Substance use is associated with several adverse health outcomes and comorbidities, including risk for overdose, HIV, other sexually transmitted infections (STI), and death(Brown et al., 2017; Duncan et al., 2018; Hegazi et al., 2017; Knox et al., 2017; Nerlander et al., 2018; Ocasio et al., 2016; Pakianathan et al., 2018; Quinn et al., 2016; Young et al., 2016). This makes substance use especially important in the health risk of Black men who have sex with men (BSMM), as they experience greater risk for acquiring HIV and STIs than white MSM despite reporting less frequent sexual risk behaviors (CDC, 2018a, b; Millett et al., 2007; Millett et al., 2012). Substance use results in $11 billion in healthcare costs and $193 billion in overall costs annually (Birnbaum et al., 2011; National Drug Intelligence Center, 2011) and has a major impact on BSMM in the U.S.; nationally representative sample data showed a prevalence of 6.5% for opioid use, 5.6% for crack/cocaine use, and 1.8% for amphetamine use among BSMM(Goldstein, 2016). Additionally, the relationship between substance use and sexual risk has been well-established among several MSM subpopulations(Hegazi et al., 2017; Knox et al., 2017; Nerlander et al., 2018; Ocasio et al., 2016; Pakianathan et al., 2018; Pollard et al., 2018).

Since much of the research on substance use among MSM consists of samples of mostly white men (Gonzalez-Baeza et al., 2018; Hegazi et al., 2017; Nerlander et al., 2018; Ottaway et al., 2017; Pakianathan et al., 2018), inferences about BSMM substance use in these samples are unclear and questionable. While some studies show that BSMM report lower substance use compared to other MSM (Millett et al., 2007; Millett et al., 2012), other studies indicate that many psychosocial factors are associated with substance use among BSMM(Brown et al., 2017; Card et al., 2018; Duncan et al., 2018; Dyer et al., 2012; Javanbakht et al., 2018; Jeffries and Johnson, 2018; Nerlander et al., 2018; Ottaway et al., 2017; Quinn et al., 2016; Rowe et al., 2016; Viswanath et al., 2017; Voisin et al., 2017; Wray et al., 2019). Depression, internalized homonegativity, and trauma are associated with substance use and abuse among BSMM.(Adams et al., 2018; Beymer et al., 2017; Dyer et al., 2012; Ferlatte et al., 2018; Miltz et al., 2019; Ogunbajo et al., 2018) Substance-using BSMM are also more likely to have experienced race-based and sexuality-based trauma along with intimate partner violence.(Adams et al., 2018; Beymer et al., 2017; Duncan et al., 2018) Some BSMM may use substances such as heroin and methamphetamine to cope with social stress.(Dangerfield Ii et al., 2017) BSMM often experience concomitant challenges from poverty, stigma, violence, and high community HIV/STI prevalence that produce a cumulative effect on substance use, sexual risks, and subsequent HIV infection.(Dangerfield Ii et al., 2017; Dyer et al., 2012; Herrick et al., 2013)

Syndemic theory posits that a collection of risk factors are co-prevalent because of common social and structural drivers, which amplify the negative impact of these risk factors on health outcomes, such as substance abuse and behavioral health problems.(Dyer et al., 2012; Singer and Clair, 2003) Based on syndemic theory, race-targeted violence, sexuality-targeted violence, intimate partner violence, other traumatic experiences, depression, and internalized homophobia may interact to form a syndemic that may directly impact risk of substance use, as these factors are associated with substance use and each other.(Singer and Clair, 2003) Syndemic theory has been utilized to more effectively understand HIV/STI risk factors among SMM, including BSMM.(Buttram and Kurtz, 2015; Dyer et al., 2012; Ferlatte et al., 2018; Herrick et al., 2013; Mustanski et al., 2017; Pollard et al., 2018) Many of these syndemic factors are also consistent with minority stress theory, which posits that stigma toward minorities produces stressors that increase vulnerability to adverse psychosocial health outcomes, contributing to minority health disparities.(Meyer, 1995) Internalized homophobia, race-targeted violence, sexuality-targeted violence are notable sources of minority stress.

