AIDS and Behavior

, Volume 19, Issue 6, pp 970–980 | Cite as

A Longitudinal Investigation of Syndemic Conditions Among Young Gay, Bisexual, and Other MSM: The P18 Cohort Study

  • Perry N. HalkitisEmail author
  • Farzana Kapadia
  • Kristen L. Bub
  • Staci Barton
  • Alvaro D. Moreira
  • Christopher B. Stults
Original Paper


The persistence of disparities in STI/HIV risk among a new generation of emerging adult gay, bisexual, and other men who have sex with men (YMSM) warrant holistic frameworks and new methodologies for investigating the behaviors related to STI/HIV in this group. In order to better understand the continued existence of these disparities in STI/HIV risk among YMSM, the present study evaluated the presence and persistence of syndemic conditions among YMSM by examining the co-occurrence of alcohol and drug use, unprotected sexual behavior, and mental health burden over time. Four waves of data, collected over the first 18 months of a 7 wave, 36-month prospective cohort study of YMSM (n = 600) were used to examine the extent to which measurement models of drug use, unprotected sexual behavior, and mental health burden remained consistent across time using latent class modeling. Health challenges persisted across time as these YMSM emerged into young adulthood and the measurement models for the latent constructs of drug use and unprotected sexual behavior were essentially consistent across time whereas models for mental health burden varied over time. In addition to confirming the the robustness of our measurement models which capture a more holistic understandings of the health conditions of drug use, unprotected sex, and mental health burden, these findings underscore the ongoing health challenges YMSM face as they mature into young adulthood. These ongoing health challenges, which have been understood as forming a syndemic, persist over time, and add further evidence to support ongoing and vigilant comprehensive health programming for sexual minority men that move beyond a sole focus on HIV.


Gay and bisexual men Emerging adulthood Syndemic HIV Structural equation modeling Prospective cohort study 


La persistencia en las disparidades del riesgo de ITS/VIH en la nueva generación de adultos emergentes que son gay, bisexuales o son hombres que tienen sexo con hombres, exige marcos holísticos y nuevas metodologías para la investigación de los comportamientos relacionados con ITS/VIH para este grupo. Con el fin de comprender mejor la persistencia de estas disparidades en el riesgo de ITS/VIH entre los hombres jóvenes que tienen sexo con hombres (HJSH), el presente estudio evaluó la presencia y persistencia de las condiciones sindémicas en este grupo, examinando la concurrencia entre el consumo de alcohol y drogas, el comportamiento sexual sin protección, y la carga en la salud mental de los participantes a través del tiempo. Cuatro mediciones de información de HJSH (n = 600), recolectadas durante los primeros 18 meses de un estudio longitudinal de 7 mediciones en el transcurso de 36-meses, fueron utilizadas para examiner el grado en el que el consumo de drogas, el comportamiento sexual sin protección, y la carga en la salud mental se mantienen constantes a través de tiempo, utilizando un modelo de clase latente. Desafíos en la salud son persistentes a través de tiempo para este grupo de HJSH mientras emergen a la vida adulta, y los modelos de medición utilizados para el uso de drogas y el comportamiento sexual sin protección muestran consistencia a través del tiempo, mientras que el modelo de carga en la salud mental varia en el tiempo. Además de confirmar que los modelos de medición utilizados son robustos, también capturamos una manera mas holística de entender las condiciones de salud relacionadas con el uso de drogas, sexo sin protección, y la carga en la salud mental, demostrando el desafiante proceso que viven los HJSH en el proceso de entrar en la vida adulta. Estos desafíos para la salud, que deben ser entendidos de manera sindémica, son persistentes a través del tiempo, y suman mayor evidencia en apoyo de un programa integral de salud en hombres de minorías sexuales con un enfoque mas amplio que solo VIH.



This study was funded by the National Institute on Drug Abuse, Contract # R01DA025537.


