The model of health risks among MSM who migrate to urban centers is shown in Fig. 1.

Although migration to an urban gay subculture is a response to needs for escaping oppression and finding safety and friendship, seeking social support through urban gay subcultural attachment may increase men’s vulnerability to sexual risks and drug use [6, 8]. The model theorizes that this increased vulnerability is related to the losses of close family relationships, established social and sexual mores, and years of social capital built up within the home community that occur upon migration. The investigators’ research confirmed that these losses greatly reduce these men’s economic prospects, as well as their ability to integrate within the larger society and its breadth of social opportunities.

The model further theorizes that the urban subcultures to which men migrate are somewhat limited in their capacity to be supportive because MSM bring their inherited masculinity norms, internalized homophobia, and histories of victimization—all aspects of the syndemic affecting MSM health [7]—to this new, less-structured social realm. At the same time, the high visibility and easy availability of the sex-drugs scenes makes these settings the first points of social contact for many migrant MSM.

Certainly, many men are able to keep the “fast lane” aspects of the subculture at enough distance to lead highly productive and socially integrated lives [6, 34]. However, a large minority of men appear to be unable to find social stability either within or outside of the gay scene. Many life history interviewees said that participation in the sex-drug scenes resulted in behaviors that crossed their own sexual and psychological boundaries. A common theme of the deepening problems for these men is an habituation to being “high” on sex, drugs, or sex and drugs together [33]. The explosion of the Internet as a social and sexual connection point appears to increase risks for sexual sensation seeking and simultaneously reduce the social opportunities afforded by gay subcultures [35, 36]. Sexual sensation seeking has been shown in a number of studies to be associated with higher risks for STI and HIV as well as for mental health problems such as depression [37, 38].

Recent research suggests that the period immediately after migration to a new city is a time of heightened vulnerability for MSM. As they strive to make new social connections, these men often find that the fast lane scenes are among the most visible and accessible sources. Although the literature in this area is limited, Bianchi et al. [39] study of Latino immigrant MSM in New York found that—consistent with the model in Fig. 1—many of these MSM migrated to escape homophobic oppression and HIV stigma at home, found public sex venues to be among the most visible and available social outlets, and were especially vulnerable to unprotected sex in the first years after relocation.

To further examine how risk behaviors may be related to migration, we present here data from the baseline assessments of 325 men participating in the ongoing clinical trial mentioned earlier, the ROOM study. The study is a two-armed randomized clinical trial testing the efficacy of an empowerment theory-based small group intervention compared to an enhanced community standard of care. Multiple recruitment methods are used, including direct outreach, participant referral, and Internet and print media. Eligible men are between the ages of 18 and 55; report recent (past 90 days) unprotected anal sex with a non-monogamous partner(s); and report using drugs (excluding marijuana) on at least 3 days in the past 90 days or getting drunk three or more times in the past month. Research protocols were approved by the University of Delaware’s Institutional Review Board.

To examine whether recency of migration to South Florida was related to health risks, the sample was divided into three subgroups: those who moved to South Florida in the past year (n = 37), those who migrated between 1 and 5 years prior to study entry (n = 56), and those who resided in South Florida for more than 5 years (n = 232). Measures of health risks were compared across groups using unpaired two-sample two-tailed t tests. Comparisons based on three of these variables are reported here: (1) the proportion of people each participant regularly socializes with who use drugs, measured on a 5-item scale ranging from “0 = none to 4 = all”; (2) the number of unprotected anal sex encounters with non-primary partners in the past 90 days; and (3) HIV serostatus.

We also examined the proportion of migrant HIV-negative MSM who seroconverted within 5 years of moving to South Florida. Men who were born in South Florida and those who moved to South Florida as children (under the age of 18) were excluded from this analysis. Finally, because some health risk measures, such as HIV-positive serostatus, might be expected to be associated with older age, we constructed one-way ANOVA models comparing the newest migrants (within the past year) to the other two groups on each of the risk measures controlling for age.

Demographic and health and social risk characteristics are shown in Table 1. The participants are generally characterized by high education but low income, and high levels of substance dependence, mental health problems, HIV infection and ongoing sex risk.

