 (13.2)	.		.		.
No	309 (86.8)	.		.		.
HIV antibody test results^b
From NHBS on-site rapid testing			.2		.02***		.87
HIV antibody positive	99 (33.3)	15 (15.2)		20 (20.2)		48 (48.4)
HIV antibody negative	198 (66.7)	20 (10.1)		20 (10.1)		98 (49.5)

Numbers may not sum up to 356 due to missing responses. ^bExcludes all missing/unknown results; n = 297.

***

p < .05. ****p < .001. *****p < .0001.

Several demographic factors were associated with HIV antibody-positive results. Participants in older age groups were more likely to be PLWH than younger participants (t = 4.29, p < .0001). Also, NH Black MSM were more likely to be PLWH than NH White (t = 2.43, p = .016). Those who made less than US$20,000 in annual income were more likely to be PLWH than those who made higher incomes (t = −2.74, p = .007). Having insurance was also associated with having HIV antibody-positive test results compared with those that did not have insurance (t = 3.03, p = .003). Finally, those who were unemployed had a higher proportion of HIV antibody-positive test results than those who reported being employed (t = 2.94, p = .004). HIV-positive antibody test results were significantly associated with experiences of MSM-related violence (t = 2.42, p = .02) but were not significantly related to severe PD and MSM-related discrimination.

Multivariable Regressions and Associations

A multivariable model tested MSM-related discrimination, MSM-related violence, and severe PD by HIV antibody test result, adjusting for age group, race/ethnicity, and insurance status (Table 4). Based on the model, the strength of the associations increased: age group, with those aged 45 and older having the highest likelihood of living with HIV (adjusted odds ratio [AOR]: 8.1, 95% confidence interval [CI]: [3.4, 19.0]), NH Black race/ethnicity compared with NH White (AOR: 11.7, 95% CI [4.1, 33.4]), and having health insurance compared with those who were not insured (AOR: 3.3, 95% CI [1.6, 6.7]). Those who reported experiences of MSM-related violence were 3.6 times more likely to have HIV antibody-positive test results (AOR: 3.6, 95% CI [1.5, 8.8]). Severe PD and MSM-related discrimination were not associated with HIV antibody-positive test results, even upon adjustment for covariates.

Table 4.

Unadjusted and Adjusted Associations of Experiences of Severe Psychological Distress (PD), Discrimination, and Violence With HIV Antibody Test Results^a

Demographics	Unadjusted			Adjusted
Demographics	OR	p	95% CI	OR	p	95% CI
Age
18–24	REF	.	.	.	.	.
25–34	2.13	.03***	[1.1, 4.16]	2.59	< .01***	[1.28, 5.25]
35–44	2.96	.01***	[1.24, 7.04]	5.46	< .001****	[2.05, 14.55]
45+	5.1	< .0001*****	[2.41, 10.77]	8.07	< .0001*****	[3.42, 19.02]
Race/ethnicity
Non-Hispanic Black	5.96	< .001****	[2.28, 15.56]	11.73	< .0001*****	[4.12, 33.43]
Non-Hispanic White	REF	.	.	.	.	.
Hispanic	2.76	.21	[.57, 13.49]	7.59	.02***	[1.36, 42.32]
Non-Hispanic Other	3.07	.37	[.27, 35.33]	4.1	.27	[.33, 51.09]
Insurance status
Currently insured	2.56	< .01***	[1.37, 4.78]	3.27	< .01***	[1.6, 6.67]
Not insured	REF	.	.	.	.	.
Individual social-level factors
Severe psychological distress	1.59	.21	[.78, 3.26]	1.3	.58	[.51, 3.33]
MSM-related discrimination	.96	.87	[.59, 1.56]	0.9	.74	[.49, 1.65]
MSM-related violence	2.25	.02***	[1.15, 4.42]	3.62	< .01***	[1.48, 8.83]

Numbers may not sum up to 297 due to missing responses.

***

p < .05. ****p < .001. *****p < .0001.

Discussion

This article is the first to report findings from the NHBS-MSM5 cycle and illustrates the unique portfolio of MSM living in the Memphis MSA. The sample population was primarily highly educated, employed, and with health insurance. Yet, the sample reports low income despite these factors. Furthermore, there is a high HIV prevalence and increased rates of severe PD, and MSM-related violence and discrimination. Although MSM in this study population were seemingly stable socioeconomically, some participants were still underpaid and encountered violence, discrimination, and PD, which contributed to HIV vulnerability.

