Dissertations and Theses

Date of Degree


Document Type


Degree Name

Doctor of Philosophy (Ph.D.)


Community Health and Social Sciences


Christian Grov

Committee Members

Nicholas Grosskopf

Ivan Balan

Subject Categories

Public Health


HIV/AIDS, MSM, HIV Prevention, Engagement in care


Background: HIV continues to be a pervasive public health issue in the United States with more than 1.2 million people living with HIV (PLWHIV) across the nation. Gay, bisexual and other men who have sex with men (GBM) account for over two-thirds of all new HIV diagnoses with racial and ethnic minorities shouldering a large proportion of the burden of disease. Although HIV transmission is predominantly driven by sexual behaviors, there are underlying complex individual, behavioral, and structural factors that contribute to high rates of sexual behavior and subsequent HIV acquisition. Moreover, difficulties remain in maximizing linkage to care and viral suppression for PLWHIV. Despite the wealth of research showing the importance of viral suppression as a tool for controlling the HIV epidemic, over one-quarter of HIV-positive GBM are not fully engaged in HIV primary medical care; Sexual minority populations of color experience starkly worse rates of engagement in HIV care. This multi-method dissertation aimed to understand how multi-level factors compound HIV risk in a U.S. national sample of GBM and to describe engagement in HIV care among those newly diagnosed with HIV. The following specific aims were addressed:

Aim 1: Measure exposure to syndemic conditions, describe the conditions most likely to co-occur and examine their association to HIV risk.

Aim 2: Describe the levels of resilience and identify associations with HIV risk and conduct comparisons by race/ethnicity, region, age and other socio-demographic characteristics.

Aim 3: Describe the barriers and facilitators to engagement in prompt HIV care 3-months after the delivery of an HIV-positive result.

Methods: Data for this study was collected as part of the Together 5,000 study, a U.S. national, internet-based cohort study of men, transgender men, and transgender women who have sex with men. For Aims 1 and 2, we conducted secondary analysis of quantitative survey data from a cohort of 6,118 GBM ages 16-49 at high risk for HIV transmission. The surveys gathered data on demographics, HIV risk behaviors, HIV and STI testing history, mental health, and interpersonal factors. For Aim 1, we evaluated the prevalence of syndemic conditions and explored their associations with HIV risk. Descriptive statistics were used to describe the sample and the prevalence of syndemic conditions. The associations were determined using adjusted multiple linear regressions. For Aim 2, we measured and described the sociodemographic differences in levels of resilience and explored the association between resilience and HIV risk. The associations were determined using adjusted multiple linear regressions. For aim 3, we conducted secondary analysis of qualitative in-depth interviews from 50 GBM diagnosed HIV-positive during their participation in Together 5,000. The goal of Aim 3 was to described participants experiences getting linked-to-care and identify barriers and facilitators to engagement in HIV care using thematic analysis.

Results: In Aim 1 we found a high prevalence of intimate partner violence (IPV), experiences of childhood sexual abuse, homelessness and mental health issues. Further, IPV, depression, polydrug use, incarceration history and homelessness were positively associated with HIV risk. We also demonstrated that increasing cumulative syndemic conditions were associated with higher HIV risk. Those who reported 3 or more co-occurring conditions had the highest risk for HIV. In Aim 2, we found higher mean resilience scores among those identifying as black, with higher education, having full-time employment, higher incomes, and those who have health insurance. Although we found no statistically significant association between resilience and our composite measure of HIV risk, we did find a significant association between higher resilience and lower condomless receptive anal sex acts in the last 3 months. In Aim 3, we found that the majority of participants reported being linked-to-care, while only 74.5% of those reported initiating ART. Thematic analysis identified 4 major themes related to participants’ engagement in care: 1) Reasons for HIV testing (e.g., HIV self-testing and expectation of positivity), 2) Linkage-to-care (e.g., appointment/logistic issues and social support as encouragement), 3) Barriers (e.g., financial burden, competing priorities and fear/stigma) and facilitators (e.g., financial assistance, patient-provider relationships, auxiliary support services and health agency) to engagement in HIV care, and 4) PrEP as a missed prevention opportunity.

Conclusion: Overall, the findings from this multi-method dissertation suggest that the HIV epidemic is complex, and therefore an effective response requires an understanding of the diversity and dynamic nature of individuals, communities, and our socio-political environment. We demonstrated that environmental and behavioral factors such as homelessness, incarceration are prevalent among GBM in the U.S. and contribute to HIV acquisition, thus offering compelling evidence for the adoption of these variables in future syndemic models. Further, there needs to be a more comprehensive investigation of the unique risk factors in this population, particularly those that may impact uptake and adoption of preventive HIV health behaviors, such as pre-exposure prophylaxis (PrEP). For instance, larger structural factors like societal racial discrimination, anti-immigration laws, lack of health insurance coverage and unemployment can significantly impact adherence to biomedical tools and use of testing services. Future research should explore these social and structural determinants within the context of HIV prevention. There is a need for targeted interventions for those at the highest risk, particularly racial and ethnic minorities and those from impoverished communities to increase HIV testing frequency and facilitate better engagement in care. Further, as seen in our study findings, HIV prevention is a multi-faceted process. As such, there is a need for a more holistic approach to prevention, wherein HIV prevention is conceptualized as more than just HIV testing and PrEP initiation but that takes into account intrapersonal (e.g,, resilience) and interpersonal factors (e.g., social support). Finally, addressing policy-, social- and individual-level barriers could improve GBM’s engagement in HIV care. Capitalizing on GBM’s health agency through partnerships with local agencies and fostering better patient-provider relationships could optimize continuity of HIV care. We possess the tools needed to end the HIV epidemic in the U.S., particularly by advocating for a new federal policy which streamlines HIV testing, linkage-to-care and ART initiation.

Included in

Public Health Commons



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