Substance Use and Mental Health as Mediators of the Association Between Intimate Partner Violence Victimization and Condomless Sex with Serodiscordant Partners Among Black Sexual Minority Men Living with HIV

Abstract

Black sexual minority men (SMM) are disproportionately impacted by HIV in the United States. Intimate partner violence (IPV), substance use, and depression are associated with HIV risk behavior such as condomless sex. In this study, we assessed cross-sectional associations between multiple types of IPV victimization and condomless sex with serodiscordant partners. We then evaluated the mediating roles of mental health and substance use, in a sample of 213 Black SMM living with HIV. We used validated scales to assess IPV victimization, depression, post-traumatic stress symptoms, general mental health, and substance use. All independent variables (IPV type) that had at least a marginal (p < .10) association with the dependent variable (condomless sex with a serodiscordant partner) and any potential mediator were included in mediation models. Mediator role was determined based on a statistically significant outcome (p < .05) in the mediation model. Physical assault, injury-inducing IPV, and sexual coercion were each positively correlated with condomless sex. Depression, overall mental health, and substance use were associated with physical assault and injury-inducing IPV, and depression was associated with sexual coercion IPV. Both physical assault and injury-inducing IPV were associated with overall mental health, but none of the mental health and substance use measures mediated the associations between IPV and condomless sex. Findings suggest that HIV prevention efforts for Black SMM may need to incorporate IPV screening and prevention services. Further research is needed to understand the psychosocial pathways by which physical forms of IPV relate to condom use.

Keywords

domestic violence alcohol and drugs LGBT male victims sexual assault mental health and violence

Introduction

Black sexual minority men (SMM)—who identify as gay, bisexual, or who are attracted to or have sexual contact with people of the same gender, are disproportionately impacted by HIV in the United States (US). Black SMM accounted for 26% of all new HIV diagnoses and 37% of new diagnoses among SMM in the US in 2019, even though they comprise less than 1% of the US population (Centers for Disease Control and Prevention, 2021). The lifetime risk for HIV infection is estimated to be one in six among all SMM compared to one in two among Black SMM (Centers for Disease Control and Prevention, 2021). Between 2015 and 2019, an estimated 57% of Black SMM living with HIV engaged in condomless sex, and an estimated 70% of Black SMM living with HIV reported having any sex with a partner who is not living with HIV or whose status was unknown (Dasgupta et al., 2020).

One factor found to be associated with condomless anal sex is intimate partner violence (IPV) (Buller et al., 2014a; Stephenson & Finneran, 2017). IPV refers to behaviors such as acts of physical, psychological, and sexual violence, and controlling behaviors that can cause significant harm to an individual in an intimate relationship (Callan et al., 2021). The types of IPV observed among SMM are similar to those observed in heterosexual or mixed-sex couples, including psychological, sexual, and physical abuse (Callan et al., 2021). However, SMM experiencing IPV may face societal and internalized homophobia, bisexual invisibility, and lack of available IPV-related resources tailored for SMM that may contribute to or exacerbate the violence (Callan et al., 2021). SMM who experience IPV also report higher rates of being fearful, being concerned for their safety, experiencing any of the measured post-traumatic stress disorder (PTSD) symptoms, and having been injured compared to their heterosexual counterparts (Chen et al., 2020). In terms of rates of IPV, observed IPV rates among SMM are similar to or higher than those documented among women or heterosexual men (Chen et al., 2020; Finneran & Stephenson, 2013; Whitfield et al., 2021). Based on a systematic review of convenience samples of over 32,000 SMM, the estimated pooled prevalence of IPV victimization (i.e., experiencing IPV) among SMM was 33% (Liu et al., 2021), and the pooled prevalence estimates for experiencing physical violence, sexual violence, and emotional violence were 17%, 9% and 33%, respectively (Liu et al., 2021). Among Black SMM, prevalence estimates of experiencing any form of IPV from convenience samples range from 29% (Welles et al., 2011) to 52% (Williams et al., 2015). A meta-analysis of 17 studies found that IPV victimization was associated with living with HIV, and doubled the odds of having condomless sex among SMM (Buller et al., 2014a); the authors did not clarify if condomless sex was consensual or coerced.

Substance use problems and mental health problems such as depression and PTSD may also be associated with IPV victimization. Theories suggest that substance use and mental health issues could impair judgment and impulse control and thus lead to inability to remove oneself from or de-escalate imminent IPV (Geyen & Bailey, 2021; Wu et al., 2015). A meta-analysis of 285 studies found that alcohol and drug use are significantly related to IPV victimization among men and women (Cafferky et al., 2018). Similar results for substance use have been observed among Black SMM, with heavy drinking and methamphetamine use both being significantly associated with IPV victimization (Wu et al., 2015). As for mental health, a meta-analysis of 207 studies with samples including men and women found that depression and PTSD are correlated with IPV victimization (Spencer et al., 2019). While the literature on the association between IPV victimization and mental health is limited for black SMM, there is evidence that depression and PTSD symptoms are associated with IPV victimization among SMM (Anderson et al., 2017; Robles et al., 2022).

