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PMC Articles

Intersecting Epidemics: Examining the Impact of Internalized Homophobia and Depression Symptoms on HIV Testing Through a Suicide Syndemic Among Young Black Men Who Have Sex with Men

PMCID: PMC12795934

PMID: 39476098

Abstract

Young Black men who have sex with men (BMSM) in the USA face disproportionate rates of HIV incidence. Mental health vulnerabilities, including depression, anxiety, substance use, and trauma, further exacerbate the HIV epidemic among this population. Internalized homophobia, discrimination, and depression contribute to elevated rates of suicidal behavior among young BMSM, which in turn may influence engagement in HIV prevention behaviors, such as HIV testing. However, limited research has examined the interplay among suicidal behaviors, internalized homophobia, depression, and HIV testing among young BMSM. This study utilized syndemic theory to explore the relationships among these factors in a sample of 400 young BMSM ages 18–29. Results indicate alarming rates of suicidal behavior among young BMSM, with significant associations among internalized homophobia, depression symptoms, suicidal behavior, and HIV testing. The findings underscore the urgent need for targeted mental health interventions and HIV prevention services tailored to address the unique challenges faced by young BMSM. Comprehensive, multi-level, community-centered interventions are essential to address the syndemics affecting young BMSM, promoting holistic health and well-being while improving outcomes across the HIV prevention continuum.

Full Text

Black men who have sex with men (BMSM) in the USA are overrepresented in HIV incidence [1–4]. The current lifetime risk of acquiring HIV among BMSM is 50%, with some estimates suggesting that upward of 60% of BMSM could acquire HIV by the time they reach 40 years old [1]. However, in the USA, internalized homophobia, discrimination, depression, and other factors are likely to contribute to reporting bias and underestimates by men who have sex with men (MSM) [5, 6].
In the past 40 years, increasing attention has been focused on the multidimensional mental health vulnerabilities of men who have sex with men, including issues such as depression, anxiety, substance use, and trauma [6]. For instance, in a survey of 829 BMSM from 41 states across the USA, rates of depression among participants were found to be as high as 33%, nearly five times higher than the national rate for all adults [7]. BMSM experience the adverse impacts of both racism and homophobia, resulting in greater disparities in depression and other mental health outcomes compared to other racial and ethnic minority groups [7–9]. Depression within the BMSM community is linked to an increased risk of HIV transmission [7]. Addressing these overlapping challenges requires tailored interventions that account for the unique experiences of MSM, providing comprehensive mental health support, and reducing barriers to care such as racism, homophobia, and lack of access to culturally competent providers.
In addition to depression, emerging research has suggested that suicide rates for LGBTQI + individuals, including BMSM, are alarming. Young men ages 18 to 25 face elevated rates of suicidal ideation, with 18.4% of gay men and 22.2% of bisexual men experiencing it [10–12], in contrast to 6.7% of heterosexual men [10–12]. Similarly, 7.4% of gay and bisexual men in this age group have planned suicide attempts, compared to 1.9% of heterosexual men [10–12]. Additionally, 3.3% of gay and bisexual young men have attempted suicide, while only 1.1% of heterosexual young men have done so [10–12]. In a recent study among a national sample of 400 BMSM ages 18 to 29, 33% of the sample reported planning to die by suicide and 27% attempted suicide [10]. Addressing mental health and suicide among BMSM may increase HIV prevention behaviors, including HIV testing.
HIV testing plays a vital role in both national and local strategies aimed at stemming the HIV epidemic. It serves as the entry point to the HIV prevention continuum, allowing individuals to become aware of their status and access necessary care, including pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) [13]. Though rates of HIV testing have increased over time, there remains a notable number of MSM who have never been tested for HIV, especially those under age 25 [13]. Research into barriers to HIV testing has examined factors such as stigma, discrimination, poverty, and substance use, but there is a dearth of literature focused on how internalized homophobia [13] and depression symptoms influence HIV testing, and to our knowledge, there is a dearth of literature that examines how suicidal behaviors influence HIV testing among BMSM.
As a critical component of HIV prevention as well as a connection to HIV care, understanding factors that affect HIV testing or lack thereof is an important part of reducing HIV-related disparities among BMSM [14]. Literature examining HIV vulnerability among MSM has found societal factors such as stigma to be among the drivers of the disproportionate HIV burden faced by MSM [15–19]. BMSM experience high levels of stigmatizing events, such as discrimination related to their sexual orientation [18, 19]. Such stigmatizing experiences have been linked to a higher likelihood of engagement in behaviors contributing to HIV vulnerability, including engagement in unprotected anal sex or sex under the influence of substances, use of preexposure or postexposure prophylaxis, and HIV testing [20–24].
One pathway connecting homophobic stigma and HIV burden is through the internalization of stigma experiences [25]. As a result of persistent stigmatizing experiences, MSM may come to internalize negative attitudes and beliefs associated with their sexual minority identity [25]. Previous work suggests higher internalized homophobia may cause reduced engagement in HIV prevention behaviors, including HIV testing, among MSM [26–29]. In a recent study of 907 Korean men who identify as gay or bisexual, lower internalized homophobia predicted higher HIV testing prevalence [27]. Although literature examining the relationship between internalized homophobia and HIV testing among BMSM is limited, it similarly predicts lower testing among those with higher internalized homophobia [28, 29]. For instance, a study of 4174 BMSM recruited from Black Pride events in six US cities (Atlanta, Detroit, Houston, Memphis, Philadelphia, and Washington, DC) between 2014 and 2017 found that BMSM who reported higher levels of internalized homophobia were 1.4 times more likely to have never engaged in HIV testing relative to their counterparts with lower internalized homophobia [13].
