Since early in the HIV epidemic, Hispanics/Latinxs (henceforth: Latinxs) have been impacted disproportionally. Among Latinxs in the U.S., the data are alarming; 25% of new HIV infections occur among Latinxs. Latinx men who have sex with men (MSM) are the only subgroup with increasing rates of new diagnoses in recent years, as compared with other groups (Centers for Disease Control and Prevention, 2019). If this trend continues, as many as one in four Latinx MSM will be diagnosed with HIV in their lifetime (CDC, 2015). In Philadelphia, the HIV prevalence in 2018 was highest among non-Latinx Blacks (1,883.9 per 100,000 population), followed by Latinx (1,579.3). In 2018, the highest rate of new HIV diagnosis was among Latinxs (46.0 per 100,000 population), followed by non-Latinx Blacks (38.9) and non-Latinx Whites (13.9) (Philadelphia Department of Public Health, 2019).

Disparities in HIV risk are attributed to psychosocial and environmental conditions that disproportionately impact gay and bisexual Latinxs (Frye et al., 2014). Numerous factors contribute to an elevated HIV risk for Latinx MSM, including substance use (Deiss et al., 2008; Fernández et al., 2005), discrimination (Diaz, Ayala, & Bein, 2004; Nakamura & Zea, 2010), stigma, social isolation, migration experiences (Bianchi, Reisen, Zea, Poppen, & Shedlin, 2007; Carrillo, 2004), and cultural factors (CDC, 2016; Hoebbel & Fals-Stewart, 2003; Stappenbeck, Hoebbel, & Fals-Stewart, 2004). Latinx MSM may feel fúrther compelled to engage in risky behaviors as a coping mechanism for internalized homophobic feelings as well as real or perceived negative perceptions about their sexual orientation (S. D. Rhodes, Yee, & Hergenrather, 2006; Sandfort, Melendez, & Diaz, 2007) (Ayala, Bingham, Kim, Wheeler, & Millett, 2012). Latinx immigrant MSM, some of whom are in the U.S. without legal documentation, may face additional social stressors that influence sexual behaviors, including the anxiety of not having legal U.S. residency status, the complexity of navigating various cultural contexts (e.g., mainstream U.S. culture, white gay community culture, Latinx culture) and the loneliness, isolation, and depression that often results from “secret-keeping” (i.e., sexual orientation disclosure) and family estrangement (Diaz & Ayala, 1999; Shedlin, Decena, & Oliver-Velez, 2005) (Hess et al., 2015; Javanbakht et al., 2009; Murphy, Gorbach, Weiss, Hucks-Ortiz, & Shoptaw, 2013; Rietmeijer, Wolitski, Fishbein, Corby, & Cohn, 1998).

Syndemic theory may explain high rates of HIV/AIDS among Latinx MSM. This theory posits that multiple risk factors interact synergistically to increase vulnerability (Singer & Clair, 2003). Co-occurring conditions, such as alcohol and other substance abuse, depression, and violence, may collectively influence HIV risk behaviors among Latinx MSM (Mizuno et al., 2012; Wilson et al., 2014). Syndemic theory postulates that assessing the overall impact of psychosocial and other conditions, rather than the additive effects of separate factors, provides a better assessment of risk (Singer & Clair, 2003). The present study extends recent work on syndemics and HIV risk among sexual minorities (Latinx and non-Latinx) (Beymer et al., 2016; Halkitis et al., 2013; O. Martinez et al., 2016; Mimiaga et al., 2015; Mizuno et al., 2012; O’Leary, Jemmott, Stevens, Rutledge, & Icard, 2014; Santos et al., 2014; Wilson et al., 2014) by providing an assessment of the relative predictive power of syndemic and non-syndemic approaches to understanding HIV sexual risk behaviors among Latinx MSM. This is particularly important in light of Mustanski and colleagues’ analysis of HIV/STI incidence and risk behaviors among MSM (2016), which found that the effectiveness of syndemic approaches may vary across racial and ethnic groups.

