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Progress Through Resiliency
Syndemics, Strengths and HIV Among Men Who Have Sex With Men (MSM)

By Amy Herrick, Mary Hawk, Mackey Friedman, ChingChe Chiu, James Egan, Mark Friedman and Ron Stall

November/December 2011

Progress Through Resiliency

While improvements in approaches to HIV prevention have been made over the 30 years since the start of the AIDS epidemic, HIV among MSM is far from eradicated. Despite more than two decades of prevention efforts focused toward MSM, the rates of HIV infection in this population continue to rise.


What Is the State of the HIV/AIDS Epidemic Among Men Who Have Sex With Men (MSM) in the U.S.?

A 2008 report released by the Centers for Disease Control and Prevention (CDC) showed that MSM accounted for 46% of all new HIV infections and HIV infection rates among young MSM increased at a rate of about 12% each year between 2001 and 2006. This report further noted that MSM were the only risk group who experienced an increase i n infection rates during this time. In fact, according to a recent study by researchers at the University of Pittsburgh, even if the rate of HIV infection among MSM remains at the current level, by the time a group of young MSM (18 years old) reach the age of 40, 41% of them will be HIV-positive. We cannot make any progress in fighting the HIV/AIDS epidemic in the U.S. unless we find ways to lower rates of HIV transmission among MSM.


How Do Other Health Disparities Among MSM Relate to Risk for HIV/AIDS?

A growing set of recent scientific papers had shown that health problems among MSM are interconnected and function as a group to increase HIV risk in this population. Because they are sexual minorities, gay, bisexual, and other MSM experience massive minority stress and social marginalization (for example, widespread bullying, gay-bashing, and other forms of violent harassment). Studies suggest that these negative experiences increase a person's risk for multiple health issues, including depression, anxiety, drug use, and sexual risk behaviors. This process happens over time as people are exposed to discrimination and social marginalization. These experiences cause stress to the individual, resulting in lowered self-esteem, increased emotional distress, and a sense of social isolation, all of which cause a person to be more vulnerable to serious emotional and physical health problems.

According to the CDC, a syndemic is, "Two or more afflictions, interacting synergistically, contributing to excess burden of disease in a population." In other words, negative health conditions are thought to interact to form a syndemic: synergistic epidemics that, together, can lower a person's overall health and make him or her more susceptible to disease. For example, health problems such as drug use, depression, and domestic violence have been found to interact so that their impact on the overall health of the person is greater than what we might expect from looking at each affliction separately.

While many studies involving MSM have shown interconnections between health problems, such as drug use and high-risk sex, two recent studies have focused on syndemic conditions in samples of adult MSM and young MSM. These two studies showed that as the number of psychosocial conditions (such as depression, anxiety, and experience of abuse) a person has increases, so will his likelihood of having unprotected anal sex, as well as his likelihood of becoming infected with HIV. It has been suggested that this set of co-occurring psychosocial health problems operating together as a syndemic may actually be driving the HIV epidemic among MSM, while also working to raise the levels of other health problems among MSM.


46 percent of new HIV infections are among gay men, according to the CDC.


If Syndemics Are So Widespread, Then Why Are So Many MSM Doing So Well?

Men who have sex with men exist in a world where adversity and marginalization are everywhere. Many MSM grew up in a world hearing that they were abnormal or even immoral. They live in a world where they are denied equal rights. As previously mentioned, this type of second-class citizenship can lead to health problems for many people. However, even though the vast majority of MSM have experienced some form of adversity, the majority have not experienced the harmful effects of those experiences to the point of developing health problems. Rather, most men survive adversity and are somehow protected from the negative consequences of those experiences. This capacity for a person to successfully cope with adversity is called "resilience."

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Resilience requires two components: 1) exposure to adversity and 2) success in overcoming adversity. Resilience Theory states that there are traits, skills, and support systems that help people thrive despite difficult conditions. The theory further acknowledges that all people have the capacity for resilience, but, in order for resilience to be fully developed, protective factors must be present that offset the impact of adversity.

