Modeling the Impact of Social Discrimination and Financial Hardship on the Sexual Risk of HIV Among Latino and Black Men Who Have Sex With Men

摘要

Objectives. We examined the impact of social discrimination and financial hardship on unprotected anal intercourse with a male sex partner of serodiscordant or unknown HIV status in the past 3 months among 1081 Latino and 1154 Black men who have sex with men (MSM; n?=?2235) residing in Los Angeles County, California; New York, New York; and Philadelphia, Pennsylvania. Methods. We administered HIV testing and a questionnaire assessing 6 explanatory variables. We combined traditional mediation analysis with the results of a path analysis to simultaneously examine the direct, indirect, and total effects of these variables on the outcome variable. Results. Bivariate analysis showed that homophobia, racism, financial hardship, and lack of social support were associated with unprotected anal intercourse with a serodiscordant or sero-unknown partner. Path analysis determined that these relations were mediated by participation in risky sexual situations and lack of social support. However, paths between the explanatory variable and 2 mediating variables varied by participants’ serostatus. Conclusions. Future prevention research and program designs should specifically address the differential impact of social discrimination and financial hardship on lack of social support and risky sexual situations among Latino and Black MSM. Men who have sex with men (MSM) continue to make up the most disproportionately affected risk group for HIV/AIDS, representing more than half of all people living with HIV/AIDS and more than 60% of all new HIV infections in the United States. 1–3 HIV seroprevalence among Latino and Black MSM is particularly troubling, with estimates ranging from 17% to 46%. 4–6 Several theories have attempted to explain—at the individual level—racial and ethnic differences in HIV prevalence and infection rates among MSM. 7 Although the HIV behavioral research literature has documented important associations among psychosocial variables, substance use, and sexual risk for HIV, little evidence has suggested a strictly behavioral basis for racial and ethnic disparities in HIV seroprevalence and seroincidence. 8,9 Several investigators 10–14 have begun examining macro- or social-level factors that may contribute to disparities in HIV rates among Latino and Black MSM. This important shift in focus away from individual-level and mainly behavioral correlates of sexual risk can ultimately expand available prevention opportunities to include those for which the locus of intervention is not the individual. 15 For example, experiences of social discrimination (self-reported experiences of homophobia and racism) and financial hardship have been shown to be associated with heightened risk for HIV infection among Latino and Black MSM 16–18 and have led to interventions that range from social marketing initiatives to community mobilization efforts designed to educate the public and instigate social action. 19–22 However, few investigators have explored the precise psychosocial or situational mechanisms through which experiences of social discrimination affect the risk of HIV acquisition and transmission. One exception worth noting is Diaz et al., 17 who developed a 10-item scale that measured participation in contexts, settings, and situations that, according to Latino MSM focus-group participants, made it difficult to practice safe sex. In their study, difficult situations included sex in interpersonal relationships of unequal power, sex under the influence of drugs or alcohol, and sex in someone else's home. Mays et al. 11 pointed out the importance of possible links among social inequality, culture, social support, and interpersonal relationships in HIV-related risk. However, no previous study has examined mediating factors linking social discrimination and financial hardship with the sexual risk for HIV acquisition and transmission among HIV-positive and HIV-negative Latino and Black MSM across multiple large urban areas. 23 The Brothers y Hermanos research project was a multisite study funded by the Centers for Disease Control and Prevention to identify the sociocultural, psychosocial, and behavioral predictors of HIV infection among Latino and Black MSM. Using respondent-driven sampling techniques, we administered HIV testing and a survey questionnaire to assess experiences of racism, homophobia, financial hardship, lack of social support, situations that made using condoms during sex more difficult—such as exchange sex, having sex in a casual partner's home, or having a more masculine sex partner—and recent unprotected anal intercourse with a male sex partner of serodiscordant or unknown HIV status (hereinafter termed serodiscordant or unknown-status unprotected anal intercourse). In this study, we examined the associations among experiences of social discrimination, financial hardship, and serodiscordant or unknown UAI among Latino and Black MSM living in Los Angeles County, California; New York, New York; and Phila