Project ROOM Survey Data
Demographics and Syndemic Health Disparities
Results for demographics and syndemic health disparities are shown in Table 1. On average, African American/Black MSM from Project ROOM were approximately 2 years younger than Caucasian/White MSM (39.3 vs. 42; p = 0.008).
Rates of binge drinking (five or more drinks at one sitting) and the misuse of prescription sedatives and opioids in the past 90 days did not significantly differ by race/ethnicity. Compared to Caucasian/White MSM, Black men were more likely to report marijuana (75.9 vs. 60.0 %; p = 0.004), powder cocaine (59.3 vs. 35.6 %; p < 0.000), crack cocaine (40.7 vs. 15.6 %; p < 0.000), and ecstasy use (27.8 vs. 14.8 %; p = 0.004). Caucasian/White men were more likely to use methamphetamine (28.4 vs. 13.0 %; p = 0.002) than African American/Black MSM. However, African American/Black MSM from Project ROOM reported nearly two and a half times the number of days high/drunk (34.4 vs. 14.0; p < 0.000) and nearly double the number of times drugs were used during sex (77.7 vs. 40.2; p < 0.000) compared to Caucasian/White men.
The mean numbers of sex partners and unprotected sex frequency were not significantly different for Black and White MSM. Buying sex during the past 90 days was nearly three times more prevalent among African American/Black MSM (49.1 %) compared to Caucasian/White MSM (17.6 %; p < 0.000). The rate of African American/Black MSM who traded or sold sex during the past 90 days was also higher (36.1 %) compared to Caucasian/White MSM (18.4 %; p < 0.000).
More African American/Black men met the criteria for substance dependence (42.6 vs. 24.0 %; p < 0.000) than Caucasian/White men. African American/Black MSM and Caucasian/White MSM did not differ on other syndemic variables.
Structural Inequality Indicators
African American/Black MSM were less likely to report high school completion (82.4 vs. 92.8 %; p = 0.003) or 4 or more years of college (14.8 vs. 40.0 %; p < 0.000) than White men. The rate of African American/Black men who reported working full time (11.1 vs. 30.4 %; p < 0.000) was less than that of Caucasian/White men. Past year homelessness was more likely to be reported by African American/Black MSM compared to Caucasian/White MSM (44.4 vs. 21.2 %; p < 0.000) as was arrest history (82.4 vs. 60.4 %; p < 0.000).
The rate of African American/Black men endorsed gay identity was lower compared to that of Caucasian/White men (58.3 vs. 90.8 %; p < 0.000). HIV-positive serostatus was more prevalent among African American/Black MSM than Caucasian/White MSM (63.9 vs. 46.4 %; p = 0.002).
The mean number of people available for social support among African American/Black MSM was 12 (SD, 8.5; range, 0–45) compared to more than 17 for Caucasian/White MSM (SD, 10.3; p < 0.000). African American/Black MSM were less likely to report coping by getting help and emotional support from others (38 vs. 52.8 %; p = 0.010) and being satisfied with their living situation (64.8 vs. 76.4 %; p = 0.024) compared to Caucasian/White men.
Syndemic Health Disparities
Participants described using a range of substances, including alcohol, marijuana, cocaine, and crack cocaine. Eligibility criteria ensured that all participants were heavy substance users; however, during the qualitative interview which took place following study completion, none of them seemed to truly enjoy alcohol or drug use. As one participant said, “Drugs are not fun. Whoever tells somebody drugs are fun is lying. Drugs are not fun.” Implicit in this statement is a feeling of fatigue, as nearly all participants described drugs and alcohol having been a part of their lives for many years. Often drugs and alcohol were present from a very early age. When asked to describe his family, one participant described his childhood in this way, “My family is kind of, like, either they’re uppity with their nose in the air, or they’re like, drug addicts.” This participant went on to say:
Growing up [drugs] was all I seen. My mom, like, my mom worked pretty much all the way to her death, so from 10 to about 16, 17, I was always home by myself, or she’ll have [my family] over there to, like, babysit me. Well, what she don’t know is they were smoking weed and smoking crack inside of her house, so growing up that’s all I seen was drug abuse, alcohol… My mom was an alcoholic, so drug abuse, alcohol abuse, so… It got to the point where I think now that subconsciously it’s like, “Oh, this is a normal thing to do.”