Protective factors that are present in an MSM at a young age may grow stronger as he matures. For instance, pride is a quality that is often associated with sexual minority communities. Despite the negative messages that MSM hear about their sexuality, many learn to cast off shame and internalized homophobia, and take pride in their sexuality and in their communities. This process may increase resilience. For example, data from a longstanding research study involving MSM from several cities showed that exposure to homophobia and gay-related victimization (such as gay-bashing and harassment) were associated with internalized homophobia during the time the men were coming out. However, homophobic experiences were not significantly associated with the men's current levels of internalized homophobia. This suggests that the men were able to overcome internalized homophobia as they matured and, in the process, improved their health. Understanding more about how MSM exhibit resilience could teach us a lot about how to raise levels of health in our communities.


How Could a Focus on the Strengths and Resiliencies Found Among MSM Offer New Approaches to HIV Prevention?

In a review of the effectiveness of HIV prevention interventions targeting MSM, one researcher found that these interventions resulted in a 23% reduction in the odds of engaging in unprotected anal intercourse. This suggests that current prevention paradigms are effectively addressing some degree of risk. Nonetheless, there is little or no evidence that health disparities between MSM and non-MSM are diminishing, nor is the risk of HIV infection decreasing among MSM. In order to minimize or eliminate health disparities, the effectiveness of current prevention efforts will need to be increased. Resilience Theory offers a means to accomplish this.

The content and impact of strengths-based approaches to HIV prevention support the idea that health promotion may be as important as risk reduction in the elimination of health disparities. Strengths-based programs are driven by the philosophy that resilience and competency-building are critical in supporting healthy development. Strengths-based programs encourage community building, belief in the future, self-efficacy, positive identity, spirituality, and self-determination, among many others. A comprehensive review of strengths-based programs found that this type of prevention intervention improves interpersonal skills, strengthens relationships, and increases self-control, self-efficacy, academic achievement, problem solving, and other competencies. These programs may also help people lower drug and alcohol use, violence, and high-risk sexual behavior, and these effects tend to be sustained over time. However, strengths-based approaches to improving health among MSM remain understudied and not well understood.


41 percent of gay men will become HIV positive by the time they turn 40, if current rates continue.


How Can We Move the Field Forward?

It has been 30 years since HIV began to decimate the MSM population. Since then, health disparities among MSM have been forced into the forefront of LGBT consciousness. Although some work has been done to address these disparities, major health disparities still exist among men who have sex with men.

Future studies are needed to expand our knowledge of the ecological context of health risk among a highly vulnerable population. To accomplish this, it will first be important to expand the scope of prevention research to focus on protective factors as well as risk factors. We can learn a lot from those who have faced adversity and thrived, relative to those who have experienced the negative outcomes that prevention programs aim to avoid. Second, there is a need to examine protective factors beyond those at the individual level. Resilience Theory suggests that community and interpersonal protective factors are needed in order for an individual to develop resilience. To the extent that this view is correct, a narrow focus on individual level risk and protective factors will not be likely to eliminate health disparities. Finally, there needs to be a focus on identifying modifiable protective factors so that they can be directly applied to prevention and health promotion programs.

Many MSM health studies have demonstrated an association between health risk behaviors and individual personality characteristics such as sensation-seeking or impulsivity. While knowledge of these factors is necessary for our understanding of prevention, the particular factors themselves are very difficult to affect through effective interventions. It is more feasible to effect change on the interpersonal or community level by developing a mentoring program or setting up community centers, or by making policy-level changes like the adoption of anti-bullying legislation, or federal laws that recognize sexual minorities as full and equal citizens (e.g. same-sex marriage and adoption laws).

It has long been acknowledged that sexual minorities face health disparities, not because of who they are, but because of the environment in which they live. All the same, prevention efforts tend to focus on changing the individual with messages about more condom use, less substance use, and so on. Although data show that MSM exhibit considerable strength in reducing or avoiding health-related risks, this strength has been under-emphasized in public health prevention work. These factors may be of particular importance as we enter an era of combination prevention, in which behavioral and biomedical interventions are combined to lower risk of HIV transmission by lowering background rates of community viral loads. A focus on resiliencies may support, for instance, adherent use of biomedical interventions among MSM. Resilience Theory and strengths-based approaches to prevention provide a framework to advance prevention and health promotion by identifying new techniques that will increase the effectiveness of current public health models and improve the health of MSM.