Substance use and mental health problems are also associated with condomless sex. A large study of 2,915 adults not living with HIV found that recent substance use was associated with an increased likelihood of condomless sex (Fredericksen et al., 2021). A meta-analysis found that alcohol use among people living with HIV was associated with condomless sex with serodiscordant partners (Przybyla et al., 2018). Similarly, a study of 553 SMM found that alcohol use was associated with any condomless sex (Mansergh et al., 2020). Depression has also been found to positively correlate with condomless sex with partners of different HIV status among SMM (Houston et al., 2012; Miltz et al., 2020). Depression has been found to be significantly higher among Black SMM living with HIV who report condomless anal sex with partners not living with HIV (Reisner et al., 2009).

The few studies that have explored substance use and mental health problems as mediators of the association between IPV victimization and condomless sex have resulted in mixed findings. Mittal et al. found that depression and drug use did not mediate the relationship between IPV victimization and condomless sex among women (Mittal et al., 2011). On the other hand, among a sample of men and women, substance use, depression, and anxiety mediated the association between IPV and condomless sex (Senn et al., 2016). Similarly, in a sample of women not living with HIV and currently experiencing IPV, PTSD symptoms mediated the association between experiencing psychological IPV and condomless sex (Overstreet et al., 2015). There are no studies we are aware of looking at the potential mediating role of substance use and mental health among SMM. Such research is critical for informing comprehensive interventions that seek to address the impact and ramifications of IPV among Black SMM.

To begin to address this gap in the literature, we examined the cross-sectional associations between multiple types of IPV victimization and condomless sex with serodiscordant partners, and the role of mental health (i.e., depression, PTSD symptoms, and overall mental health) and substance use as mediators of this association, in a sample of Black SMM living with HIV. We hypothesized that IPV victimization would be indirectly associated with condomless sex via higher occurrence of substance use and mental health symptoms.

Methods

Study Design

The cross-sectional correlational analysis presented in this paper used baseline data from Rise, a randomized controlled trial of an antiretroviral therapy (ART) adherence counseling intervention that was culturally tailored for Black Americans (ClinicalTrials.gov #NCT03331978) (Bogart et al., 2022; Wagner et al., 2016). The study took place between January 2018 and December 2021 in Los Angeles County, California with enrollment conducted from January 2018 to July 2020. The study was conducted at APLA Health—a large community-based organization that is connected to a Federally-Qualified Health Center. APLA Health’s mission is to provide LGBTQ+ empowering healthcare, support services, and HIV specialty care; APLA Health also provides primary care, including behavioral health services, sexual health services, and HIV testing and HIV specialty services (APLA Health, 2023). The study protocol was approved by the RAND Human Subjects Protection Committee. Data for the study were collected through a combination of self-report questionnaires, blood draws via venipuncture for HIV viral load, and data downloads from electronically monitored medication caps using Medical Event Monitoring System (MEMS) (AARDEX INC.) for medication use patterns.

Study Participants

Participants were recruited via flyers, in-reach at the community-based organization, and direct outreach (to other organizations/clinics, at local events, and on the street), as well as participant referrals. Inclusion criteria for the randomized controlled trial were: “(a) Black/African American (if mixed race, primarily identify as Black/African American), (b) currently living with HIV, (c) 18 years of age or older, (d) prescribed ART in the past 12 months, (e) self-reported adherence problems (i.e., missed at least one ART dose in the past month) and/or detectable viral load in the last 6 months; and (f) willing to use an electronic adherence monitoring device. A sample of 245 participants completed the baseline assessment and randomization, of whom 213 were men who reported being SMM and thus comprised the analytic sample for this analysis. Those who were included in the analytic sample for this paper identified as SMM (n = 211) or transgender male (n = 2) and reported having any anal sex with a man in the past 3 months. Of the 32 individuals who were excluded, 11 self-identified as transgender female and the remainder identified as female. Participants were enrolled in the study from January 2018 to July 2020. All participants gave written informed consent and received $30 for the baseline assessment.

Measures

Sociodemographic Characteristics

Participants were asked to report their date of birth (from which age was calculated), gender identification, sexual orientation, education level, housing status in the past year, and current employment status.

HIV-Related Characteristics

Participants were asked to report years since their diagnosis with HIV, and whether their viral load was detectable (i.e., not suppressed), undetectable, or not known. We also abstracted medical record data on viral suppression; self-reported data were used for individuals for whom we were unable to obtain medical record viral load data.