  1. 1.
    Centers for Disease Control and Prevention. Estimated HIV incidence in the United States, 2007–2010. 2013 Sep 28. Report No.: 17(4).Google Scholar
  2. 2.
    Centers for Disease Control and Prevention. HIV surveillance in adolescents and young adults. CDC Resource Library Slide Set. 2011. 9-28-2013.Google Scholar
  3. 3.
    Centers for Disease Control and Prevention. HIV surveillance in men who have sex with men (MSM). CDC Resource Library Slide Set. 2011. 9-28-2013.Google Scholar
  4. 4.
    Centers for Disease Control and Prevention. HIV among gay and bisexual men. 2012.
  5. 5.
    HIV Epidemiology and Field Services Program. Pediatric/adolescent HIV/AIDS surveillance in New York City: Annual Report. 2012. 9-28-2013.Google Scholar
  6. 6.
    New York City Department of Health and Mental Health. HIV epidemiology & field services semiannual report. 2012 Apr. Report No.: 7.Google Scholar
  7. 7.
    Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2011. Atlanta: U.S. Department of Health and Human Services; 2012.Google Scholar
  8. 8.
    Patton ME, Su JR, Nelson R, Weinstock H. Primary and secondary syphilis–United States, 2005–2013. MMWR Morb Mortal Wkly Rep. 2014;63(18):402–6.PubMedGoogle Scholar
  9. 9.
    Solomon MM, Mayer KH, Glidden DV, Liu AY, McMahan VM, Guanira JV, et al. Syphilis predicts HIV incidence among men and transgender women who have sex with men in a pre-exposure prophylaxis trial. Clin Infect Dis. 2014. doi: 10.1093/cid/ciu450.
  10. 10.
    Arnett JJ. Emerging adulthood. A theory of development from the late teens through the twenties. Am Psychol. 2000;55(5):469–80.PubMedCrossRefGoogle Scholar
  11. 11.
    Floyd FJ, Bakeman R. Coming-out across the life course: implications of age and historical context. Arch Sex Behav. 2006;35(3):287–96.PubMedCrossRefGoogle Scholar
  12. 12.
    Rosario M, Schrimshaw EW, Hunter J. Ethnic/racial differences in the coming-out process of lesbian, gay, and bisexual youths: a comparison of sexual identity development over time. Cultur Divers Ethnic Minor Psychol. 2004;10(3):215–28.PubMedCrossRefGoogle Scholar
  13. 13.
    Rotheram-Borus MJ, Fernandez MI. Sexual orientation and developmental challenges experienced by gay and lesbian youths. Suicide Life Threat Behav. 1995;25(Suppl):26–34 discussion 35-9.PubMedGoogle Scholar
  14. 14.
    Rosario M, Schrimshaw EW, Hunter J. A model of sexual risk behaviors among young gay and bisexual men: longitudinal associations of mental health, substance abuse, sexual abuse, and the coming-out process. AIDS Educ Prev. 2006;18(5):444–60.PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    Herrick AL, Marshal MP, Smith HA, Sucato G, Stall RD. Sex while intoxicated: a meta-analysis comparing heterosexual and sexual minority youth. J Adolesc Health. 2011;48(3):306–9.PubMedCentralPubMedCrossRefGoogle Scholar
  16. 16.
    Marshal MP, Friedman MS, Stall R, King KM, Miles J, Gold MA, et al. Sexual orientation and adolescent substance use: a meta-analysis and methodological review. Addiction. 2008;103(4):546–56.PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Marshal MP, Dietz LJ, Friedman MS, Stall R, Smith HA, McGinley J, et al. Suicidality and depression disparities between sexual minority and heterosexual youth: a meta-analytic review. J Adolesc Health. 2011;49(2):115–23.PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    Alvy LM, McKirnan DJ, Mansergh G, Koblin B, Colfax GN, Flores SA, et al. Depression is associated with sexual risk among men who have sex with men, but is mediated by cognitive escape and self-efficacy. AIDS Behav. 2011;15(6):1171–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Houston E, Sandfort T, Dolezal C, Carballo-Dieguez A. Depressive symptoms among MSM who engage in bareback sex: does mood matter? AIDS Behav. 2012;16(8):2209–15.PubMedCentralPubMedCrossRefGoogle Scholar
  20. 20.