Over the course of their substance use careers, men began to make connections between alcohol and drug use and HIV risk. This theme emerged when the men were asked to describe their use of alcohol or drugs. As was stated during one interview, “You know something? When I get high, I’m more likely to have unprotected sex. It’s like one plus one equals two.” None of the participants discussed substance use and HIV in terms of a syndemic, but the concept was a daily lived experience that the men knew very well. Thinking about other African American/Black MSM he has known, one young Project ROOM participant described it this way:
I started on alcohol, I went to weed, from weed I went to cocaine, from cocaine I went to partying every night, maybe not so much as all the time unprotected sex, but most of the time unprotected sex, and then I could have very easily went… There was only two more steps: crack and… bam [HIV]. So that’s why, like, if the circumstances would have changed, if the moon would have aligned just right, it could have easily have been me.
A majority of participants saw the negative consequences of substance use from an early age. Moreover, there was an awareness that substance use, especially crack cocaine, seemed to lead to an HIV-positive diagnosis for many men.
Men also connected mental and psychosocial problems, including loneliness, depression, and stigma or discrimination based on sexual orientation or same-sex behavior to substance use. For example, participants described being on the “down low,” such that men actively concealed their sexual behaviors, and used alcohol and drugs to cope with feelings of inadequacy. As one man stated, “Drugs are used to fill the void of loneliness associated with being gay and to deal with the gay issue. It’s a way for us to let down our inhibitions.” In the words of another participant, “Black gay guys have no outlet, except maybe drugs, because there’s no acceptance. Drugs and depression go hand in hand.” Like the syndemic nature of substance use and HIV risk, men were also aware of the interconnectedness of substance use and other mental, emotional, or psychological problems they were facing.
In addition to using alcohol or drugs, “buying” or “trading or selling” sex in exchange for money or drugs were mentioned by four participants as coping behaviors, two of whom had histories of sex trading. One participant described low self-esteem and feelings of being unwanted as facilitating his belief that he could only meet men through an exchange of drugs for sex. Another participant described selling sex as a way of “healing” from life’s disappointments or limitations and from feeling pain. Both men, however, also described the excitement associated with it. “I had a 9 to 5 and I wanted excitement. It was a way to feel hot or wanted, to do something wild,” said one man. In the words of another, “I didn’t know of it in Georgia. When I came down here, I found it fascinating, how easy it was, the choices, the variety. I was almost overwhelmed with excitement.” Though not all men reported “buying” or “trading or selling” sex, it was noted by one participant that if someone is using drugs and in a relationship, trading sex is essentially what he is doing, whether he admits it or not.
Participants’ use of alcohol, drugs, or sex to cope with mental health problems or stigma was a cycle for many participants. Yet, some participants had additional need for substance use as a coping mechanism. Victimization, particularly childhood victimization was described by three participants. The desire to numb these feelings with substance use, in addition to other stressors, was seen as necessary to survive.
Structural Inequality Indicators
Structural inequalities experienced within African American communities also weighed heavily on many men. These also impacted substance use behaviors. Several participants described feelings of stress induced by a lack of money, jobs, and healthcare, which in turn led to coping behaviors based on alcohol and drug use. One participant said, “Black guys have more hardships; White and Hispanic guys have jobs, healthcare.” Another participant described himself upon enrolling in the Project ROOM study in this way, “Usually I would’ve been like, “Aw, man, I ain’t got no job. How am I gonna pay these bills?” and that would have drove me to, like, get high and drink, and, like, drink it all away.” While this was a theme that emerged during the interviews, some men described more severe problems than others:
I feel inadequate in pretty much every situation. I mean everybody—you listen to everybody and they talk about their jobs and the kind of house they have, the kind of car they drive. And you’re on the bus. You’re renting an apartment. You’re on Social Security disability. You’re HIV-positive. You know, that kind of thing.