Alongside internalized stigma, mental well-being plays an important role in HIV vulnerability among MSM. Literature indicates that the presence of mental health conditions such as depression is linked to higher odds of HIV acquisition [30–32], and the prevalence of HIV is higher among those with mental illness, including depression [30, 33, 34]. It is suggested that people suffering from depression may be more likely to engage in sexual behaviors considered higher risk for HIV acquisition, such as the use of substances prior to sex and unprotected sex [30, 35]. People suffering from depression may also exhibit lower preexposure prophylaxis adherence and potentially lower HIV testing [36–39].
Evidence on HIV testing odds is conflicting, as several studies, including a 2009 systematic review [38], suggested lower HIV testing prevalence among those experiencing severe mental illness [36]. Yet there is work that suggests otherwise, demonstrating higher levels of HIV testing among those living with depression or other mental illnesses [13, 37, 40]. Similarly, limited literature suggests a complicated relationship between depression and HIV testing among BMSM. In the aforementioned study of 4174 BMSM recruited across six cities, Matthews et al. [13] found that BMSM with depressive symptoms were approximately 1.5 times more likely to have never tested for HIV than to have tested at least once in their lifetime. Likewise, another study of 1553 Black sexual minority men elucidated a lower likelihood of having been tested for HIV among those with depressive symptoms [41]. These findings are in contrast with those reported by Chandler et al. [42], who did not find differences in past-6-month testing frequency based on the presence of moderate to severe depression symptoms, independently, in a sample of 3,294 BMSM living in the United States. They did find, however, that synergy between polydrug use and depression and problematic drinking and depression resulted in a lower likelihood of HIV testing in the past six months [42]. This is not an isolated finding, as studies with differing samples have demonstrated that lower HIV testing prevalence among those with mental health concerns is actualized in the presence of other syndemic factors [43, 44].
Sexual minority adults consistently experience higher rates of suicide attempts compared to their heterosexual counterparts, highlighting ongoing disparities in mental health outcomes [45–47]. Generally, higher rates of suicide are more commonly observed in White populations as compared to Black and Hispanic populations [48, 49]. However, bourgeoning research suggested that BMSM are at severe risk for suicide [10, 50, 51]. In one recent study that used a national sample of 497 Black and 1536 White sexual minority males (ages 16 to 25), results indicated that among Black participants, structural racism and anti-LGBTQI + policies were significantly correlated with increased levels of depressive symptoms, heavy drinking, perceived burdensomeness, thwarted belongingness, self-harm behaviors, and suicide attempts [52]. In another online national study among 400 BMSM ages 18 to 29, results indicated that internalized homophobia and depression symptoms increased suicidal attempts [50]. However, the literature on suicidality among young BMSM has been significantly understudied, and no studies have examined the potential link between suicidality and HIV prevention behaviors in this population.
Syndemic theory posits that epidemics of multiple physical, psychological, social, and structural factors co-occur among disadvantaged groups due to adverse social conditions [53]. Syndemic frameworks have been utilized to explain elevated HIV risk in sexual and gender minority populations (SGM) [53–59] but have only recently been applied to examine the impact of a suicide syndemic on engagement in the continuum of care for young BMSM of unknown HIV status [60–62]. A syndemic is defined as the co-occurrence of two or more conditions that interact synergistically to increase the burden of disease outcomes [63].
While extant literature highlights the health effects associated with each of the individual conditions that characterize a suicide syndemic (planning, ideation, and attempts), which are well documented and salient for population health [64, 65], the health effects of a potential suicide syndemic on HIV testing are scant. Suicidal planning, ideation, and attempts, which are seemingly sequential in nature, theoretically represent a syndemic, wherein exposure to one factor reinforces the co-occurrence of the other factors, producing synergy, reciprocity, and multi-directionality among the factors [66–68].
These factors are known to independently influence HIV testing [69, 70]; however, the synergistic impact of all three suicide factors on HIV testing is less understood. Moreover, mediating pathways that are indirectly affected by the suicide syndemic and their impact on HIV testing have yet to be tested. Furthermore, it is unclear whether such syndemic manifestations and their association with HIV testing are more salient in young BMSM at increased risk of acquiring HIV compared to young BMSM whose experiences do not form a syndemic.
Internalized homophobia and depressive symptomatology are known factors that impact engagement in care for people living with HIV [71, 72], the first step of which is to know your status by getting tested for HIV. Suicidal planning, ideation, and attempts may form a suicide syndemic, characterized by these three factors not only co-occurring but also mutually reinforcing one another.
The survey was programmed with Qualtrics software for different sampling sites. An anonymous link was generated and included on a recruitment flyer, which was then distributed via social media sites (Facebook and Twitter) and provided to community-based organizations and Amazon Mechanical Turk (M-Turk) [10, 50, 51]. The principal investigator and research assistants distributed the survey via social media every morning at 8 a.m. Eastern time.
Amazon M-Turk offers a cost-effective and speedy recruitment method for research across various fields, including public health [10, 50, 51]. To access and participate in the survey, M-Turk registrants needed to have a 95% or higher approval rating from previous surveys, be 18 years or older, and reside in the USA, as verified during their initial M-Turk registration [10, 50, 51]. Furthermore, individuals logging into the M-Turk platform during the survey week were informed of the opportunity to take a survey focused on HIV and assets for BMSM. They were told that the survey would require approximately 20 min and would be available daily at 8 a.m. Eastern Standard Time. Participants were instructed to complete the survey in one session, and they received a US$1 compensation along with other incentives from M-Turk [10, 50, 51].