While many psychosocial and structural factors can increase substance use and related health risk among BSMM, social support can be an important buffer against these adverse health outcomes.(Barry et al., 2018; Buttram, 2019; Friedman et al., 2019; Hermanstyne et al., 2018) BSMM Social relationships are key elements of resilience and facilitators of substance use reduction(Buttram, 2019) by improving one’s ability to cope with stress, facilitating resilience. This may attenuate the association between the aforementioned syndemic and substance use among BSMM.

The primary aim of this study was to identify depression, internalized homophobia, and traumatic experiences as a syndemic associated with substance use longitudinally among BSMM. This study also explored social support as an modifier of this association, and tested the association between social support and transitions between syndemic statuses. We hypothesized that syndemic statuses would be associated with greater substance use, that increased social support would attenuate this association, and that social support would be associated with more optimal transitions from syndemic statuses to non-syndemic statuses, and maintenance of non-syndemic status.

We identified a syndemic of several dimensions of trauma, depression, and internalized homophobia among BMSM over time, confirming our hypotheses. The high prevalence of these factors indicates crucial needs among BSMM. More than half of the sample experienced race-targeted violence and sexuality-targeted violence in the past 6 months. Nearly half had a risk of depression (CESD-20 of 16 or more). Approximately a quarter of the sample had experienced intimate partner violence in the past 6 months as well. These factors formed a syndemic prospectively associated with greater substance use after 12 months of follow-up. Findings are consistent with our understanding of each of these factors individually; several studies have documented the association between these factors and substance use.(Jeffries and Johnson, 2018; Miltz et al., 2019; Ogunbajo et al., 2018; Quinn et al., 2016; Smith et al., 2016; Voisin et al., 2017) Our study is novel in that we identified these as components of a syndemic, and identified that the syndemic is transient at the individual level. Substance abuse interventions tailored to BSMM should address these psychosocial syndemic contexts, which change overtime. Experiences of sexuality-targeted violence, experienced race-targeted violence, and internalized homophobia were especially impactful, demonstrating the most stark differences between high and low-risk statuses. These are critically important considerations for public health intervention and policy among BSMM that are directly related to their multiple minority status. A “one-size fits alf’ approach to substance use harm reduction and treatment policy does not appropriately consider the additional psychosocial and structural stressors faced by minority populations such as BSMM. This is relevant not only to substance use, but also to several additional outcomes directly associated with substance use, including sexual risk behaviors that increase the HIV/STI risk. In the context of the disproportionate HIV/STI burden among BSMM (CDC, 2018a, b), more effectively informed substance abuse interventions are of significant public health importance.

While we identified three overall “high-risk” syndemic statuses with distinct differences related to the proportions of syndemic factors and how strongly social support moderated the association with 12 month substance use. High risk status A was characterized by the greatest syndemic factors overall but the lowest polysubstance use of the three high-risk profiles, and was the least attenuated by social support. Conversely, high risk-status C had the lowest syndemic factors of the three high-risk statuses, and was the most attenuated by social support. The strength of interaction with social support paralleled the proportions of social support in each profile as well, with high-risk status A having the lowest social support, and high-risk status C having the highest social support of the high-risk statuses. Participants in high-risk status A may be the most marginalized overall, and thus social support is a less impactful deterrent to substance use and abuse. Notably this was the largest status as well, nearly twice as large as the low-risk status. This underscores the burden of these syndemic factors among BSMM.

