Structural violence, first described by Galtung (1969), is a framework that examines the harm caused by political, economic, and social structures and the ways in which those systems contribute to inequitable opportunities to fulfill one’s basic human needs.1 In line with this conceptualization, racism is considered a form of structural violence wherein Black and Brown people are systematically excluded from spaces and denied opportunities to participate. Indeed, structural violence has been characterized as “the mechanism that carries white supremacist principles forward, impeding health equity.”2 While structural violence is a result of anti-Black historical processes and institutional norms and practices,1,3 it can also manifest and be reinforced at the individual level by way of upholding racist norms, over-surveilling, perpetuating stereotypes, and supporting structures that contribute to patterns of oppression.4 As such, racism, in all forms, is inherently violent, as it violates individual dignity, safety, and social and psychological wellbeing of individuals.
The continuous traumatic violence and HIV care model put forth by Quinn et al. (2021), demonstrates how cumulative forms of violence, including the violence of racial discrimination, can influence HIV care outcomes directly and via psychological distress, internalized stigma, or trauma-related symptoms.5 This model similarly recognizes the importance of potential protective factors that may buffer the effects of violence, including social support, self-efficacy, and future orientation.5 In the current study, we aim to test one aspect of this model, examining the relationship between racial discrimination—an indicator of anti-Black racism –, HIV care engagement, and antiretroviral medication adherence (ART) among a sample of Black sexually minoritized men (SMM). As part of this, we also seek to understand the role of social support in promoting ART adherence and engagement in HIV care.
Research has demonstrated numerous harms associated with racism, including among individuals living with or at risk for HIV. For example, the state structural racism index (as measured by a combination of segregation, incarceration, education, employment, and economic indices) has been found to predict racial disparities in HIV-related mortality rates.6 Among Black SMM, racism-related mistreatment from healthcare providers is associated with longer elapsed time since one’s last HIV appointment.7 Additionally, racial discrimination can negatively influence HIV testing8 and ART adherence.9
The effects of racism on HIV outcomes may be operating via psychosocial factors. For example, among a sample of Black gay and bisexual men living with HIV, Bogart and colleagues found that intersectional discrimination, based on race, sexual identity, and HIV status, were associated with greater depressive symptoms.10 Further, racial discrimination among Black SMM is associated with greater levels of emotional regulation difficulties and heavy drinking.11 These factors—depressive symptoms, emotional regulation, substance use—may subsequently influence HIV outcomes.5 Individuals struggling to cope with their HIV status may avoid HIV care engagement or medication adherence in an attempt to minimize the distress associated with their status.12 A systemic review found that the odds of achieving optimal ART adherence were lower among individuals with depression when compared with those reporting no depression.13 That said, a recent study among SMM in San Francisco found no evidence that depressive symptoms lead to an increase in ART nonadherence among men living with HIV, although they did find an association between depressive symptoms and concurrence of ART nonadherence and condomless sex.14
Community connection and support may also be important to consider when seeking to understand the impact or consequences of racial discrimination on HIV care, as social connectedness has been found to mitigate the associations between racial discrimination and numerous health outcomes.15,16 For example, connections to the gay community have been found to reduce minority stress and mental distress17 and support sexually minoritized men in coping with sexuality-related stigma.18 Specifically, support from within Black LGBTQ spaces may be particularly beneficial in supporting mental health and HIV care. Prior research has found that Black LGBTQ community connectedness mediates the effects of racial discrimination on PrEP use among Black SMM and transgender women.19 Black LGBTQ communities may support HIV care engagement and ART adherence and may also be critical in helping Black SMM cope with anti-Black racism and reduce mental distress associated with racial discrimination.17 That said, while social support may be protective for some SMM, others may face challenges in harnessing and sustaining needed support.18 Experiences of discrimination may also inhibit social connectedness,20 as avoidance and isolation are potentially useful coping mechanisms.21
In light of this prior research, our study aimed to understand the effects of racial discrimination and Black LGBTQ community connectedness on HIV care engagement and ART adherence. In line with a structural violence framework and the continuous traumatic violence and HIV care model,5 we hypothesized that racial discrimination would be negatively associated with HIV care engagement and ART adherence, and that this relationship would be mediated by depressive symptoms. Further, we hypothesized that Black LGBTQ community connection would be associated with fewer depressive symptoms and greater HIV care engagement and ART adherence.