The suicide syndemic factor included suicide planning, ideation, and attempts. We assessed suicide attempts using a single item that asked respondents to indicate whether they had attempted to end their life within the previous 12 months. Response categories were 1 = yes and 0 = no [39]. Suicide planning was assessed with a single item that asked participants whether they had made a plan to end their life within the previous 12 months. Response categories were 1 = yes and 0 = no [39]. We assessed suicide attempts using a single item that asked respondents to indicate whether they had attempted to end their life within the previous 12 months. Response categories were 1 = yes and 0 = no [39]. Suicide ideation was measured using a single item that asked respondents to indicate whether they considered ending their life in the previous 12 months. Response categories were 1 = yes, 0 = no. We created a latent variable with these three observed variables (suicide attempts, suicide planning, and suicide ideation). This latent construct was tested for model fit using the chi-square, root square mean error, Tucker–Lewis index, and comparative fit index.
We used the Center for Epidemiological Studies Depression Scale (CESD-10) to measure depression symptoms [43]. The CESD-10 assesses depressive symptoms experienced in the past week. Prior research has validated the measure among clinically depressed populations, the general population, and sexual minorities of color [7]. Sample items included “How many times in the past week did you feel as good as other people?” and “How many times in the past week did you have trouble keeping your mind on task?” Response options range from zero (Rarely or never) to 3 (Most or all of the time). The CESD-10 scores range from zero to 30, with higher scores indicating more depressive symptoms (Cronbach’s α = 0.81). Individuals with scores above 20 were classified as having moderate to severe depression symptoms [44].
Preliminary data analyses included the examination of normality, alpha-level (α) reliabilities, and descriptive statistics. We calculated descriptive statistics to convey the distribution of these constructs within the sample. Table 1 presents demographic statistics of categorical key study variables, and Table 2 presents continuous key variables (N = 400). Table 3 presents bivariate correlations of study variables.

Our first step in the main analysis was to conduct a confirmatory factor analysis to test a measurement model of suicide syndemic (Fig. 1). The model fit was assessed using the model Chi-square, the root mean square error of approximation (RMSEA), the comparative fit index, and the Tucker–Lewis index. Once an adequate fit was determined, we performed structural equation modeling using M-Plus version 8.3. We investigated whether internalized homophobia and depression symptoms were associated with HIV testing through a suicide syndemic (Fig. 2). The mean-and-variance-adjusted weighted least squares estimator was used, which is preferred when the dependent variables are categorical and when data are not normally distributed. Standardized beta coefficients and p values were included (Table 4).
In total, 28% of BMSM reported that they had attempted suicide, 34% of the sample reported that they had planned for suicide, and 38% self-reported that they thought about suicide (Table 1). BMSM reported moderate forms of internalized homophobia (M = 3.0; SD = 1.24). The mean for depression symptoms among this population was 14.46 (SD = 5.97), which means the young in this sample are depressed (Table 2). Correlation results (Table 3) showed that suicide planning was positively associated with suicide attempts (r = 0.62, p < 0.001). Suicide ideation was positively associated with suicide attempts (r = 0.67, p < 0.001) and suicide planning (r = 0.74, p < 0.001). Depression symptoms were positively associated with suicide attempts (r = 0.40, p < 0.001) and suicide ideation (r = 0.45, p < 0.001). Internalize homophobia was correlated with suicide attempts (r = 0.41, p < 0.001), suicide planning (r = 0.50, p < 0.001), and depression symptoms (r = 0.62, p < 0.001).
For the mediator, a latent factor was formed using items from three separate constructs of suicidal behavior. The latent factor was formed to create a suicide syndemic. Factor loadings on the suicide syndemic ranged from 0.75 to 0.89. The suicide syndemic provided a good model fit: χ2(3) = 93.87, p = 0.51, RMSEA = 0.02, comparative fit index = 0.99, Tucker–Lewis index = 0.99 (Fig. 1).
The structural equation modeling results on HIV testing, including standardized betas and p-values, are displayed in Fig. 2. The model examined the direct and indirect associations between internalized homophobia, depression symptoms, suicide syndemic, and HIV testing. The hypothesized model also demonstrated a good fit for the study data (Table 4). Suicide syndemic explained 70% of the variance in HIV testing. Our results indicated that internalized homophobia was directly and positively associated with depression symptoms (β = 0.63, p < 0.001). Depression symptoms were direct and positively associated with suicide syndemic (β = 0.58, p < 0.001). Lastly, suicide syndemic was directly and negatively associated with HIV testing (β =  − 0.36, p < 0.001). Internalized homophobia was indirectly and negatively associated with HIV testing (β =  − 0.05, p = 0.01). Depression symptoms were also indirectly and negatively associated with HIV testing (β =  − 0.02, p < 0.001) (Table 5).

The findings of this study reveal concerning and alarming rates of suicidal behavior among young BMSM, with a significant proportion reporting suicide attempts (25%), planning to die by suicide (28%), and suicidal ideation (31%). These rates underscore the urgent need for targeted mental health interventions and support services tailored to address the unique challenges faced by young BMSM, including racism and discrimination, stigma, lack of mental health resources, and safety net clinics [10, 50–52]. These findings are consistent with the existing literature on suicide disparities among BMSM [10, 73–75]. Addressing suicide among young Black men requires a multifaceted approach that considers the intersections of race, sexuality, and mental health, which can help them achieve optimal health.