    O’Cleirigh C, Newcomb ME, Mayer KH, Skeer M, Traeger L, Safren SA. Moderate levels of depression predict sexual transmission risk in HIV-infected MSM: a longitudinal analysis of data from six sites involved in a “prevention for positives” study. AIDS Behav. 2013;17(5):1764–9.PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Halkitis PN, Siconolfi D, Fumerton M, Barlup K. Risk bases in childhood and adolescence among HIV-negative young adult gay and bisexual male barebackers. J Gay Lesbian Soc Serv. 2008;20(4):288–314.PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Beidas RS, Birkett M, Newcomb ME, Mustanski B. Do psychiatric disorders moderate the relationship between psychological distress and sexual risk-taking behaviors in young men who have sex with men? A longitudinal perspective. AIDS Patient Care STDS. 2012;26(6):366–74.PubMedCrossRefGoogle Scholar
  23. 23.
    Dyer TP, Shoptaw S, Guadamuz TE, Plankey M, Kao U, Ostrow D, et al. Application of syndemic theory to black men who have sex with men in the Multicenter AIDS Cohort Study. J Urban Health. 2012;89(4):697–708.PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    Halkitis PN, Kupprat SA, Hampton MB, Perez-Figueroa R, Kingdon M, Eddy JA, et al. Evidence for a syndemic in aging HIV-positive gay, bisexual, and other MSM: implications for a holistic approach to prevention and healthcare. Nat Resour Model. 2012;36(2):10.PubMedCentralGoogle Scholar
  25. 25.
    Halkitis PN, Moeller RW, Siconolfi DE, Storholm ED, Solomon TM, Bub KL. Measurement model exploring a syndemic in emerging adult gay and bisexual men. AIDS Behav. 2013;17(2):662–73.PubMedCentralPubMedCrossRefGoogle Scholar
  26. 26.
    Klein H. Using a syndemics theory approach to study HIV risk taking in a population of men who use the internet to find partners for unprotected sex. Am J Mens Health. 2011;5(6):466–76.PubMedCrossRefGoogle Scholar
  27. 27.
    Mustanski B, Andrews R, Herrick A, Stall R, Schnarrs PW. A syndemic of psychosocial health disparities and associations with risk for attempting suicide among young sexual minority men. Am J Public Health. 2014;104(2):287–94.PubMedCentralPubMedCrossRefGoogle Scholar
  28. 28.
    Mustanski B, Garofalo R, Herrick A, Donenberg G. Psychosocial health problems increase risk for HIV among urban young men who have sex with men: preliminary evidence of a syndemic in need of attention. Ann Behav Med. 2007;34(1):37–45.PubMedCentralPubMedCrossRefGoogle Scholar
  29. 29.
    Santos GM, Do T, Beck J, Makofane K, Arreola S, Pyun T, et al. Syndemic conditions associated with increased HIV risk in a global sample of men who have sex with men. Sex Transm Infect. 2014;90(3):250–3.PubMedCrossRefGoogle Scholar
  30. 30.
    Storholm ED, Halkitis PN, Siconolfi DE, Moeller RW. Cigarette smoking as part of a syndemic among young men who have sex with men ages 13–29 in New York City. J Urban Health. 2011;88(4):663–76.PubMedCentralPubMedCrossRefGoogle Scholar
  31. 31.
    Singer M. AIDS and the health crisis of the U.S. urban poor; the perspective of critical medical anthropology. Soc Sci Med. 1994;39(7):931–48.PubMedCrossRefGoogle Scholar
  32. 32.
    Singer M, Clair S. Syndemics and public health: reconceptualizing disease in bio-social context. Med Anthropol Q. 2003;17(4):423–41.PubMedCrossRefGoogle Scholar
  33. 33.
    Liao M, Kang D, Tao X, Cox C, Qian Y, Wang G, et al. Syndemics of syphilis, HCV infection, and methamphetamine use along the east coast of China. BMC Public Health. 2014;17(14):172. doi: 10.1186/1471-2458-14-172.:172-14.CrossRefGoogle Scholar
  34. 34.
    Yu F, Nehl EJ, Zheng T, He N, Berg CJ, Lemieux AF, et al. A syndemic including cigarette smoking and sexual risk behaviors among a sample of MSM in Shanghai, China. Drug Alcohol Depend. 2013;132(1–2):265–70.PubMedCentralPubMedCrossRefGoogle Scholar
  35. 35.
    Stall R, Mills TC, Williamson J, Hart T, Greenwood G, Paul J, et al. Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. Am J Public Health. 2003;93(6):939–42.PubMedCentralPubMedCrossRefGoogle Scholar
  36. 36.
    Halkitis PN, Kapadia F, Siconolfi DE, Moeller RW, Figueroa RP, Barton SC, et al. Individual, psychosocial, and social correlates of unprotected anal intercourse in a new generation of young men who have sex with men in New York City. Am J Public Health. 2013;103(5):889–95.PubMedCentralPubMedCrossRefGoogle Scholar
  37. 37.