All men participating in the qualitative interviews currently described themselves as gay. However, the majority of men described openly identifying as gay or portraying oneself as gay in the African American community as unacceptable and potentially dangerous. “You mention the word ‘gay’ and the next thing you know, you’re ousted,” said one participant. He went on to say, regarding not identifying as gay, that “You avoid a lot of the fights. You avoid the possible conflict.” This theme was echoed by nearly all men with reasons for such attitudes ranging from churches that describe same-sex behavior as sinful, to the influence of slavery in which African American men were historically emasculated, leading to the development of a hypermasculine persona. Participants stated that the avoidance of being identified as gay causes many men to also have sex with women or to embrace a “down low” identity.
Similar to experiences of African American/Black men in other communities, men in the sample reported histories of arrest, jail, and juvenile detention. In these discussions, two subthemes emerged. In the first, participants told about intentionally breaking the law. For example, one young participant described being in and out of jail and juvenile detention centers for 5 years in this way, “You know, like anything that I do, I dedicate myself to it, and I do it well. So, when I was a badass, I got in trouble and I got in trouble pretty good.” In the second subtheme, participants told of not breaking the law and being punished for crimes they did not commit. For instance, one participant, stated, “I was 15 years old, did 13 years for a crime I didn’t commit, and it was a sex charge. And, like I said, I didn’t commit it, but my family was poor, I was poor, we could only afford a public defender, and that’s what happened.” The consequences of criminal justice system involvement by African American/Black MSM were known by all men, which included limited educational and employment opportunities, mental distress, and increased substance use as a coping behavior.
The social environment of participants affected many aspects of their lives. One participant described the process of choosing friends based on what a potential friend could offer, “The people I would search out would be drug addicts, alcoholics, partiers, because I’m like, “Okay, I don’t have a car, but if I get with this person and they wanna go out, I’ve got a ride to the club and back,” or, you know, “Maybe if I run out of money, this person’s got the same habit I do. So maybe they’ll have something and I’ll go over to their house.” Another participant described himself as being, “not the most savvy” when it came to alcohol and drug use, however, his social circle was heavily involved in it and influenced his substance use and his access to drugs. Because of substance-use-centered relationships such as these, a majority of participants described a lack of social support within their family and friendship networks. While some participants mentioned having insufficient material support, a majority described being in need of emotional support. Given the stigma and discrimination associated with same-sex behavior in many African American communities, many participants did not have anyone to talk to about such problems, feelings, or emotions. As one participant described:
If you give a black guy support, they’ll be your friend for life…it’s not always money support either. Somebody to talk to, somebody to be there, and somebody to hang out with that’s positive, other than, like, what they’re use to—the drugs, the alcohol, the gangbangers, the thugs, the criminals—you know, somebody positive.
The biggest reason African American/Black MSM from Project ROOM were not satisfied with their current living situation was related to their financial circumstances. Participants reported living in undesirable neighborhoods or apartments or with objectionable people because they did not have the financial freedom to go elsewhere. One participant living in Miami Beach described the city as “not cheap” and “a great place to be if you have money.” He, on the other hand, was unable to find work and described it as “an economically difficult time.” Another participant told about his small, affordable housing unit in downtown Miami. It was here that he began interacting with “partier-types” of people, which had a major impact on his behavior. In addition, many men reported histories of bad living situations from which they eventually removed themselves. In particular, one participant grew up in Miami’s Liberty City neighborhood and has vivid memories of riots, seeing many of his friends go to jail, poor schools, and a host of daily struggles. Another man described his living situation in the Overtown neighborhood of downtown Miami. The rampant drugs and violence, including the shooting of a 4-year-old girl, contributed to his mental distress and feelings of insecurity. Though, for several years, he could not afford to go elsewhere, he moved away as soon as he was able. Still others told of growing up in racially segregated neighborhoods in northern cities before eventually moving to South Florida.