Multilevel Racism & Discrimination and PrEP Outcomes Among Black SMM in the Southeastern U.S.

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PROJECT SUMMARY Inequities in health manifest as a result of systemic minority stressors and social injustices. Racism and discrimination are salient minority stressors and social injustices for Black sexual minority men (SMM) because Black SMM anticipate and experience discrimination at different ecological levels (intrapersonal, interpersonal, and community) due to their interconnected identities (e.g., race, sexual minority status, HIV status). These multiple exposures concomitantly contribute to increased HIV vulnerability among Black MSM: 1 in 2 Black SMM will be diagnosed with HIV in their lifetime, compared to 1 in 11 for White MSM, if current trends remain unchanged. There is increasing interest in understanding an individual's ability to adapt to or resist life's adversities or stressful events (i.e., minority strengths framework). Thus, an integrated minority social-structural stress and minority strengths theory model will be tested in the proposed application to delineate the multilevel discrimination predictors of HIV prevention outcomes, and understand how resilience moderates these associations. First, we hypothesize that greater anticipation and experiences of discrimination are predictive of infrequent testing for sexually transmitted infections, including HIV, and lower pre-exposure prophylaxis (PrEP) use, retention in care, PrEP adherence, and PrEP protection over a 36-month follow-up period among Black MSM in the Deep South. Next, we hypothesize that differing levels of resilience will moderate the associations between discrimination and HIV prevention. Finally, we will conduct qualitative focus groups with social mapping to validate the quantitative results in Aims 1&2 and to identify and/or adapt effective social-structural and/or strengths-based interventions to mitigate the effect of SRD on PrEP outcomes among Black SMM. Three integrated specific aims are proposed to test these hypotheses. In Specific Aim 1, to evaluate the relationships between SRD factors and PrEP continuum outcomes among Black SMM in two Southeastern U.S. cities over a 36-month follow-up period, using multilevel modeling techniques. In Specific Aim 2, to determine the moderating effects of resiliency factors on the relationships between SRD factors and PrEP continuum outcomes among Black SMM in two Southeastern U.S. cities through moderation analyses. And finally, in Specific Aim 3, to a. gain contextually-grounded explanations of the quantitative results via focus groups; b. “geo-narratives” of the geographical landscape of Black SMM using social mapping; and c. synthesize the quantitative and qualitative results via data triangulation methods. Broadly, this research will enhance our understanding of how SRD discrimination contributes to inequities in HIV and provide insight into three long-standing questions in the field of HIV epidemiology: (1) minority stress mechanisms that contribute to HIV prevention outcomes, (2) intrapersonal traits that buffer the associations of minority stressors with HIV prevention, and (3) identification and/or adaptation of social- structural or strengths-based interventions to mitigate HIV among Black SMM.