    Halkitis PN, Figueroa RP. Sociodemographic characteristics explain differences in unprotected sexual behavior among young HIV-negative gay, bisexual, and other YMSM in New York City. AIDS Patient Care STDS. 2013;27(3):181–90.PubMedCentralPubMedCrossRefGoogle Scholar
  38. 38.
    Kapadia F, Siconolfi DE, Barton S, Olivieri B, Lombardo L, Halkitis PN. Social support network characteristics and sexual risk taking among a racially/ethnically diverse sample of young, urban men who have sex with men. AIDS Behav. 2013;17(5):1819–28.PubMedCentralPubMedCrossRefGoogle Scholar
  39. 39.
    Siconolfi DE, Kapadia F, Halkitis PN, Moeller RW, Storholm ED, Barton SC, et al. Sexual health screening among racially/ethnically diverse young gay, bisexual, and other men who have sex with men. J Adolesc Health. 2013;52(5):620–6.PubMedCentralPubMedCrossRefGoogle Scholar
  40. 40.
    Robinson SM, Sobell LC, Sobell MB, Leo GI. Reliability of the timeline followback for cocaine, cannabis, and cigarette use. Psychol Addict Behav. 2014;28(1):154–62.PubMedCrossRefGoogle Scholar
  41. 41.
    Trauma Awareness and Treatment Center. Post-traumatic stress disorder scale. 2014.Google Scholar
  42. 42.
    Beck AT, Steer RA. Internal consistencies of the original and revised beck depression inventory. J Clin Psychol. 1984;40(6):1365–7.PubMedCrossRefGoogle Scholar
  43. 43.
    Winter LB, Steer RA, Jones-Hicks L, Beck AT. Screening for major depression disorders in adolescent medical outpatients with the beck depression inventory for primary care. J Adolesc Health. 1999;24(6):389–94.PubMedCrossRefGoogle Scholar
  44. 44.
    Russell DW. UCLA Loneliness Scale (Version 3): reliability, validity, and factor structure. J Pers Assess. 1996;66(1):20–40.PubMedCrossRefGoogle Scholar
  45. 45.
    Hu L, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis:conventional criteria versus new alternatives. Struct Equ Modeling. 1999;6(1):1–55.CrossRefGoogle Scholar
  46. 46.
    Muthen, Muthen. MPlus users guide. 6th ed. Los Angeles; 1998.Google Scholar
  47. 47.
    Singer M. Pathogen-pathogen interaction: a syndemic model of complex biosocial processes in disease. Virulence. 2010;1(1):10–8.PubMedCentralPubMedCrossRefGoogle Scholar
  48. 48.
    Singer MC, Erickson PI, Badiane L, Diaz R, Ortiz D, Abraham T, et al. Syndemics, sex and the city: understanding sexually transmitted diseases in social and cultural context. Soc Sci Med. 2006;63(8):2010–21.PubMedCrossRefGoogle Scholar
  49. 49.
    Marshal MP, King KM, Stepp SD, Hipwell A, Smith H, Chung T, et al. Trajectories of alcohol and cigarette use among sexual minority and heterosexual girls. J Adolesc Health. 2012;50(1):97–9.PubMedCentralPubMedCrossRefGoogle Scholar
  50. 50.
    Pollock JA, Halkitis PN, Moeller RW, Solomon TM, Barton SC, Blachman-Forshay J, et al. Alcohol use among young men who have sex with men. Subst Use Misuse. 2012;47(1):12–21.PubMedCrossRefGoogle Scholar
  51. 51.
    Dermody SS, Marshal MP, Cheong J, Burton C, Hughes T, Aranda F, et al. Longitudinal disparities of hazardous drinking between sexual minority and heterosexual individuals from adolescence to young adulthood. J Youth Adolesc. 2014;43(1):30–9.PubMedCentralPubMedCrossRefGoogle Scholar
  52. 52.
    Halkitis PN, Wolitski RW, Millet GA. A holistic approach to addressing HIV infection disparities in gay, bisexual, and other MSM. Am Psych. 2013;68(4):261–73.CrossRefGoogle Scholar
  53. 53.
    Halkitis PN. The AIDS generation: stories of survival and resilience. New York: Oxford University Press; 2013.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Perry N. Halkitis
    • 1
    • 2
    • 3
    Email author
  • Farzana Kapadia
    • 1
    • 2
    • 3
  • Kristen L. Bub
    • 4
  • Staci Barton
    • 1
  • Alvaro D. Moreira
    • 1
  • Christopher B. Stults
    • 1
  1. 1.Center for Health, Identity, Behavior & Prevention StudiesNew York UniversityNew YorkUSA
  2. 2.Global Institute of Public HealthNew York UniversityNew YorkUSA
  3. 3.Department of Population Health, Langone School of MedicineNew York UniversityNew YorkUSA
  4. 4.Department of Educational PsychologyUniversity of IllinoisUrbana-ChampaignUSA

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