Intimate Partner Violence

IPV victimization was assessed using the revised Conflict Tactics Scales, a short form of the Conflict Tactics Scales, which has been recommended for use when testing time is limited (Straus & Douglas, 2004). Participants were asked how often (number of times in the past year) they experienced four different types of IPV from their partner in the past year: physical assault (how often the participant was pushed, shoved, slapped, punched, kicked, or beat up by their partner); injury-inducing (how often the participant had a sprain, bruise, cut, or needed to see a doctor because of a fight with a partner); sexual coercion (how often their partner used force or insisted to have sex); and psychological aggression (how often their partner insulted, swore, shouted, yelled at them, or destroyed their belongings or threatened to hit them). For each IPV type, a dichotomous variable was created to indicate the presence of that type of IPV in the past year.

Substance Use

Substance use was measured using items from the Addiction Severity Index (McLellan et al., 1992). Participants were asked how many times they used heroin, crack cocaine, powder cocaine, prescribed tranquilizers other than as prescribed, prescribed opioids other than as prescribed, methamphetamine, party drugs (e.g., ecstasy), poppers, or any other drugs (excluding marijuana), in the past 30 days. A dichotomous variable was generated for any drug use in the past 30 days. Alcohol use was measured using the Alcohol Use Disorders Identification Test (Saunders et al., 1993).

Mental Health

Depression was measured using the eight-item Patient Health Questionnaire (PHQ-8) (Kroenke et al., 2009). Each item assesses a symptom that corresponds to the criterion for diagnosing depression in the Diagnostic Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association, 2013). PHQ-8 was used in this study because depression was not the main focus. Item sum scores on the PHQ-8 greater than 9 (range: 0–24) have been shown to correspond highly with major depression (Kroenke et al., 2009), and this same cutoff was used in this study to reflect depression. PTSD was measured using the Primary Care PTSD Screen, a four-item scale that asked participants to think about a stressful event that was frightening, horrible, or upsetting. They were asked to answer yes or no about whether they experienced nightmares, difficulty thinking, were easily startled, or had feelings of detachment from others in the past month (Cameron & Gusman, 2003; Steele et al., 2014). A dichotomous variable was generated to indicate if participants answered yes to one or more of these. Overall mental health was assessed with the four-item subscale of the Health-related Quality of Life scale (Hays et al., 2009). The four items asked participants to rate their mental health, their quality of life, their satisfaction with their social activities and relationships, and how often they have been bothered by emotional problems such as feeling anxious, depressed, or irritable on a scale of 1 to 5. Scores on the subscale were an average measure of the four items with higher scores indicating better state of mental health overall.

Condomless Sex with a Male Partner(s) Not Living with HIV

Participants were asked in separate questions how often they had receptive and insertive anal sex with men in the past 3 months, and of those times, the number of times a condom was not used. Among the times they had receptive and insertive anal sex in the past 3 months without a condom, they were asked how many of these times were with a partner believed to be living with HIV, and how many times with a partner believed to be not living with HIV, in separate questions. A dichotomous variable was created to indicate those who reported having any condomless anal sex in the past 3 months with a partner believed to be not living with HIV. Data were not collected on whether condomless sex was coerced or consensual.

Data Analysis

Initial analyses using bivariate statistics (chi-squared tests; two-tailed, independent t-tests) were conducted to examine associations between the experience of each type of IPV victimization and the primary dependent variable (DV), any condomless sex with an HIV-negative partner, as well as the potential mediators (i.e., mental health and substance use). To identify our mediation models, we required there be at least marginal (p < .10) associations between (a) the independent variable (IV; IPV type) and the DV (condomless sex with partners not living with HIV); and (b) the IV and the potential mediator. If these two requirements were met, we proceeded with mediation analysis (Kraemer et al., 2002). A conceptual diagram of the associations between the key variables is shown in Figure 1.

Figure 1.

Conceptual diagram of the associations between intimate partner violence and condomless sex, with mental health and substance use as mediators.

For potential mediators, we estimated single mediation models with each potential mediator. Structural equation modeling in Stata version 16.1 (StataCorp LLC) was used to conduct the analyses. We estimated odds ratios for the association between the IV and the DV, with and without the mediator included in the model. We then estimated the direct effect between the IV and the DV and the indirect effect of the IV that goes through the mediator, that is, whether the mediator changed the magnitude of the association between the IV and the DV. A mediator was determined to have a partial mediating role if both the direct effect and the indirect effect were statistically significant. A mediator was determined to have a full mediating effect if only the indirect effect was statistically significant. Standard errors and confidence intervals for significance testing were calculated using a bootstrap approach with 2,500 replications (Zhao et al., 2010). All analyses were conducted among all Black SMM (N = 213). Sensitivity analysis was conducted in a subsample of Black SMM who reported having anal sex with a partner not living with HIV (N = 186). Age, marital status, education status, and viral suppression were included as controls in all models.