We found that greater current social support was associated with transition from high to low-risk status. This is consistent with the attenuative interaction we identified between current social support and high-risk profiles. Social support has been demonstrated as a key factor in both substance use recovery and prevention of substance use initiation in previous studies.(Buttram, 2019; Buttram and Kurtz, 2015) A strong social support network can be instrumental in the ability to healthily cope with stressors, deterring maladaptive coping through substance abuse.(Pollard et al., 2018) Peer support may be impactful to effective harm reduction, preventing adverse substance use outcomes such as substance overdose. This is useful for the development of intervention research and policy, as this underscores the importance of social support in the success of substance abuse interventions. The formation of healthy support networks has been a core component of many social policies and programs for the treatment of substance abuse; these networks may be of notable importance for developing harm reduction strategies and facilitating substance abuse treatment among BSMM. The relevance of social support in buffering the adverse effects of syndemics may also reflect how social support can foster resilience among BSMM. A study by Fadardi et al found that an adaptive motivational structure characterized by approach tendencies, good knowledge of what to do, high senses of control and commitment, high expectations of success, and emotional involvement in pursuit of the goal, was associated with lower substance use.(Fadardi et al., 2010) Given that BSMM are a marginalized population with multiple minority status, resilience is especially important to coping with additional discrimination-related stressors, including the sexuality-targeted violence, race-targeted violence, and internalized homophobia that partially comprised our measured syndemic.

Our research has several strengths. We utilized a large, multicenter cohort of BSMM at several sites across the United States, allowing our research to include BSMM from several geographic backgrounds. The use of prospective cohort data with a distal outcome allowed us to effectively assess temporality; this is of critical importance, as substance use otherwise has a bidirectional association with mental health. Prospective analyses are necessary to ensure we capture substance use measures subsequent to our exposures of interest. Our study also used several multi-item measures for each syndemic factor, allowing us to identify a nuanced syndemic covering several dimensions of trauma, violence, and mental health. While there is much literature on syndemics among BSMM, prospective analyses of syndemics with transitions in syndemic status over time are far more limited. Our study helps fill this significant gap in the literature. Finally, our use of LTA contributed several strengths to our research. First, much like latent class and latent profile analyses, we were able to identify multiple profiles with distinct, non-linear differences in syndemic factors. Additionally, LTA was able to identify changes in syndemic factors over time, with approximately half of all participants transitioning between high and low risk groups. In developing our understanding of risk factors cumulatively affecting health outcomes among BSMM, research should acknowledge that adverse psychosocial and structural circumstances are not inherently static, and can change over time. LTA acknowledges this by allowing for the measurement of these changes.

There are limitations in our research that are important to acknowledge. First, because our study was limited to BSMM, results are not generalizable to MSM of other racial/ethnic groups, or to populations other than MSM. Our focus on BSMM is warranted however given the additional relevance of substance use to several adverse health outcomes in this population. Because our cohort lasted 12 months, and our research necessitated a temporally distal substance use outcome, we could only assess syndemic profile transitions in a six month period. As there were some differences in the recall period between some of our syndemic factors, the syndemic factors may not be completely concurrent. They do precede the recall period for our prospective outcome however, so temporality is preserved. Our outcome is limited to use of substances, which does not necessarily indicate substance dependence. Given the growing decriminalization, legalization, and acceptance of marijuana use across the United States, marijuana use in current times is not likely to be fully reflective of marijuana use a decade earlier, when our data were collected. Finally, social desirability bias is likely to affect our measures.

Our research identified a syndemic of race and sexuality-targeted violence, intimate partner violence, other traumatic experiences, depression, and internalized homophobia that was associated with greater risk of substance use after 12 months. These results were largely unchanged after adjustment for age and socioeconomic factors. Social support mitigated this association, in part due to negative associations between social support and transition from low to high-risk status. Future research into the longer-term impact of trauma and mental health on substance use is recommended. This may also provide a better understanding of long-term transitions between syndemic statuses and substance use. More detailed studies into the mechanisms of how social support attenuates the association between this syndemic and substance use may further our understanding of social support can better inform substance abuse and harm reduction interventions in this population; the role of peer support in substance recovery is an especially important area for future research. Resiliency and motivation among BSMM are notably important focal points for future research. More effective and accessible substance-related harm reduction services for BSMM, such as needle exchange programs, are also of great importance. These services can often help prevent serious adverse substance-related outcomes, and are thus critically important to the health of substance-using BSMM. Social and legal policy that directly addresses many of the syndemic factors identified, particularly sexuality and race-targeted violence, are necessary for effective substance use harm reduction, and thus subsequent HIV and STI vulnerability in this population. Policy informed by a nuanced understanding of the patterns of these syndemic factors and their relationship with substance use is necessary to health promotion towards BSMM.