Most of the study population was young (aged <35 years old) and NH Black. Sociodemographic characteristics, such as insurance status, educational attainment, and annual income, affect HIV health disparities within NH Black MSM populations. Indeed, cities with high poverty and lower education have observed a heightened prevalence of HIV among this population (German et al., 2017). There is a rapid growing concern with the rise in HIV incidence among young, NH Black MSM (YBMSM). YBMSM are a priority population for CDC because this demographic is less likely to be aware of their HIV status and are disproportionately affected by HIV (Centers for Disease Control and Prevention, 2020). The results also identified MSM who were older, NH Black, and insured were more likely to be PLWH. Older age and race/ethnicity as indicators for heightened HIV vulnerability corroborates prior knowledge; however, having health insurance is inconsistent as a factor for HIV acquisition and warrants further investigation among Southern MSM populations (Kates & Levi, 2007).

These results suggest that severe PD is heavily associated with experiences of MSM-related violence and discrimination. Severe PD was reviewed as a mediating component of the relationship between MSM-related violence and positive HIV test results but did not find any significance. However, further robust mediation analyses to understand the driving forces between these factors are needed. PLWH experience higher rates of trauma, “events such as family and social violence, rapes and assaults, disasters,. . .and predatory violence [which] confront people with such horror and threat that it may temporarily or permanently alter their capacity to cope,” and can result in negative health outcomes, particularly within HIV-related care (Brezing et al., 2015; van der Kolk, 2000, p. 7). MSM living with HIV have an increased likelihood of experiencing negative psychological outcomes, including disassociation and extreme stress, after traumatic events compared with non-MSM (Kamen et al., 2012). Evidence-based approaches to address trauma have been an emerging form of research and implementation in the HIV care continuum. Trauma-informed care, from prevention to treatment, has shown promising results for patients living with or vulnerable to HIV (Piper et al., 2021). The strong associations between severe PD, MSM-related discrimination and violence could further advise trauma-informed HIV care and mental health services for MSM populations.

Those who reported experiences of MSM-related violence were 3.6 times more likely to have HIV antibody-positive test results than those who did not experience violence. These results substantiate prior literature that indicates MSM living with HIV experience high rates of violence (Siemieniuk et al., 2013). In Tennessee, bias-motivated crime toward those in the lesbian, gay, bisexual, transgender, queer and/or questioning, and others (LGBTQ +) community (i.e., hate crimes) increased by 9% from 2019 to 2021. Race/ethnicity bias and sexual orientation bias were the first and second most common motivators for hate crime-related assaults in 2021, at 64.9% and 14.9%, respectively (Tennessee Bureau of Investigation, 2022). In the same year, Shelby County reported an increase in major violent crimes, including aggravated assaults, gun-related violent incidents, and homicides compared with rates in 2020 (Memphis Crime Commission, 2022). Homophobia, stigma, and prejudice against the LGBTQ+ community put MSM in a vulnerable position, especially those in communities with high violence incidence. High crime rates overlap with increased HIV rates in urban areas (Hotton et al., 2019). Intimate partner violence, relational power dynamics, and lack of condom negotiation can act as predictors of HIV and HIV vulnerability for MSM, especially those who are racial/ethnic minorities, report lower incomes, and live in urban settings (Lichtenstein et al., 2018; Stephenson et al., 2016). Evidence-based interventions are necessary to provide MSM in Memphis with a safer environment and better HIV prevention and treatment outcomes.

The Compendium of Evidence-based Interventions and Best Practices for HIV Prevention integrates social structural factors related to HIV care and assimilates them into intervention strategies (Centers for Disease Control and Prevention, n.d.-a). These findings would be especially suitable for interventions, such as Transforming from HIV Prevention Practice to Prevention Innovation (TRANSFORM), which broadly focuses on culturally appropriate HIV care delivery for MSM of color vulnerable to or living with HIV through efforts with state health departments, community-based organizations (CBOs), and social and behavioral health services (Centers for Disease Control and Prevention, n.d.-c). These results could also augment condom use interventions, particularly among younger, NH Black populations in the Southern United States, by incorporating stigma reduction, violence prevention, and partner abuse education and strategies (Crosby et al., 2014). The Health Resources and Services Administration Homeless Initiative, which sought to reduce the multilayered stigma for PLWH who were unhoused and experiencing mental health and substance use disorders, is an excellent example of community-level stigma reduction (Maskay et al., 2018). Interventions that explore community-level HIV- and MSM-related stigma reduction education, with a focus on discrimination and violence prevention, in the Southern United States could help create a safer space for PLWH (Pichon, Stubbs, & Teti, 2022). Utilizing treatment as prevention (TaSP) and U=U campaigns to reduce HIV- and MSM-related stigma in Southern MSM populations vulnerable to or living with HIV could be helpful in other prevention and treatment strategies (National Institute of Allergy and Infectious Diseases, 2019). Extant literature also describes strategies for PrEP navigation and uptake among Memphis-based MSM, with main facilitators through trusted connections, like peers and medical providers who are similar demographics to patients, as well as opportunities for engagement and access (Pichon, Teti, Betts, et al., 2022; Pichon, Teti, McGoy, et al., 2022). Results from the present study can inform these existing and ongoing measures by encouraging the examination of individual and social experiences, including MSM-related violence, discrimination, and severe PD and how each contributes to PrEP navigation, use, and adherence among Southern MSM populations.