Results

Sample Characteristics

Table 1 lists the characteristics of the 213 Black SMM in the analytic sample. Mean age was 46 (SD = 12.6), and mean time since HIV diagnosis was 16 years (SD = 10.1). Sixty-nine individuals in the sample (32%) reported any condomless anal sex with men in the past 3 months, including 58 who reported any condomless anal sex in the past 3 months with a partner believed to be not living with HIV. A subgroup of 186 Black SMM reported having anal sex with a male partner not living with HIV in the past 3 months. The 186 men who reported anal sex with male partners not living with HIV did not differ from the remaining 27 SMM participants who reported no anal sex with male partners not living with HIV on any sociodemographic variable, except age, and frequency of any condomless anal sex (see Table 1). The 58 men who reported having condomless anal sex with male partners not living with HIV were younger and had higher rates of experiencing all forms of IPV, depression, PTSD, drug use, and alcohol use, compared to the 155 men who reported no condomless anal sex with male partners not living with HIV.

Table 1.

Sample Characteristics Among Black Sexual Minority Men (SMM) Living with HIV (N = 213), And Comparisons of Those Reporting Recent Anal Sex (N = 186) or No Recent Anal Sex (N = 27) With Partners Not Living with HIV, and Those Reporting Recent Condomless Anal Sex (N = 58) or No Recent Condomless Anal Sex (N = 155) With Partners Not Living with HIV.

Characteristic	All SMM (N = 213) Freq (%) or Mean (SD)	Anal sex with partner not living with HIV (N = 186) Freq (%) or Mean (SD)	NO anal sex with partner not living with HIV (N = 27) Freq (%) or Mean (SD)	Condomless anal sex with partner not living with HIV (N = 58) Freq (%) or Mean (SD)	NO condomless anal sex with partner not living with HIV (N = 155) Freq (%) or Mean (SD)
Sociodemographic characteristics
Age	46.0 (12.6)	45.0 (12.6)**	52.4 (10.7)**	40.2 (12.7)**	48.1 (11.8)**
Highest education completed
Less than high school	27 (12.7%)	23 (12.4%)	4 (14.8%)	7 (12.1%)*	20 (12.9%)*
High school diploma or GED	52 (24.4%)	47 (25.3%)	5 (18.5%)	17 (29.3%)	35 (22.6%)
Some college, but no degree	74 (34.7%)	61 (32.8%)	13 (48.1%)	12 (20.7%)	62 (40.0%)
College degree or above	60 (28.2%)	55 (29.6%)	5 (18.5%)	22 (37.9%)	38 (24.5%)
Annual income
No current income	33 (15.5%)	28 (15.1%)	5 (18.5%)	16 (27.6%)**	17 (11.3%)**
$1–$10,000	67 (31.5%)	61 (32.8%)	6 (22.2%)	17 (29.3%)	50 (33.1%)
$10,000–$20,000	83 (39.0%)	71 (38.2%)	12 (44.4%)	15 (25.9%)	68 (45.0%)
$20,001–$30,000	15 (7.0%)	12 (6.5%)	3 (11.1%)	5 (8.6%)	10 (6.6%)
$30,001–$40,000	4 (1.9%)	4 (2.2%)	0 (0%)	3 (5.2%)	1 (0.7%)
Over $40,000	7 (3.3%)	7 (3.8%)	0 (0%)	2 (3.4%)	5 (3.3%)
Married/living with partner	18 (8.4%)	16 (8.6%)	2 (7.4%)	5 (8.6%)	13 (8.4%)
HIV-related characteristics
Years since HIV diagnosis	16.0 (10.1)	15.6 (10.2)	18.9 (9.6)	13.2 (10.3)*	17.0 (9.9)*
Viral load suppressed	160 (75.1%)	140 (75.0%)	20 (70.1%)	44 (77.2%)	116 (76.3%)
Mental health and substance use
Depressed (PHQ score ≥ 10)	66 (31.0%)	58 (31.2%)	8 (29.6%)	25 (43.1%)*	41 (26.5%)*
PTSD	59 (27.7%)	55 (29.6%)	4 (14.8%)	21 (36.2%)+	38 (24.5%)⁺
Overall mental health	2.8 (0.9)	2.8 (1.0)	2.8 (0.9)	2.6 (0.8)*	2.9 (1.0)*
Drug use in the past month	86 (40.4%)	79 (42.5%)	7 (25.9%)	29 (50.0%)+	57 (36.8%)⁺
Alcohol use	3.0 (4.8)	3.1 (5.0)	2.04 (3.1)	4.1 (5.7)+	2.6 (4.4)⁺
Intimate partner violence
Physical assault	30 (14.1%)	27 (14.5%)	3 (11.4%)	14 (24.1%)*	16 (10.3%)*
Injury-inducing	34 (16.0%)	32 (17.2%)	2 (7.4%)	15 (25.9%)*	19 (12.3%)*
Sexual coercion	19 (8.9%)	17 (9.1%)	2 (7.4%)	12 (20.7%)**	7 (4.5%)**
Psychological aggression	63 (29.6%)	56 (30.1%)	7 (25.9%)	22 (37.9%)+	41 (28.4%)⁺
Experienced at least one type of IPV	66 (31.0%)	59 (31.7%)	7 (25.9%)	24 (41.4%)	42 (27.1%)*
Outcome variable
Condomless sex	69 (32.4%)	69 (37.1%)**	0 (0%)**	58 (100.0%)**	11 (7.1%)**

