Medical Research: What is the background for this study?
Dr. Halkitis: The P18 Cohort Study is a prospective cohort study of gay, bisexual and other young men who have sex with men (YMSM) which seeks to examine the development of health behaviors as these young men transition from adolescent to adulthood. Officially named “Syndemic Production among Emergent Adult Men”, this study was funded by the National Institute on Drug Abuse from 2009-2014 and renewed on March 1, 2014 for an additional five years.
The original aims of the study were as follows:
- 1) to develop and test theoretically informed measurement models of the covariance of illicit drug use, unprotected sexual behavior and mental health burden (multiple overlapping epidemics known as a syndemic) among emergent adult HIV-negative YMSM within and across time;
- 2) to delineate the risk and protective bases- physical factors (e.g., pubertal onset, HIV status, etc.), relational and structural factors (e.g., family history of psychopathology, current romantic relationships, peer support, neighborhood factors, etc.), and psychosocial factors (e.g., sexual identity, internalized homophobia, hyper-masculine conceptions, etc.) that predict the development of syndemics; and
- 3) to determine the extent to which the development of a syndemic varies by race/ethnicity, social class, and homelessness/housing instability.
- In this current five year continuation we also seek
- 1) to describe the social and sexual networks of YMSM, and to examine the relationship between social and sexual network-level structural characteristics, social support and normative influences on syndemic production (illicit drug use, unprotected sexual behaviors, and mental health burden) in YMSM, singly and in combination with the physical, psychosocial, and relational predictors, both within and across time;
- 2) to describe the acquisition of sexually transmitted infections (STIs) in YMSM, specifically, urethral and rectal gonorrhea and chlamydia, pharyngeal gonorrhea as well as syphilis serology; and to determine the extent to which physical, relational, and psychosocial factors explain STI acquisition as part of the syndemic model within and across time.
- A third exploratory aim was also added: 3) to describe HIV clinical treatment markers (i.e., HIV viral load, ART uptake and adherence, HIV care) among HIV+ YMSM, and to assess the extent to which physical, relational, and psychosocial factors are associated with differences in these clinical markers among HIV+ YMSM, both within and across time. The study is led by Drs. Perry N Halkitis and Farzana Kapadia at New York University’s Center for Health, Identity, Behavior & Prevention Studies.
Potential participants were recruited through both active (e.g., approaching individuals to solicit study participation) and passive (e.g., flyer posting, website advertisements) methods from June 2009 to May 2011. Eligibility criteria included being 18-19 years old, biologically male, residing in the NYC metropolitan area, having sex (any physical contact that could lead to orgasm) with a man in the last 6 months, and reporting a seronegative or unknown HIV status at baseline. We ensured the diversity of our sample by setting a fixed recruitment quota for participants in each targeted racial/ethnic group, such that African Americans, Latino (across race), Asian-Pacific Islander (API), and mixed race men comprised the majority of the sample. All participants provided written, informed consent before data was collected and were compensated for their time and effort upon completing the baseline assessment. The New York University’s Institutional Review Board (IRB) approved all study protocols and a federal Certificate of Confidentiality protects these data.
A total of 2,068 participants were screened for eligibility to participate in the study, and 600 participants completed the baseline assessment in the first wave of the study. In 2014, we began the second wave and opened to cohort to recruit a baseline sample of 650 YMSM who will now be between the ages of 22-23; recruitment of participants is still underway.
Medical Research: What are the main findings?
Dr. Halkitis: Numerous publications have been generated from the P18 Cohort Study and can be accessed at www.chibps.org. A recent publication, “Incidence of HIV infection in Young Gay, Bisexual, and other YMSM: The P18 Cohort Study” became available in the May 2015 of JAIDS, the Journal of Acquired Immune Deficiency Syndromes. This paper reports that over a 36 month follow-up period, during the first wave of the study, 7.2% of study participants seroconverted, with Black and Hispanic men much more likely to seroconvert over this time frame than White men. This finding aligns with epidemiological trends for HIV infection at the national and local, NYC, levels. Also, men reporting a lower familial socioeconomic status were more likely to seroconvert than men reporting high familial socioeconomic status, and Black men were more likely to report a lower socioeconomic status. Moreover, the Black young men who seroconverted were more likely to reside in neighborhoods with higher area-level poverty and higher area-level HIV prevalence. Additionally we found that men who reported anal sex without a condom in the 30 days prior to assessment were no more likely to seroconvert than those who reported sex with a condom. However, an earlier age of sexual debut was a predictor of HIV seroconversion.
Medical Research: What should clinicians and patients take away from your report?
Dr. Halkitis: Most significantly, clinicians must realize that the HIV epidemic while transmitted sexually is not solely driven by behavioral factors. Specifically, even though Black and Hispanic young gay men were more likely to seroconvert, they were no more likely to engage in “risky sex” than their White peers. Clinicians must understand that the HIV epidemic is driven by structural inequalities such as differences in socioeconomic status and thus must work inter-professionally with public health leaders and policy makers to alleviate the inequalities that drive disease. Finally, clinicians must be attuned to the sexual lives of young gay men as they emerge into adolescence and transition from adolescence into young adulthood. Clinicians must be willing to have open and honest conversations about sex and sexuality that are free of judgment, acknowledge and respect the sexuality of young gay men, and provide more sophisticated risk reduction information, rather than the overly simplistic recommendation of “use a condom every time.” Such conversations may empower young gay men to develop effective and sustainable strategies for protecting their sexual health. Clinicians must also recognize that the explanations for the persistence of the HIV epidemic in the U.S. based on race alone are insufficient. They must also recognize and take into account the diversity of life experiences that young gay men bring to clinical setting including the experiences of poverty, stigma and discrimination, which may all exacerbate HIV risk. In effect HIV risk for a young, poor Black gay man is not the same as that for a middle class, young Black gay man.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Halkitis: The P18 Cohort Study is ongoing and who hope to generate an even more granular level of knowledge about the structural, social, psychosocial, and behavioral factors that often undermine the overall health and well-being of young gay men. We hope to develop an understanding of the HIV risk and health, overall, of a new generation of young gay men that is not driven by our understanding of the generation that came of age in the early days of the epidemic. In other words, we hope to shed light from our research on the need to develop holistic strategies for healthcare delivery for a new generation of young gay men that is not solely focused on HIV but in which HIV is one element of a constellation of health and mental health issues with which this new generation of young gay men face.
Perry Halkitis, Farzana Kapadia, Danielle Ompad. Incidence of HIV infection in Young Gay, Bisexual, and other YMSM. JAIDS Journal of Acquired Immune Deficiency Syndromes, 2015; 1 DOI: 10.1097/QAI.0000000000000616
MedicalResearch.com Interview with:, Perry N Halkitis, Ph.D., M.S., MPH, Professor of Applied Psychology, Global Public Health, and Population Health/Medicine, & New York University (2015). Black Young Gay Men From Poor Neighborhoods More Likely To Contract HIV MedicalResearch.com