Prevalence estimates of internalized homophobia and depression symptoms among the study participants highlight the intersecting psychosocial stressors experienced by young BMSM, which may contribute to their heightened vulnerability to suicidal behavior. This is consistent with research that reported that depression severity and internalized homophobia directly and indirectly increased suicide attempts [76, 77]. Internalized homophobia, in particular, emerges as a significant correlate of suicidal behavior, suggesting the detrimental impact of societal stigma and discrimination on the mental health and well-being of BMSM individuals [77–80].
When developing and designing interventions and prevention programs for young Black BMSM, it is critical to adopt culturally competent frameworks rooted in an Afrocentric paradigm. Afrocentric priorities emphasize key principles and practices that celebrate African cultural norms, values, and perspectives [81, 82]. This approach aims to affirm and honor African identities and ways of knowing, often in response to historical marginalization and the dominance of Eurocentric viewpoints [81, 82]. By integrating these elements, we can effectively address the unique experiences and challenges faced by young BMSM, particularly concerning internalized homophobia and depression [83–86]. For example, cultural affirmation and pride—highlighting the richness of African cultures, languages, traditions, and histories—can be woven into programs that promote pride in African heritage and foster positive narratives surrounding Black identity and LGBTQ + community membership.
Moreover, incorporating social justice and liberation into mental health programs is essential for advancing equity and justice within African American communities. This approach involves actively teaching young men to help dismantle systemic racism, discrimination, and all forms of social injustice that impede the well-being and progress of these communities. By teaching them to advocate for LGBTQ + rights and racial equity, we can effectively tackle external sources of stress and discrimination. Additionally, it is vital to educate young Black MSM about systemic issues and empower them to become agents of change within their communities. By integrating these Afrocentric priorities [81, 82], mental health and HIV interventions can become more culturally relevant and supportive, helping to reduce internalized homophobia and depression among young Black men and fostering a greater sense of belonging and well-being.
Study findings related to the association between the suicide syndemic and HIV testing are particularly noteworthy. Individuals experiencing higher levels of suicidal behavior may be less likely to engage in HIV testing, potentially due to various psychosocial barriers, including structural stigma, discrimination, fear, and disengagement from mental health services [6]. Future studies should consider intervention approaches to promote engagement in the HIV prevention continuum, including HIV testing, among individuals who screen for suicidality.
Overall, these findings underscore the urgent need for comprehensive, community-centered, and competent interventions that address mental health and psychosocial well-being among young BMSM while also integrating HIV prevention strategies. Community-engaged frameworks like the Meaningful Involvement of People Living with HIV/AIDS Framework [81, 87] for sexual minority men of color can be adapted to inform the development of targeted HIV prevention strategies and services. Providing accessible and culturally competent mental health services for individuals at risk for suicide or living with HIV can help address underlying mental health challenges that may be impacting their willingness to engage in HIV testing. Working to reduce the stigma surrounding suicide, mental health, and HIV can create a more supportive environment that encourages individuals to seek help, including HIV testing and mental health services, without fear of judgment or discrimination. By addressing the intersecting challenges of internalized homophobia, depression, and suicidal behavior, tailored interventions have the potential to promote holistic health and well-being among young BMSM while improving outcomes in the HIV prevention continuum [6, 79, 80, 88].

Sections

"[{\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR1\", \"CR4\", \"CR1\", \"CR5\", \"CR6\"], \"section\": \"Background\", \"text\": \"Black men who have sex with men (BMSM) in the USA are overrepresented in HIV incidence [1\\u20134]. The current lifetime risk of acquiring HIV among BMSM is 50%, with some estimates suggesting that upward of 60% of BMSM could acquire HIV by the time they reach 40\\u00a0years old [1]. However, in the USA, internalized homophobia, discrimination, depression, and other factors are likely to contribute to reporting bias and underestimates by men who have sex with men (MSM) [5, 6].\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR6\", \"CR7\", \"CR7\", \"CR9\", \"CR7\"], \"section\": \"Background\", \"text\": \"In the past 40\\u00a0years, increasing attention has been focused on the multidimensional mental health vulnerabilities of men who have sex with men, including issues such as depression, anxiety, substance use, and trauma [6]. For instance, in a survey of 829 BMSM from 41 states across the USA, rates of depression among participants were found to be as high as 33%, nearly five times higher than the national rate for all adults [7]. BMSM experience the adverse impacts of both racism and homophobia, resulting in greater disparities in depression and other mental health outcomes compared to other racial and ethnic minority groups [7\\u20139]. Depression within the BMSM community is linked to an increased risk of HIV transmission [7]. Addressing these overlapping challenges requires tailored interventions that account for the unique experiences of MSM, providing comprehensive mental health support, and reducing barriers to care such as racism, homophobia, and lack of access to culturally competent providers.