More interventions are needed to support psychosocial change with respect to displays and reports of severe PD among MSM. There is great importance in public health practice to identify mental health needs during intake and assessment of clients living with HIV, while linking them to other forms of care in state and federal services, like Ryan White Plan B programs (Kalokhe et al., 2023). These intake processes could be modeled after the psychological and trauma-informed support services offered by CBOs in Memphis to PLWH (Pichon, Teti, & Brown, 2022). In addition, utilizing clinically trained behavioral health specialists who provide care to MSM and other individuals struggling with sexual identity would be a valuable resource for addressing MSM mental health needs. The collaboration between public health governmental agencies and CBOs to cocreate coping strategies and techniques for severe PD, violence, and discrimination, such as trauma-informed care, would be beneficial to include in interventions and other relevant programs. Community-based interventions developed in partnership with MSM may be a key consideration for the implementation of these study findings (Pichon, Wilkins, et al., 2022). This would require the advocation of additional funding from state health departments to support this work. Outreach would benefit from the integration and support of community-based interventions that are evidence-informed rather than evidence-based, as this change would create opportunities for more local implementation science research to develop future curricula.

This study was subject to limitations. The NHBS survey is a cross-sectional study design, and therefore causation cannot be implied. The measures for MSM-related discrimination and MSM-related violence were developed by CDC for the NHBS questionnaire, which is a multiyear, multisite nationally administered survey. As such, these measures may be limited by the scope of NHBS contexts and may not have been rigorously examined for reliability and validity. Anonymous, self-reported experiences of sensitive topics, such as severe PD, discrimination, and violence, may be underreported among this population. Self-report bias may be existing for those who conveyed experiencing the exposure variables, as this study did not validate the occurrence of these incidents. The NHBS-MSM5 cycle did not include a qualitative component for MSM to further discuss their experiences of violence, discrimination, and PD. In addition, these findings may not generalize to all MSM, particularly those outside of the Southern United States.

Mixed-methods research, with the inclusion of qualitative in-depth interviews, on MSM-related violence, MSM-related discrimination, and severe PD among MSM populations would provide nuanced information and better contextualize the survey findings. Involvement with CBOs and health care entities serving MSM would build trust among this priority population. To facilitate building trust, data fact sheets from these findings could be disseminated at MSM community advisory meetings, further strengthening confidence among these groups while sharing important results. In addition, offering technical assistance training would be greatly advantageous to build community capacity to use the current and future NHBS data to inform Ending the HIV Epidemic in the United States agency-initiated grant submissions. Understanding how these results further contribute to trauma-informed therapies would be most beneficial through randomized control trials or longitudinal study designs, as it relates to experiences of MSM-related violence across various MSM subgroups, including mental health-focused care tailored for Black MSM.

Conclusion

This study revealed that Memphis-based MSM experience multilevel social and structural conditions that could increase vulnerability to HIV. Utilizing on-site HIV testing in CBOs or clinical settings may be an opportunity to screen for experiences like violence, discrimination, and severe PD, and offer community resources for comprehensive care, such as trauma-informed therapies and stigma reduction projects, as a strategy for the successful implementation of HIV prevention and treatment programs among MSM in the Memphis MSA.

Footnotes

Acknowledgements

This work would not be possible without the dedicated efforts of Monica Kent, Iran Yarbrough, the Memphis NHBS field team, and our NHBS-MSM5 participants. A special thank you goes to Samantha Mathieson and Riley Gulbronson for their assistance on the statistical output for this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Centers for Disease Control and Prevention National HIV Behavioral Surveillance network (grant ID PS16-1601).

ORCID iD

Meredith R. Denney

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