Extending the Minority Stress Model to Incorporate HIV-Positive Gay and Bisexual Men's Experiences: A Longitudinal Examination of Mental Health and Sexual Risk Behavior

Background: Minority stress theory represents the most plausible conceptual framework for explaining many health disparities for gay and bisexual men (GBM). However, little focus has been given to including the unique stressors experienced by HIV-positive GBM within such models. As such, we explored the role of HIV-related stressors within a minority stress model of mental health and sexual behavior for HIV-positive GBM.

Methods: We conducted a longitudinal study over 6 months with a diverse sample 138 HIV-positive GBM in New York City. We collected data regarding sexual minority stressors (internalized homonegativity, gay-related rejection sensitivity) and HIV-related stressors (internalized HIV stigma, HIV-related rejection sensitivity), as well as emotion regulation, mental health (depression, anxiety, sexual compulsivity, and hypersexuality), and condomless anal sex (CAS) with all male partners and HIV serodiscordant male partners. We used two latent variables—one for depression and anxiety and one for sexual compulsivity and hypersexuality—as outcomes within path analyses; the two CAS variables were treated as Poisson-distributed outcomes and analyzed within a second model.

Results: Path analyses revealed that internalized homonegativity and internalized HIV stigma were significantly associated with both latent mental health outcomes and serodiscordant CAS while gay-related and HIV-related rejection sensitivity were not. Moreover, emotion regulation mediated the influence of both forms of internalized stigma on depression/anxiety, sexual compulsivity/hypersexuality, and serodiscordant CAS. Results revealed that internalized HIV stigma was more strongly associated with all outcomes than was internalized homonegativity.

Conclusions: Internalized HIV stigma appears to be a stronger influence on mental and sexual health for HIV-positive GBM than internalized homonegativity, and both forms of internalized stigma appear to stronger than gay-related and HIV-related rejection sensitivity. We identified two targets of behavioral interventions that may lead to improvements in mental health and reductions in sexual transmission risk behaviors—maladaptive cognitions underlying negative self-schemas and difficulties with emotion regulation. Techniques for cognitive restructuring and emotion regulation may be particularly useful in the development of interventions that are sensitive to the needs of this population. Structural interventions that can reduce societal stigma are critical for preventing health disparities for future generations.