The results comparing the three subgroups on health and health risk measures are shown in Figs. 2, 3 and 4.

Each measure of health and health risk appeared to deteriorate after living in South Florida for more than one year. The two subgroups of men who had been living in South Florida longer than one year reported socializing with more people who use drugs compared to the subgroup of men who had lived there less than one year (t = 2.82, P = .005). The mean number of unprotected anal sex encounters in the past 90 days was 13 for the past year migrants, 33 for those who moved to South Florida between 1 and 5 years ago, and 21 for men resident for more than 5 years (t = 2.69, P = .009 for the difference between past year migrants and those who moved 1–5 years ago; t = 2.13, P = .03 for the difference between those who moved to South Florida 1–5 years ago and men resident for more than 5 years). HIV prevalence rates were 27% for past year migrants and 50 and 48% for the longer-resident groups, respectively (t = 2.43, P = .02 for the difference between past year migrants and the combined two groups of longer residence). In multivariate models controlling for age, age was non-significant and p values substantially unchanged for each of the three health risk measures (data not shown).

In the examination of HIV seroconversion, 39 men who reported being HIV-negative adults at the time they moved to South Florida said they were diagnosed with HIV infection within 5 years of migration. As a proportion of all men who said they were HIV-negative adults when they moved to South Florida (N = 125), 31.2% seroconverted within 5 years.

The main limitation of these preliminary findings is that they are not based on longitudinal data, and therefore it is not possible to determine a causal association between migration and changes in health and social risks. Moreover, the sample includes only substance-using men at high risk for transmission and infection of HIV; therefore, the findings cannot be generalized to the larger South Florida MSM population. Finally, South Florida’s multi-ethnic, transient, and entertainment-focused gay subculture is unique to its space and time. In this regard, however, it must be recognized that sex-drugs scenes are evident in every urban gay subculture in the US [8, 40].

Nevertheless, the behavioral patterns that emerge from the baseline assessment data tend to confirm the theoretical model presented above. Recent migrants report lower levels of HIV infection, unprotected sex, and socializing with drug users than men who have resided in South Florida for longer periods of time, and the cross-sectional data suggest that these health and social risks may rise rapidly after migration. Three other findings support the idea that MSM who move to a new urban center are at heightened vulnerability in the immediate post-migration period: (1) men who lived in South Florida for 1–5 years reported significantly greater numbers of unprotected sex acts than either the newest (past year) migrants or those who lived in South Florida for more than 5 years; (2) almost one-third of HIV-negative adult men seroconverted within 5 years of moving to South Florida; and, (3) HIV prevalence rates are essentially the same for both groups of men who resided in South Florida for more than 1 year. These results all point to the likelihood that men who migrate to South Florida embrace the uninhibited fast lane subculture quickly upon arriving; but that they weary of it after several years, eventually reducing their health risks but only after a substantial number of them become HIV infected. Longitudinal research—and research in other cities—is needed to further support the connection between migration and health and social risks among MSM.

Because the social ties and living patterns that men initially establish in their new community tend to be self-sustaining, the immediate post-migration period may represent a key intervention opportunity to help MSM establish healthy and productive affiliations. Interventions to reduce drug use and sexual risks may be more successful to the extent that they address men’s needs for—and skills at attaining—social relationships with men who do not participate in sex-drug scenes, as well as stronger ties to the broader community. Culturally appropriate and accessible health services are also urgently needed for men who have already developed harmful substance use and sexual behavior patterns.