p-Value calculated based on chi-square test used for categorical variables and t-tests used for continuous variables.

IPV: Intimate partner violence; PHQ: Patient Health Questionnaire; PTSD: post-traumatic stress disorder; SMM: sexual minority men.

p < .10. *p < .05. **p < .01.

Bivariate Associations of IPV with Condomless Sex, Mental Health, and Substance Use

Nearly a third (31%) of all Black SMM in the sample experienced at least one type of IPV in the past year. Experience of any psychological IPV was the most common type of IPV victimization reported (N = 63; 29.6%), followed by injury-inducing (N = 34; 16.0%), physical assault (N = 30; 14.1%), and sexual coercion (N = 19; 8.9%) (see Table 1). In bivariate analysis, those who reported any sexual coercion (68.4% vs. 30.3%; p = .001), any physical assault (53.3% vs. 30.5%; p = .014), and any injury-inducing IPV (50.0% vs. 30.6%; p = .029) reported higher rates of any condomless anal sex with partner not living with HIV compared to those who did not report these types of IPV (see Table 2).

Table 2.

Condomless Sex, Mental Health, and Substance Use Comparing Those Who Experienced IPV Versus Those Who Did Not Among All SMM (N = 213) and SMM Who Reported Anal Sex With HIV-Negative Partner(s) (N = 186).

	Physical Assault N (%) or Mean (SD)		Injury-Inducing N (%) or Mean (SD)		Sexual Coercion N (%) or Mean (SD)		Psychological Aggression N (%) or Mean (SD)
Variable	No IPV N = 183	IPV N = 30	No IPV N = 179	IPV N = 34	No IPV N = 194	IPV N = 19	No IPV N = 150	IPV N = 63
ALL SMM (N = 213)
Condomless sex with partner not living with HIV	44 (24.0%)*	14 (46.7%)*	43 (24.0%)*	15 (44.1%)*	46 (23.7%)**	12 (63.2%)**	36 (24.0%)	22 (34.9%)
Mental health
Depressed (PHQ ≥ 10)	51 (27.9%)*	15 (50.0%)*	49 (27.4%)**	17 (50.0%)**	56 (28.9%)*	10 (52.6%)*	42 (28.0%)	24 (38.1%)
PTSD	48 (26.8%)	11 (36.7%)	48 (27.4%)	11 (32.4%)	51 (26.8%)	8 (42.1%)	35 (24.0%)*	24 (38.1%)*
Overall mental health	2.9 (1.0)**	2.34 (0.7)**	2.9 (1.0)*	2.4 (0.7) *	2.8 (1.0)	2.5 (0.6)	2.9 (1.0)**	2.5 (0.8)**
Substance use
Drug use in the past month	66 (36.3%)**	20 (66.7%)**	64 (36.0%)**	22 (64.7%)**	76 (39.4%)	10 (52.6%)	52 (34.9%)*	34 (54.0%)*
Alcohol use	2.8 (4.7)	4.3 (5.6)	2.7 (4.6)*	4.6 (5.6) *	3.0 (5.0)	3.2 (3.4)	2.7 (4.8)	3.7 (4.8)
	No IPV N = 159	IPV N = 27	No IPV N = 154	IPV N = 32	No IPV N = 169	IPV N = 17	No IPV N = 130	IPV N = 56
SMM who reported anal sex with partner(s) not living with HIV (N = 186)
Condomless sex with partner not living with HIV	44 (27.7%)*	14 (51.9%)*	43 (27.9%)*	15 (46.9%)*	46 (27.2%)**	12 (70.6%)**	36 (27.7%)	22 (39.3%)
Mental health
Depressed (PHQ ≥ 10)	45 (28.3%)*	13 (48.1%)*	43 (27.9%)*	15 (46.9%)*	50 (29.6%)	8 (47.1%)	37 (28.5%)	21 (37.5%)
PTSD	44 (28.4%)	11 (40.7%)	44 (29.3%)	11 (34.4%)	48 (29.1%)	7 (41.2%)	33 (26.2%)⁺	22 (39.3%)⁺
Overall mental health	2.9 (1.0)**	2.3 (0.7)**	2.9 (1.0)**	2.4 (0.7)**	2.8 (1.0)	2.4 (0.5)	2.9 (1.0)**	2.5 (0.8)**
Substance use
Drug use in the past month	61 (38.6%)**	18 (66.7%)**	58 (37.9%)**	21 (65.6%)**	69 (41.1%)	10 (58.8%)	48 (37.2%)*	31 (55.4%)*
Alcohol use	2.9 (4.9)⁺	4.7 (5.8)⁺	2.8 (4.8)*	4.8 (5.7)*	3.2 (5.2)	3.1 (3.6)	2.8 (5.0)	4.0 (5.0)