We explored syndemic conditions leading to HIV risk behaviors among sexual minority Latinxs in Philadelphia, Pennsylvania using data from the National HIV Behavioral Surveillance System (NHBS). We hypothesized that a syndemic of psychosocial conditions would be associated with sexual risk among Latinx MSM. To our knowledge, this is the first study to explore the impact of syndemic conditions on adult sexual HIV risk behaviors among a representative sample of sexual minority Latinxs in Philadelphia. We also compared two analytical approaches, a combined syndemic factor (ie. a syndemic approach) versus separate individual syndemic factors (ie. traditional epidemiological approach), in order to understand their capacity to explain HIV risk among this population.

This study utilized a multistage approach. Quantitative cross-sectional survey data from Latinx MSM in Philadelphia were analyzed to assess sexual risk behaviors, using both syndemic and non-syndemic approaches.

Sample characteristics appear in Table 1. The average age of participants was 31 years (SD=9.01). Almost half of participants (n=226, 49%) completed surveys in NHBS Round 4; the remainder were approximately evenly divided between rounds 2 and 3. Seventy percent (n=310) of participants who provided data for Hispanic ancestry identified as Puerto Rican. More than half of those who provided data for racial identity (n=196, 52%) identified as Black or African American, and 35% identified as White (n=130). Approximately three-quarters of the sample identified as gay or homosexual (n=342, 74%), and the remainder identified as bisexual. A substantial majority were born in the U.S. (n=378, 81%), and a smaller majority had health insurance (n=302, 65%). Most participants reported either full or part-time employment (n=328, 71%), though one-fifth were unemployed at the time of their surveys (n=86, 19%). Eighty-nine percent of participants (n=412) had completed high school. Almost half reported incomes below $20,000 (n=212, 46%), though 20% (n=92) reported incomes of $50,000 or higher.

Eight percent of participants (n=36) reported engagement in sexual exchange (as a sex worker or client) in the previous 12 months. Nearly half reported heavy drinking in the previous month (n=212, 46%), and slightly more than one-third reported prior experiences with homophobic discrimination (n=166, 36%). Forty-five percent of participants (n=210) reported one of these syndemic factors, and 20% (n=94) reported at least two. Of those factors excluded from the syndemic scale, 16% of participants reported homelessness in the past year (n=72), and 6% reported arrest or detention in this period (n=30). Participants reported a mean of 4.09 male partners (SD=6.17) in the past 12 months. Those who reported involvement with main male partners in this period (n=96) reported a mean of 1.38 main male CAI partners (SD=1.22), and those who reported involvement with casual male partners (n=162) reported a mean of 2.23 casual CAI partners (SD=4.49)

Our results demonstrate that Latinx MSM continue to be highly vulnerable to HIV infection, and the synergistic interaction of risk factors impact sexual HIV risk behaviors. Our study also highlights the importance of including factors beyond only psychosocial in syndemic research. We demonstrate that environmental and behavioral factors such as homelessness, incarceration, and engagement in sex exchange can and should be included when investigating HIV behavioral risk factors through syndemic theory. In addition, we demonstrate that both syndemic and non-syndemic analyses provide information about the impact of risk factors on HIV risk behavior.

Our syndemics framework analysis provided evidence that the presence of at least two of the five risk factors we examined was associated with more male partners and more casual male CAI partners. This model also explained the variance in acts of CAI with a main male partner and CAI with casual male partners, but did not perform as well with regard to the total number of male partners. In contrast, our non-syndemic models showed the association between experiencing homophobia and homelessness and the number of male partners, as well as the impact of heavy drinking on the number of casual male CAI partners. This approach also better explained variability in the total number of male partners, but did not show any significant impact of sex exchange and incarceration on our outcome variables.