\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR10\", \"CR12\", \"CR10\", \"CR12\", \"CR10\", \"CR12\", \"CR10\", \"CR12\", \"CR10\"], \"section\": \"Background\", \"text\": \"In addition to depression, emerging research has suggested that suicide rates for LGBTQI\\u2009+\\u2009individuals, including BMSM, are alarming. Young men ages 18 to 25 face elevated rates of suicidal ideation, with 18.4% of gay men and 22.2% of bisexual men experiencing it [10\\u201312], in contrast to 6.7% of heterosexual men [10\\u201312]. Similarly, 7.4% of gay and bisexual men in this age group have planned suicide attempts, compared to 1.9% of heterosexual men [10\\u201312]. Additionally, 3.3% of gay and bisexual young men have attempted suicide, while only 1.1% of heterosexual young men have done so [10\\u201312]. In a recent study among a national sample of 400 BMSM ages 18 to 29, 33% of the sample reported planning to die by suicide and 27% attempted suicide [10]. Addressing mental health and suicide among BMSM may increase HIV prevention behaviors, including HIV testing.\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR13\", \"CR13\", \"CR13\"], \"section\": \"Background\", \"text\": \"HIV testing plays a vital role in both national and local strategies aimed at stemming the HIV epidemic. It serves as the entry point to the HIV prevention continuum, allowing individuals to become aware of their status and access necessary care, including pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) [13]. Though rates of HIV testing have increased over time, there remains a notable number of MSM who have never been tested for HIV, especially those under age 25 [13]. Research into barriers to HIV testing has examined factors such as stigma, discrimination, poverty, and substance use, but there is a dearth of literature focused on how internalized homophobia [13] and depression symptoms influence HIV testing, and to our knowledge, there is a dearth of literature that examines how suicidal behaviors influence HIV testing among BMSM.\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR14\", \"CR15\", \"CR19\", \"CR18\", \"CR19\", \"CR20\", \"CR24\"], \"section\": \"Internalized Homophobia and HIV Testing\", \"text\": \"As a critical component of HIV prevention as well as a connection to HIV care, understanding factors that affect HIV testing or lack thereof is an important part of reducing HIV-related disparities among BMSM [14]. Literature examining HIV vulnerability among MSM has found societal factors such as stigma to be among the drivers of the disproportionate HIV burden faced by MSM [15\\u201319]. BMSM experience high levels of stigmatizing events, such as discrimination related to their sexual orientation [18, 19]. Such stigmatizing experiences have been linked to a higher likelihood of engagement in behaviors contributing to HIV vulnerability, including engagement in unprotected anal sex or sex under the influence of substances, use of preexposure or postexposure prophylaxis, and HIV testing [20\\u201324].\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR25\", \"CR25\", \"CR26\", \"CR29\", \"CR27\", \"CR28\", \"CR29\", \"CR13\"], \"section\": \"Internalized Homophobia and HIV Testing\", \"text\": \"One pathway connecting homophobic stigma and HIV burden is through the internalization of stigma experiences [25]. As a result of persistent stigmatizing experiences, MSM may come to internalize negative attitudes and beliefs associated with their sexual minority identity [25]. Previous work suggests higher internalized homophobia may cause reduced engagement in HIV prevention behaviors, including HIV testing, among MSM [26\\u201329]. In a recent study of 907 Korean men who identify as gay or bisexual, lower internalized homophobia predicted higher HIV testing prevalence [27]. Although literature examining the relationship between internalized homophobia and HIV testing among BMSM is limited, it similarly predicts lower testing among those with higher internalized homophobia [28, 29]. For instance, a study of 4174 BMSM recruited from Black Pride events in six US cities (Atlanta, Detroit, Houston, Memphis, Philadelphia, and Washington, DC) between 2014 and 2017 found that BMSM who reported higher levels of internalized homophobia were 1.4 times more likely to have never engaged in HIV testing relative to their counterparts with lower internalized homophobia [13].\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR30\", \"CR32\", \"CR30\", \"CR33\", \"CR34\", \"CR30\", \"CR35\", \"CR36\", \"CR39\"], \"section\": \"Depression and HIV Testing\", \"text\": \"Alongside internalized stigma, mental well-being plays an important role in HIV vulnerability among MSM. Literature indicates that the presence of mental health conditions such as depression is linked to higher odds of HIV acquisition [30\\u201332], and the prevalence of HIV is higher among those with mental illness, including depression [30, 33, 34]. It is suggested that people suffering from depression may be more likely to engage in sexual behaviors considered higher risk for HIV acquisition, such as the use of substances prior to sex and unprotected sex [30, 35]. People suffering from depression may also exhibit lower preexposure prophylaxis adherence and potentially lower HIV testing [36\\u201339].\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR38\", \"CR36\", \"CR13\", \"CR37\", \"CR40\", \"CR13\", \"CR41\", \"CR42\", \"CR42\", \"CR43\", \"CR44\"], \"section\": \"Depression and HIV Testing\", \"text\": \"Evidence on HIV testing odds is conflicting, as several studies, including a 2009 systematic review [38], suggested lower HIV testing prevalence among those experiencing severe mental illness [36]. Yet there is work that suggests otherwise, demonstrating higher levels of HIV testing among those living with depression or other mental illnesses [13, 37, 40]. Similarly, limited literature suggests a complicated relationship between depression and HIV testing among BMSM. In the aforementioned study of 4174 BMSM recruited across six cities, Matthews et al. [13] found that BMSM with depressive symptoms were approximately 1.5 times more likely to have never tested for HIV than to have tested at least once in their lifetime. Likewise, another study of 1553 Black sexual minority men elucidated a lower likelihood of having been tested for HIV among those with depressive symptoms [41]. These findings are in contrast with those reported by Chandler et al. [42], who did not find differences in past-6-month testing frequency based on the presence of moderate to severe depression symptoms, independently, in a sample of 3,294 BMSM living in the United States. They did find, however, that synergy between polydrug use and depression and problematic drinking and depression resulted in a lower likelihood of HIV testing in the past six months [42]. This is not an isolated finding, as studies with differing samples have demonstrated that lower HIV testing prevalence among those with mental health concerns is actualized in the presence of other syndemic factors [43, 44].