Freq (%) or mean (SD) presented in table. p-Value calculated based on the chi-square test used for categorical variables and t-tests used for continuous variables.

IPV: Intimate partner violence; PHQ: Patient Health Questionnaire; PTSD: post-traumatic stress disorder; SMM: sexual minority men.

p < .10. *p < .05. **p < .01.

Because physical assault, injury-inducing, and sexual coercion IPV were each associated with condomless anal sex with partner not living with HIV, we next examined how these three types of IPV were associated with mental health and substance use, to identify potential mediators of the relationship between these types of IPV victimization and condomless anal sex. The presence of any physical assault, injury-inducing, and sexual coercion IPV was each associated with depression. Any physical assault and any injury-inducing IPV victimization were each associated with lower overall mental health scale scores (see Table 2). Any physical assault and any injury-inducing IPV were each associated with higher rates of using any drugs in the past month, and injury-inducing IPV was also associated with higher alcohol use (see Table 2). Nearly all of these bivariate relationships were also evident in the subgroup of SMM who reported anal sex with partners not living with HIV.

Mediators of the Association Between IPV and Condomless Anal Sex

Physical Assault Measure of IPV Victimization

Although depression status, overall mental health, and drug use were all significantly associated with any condomless sex with partner(s) not living with HIV, none of them mediated the association between condomless sex with partner(s) not living with HIV and physical assault (i.e., the indirect effect in each model was not statistically significant). Physical assault IPV had a significant direct effect on any condomless sex with partner(s) not living with HIV in all models, and overall mental health was significantly associated with condomless sex with partner(s) not living with HIV in its mediation model (see Table 3).

Table 3.

Adjusted Mediation Analysis of IPV and Condomless Sex with People Not Living with HIV in the Whole Sample (N = 213).

	Without Mediator OR [95% CI]	With Mediator OR [95% CI]
Model	IPV → Condomless Sex	IPV → Condomless Sex	Mediator → Condomless Sex	Indirect Effect	Direct Effect	Mediation
ALL SMM (N = 213)
IPV type: Physical assault
Depressed (PHQ ≥ 10)	1.9 [0.8, 4.8]	1.6 [0.6, 4.5]	1.8 [0.9, 3.6]	1.2 [0.9, 1.4]	2.4 [1.0, 5.7] *	No
Overall mental health		1.5 [0.5, 4.1]	0.7 [0.5, 1.0] *	1.2 [1.0, 1.4]⁺	2.4 [1.0, 5.5] *	No
Drug use in the past month		1.6 [0.6, 4.3]	1.4 [0.7, 2.9]	1.1 [0.9, 1.4]	2.4 [1.1, 5.6] *	No
IPV type: Injury-inducing
Depressed [PHQ ≥ 10]	1.8 [0.7, 4.3]	1.6 [0.6, 4.0]	1.8 [0.9, 3.6]	1.2 [1.0, 1.4]	2.2 [0.9, 4.9]⁺	No
Overall mental health		1.5 [0.6, 4.0]	0.7 [0.5, 1.0] *	1.1 [1.0, 1.3]⁺	2.2 [1.0, 4.8]⁺	No
Drug use in the past month		1. 6 [0.6, 4.0]	1.4 [0.7, 2.9]	1.1 [0.9, 1.4]	2.2 [1.0, 5.0]⁺	No
Alcohol use		1.6 [0.7, 4.1]	1.1 [1.0, 1.1]	1.1 [0.9, 1.3]	2.3 [1.1, 5.1] *	No
IPV type: Sexual coercion
Depressed (PHQ ≥10)	4.1 [1.2, 14.3]*	3.9 [0.8, 18.9]⁺	1.7 [0.8, 3.6]	1.2 [0.9, 1.4]	2.2 [1.0, 4.8]⁺	No

All models controlled for age, marital status, education, and viral suppression and used bootstrapped standard errors with 2,500 replications.

