Health Disparities among Adolescent Sexual Minority Males: Associations with Multilevel Stigma and Implications for Pre-Exposure Prophylaxis Uptake
Open AccessBackground: Adolescent sexual minority males (ASMM) experience health disparities, including elevated rates of HIV, depression, and substance use. These health disparities have been characterized as a “syndemic” in that they co-occur, interact, and are produced by conditions of social inequality. This dissertation investigates two research questions: 1) How is HIV sexual risk behavior related to multilevel sexual stigma among ASMM, and 2) How do psychosocial health problems impact HIV pre-exposure prophylaxis (PrEP) uptake among ASMM?Aims and Hypotheses: Chapter 2 examined the hypothesis that state-level structural stigma would be positively associated with HIV sexual risk behavior, with positive indirect effects via interpersonal stigma, individual stigma, and psychosocial health problems. We also investigated differences in these associations by stage of adolescent development, hypothesizing that associations would be stronger in later adolescence compared to earlier adolescence. Chapter 3 investigated whether psychosocial health problems moderate an Information-Motivation-Behavioral Skills (IMB) model of willingness and intention to use PrEP. We first hypothesized that PrEP-related information and motivation would have indirect associations with PrEP willingness and intention via PrEP-related behavioral skills. We then tested the hypothesis that the magnitude of these associations would be attenuated among ASMM with psychosocial health problems compared to ASMM without psychosocial health problems.Methods: We performed a secondary analysis of cross-sectional baseline data from a randomized controlled trial testing the efficacy of an HIV prevention intervention (“SMART”), which enrolled ASMM ages 13-18 in the U.S. between 2018 and 2020. Chapter 2 also used publicly available demographic, public opinion, and policy data to construct a measure of state-level structural stigma. Structural equation modeling and multigroup methods were used for the statistical analyses.Results: In Chapter 2, there were no significant direct or indirect associations between state-level structural stigma and HIV sexual risk behavior. There was, however, a series of significant direct associations between structural stigma and victimization, victimization and substance use, and substance use and HIV sexual risk behavior. Multigroup analysis revealed equivalent associations among the key variables in early, middle, and late adolescence. The exception was a direct association between victimization and HIV sexual risk behavior in early adolescence only. In Chapter 3, information and social motivation were indirectly associated with willingness and intention to use PrEP via behavioral skills. In contrast, personal motivation was directly associated with willingness and intention to use PrEP. Depression and problematic substance use did not moderate these associations. Discussion: The findings presented in Chapter 2 provide preliminary evidence of links between structural stigma, victimization, substance use, and HIV sexual risk behavior among ASMM. As the corresponding indirect effect was not significant, these relationships should be further evaluated in future studies. Efforts to intervene on the pathway from sexual stigma to HIV sexual risk behavior among ASMM should be developmentally-appropriate and should target multiple levels of stigma to achieve the greatest impact. The findings presented in Chapter 3 show that, among ASMM, the IMB model is an accurate theory of willingness and intention to use PrEP, which are important precursors of PrEP adoption. The IMB model of willingness and intention to use PrEP remains accurate in the presence of depressive symptoms and problematic substance use.
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