How Do We Train the Next Generation of Health Care Workers Interested in LGBT Health?

LGBT populations face numerous health disparities, of which HIV/AIDS is only the most widely recognized. The extent and breadth of these health disparities requires a new generation of health professionals trained to address these issues among a wide variety of LGBT populations. Accordingly, the Graduate School of Public Health at the University of Pittsburgh initiated the first certificate program in LGBT Health in the United States in 2006. The mission of the LGBT Public Health Certificate is to provide students with a comprehensive understanding of the special public health challenges of LGBT populations and the scientific tools necessary to intervene to prevent these problems. These skills include the design, implementation, and evaluation of programs to improve health levels among LGBT populations, as well as the ability to conduct intervention and epidemiological research and policy analysis to enhance the health and well-being of individuals related to sexual orientation and/or gender identity/presentation. In addition, students participate in annual Summer Institutes which bring together national experts in various aspects of LGBT health. Summer Institutes have, to date, focused on violence against LGBT youth; chronic diseases among lesbians; trans health; and resiliency among MSM.

Currently, the program has about 20 students, who are studying a broad range of health problems among LGBT populations. All of the students in the program are fulfilling the requirements for the Certificate while they are completing MPH or DrPH/PhD degrees at the University of Pittsburgh. Doctoral students in the program are encouraged to work with professors to produce papers for publication, and have so far published about 35 papers as a result of these collaborative efforts. Graduates from the program are already taking positions with organizations that are conducting research and/or providing service to LGBT populations. We look forward to seeing the ongoing contributions of students and graduates of the program in terms of addressing key health issues among LGBT populations.


Sexual Risk or Context, Which Best Accounts for HIV Infection Rates Among Black MSM?

A basic assumption underlying current approaches to HIV prevention is that the best way to lower HIV infection rates among MSM is to reduce rates of HIV sexual risk-taking. Most studies that have measured rates of HIV prevalence among black MSM find rates of HIV infection that are sometimes several times higher than those found among other MSM populations. Does this mean that black MSM have rates of sexual risk-taking that are several times higher than those found among other MSM populations?

Greg Millett, then with the CDC's Division of HIV/AIDS Prevention, conducted a set of careful literature reviews to address this question. Millett tested whether African American MSM were more likely to be at sexual risk for HIV; less likely to disclose sexual identity; more likely to use recreational drugs, to have a history of STDs, to get HIV tested, or to have sex with a known HIV-positive partner; and, if positive, less likely to be on antiretroviral treatment. What he found was that African American MSM were not more likely to have higher rates of sexual risk-taking, to use recreational drugs, to have sex with a known HIV-positive person, or to get tested less frequently, but they were more likely to not identify as gay; to have a history of having an STD; and, if positive, less likely to be on antiretroviral medications.

Millett's findings suggest that being part of a population that engages in medical care less frequently may better explain high rates of HIV infection than just sexual risk-taking. Put another way, lower access to medical care raises the proportion of African American MSM who have high HIV viremia (viral load), which then results in more HIV transmission to uninfected partners. High prevalence rates of men with elevated HIV viral loads within the tightly bound sexual networks often found among African American MSM magnify risk for HIV transmission even among men who rarely take sexual risks. Millett's analysis thus suggests that it is not simple levels of risk-taking that best explain higher HIV prevalence rates among African American MSM, but rather the context in which these men take occasional sexual risks. This suggests that strategies designed to lower community viral load through combination prevention approaches (i.e., combining behavioral and biomedical interventions with a special focus on men at highest risk) may be particularly effective among African American MSM. This could be accomplished by working with communities of black MSM to share these findings, to dispel the idea that the HIV epidemic is somehow caused by widespread sexual irresponsibility, and to work with African American MSM and service providers to find ways to help black MSM gain access to medical care so that levels of health at the individual and community level are improved.




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