IPV: Intimate partner violence; PHQ: Patient Health Questionnaire; SMM: sexual minority men.

p < .10. *p < .05. **p < .01.

Injury-Inducing Measure of IPV Victimization

Depression status, overall mental health, any drug use, and alcohol use were examined as mediators in separate models, but none were found to mediate the association between injury-inducing IPV and with partner(s) not living with HIV, as all indirect effects were nonsignificant (see Table 3). Injury-inducing IPV had a marginally significant direct effect on any condomless sex with partner(s) not living with HIV in all models except for the model with alcohol use, where the direct effect was statistically significant. Overall mental health was significantly associated with condomless sex with a partner not living with HIV in its mediation model.

Sexual Coercion Measure of IPV Victimization

Only depression was a potential mediator, but the mediation model did not reveal evidence that it mediated the relationship between sexual coercion IPV and condomless sex with partner(s) not living with HIV (see Table 3). Sexual coercion had a marginally significant direct effect on condomless sex with a partner not living with HIV.

The sensitivity analysis involving the subgroup of men who reported having any anal sex with a partner not living with HIV produced the same results (data not shown).

Discussion

In this sample of Black SMM living with HIV, rates of IPV victimization in the past year were relatively high, ranging from 9% to 30% depending on the type of IPV; 31% reported at least one type of IPV. Nearly a third (31%) of the sample had depression and 40% reported recent drug use. Physical forms of IPV victimization, specifically physical assault, injury-inducing, and sexual coercion, were significantly associated with having any condomless anal sex with a serodiscordant male partner. Mental health—depression and overall mental health—and substance use were significantly associated with physical forms of IPV, but none were shown to mediate the associations between IPV and condomless sex.

The levels of IPV, depression, and substance use observed in this study are similar to those reported in other research with Black SMM (Bogart et al., 2011; Pantalone et al., 2012; Reisner et al., 2009; Welles et al., 2011; Williams et al., 2015). The observed associations between physical forms of IPV victimization and condomless sex, which were statistically significant, are also consistent with other research (Senn et al., 2016). Combined, these findings suggest that HIV prevention efforts among SMM need to account for the role of IPV victimization. They also suggest that comorbid mental health and substance use problems likely need to be included in such efforts. However, further research is needed to understand the psychosocial pathways through which IPV exposure relates to condomless sex.

IPV interventions often include components that address IPV perpetration and IPV victimization. Components that address perpetration include emotion regulation, distress tolerance, anger management, and substance use. Components that address IPV victimization include IPV screening, safety assessment, legal services, and trauma-informed mental health treatments. However, IPV services are rarely tailored to SMM or Black SMM (Buller et al., 2014b). Findings from this study suggest that organizations offering services to sexual minorities and people living with HIV may need to incorporate screening for IPV and develop tailored services that address IPV, comorbid mental health, and substance use conditions, and the aspects of IPV that can pose additional sexual risk for Black SMM. There is a lack of research and presence of culturally responsive IPV services that address the support needs of Black SMM or the barriers that Black SMM face when seeking IPV-related services (Brooks et al., 2021).

To be maximally effective, IPV interventions will need to address the unique challenges for SMM with HIV, such as possible fears about being outed by aggressors for being a sexual minority or for having HIV (Miltz et al., 2021; Scheer et al., 2020), limited support for survivors when families of origin have not been accepting of their sexuality or HIV status (Scheer et al., 2020), and the general lack of recognition of IPV between two men by the criminal justice and legal systems (Hirschel & McCormack, 2021). Given condomless sex can increase the likelihood of HIV transmission, the observed association between IPV and condomless sex in this sample of SMM suggests that targeting to reduce HIV transmission for SMM (for example by using long-acting ART formulations) may be particularly useful for those experiencing violence in the event of mental health problems and condomless sex. Therefore, screening for these conditions and linkage to long-acting ART may be useful for those experiencing IPV victimization. Further work is needed to develop systematic assessments of IPV for sexual minority individuals and the unique dynamics and sexual risks that can present for SMM and Black SMM experiencing IPV.