\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR45\", \"CR47\", \"CR48\", \"CR49\", \"CR10\", \"CR50\", \"CR51\", \"CR52\", \"CR50\"], \"section\": \"Suicidality\", \"text\": \"Sexual minority adults consistently experience higher rates of suicide attempts compared to their heterosexual counterparts, highlighting ongoing disparities in mental health outcomes [45\\u201347]. Generally, higher rates of suicide are more commonly observed in White populations as compared to Black and Hispanic populations [48, 49]. However, bourgeoning research suggested that BMSM are at severe risk for suicide [10, 50, 51]. In one recent study that used a national sample of 497 Black and 1536 White sexual minority males (ages 16 to 25), results indicated that among Black participants, structural racism and anti-LGBTQI\\u2009+\\u2009policies were significantly correlated with increased levels of depressive symptoms, heavy drinking, perceived burdensomeness, thwarted belongingness, self-harm behaviors, and suicide attempts [52]. In another online national study among 400 BMSM ages 18 to 29, results indicated that internalized homophobia and depression symptoms increased suicidal attempts [50]. However, the literature on suicidality among young BMSM has been significantly understudied, and no studies have examined the potential link between suicidality and HIV prevention behaviors in this population.\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR53\", \"CR53\", \"CR59\", \"CR60\", \"CR62\", \"CR63\"], \"section\": \"Syndemic Theory\", \"text\": \"Syndemic theory posits that epidemics of multiple physical, psychological, social, and structural factors co-occur among disadvantaged groups due to adverse social conditions [53]. Syndemic frameworks have been utilized to explain elevated HIV risk in sexual and gender minority populations (SGM) [53\\u201359] but have only recently been applied to examine the impact of a suicide syndemic on engagement in the continuum of care for young BMSM of unknown HIV status [60\\u201362]. A syndemic is defined as the co-occurrence of two or more conditions that interact synergistically to increase the burden of disease outcomes [63].\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR64\", \"CR65\", \"CR66\", \"CR68\"], \"section\": \"Syndemic Theory\", \"text\": \"While extant literature highlights the health effects associated with each of the individual conditions that characterize a suicide syndemic (planning, ideation, and attempts), which are well documented and salient for population health [64, 65], the health effects of a potential suicide syndemic on HIV testing are scant. Suicidal planning, ideation, and attempts, which are seemingly sequential in nature, theoretically represent a syndemic, wherein exposure to one factor reinforces the co-occurrence of the other factors, producing synergy, reciprocity, and multi-directionality among the factors [66\\u201368].\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR69\", \"CR70\"], \"section\": \"Syndemic Theory\", \"text\": \"These factors are known to independently influence HIV testing [69, 70]; however, the synergistic impact of all three suicide factors on HIV testing is less understood. Moreover, mediating pathways that are indirectly affected by the suicide syndemic and their impact on HIV testing have yet to be tested. Furthermore, it is unclear whether such syndemic manifestations and their association with HIV testing are more salient in young BMSM at increased risk of acquiring HIV compared to young BMSM whose experiences do not form a syndemic.\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR71\", \"CR72\"], \"section\": \"Syndemic Theory\", \"text\": \"Internalized homophobia and depressive symptomatology are known factors that impact engagement in care for people living with HIV [71, 72], the first step of which is to know your status by getting tested for HIV. Suicidal planning, ideation, and attempts may form a suicide syndemic, characterized by these three factors not only co-occurring but also mutually reinforcing one another.\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR10\", \"CR50\", \"CR51\"], \"section\": \"Study Procedures and Recruitment\", \"text\": \"The survey was programmed with Qualtrics software for different sampling sites. An anonymous link was generated and included on a recruitment flyer, which was then distributed via social media sites (Facebook and Twitter) and provided to community-based organizations and Amazon Mechanical Turk (M-Turk) [10, 50, 51]. The principal investigator and research assistants distributed the survey via social media every morning at 8 a.m. Eastern time.\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR10\", \"CR50\", \"CR51\", \"CR10\", \"CR50\", \"CR51\", \"CR10\", \"CR50\", \"CR51\"], \"section\": \"Study Procedures and Recruitment\", \"text\": \"Amazon M-Turk offers a cost-effective and speedy recruitment method for research across various fields, including public health [10, 50, 51]. To access and participate in the survey, M-Turk registrants needed to have a 95% or higher approval rating from previous surveys, be 18\\u00a0years or older, and reside in the USA, as verified during their initial M-Turk registration [10, 50, 51]. Furthermore, individuals logging into the M-Turk platform during the survey week were informed of the opportunity to take a survey focused on HIV and assets for BMSM. They were told that the survey would require approximately 20\\u00a0min and would be available daily at 8 a.m. Eastern Standard Time. Participants were instructed to complete the survey in one session, and they received a US$1 compensation along with other incentives from M-Turk [10, 50, 51].