We have previously outlined a conceptual model and supporting social and psychological theory that suggests various hypothetical mechanisms of influence between the social and physical neighborhood environment and a range of health outcomes among MSM [8]. Currently, we are conducting a 4-year cross-sectional study in NYC testing these hypotheses. The metropolitan statistical area that includes NYC (New York, New Jersey and Long Island) has the 10th highest percentage of coupled households that are gay or lesbian [31] and NYC has several established and emerging gay neighborhoods and enclaves. As part of this larger study, we conducted a formative study using exploratory qualitative methods to confirm that our overall approach and instrumentation for the main quantitative phase accurately reflect the lived experiences of the focal population. The qualitative phase of the study consisted of 20 in-depth semi-structured interviews with MSM exploring their thoughts, perceptions, and experiences of the neighborhoods where they live, socialize, and have sex. We interviewed 20 men recruited from four distinct neighborhoods (5 men per neighborhood) in NYC, including: Chelsea/Hell’s Kitchen, a neighborhood with an established gay enclave that is largely white, has a significant and visible lesbian, gay, bi-sexual, transgender (LGBT) population, and has a median household income of $49,000; Fort Greene and the surrounding neighborhoods, an area of Brooklyn that is majority Black, with some visible LGBT presence, and thought to be an “emerging” gay enclave, and with a median household income of $28,070; Harlem, an historically Black neighborhood located in upper Manhattan, with a minimal LGBT presence and a median household income of $21,508; and finally, Washington Heights, a largely Latino/a neighborhood, also in upper Manhattan, with little visible LGBT presence, and a median household of $28,497 [55].

Study participants were recruited by trained study staff using both passive (posters and flyers) and active (street outreach) methods. Participants were eligible if they: (1) self-reported biological male sex at birth; (2) reported engaging in insertive or receptive anal sex with a man in the past 6 months; (3) self-reported being at least 18 years of age; (4) lived in either Chelsea or Hell’s Kitchen, Harlem, Washington Heights or Ft. Greene, Brooklyn for at least 12 months; (5) communicate in English; and (6) were willing and able to give informed consent for the study. Semi- structured face-to-face interviews were conducted in a private room at the study site; participants received $50 and a round trip MetroCard as reimbursement for their travel and in recognition of the efforts made to attend the interview.

The study protocol was reviewed by Institutional Review Boards of the institutions involved, and informed consent was collected from each participant. During the in-depth interviews, we asked participants to define and delineate (on a map) their “home” (residential) neighborhood, social neighborhood, as well as sexual neighborhood. The interviews then explored their perceptions about where they lived, socialized and had sex, as well as the relationship between neighborhoods, identity, behavior, and health. Interviews lasted approximately 1 h, were audio recorded, and professionally transcribed. Preliminary analyses were ongoing during data collection and confirmed existing foci for the main study phase as well as identified novel areas of inquiry. One Investigator (Egan) conducted all the interviews and two reviewed audio recordings and transcripts (Egan and Frye). Through discussion and reflection, salient themes and impressions emerged and were summarized with supporting quotations drawn from the transcripts.

The mean age of participants was 34 (range 20–50). The men self-identified as either Latino (30%), African American (30%), multiracial (20%), white (15%), or Asian American (5%). Ninety percent identified as gay and ten percent as bisexual. All had been living in NYC for over 1 year. Seven were HIV-positive. Five men were interviewed from each of the four focal neighborhoods. In general, we found that the concept of “neighborhood” resonated with participants, with men offering rich accounts both of various stages of life spent in different neighborhoods, and the impact of certain neighborhoods on the process of coming out or discovering their sexual orientation and identity.

The findings presented here are limited in that they are based on qualitative data from a convenience sample meant to confirm foci for the quantitative portion of a study. This preliminary analysis does begin, however, to illustrate the complex interaction between neighborhood factors (e.g., culture, racial/ethnic composition, social norms) and individual factors (e.g., socioeconomic status, gay identification, feelings of community affiliation, and racial/ethnic identity). There was a good deal of variation in how individuals experience neighborhood, and how neighborhoods shape their lives. Overall, though, we found that neighborhood affects gay men in unique ways; in particular, we found that the degree of homophobia in the social environment influences how some men behave both sexually and socially. In addition, nearly all the men interviewed described concerns around safety in both their home and social neighborhoods. The recent anti-gay sexual assaults of three Bronx [56] men represents the far end of what is a continuum of constant (and often unreported and/ or unacknowledged) threat of emotional, physical, and sexual assault that gay, bisexual and other MSM have to endure in their own neighborhoods.