Some limitations of this study should be noted. The measure of the primary DV, condomless sex with partners believed to be not living with HIV, was susceptible to inaccurate perception and lack of knowledge on the part of the respondent with regards to their sexual partners’ HIV status, history of HIV testing, or pre-exposure prophylaxis (PrEP) use; therefore, the level of transmission risk associated with condomless sex with such partners is uncertain. In particular, PrEP use can change the perception of possibilities for transmission and the impact of condomless sex for transmission. The measures of IPV victimization used in the study are based on participants’ self-reports and do not include data from participants’ partners. In addition, the Conflict Tactics Scales measure used for this study does not measure identity abuse, which can manifest among SMM because of HIV status and sexual minority status. Furthermore, our study only examines IPV survivors who report experiencing IPV from their serodiscordant partner and does not explore IPV perpetration by those living with HIV. Future research looking at IPV perpetration in a similar sample can be useful to overcome this limitation. In addition, we recruited a convenience sample of participants, so the results may not be generalizable to all Black SMM living with HIV in the US. Furthermore, we relied on cross-sectional nonexperimental data; therefore, the temporal or causal associations between the outcome, the mediators, and the exposure variables cannot be determined. Future research with longitudinal data will be useful to overcome this weakness. Additionally, while power analyses were conducted for the randomized controlled trial the sample is pulled from, it was not conducted for the analysis described in this paper. Thus, the nonsignificant findings may be related to the restricted sample size in the present analysis. Finally, it is not clear in this study whether condomless sex was forced or consensual. Future research that identifies this will help avoid potential confounding particularly for sexual coercion IPV or sexual assault.

In conclusion, the current study shows that physical forms of IPV victimization are associated with a greater likelihood of condomless anal sex with serodiscordant partners among Black SMM living with HIV. Measures of mental health problems and substance use were found to be correlated with IPV victimization, as well as condomless sex, but these measures did not serve as mediators of the association between IPV and condomless sex. These findings suggest that HIV prevention efforts among SMM living with HIV need to incorporate IPV screening and tailored prevention services, and that further research is needed to understand the psychosocial pathways by which IPV relate to condom use.

Footnotes

Authors’ contributions

Conceptualization (Bogart, Mutchler, Goggin, Wagner, Gizaw); Data curation (Bogart, Klein, Gizaw, Lawrence); Formal analysis (Gizaw, Bogart, Wagner); Funding acquisition (Bogart); Methodology (Bogart, Mutchler, Goggin, Wagner); Roles/Writing—original draft (Gizaw); Writing—review & editing (Bogart, Mutchler, Lawrence, Klein, Goggin, Storholm, Wagner).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research and/or authorship of this article: Funding for this study was provided by NINR (R01NR017334, P.I. Bogart), with additional support from NIMH (P30MH05810).

ORCID iDs

Mahlet Gizaw

Glenn J. Wagner

Author Biographies

Mahlet Gizaw, PhD, is an adjunct policy researcher at RAND Corporation. She has worked on public health intervention projects focused on HIV and mental health in Sub Saharan Africa and the United States.

Laura M. Bogart, PhD, is a Senior Behavioral Scientist at RAND Corporation and a Professor of Policy Analysis at the Pardee RAND Graduate School. A social psychologist with expertise in health inequities, she develops behavioral HIV prevention and treatment adherence interventions, with a focus on addressing intersectional stigma and medical mistrust. All of her research is conducted using principles of community-based participatory research.

Matthew G. Mutchler, PhD, is a Professor of Health Sciences at California State University, Dominguez Hills. He has conducted community-based research with AIDS Project Los Angeles (APLA) Health and other AIDS service agencies throughout Los Angeles County for 25 years.

Sean J. Lawrence is a Senior Study Coordinator at APLA Health.

David J. Klein, MS, is a Statistical Associate at RAND Corporation. He has worked on a variety of research projects studying discrimination and health disparities, especially related to HIV, and has extensive experience with the statistical analysis of complex survey data.

Kathy Goggin, PhD, is the Glasscock Endowed Chair, the Deputy Director of the Children’s Mercy Research Institute and leads the Population Health Area of Emphasis. She is also the DOP Associate Chair for Research and the Director of the Division of Health Services and Outcomes Research. She is a clinical psychologist and her research focuses on primary and secondary prevention, medication adherence, biopsychosocial predictors of health behavior change, and the development and testing of interventions to improve health outcomes and reduce disparities.

Erik D. Storholm, PhD, is an Associate Professor in the School of Public Health at San Diego State University. He is a licensed clinical psychologist with an established behavioral research program focused on reducing health inequities through behavioral and biomedical interventions that prevent HIV/STI transmission by improving mental health and reducing substance use and violence among sexual and gender minority populations.

Glenn J. Wagner, PhD, is a Senior Behavioral Scientist at the RAND Corporation. His research encompasses depression treatment intervention development and evaluation in controlled trials for people living with HIV in Sub-Saharan Africa, including treatment of perinatal depression, and examining effects on HIV care outcomes as well as mental health. He is also studying peer advocacy interventions for promoting disease prevention and protective health behaviors in the context of HIV and cervical cancer prevention.

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