\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR39\", \"CR39\", \"CR39\"], \"section\": \"Mediator: Suicide Syndemic Risk Factor\", \"text\": \"The suicide syndemic factor included suicide planning, ideation, and attempts. We assessed suicide attempts using a single item that asked respondents to indicate whether they had attempted to end their life within the previous 12\\u00a0months. Response categories were 1\\u2009=\\u2009yes and 0\\u2009=\\u2009no [39]. Suicide planning was assessed with a single item that asked participants whether they had made a plan to end their life within the previous 12\\u00a0months. Response categories were 1\\u2009=\\u2009yes and 0\\u2009=\\u2009no [39]. We assessed suicide attempts using a single item that asked respondents to indicate whether they had attempted to end their life within the previous 12\\u00a0months. Response categories were 1\\u2009=\\u2009yes and 0\\u2009=\\u2009no [39]. Suicide ideation was measured using a single item that asked respondents to indicate whether they considered ending their life in the previous 12\\u00a0months. Response categories were 1\\u2009=\\u2009yes, 0\\u2009=\\u2009no. We created a latent variable with these three observed variables (suicide attempts, suicide planning, and suicide ideation). This latent construct was tested for model fit using the chi-square, root square mean error, Tucker\\u2013Lewis index, and comparative fit index.\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR43\", \"CR7\", \"CR44\"], \"section\": \"Depression Symptoms\", \"text\": \"We used the Center for Epidemiological Studies Depression Scale (CESD-10) to measure depression symptoms [43]. The CESD-10 assesses depressive symptoms experienced in the past week. Prior research has validated the measure among clinically depressed populations, the general population, and sexual minorities of color [7]. Sample items included \\u201cHow many times in the past week did you feel as good as other people?\\u201d and \\u201cHow many times in the past week did you have trouble keeping your mind on task?\\u201d Response options range from zero (Rarely or never) to 3 (Most or all of the time). The CESD-10 scores range from zero to 30, with higher scores indicating more depressive symptoms (Cronbach\\u2019s \\u03b1\\u2009=\\u20090.81). Individuals with scores above 20 were classified as having moderate to severe depression symptoms [44].\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"Tab1\", \"Tab2\", \"Tab3\"], \"section\": \"Data Analysis\", \"text\": \"Preliminary data analyses included the examination of normality, alpha-level (\\u03b1) reliabilities, and descriptive statistics. We calculated descriptive statistics to convey the distribution of these constructs within the sample. Table 1 presents demographic statistics of categorical key study variables, and Table\\u00a02 presents continuous key variables (N\\u2009=\\u2009400). Table 3 presents bivariate correlations of study variables.\\n\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"Fig1\", \"Fig2\", \"Tab4\"], \"section\": \"Data Analysis\", \"text\": \"Our first step in the main analysis was to conduct a confirmatory factor analysis to test a measurement model of suicide syndemic (Fig.\\u00a01). The model fit was assessed using the model Chi-square, the root mean square error of approximation (RMSEA), the comparative fit index, and the Tucker\\u2013Lewis index. Once an adequate fit was determined, we performed structural equation modeling using M-Plus version 8.3. We investigated whether internalized homophobia and depression symptoms were associated with HIV testing through a suicide syndemic (Fig.\\u00a02). The mean-and-variance-adjusted weighted least squares estimator was used, which is preferred when the dependent variables are categorical and when data are not normally distributed. Standardized beta coefficients and p values were included (Table\\u00a04).\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"Tab1\", \"Tab2\", \"Tab3\"], \"section\": \"Results\", \"text\": \"In total, 28% of BMSM reported that they had attempted suicide, 34% of the sample reported that they had planned for suicide, and 38% self-reported that they thought about suicide (Table\\u00a01). BMSM reported moderate forms of internalized homophobia (M\\u2009=\\u20093.0; SD\\u2009=\\u20091.24). The mean for depression symptoms among this population was 14.46 (SD\\u2009=\\u20095.97), which means the young in this sample are depressed (Table\\u00a02). Correlation results (Table\\u00a03) showed that suicide planning was positively associated with suicide attempts (r\\u2009=\\u20090.62, p\\u2009<\\u20090.001). Suicide ideation was positively associated with suicide attempts (r\\u2009=\\u20090.67, p\\u2009<\\u20090.001) and suicide planning (r\\u2009=\\u20090.74, p\\u2009<\\u20090.001). Depression symptoms were positively associated with suicide attempts (r\\u2009=\\u20090.40, p\\u2009<\\u20090.001) and suicide ideation (r\\u2009=\\u20090.45, p\\u2009<\\u20090.001). Internalize homophobia was correlated with suicide attempts (r\\u2009=\\u20090.41, p\\u2009<\\u20090.001), suicide planning (r\\u2009=\\u20090.50, p\\u2009<\\u20090.001), and depression symptoms (r\\u2009=\\u20090.62, p\\u2009<\\u20090.001).\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"Fig1\"], \"section\": \"Measurement Model\", \"text\": \"For the mediator, a latent factor was formed using items from three separate constructs of suicidal behavior. The latent factor was formed to create a suicide syndemic. Factor loadings on the suicide syndemic ranged from 0.75 to 0.89. The suicide syndemic provided a good model fit: \\u03c72(3)\\u2009=\\u200993.87, p\\u2009=\\u20090.51, RMSEA\\u2009=\\u20090.02, comparative fit index\\u2009=\\u20090.99, Tucker\\u2013Lewis index\\u2009=\\u20090.99 (Fig.\\u00a01).\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"Fig2\", \"Tab4\", \"Tab5\"], \"section\": \"Structure Equation Model\", \"text\": \"The structural equation modeling results on HIV testing, including standardized betas and p-values, are displayed in Fig.\\u00a02. The model examined the direct and indirect associations between internalized homophobia, depression symptoms, suicide syndemic, and HIV testing. The hypothesized model also demonstrated a good fit for the study data (Table\\u00a04). Suicide syndemic explained 70% of the variance in HIV testing. Our results indicated that internalized homophobia was directly and positively associated with depression symptoms (\\u03b2\\u2009=\\u20090.63, p\\u2009<\\u20090.001). Depression symptoms were direct and positively associated with suicide syndemic (\\u03b2\\u2009=\\u20090.58, p\\u2009<\\u20090.001). Lastly, suicide syndemic was directly and negatively associated with HIV testing (\\u03b2\\u2009=\\u2009\\u2009\\u2212\\u20090.36, p\\u2009<\\u20090.001). Internalized homophobia was indirectly and negatively associated with HIV testing (\\u03b2\\u2009=\\u2009\\u2009\\u2212\\u20090.05, p\\u2009=\\u20090.01). Depression symptoms were also indirectly and negatively associated with HIV testing (\\u03b2\\u2009=\\u2009\\u2009\\u2212\\u20090.02, p\\u2009<\\u20090.001) (Table\\u00a05).