We also observed important intersections between gay identity and racial or ethnic identity, and found that the experience and expression of different identities was often based on place. This phenomenon was seen in the context of these men’s lifetime experiences of tension between sexual expression/behavior/identity and their heterosexist family and childhood neighborhood environments. Further analysis of these data will allow us to explore in greater detail these intersecting environmental and individual elements and better hypothesize what their impact might be on health behaviors and outcomes among MSM. For example, it could be theorized that the constant tension experienced between identity and place may expose MSM to unhealthy levels of stress, leading to multiple negative mental and physical health outcomes; at the same time, it is possible that exposure to positive neighborhood characteristics could engender resilience in the face of negative environmental and other health exposures. A more comprehensive understanding of the relations among behaviors and neighborhoods will provide important insights for the development of geographically specific and norms-based health outreach and programming.

The Unity in Diversity (UND) study was a culturally tailored pilot randomized clinical trial of a behavioral intervention using peer education and social networks to promote behavior change among at risk African American MSM in Baltimore, MD. The results presented here were derived from preliminary analyses of the baseline social network, demographic, and partner venue data from the Index participants (initial recruits) of the UND study.

The men in this sample were sociodemographically disadvantaged, with more than half living below the poverty line and over 75% having been incarcerated in their lifetime (Table 2). Average age was 38.2 (SD = 10.89), and 49.5% were HIV infected. The largest percentage of participants reported that they met sex partners through friends (n = 68, 36.2%), followed by bars (n = 57, 30.3%) and the Internet (n = 41, 21.8%).

Over half of participants (58.5%) reported that all of their sex partners live outside the neighborhood. About one-fifth of participants (20.7%) had partners living in the same neighborhood but not in the same household, and a similar proportion of participants had partners living in the same household. There were no statistically significant associations between number of partners met through various settings and residential distance from sexual partners.

Table 2 shows the sizes of the participants’ social and sexual networks, and Table 3 compares these networks between participants who reported living with a sex partner and those who did not.

The average total social network size was 8.72 (SD = 4.34) and the average number of sexual partners was 3.28 (SD = 1.79). There were no statistically significant differences in the size of social networks or in the number of male or female sexual partners between participants with partners living in the same household and those without partners living in the same household. There were also few differences in the size of several subnetworks, although participants with household partners reported having significantly more network members who “pitch in to help” and who they entrust with money. Participants residing with a partner reported significantly more financial support from their sex partners. They also reported more social support, including having a larger number of male partners to hang out with and see frequently. Participants who resided with a partner also reported higher network density, older network members, and a higher proportion of HIV positives in their networks. Moreover, they themselves were also more likely to be HIV-positive.

In this sample of African American MSM in Baltimore, the largest number of partners was met through friends, indicating that social networks are key factors in partner selection for these men. The second most common method of meeting partners was at bars. Although these venues depend less on network factors for meeting new partners, network members may influence the type and specific bar that participants frequent. The third most common method of meeting partners was the Internet, which is likely to be minimally influenced by peer network members, though these relationships may become important social network members. It should be noted that the number of participants reporting meeting partners through electronic media may have been inflated by recruiting participants through chat rooms. These findings suggest that African American MSM over 30 in Baltimore connect to MSM partners through face-to-face contact rather than mostly electronic media, pointing to the continued need for social network and venue-based interventions for these men.

About half of the participants only had sex partners living outside their neighborhood. The other half was split between those who had partners living in the same household and those with partners in their neighborhood but not household. We found no evidence of an association between where participants met their partners and the geographic distance between partners’ residences. However, the finding that half the men only had sex partners outside their neighborhood may indicate that these men cannot find partners within their own home neighborhoods, likely because they live in neighborhoods without much of a gay presence (and possibly with anti-gay norms). This implication is consistent with the observations given in Study 2 above.

Number of sex partners did not differ between those who lived with a sex partner and those who did not, suggesting that sex outside primary relationships may be common among this sample, and should be considered when designing interventions. Respondents whose partners lived in the same household tended to report receiving more social and financial support as measured by size of social support networks. These findings suggest that living with a partner is an important factor in receiving financial and social support. Those who lived with a partner were also more likely to be HIV-positive than those who did not live with a partner. Therefore, we do not know if the additional social support is related to HIV status or co-habitation, though it is likely that living with a partner provides the opportunity for greater social support interactions. Future research should examine how residential location of partners, including co-habitation, may be linked to important mental and physical health outcomes, including HIV care and support and HIV medication adherence.