Through both approaches, this analysis demonstrated that the individual impacts of psychosocial conditions are not necessarily equivalent to the cumulative impact of those conditions. While consistent with the logic of syndemic theory, this suggests that syndemic and non-syndemic approaches vary in their relative capacity to account for sexual risk among Latinx MSM. As we move forward in an era of biomedical prevention tools, including PrEP and U=U, these syndemic conditions should be further addressed. For example, the presence of syndemics, including lager structural conditions such as discrimination and stigma, might impact viral load suppression and adherence to medications. Study findings underscore the importance of social and structural determinants in HIV prevention and care. Future studies should explore the impact of racism and ethnic discrimination; housing insecurity; anti-immigration policies and laws; unemployment; and lack of health insurance on HIV prevention and care continua outcomes, including PrEP continuum of care.

To address growing HIV prevention and care challenges among Latinx MSM and implementation gaps, we urge researchers, clinicians, health and social service providers, policy makers, and multi-sectoral community stakeholders to adopt an implementation science framework, which will increase the uptake of effective HIV programs and interventions. Implementation science is an integrated concept that links research and practice to accelerate the development and delivery of public health approaches. Implementation science focuses on practical approaches to improve implementation and to enhance equity, efficiency, scale-up, and sustainability of programs, policies and practices (Waltz, Powell, Fernández, Abadie, & Damschroder, 2019).

Several programs and interventions have been shown to be feasible and acceptable, efficacious and/or effective among sexual and gender minority Latinxs. For example, Connecting Latinos en Parejas is a couple-based HIV biobehavioral HIV prevention and treatment intervention for Latino men and their same-sex partners (O. Martinez et al., 2018). Tal Como Somos is an educational film to reduce stigma toward gay and bisexual men, transgender individuals, and persons living with HIV/AIDS (Ramirez-Valles, Kuhns, & Manjarrez, 2014). Trans Equity Project is a homegrown community-level HIV prevention and treatment intervention for transgender men and women (O. o. m. t. e. Martinez, Lopez, Woodard, Rodriguez-Madera, & Icard, 2019). HOLA en Grupo is a group-level HIV prevention intervention for recently-arrived sexual and gender minority Latinxs (Scott D. Rhodes et al., 2017).

Despite its significance, this study has several limitations. First, a tri-city analysis using NHBS data from Baltimore, Philadelphia, and Washington, DC was pursued, however there were prohibitively few Latinx MSM participants from Baltimore and Washington, DC. Consequently, we could not determine the extent to which the documented patterns are unique to Philadelphia. Therefore, moving forward, increased efforts to collect data from Latinx MSM in Washington D.C. and Baltimore are needed. Second, due to skip patterns in prior cycles of NHBS data, it was not possible to include transgender participants in assessments of sexual risk behavior. Third, the study relied upon self-reported socio-behavioral data. NHBS includes extensive staff training and survey methods to build participant rapport and enhance validity of self-reported data, but social desirability bias may have affected study findings. Fourth, there may be limitations connected with venue-based sampling for MSM and other populations that face an elevated risk of HIV infection and transmission. Finally, it is somewhat difficult to gauge the relative effectiveness of syndemic and non-syndemic approaches with these data. In some models, participants who reported two or more factors differed significantly from those reporting no factors, however without a larger scale and sample, we do not have the data to determine whether a further increase in syndemic conditions would have been associated with a further increase in HIV risk.

To our knowledge, this is the first paper that looks at syndemics among Latinx MSM in the Philadelphia Metropolitan Area, one of the epicenters of the HIV epidemic in the U.S. Our analysis provides a description of the characteristics of Latinx MSM in Philadelphia, highlighting socioeconomic vulnerability and the high burden of syndemic conditions. Through syndemic models, we showed that the presence of particular syndemic conditions – including sex exchange– increased the number of male partners and proportion of CAI more than those with none. Future studies should further explore the impact of structural factors, including racial and ethnic discrimination; housing instability; lack of insurance; and anti-immigration rhetoric on HIV prevention and care. In addition, HIV prevention and care interventions for Latino MSM should be responsive to psychosocial and structural conditions impacting this group.