\\n\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR10\", \"CR50\", \"CR52\", \"CR10\", \"CR73\", \"CR75\"], \"section\": \"Discussion\", \"text\": \"The findings of this study reveal concerning and alarming rates of suicidal behavior among young BMSM, with a significant proportion reporting suicide attempts (25%), planning to die by suicide (28%), and suicidal ideation (31%). These rates underscore the urgent need for targeted mental health interventions and support services tailored to address the unique challenges faced by young BMSM, including racism and discrimination, stigma, lack of mental health resources, and safety net clinics [10, 50\\u201352]. These findings are consistent with the existing literature on suicide disparities among BMSM [10, 73\\u201375]. Addressing suicide among young Black men requires a multifaceted approach that considers the intersections of race, sexuality, and mental health, which can help them achieve optimal health.\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR76\", \"CR77\", \"CR77\", \"CR80\"], \"section\": \"Discussion\", \"text\": \"Prevalence estimates of internalized homophobia and depression symptoms among the study participants highlight the intersecting psychosocial stressors experienced by young BMSM, which may contribute to their heightened vulnerability to suicidal behavior. This is consistent with research that reported that depression severity and internalized homophobia directly and indirectly increased suicide attempts [76, 77]. Internalized homophobia, in particular, emerges as a significant correlate of suicidal behavior, suggesting the detrimental impact of societal stigma and discrimination on the mental health and well-being of BMSM individuals [77\\u201380].\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR81\", \"CR82\", \"CR81\", \"CR82\", \"CR83\", \"CR86\"], \"section\": \"Discussion\", \"text\": \"When developing and designing interventions and prevention programs for young Black BMSM, it is critical to adopt culturally competent frameworks rooted in an Afrocentric paradigm. Afrocentric priorities emphasize key principles and practices that celebrate African cultural norms, values, and perspectives [81, 82]. This approach aims to affirm and honor African identities and ways of knowing, often in response to historical marginalization and the dominance of Eurocentric viewpoints [81, 82]. By integrating these elements, we can effectively address the unique experiences and challenges faced by young BMSM, particularly concerning internalized homophobia and depression [83\\u201386]. For example, cultural affirmation and pride\\u2014highlighting the richness of African cultures, languages, traditions, and histories\\u2014can be woven into programs that promote pride in African heritage and foster positive narratives surrounding Black identity and LGBTQ\\u2009+\\u2009community membership.\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR81\", \"CR82\"], \"section\": \"Discussion\", \"text\": \"Moreover, incorporating social justice and liberation into mental health programs is essential for advancing equity and justice within African American communities. This approach involves actively teaching young men to help dismantle systemic racism, discrimination, and all forms of social injustice that impede the well-being and progress of these communities. By teaching them to advocate for LGBTQ\\u2009+\\u2009rights and racial equity, we can effectively tackle external sources of stress and discrimination. Additionally, it is vital to educate young Black MSM about systemic issues and empower them to become agents of change within their communities. By integrating these Afrocentric priorities [81, 82], mental health and HIV interventions can become more culturally relevant and supportive, helping to reduce internalized homophobia and depression among young Black men and fostering a greater sense of belonging and well-being.\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR6\"], \"section\": \"Discussion\", \"text\": \"Study findings related to the association between the suicide syndemic and HIV testing are particularly noteworthy. Individuals experiencing higher levels of suicidal behavior may be less likely to engage in HIV testing, potentially due to various psychosocial barriers, including structural stigma, discrimination, fear, and disengagement from mental health services [6]. Future studies should consider intervention approaches to promote engagement in the HIV prevention continuum, including HIV testing, among individuals who screen for suicidality.\"}, {\"pmc\": \"PMC12795934\", \"pmid\": \"39476098\", \"reference_ids\": [\"CR81\", \"CR87\", \"CR6\", \"CR79\", \"CR80\", \"CR88\"], \"section\": \"Discussion\", \"text\": \"Overall, these findings underscore the urgent need for comprehensive, community-centered, and competent interventions that address mental health and psychosocial well-being among young BMSM while also integrating HIV prevention strategies. Community-engaged frameworks like the Meaningful Involvement of People Living with HIV/AIDS Framework [81, 87] for sexual minority men of color can be adapted to inform the development of targeted HIV prevention strategies and services. Providing accessible and culturally competent mental health services for individuals at risk for suicide or living with HIV can help address underlying mental health challenges that may be impacting their willingness to engage in HIV testing. Working to reduce the stigma surrounding suicide, mental health, and HIV can create a more supportive environment that encourages individuals to seek help, including HIV testing and mental health services, without fear of judgment or discrimination. By addressing the intersecting challenges of internalized homophobia, depression, and suicidal behavior, tailored interventions have the potential to promote holistic health and well-being among young BMSM while improving outcomes in the HIV prevention continuum [6, 79, 80, 88].\"}]"

Metadata

"{\"issue-copyright-statement\": \"\\u00a9 W. Montague Cobb-NMA Health Institute 2026\"}"