This analysis revealed a range of factors and characteristics associated with suboptimal outcomes for YBMSM on five indicators along the HIV care continuum. Notably, some associations—such as the beneficial effect of health insurance and the detrimental effect of drug use—were significant across more than one continuum outcome. Yet, overall, each outcome had a unique set of associated factors. Understanding these distinct needs of YBMSM at each stage of the continuum and addressing them through tailored approaches is critical for achieving the prevention benefits of viral suppression through “treatment as prevention” and sustaining long-term optimal health outcomes. Below we discuss our findings at each step of the continuum and potential intervention implications for YBMSM.

The majority of HIV-positive men in this study were engaged in care. This is likely related to the fact that among those who were HIV-infected, about half (n = 102) were recruited through case management organizations or HIV providers. Although a potential source of bias, this also highlights the importance of community and health-care related partnerships with research groups to enroll HIV-infected YBMSM in large studies. Further, participants in this study reported a high overall self-efficacy for communicating with their health care providers. While not directly measured in this study, perception of racism and medical mistrust by Black patients, including BMSM, has been found to impact patient-provider communication, health care access, and uptake of prevention services [28, 29]. In prior studies, BMSM were found to be less likely to report primary care provider awareness of their sexual orientation compared to White MSM [30]. However, few studies have examined the relationships between BMSM and primary care providers, particularly among those who are HIV-positive. Additional in-depth research is needed to elucidate barriers and facilitators to optimal and productive patient-provider communication that can be targeted for interventions to impact engagement in care.

Despite high levels of care engagement there were also high rates of missed visits. Missed visits have multiple negative consequences: interruptions in ART due to lapses in insurance or drug assistance coverage, delays in health care (e.g. sexually transmitted infection screening and immunizations), and timely evaluations for ART toxicity and adherence. In this study, missed visits were associated with lower education. These results align with findings from a linkage-to-care study of 1891 adolescents and young adults living with HIV (27.8% perinatally infected; 72.2% behaviorally infected) which found that missed appointments were common among those with less education living in economically disadvantaged areas [31]. While not measured in this study, Harper et al. found that in a sample of 200 HIV-positive male adolescents, 66% of whom were Black, those with a stronger connection to their racial/ethnic identity were less likely to have missed an HIV medical appointment during the prior 3 months, while those with more negative attitudes towards gay/bisexual people were more likely to have missed appointments [32]. These findings thus highlight the importance of addressing individual, developmental and structural factors when possible.

Missed visits among YBMSM in this sample were also associated with marijuana use. The impact of marijuana on continuum of care metrics has been less studied than other substances [33, 34] and the limited studies have reported that the effect of marijuana on retention in care are inconclusive. In a study of 212 HIV seropositive YBMSM in Chicago, there was no significant association found between intermittent or heavy marijuana use and retention in care [35]. Another study, however, found weekly or daily marijuana use to be associated with loss to follow-up [36]. Given the high proportion of marijuana use among people living with HIV [37–41] as well as increasing trends towards legalization of marijuana, additional research specifically addressing the context and frequency of marijuana use and its impact on HIV care and treatment is warranted.

Most participants in this sample were on ART and reported adhering to ≥90% of their prescribed medication. While health insurance and not using cocaine (including crack) were positively associated with ART uptake, depressive symptomology was the sole factor associated with poor adherence. More than half of the sample (59.4%) reported clinically relevant depressive symptoms. It is clear that depression negatively impacts adherence; a meta-analysis across nearly 100 independent samples found that depression was significantly associated with nonadherence (p<0.0001) [42]. Addressing mental health must be an element of care provision across the continuum and in the development of interventions for those YBMSM living with HIV.

Despite overall high levels of engagement in care, ART uptake, and self-reported medication adherence, it is concerning that only 65% of HIV-positive YBMSM in this sample reported an undetectable viral load in the past six months. The finding that disclosure was associated with viral suppression may be interpreted in at least two ways. Disclosure is important for accessing support, which can impact engagement in care, medication adherence and ultimately, viral suppression [43]. Given the cross-sectional nature of this analysis, it is also plausible that those who achieved viral suppression were more likely to disclose their status to an intimate partner. Importantly, both interpretations point toward a need for greater support for status disclosure. Currently, there is a lack of interventions targeting disclosure to sex partners. In a recent review, Conserve et al. identified five trials, of which only three were efficacious and all were delivered in multiple small group sessions limiting widespread implementation [44].

Several cross-cutting factors stand out across the care continuum for YBMSM in this sample. First, substance use among HIV-infected YMSM creates challenges in health care provision and has been previously associated with decreased engagement in care and poor adherence to care and medications [45–47]. Substance use can lead to inaccurate perceptions of time, the inability to adhere to routines, and impaired decision making, all important barriers to retention in care [48]. Future studies should examine both the patterns of use as well as the pathways in which both frequent and infrequent use impact care seeking and adherence behaviors. Co-location or integration of HIV care with substance use treatment to improve long-term health outcomes for YMSM should be considered to address these issues.

Second, a majority of the sample was insured (80.3%). This aligns with data from the NHBS that found that between 2008 and 2014, current insurance status among HIV-positive MSM increased from 75% to 86% (6). Many of the participants in the current study may have considered Ryan White and ADAP (AIDS Drug Assistance Program) benefits as insurance. Another explanation for the high percentage insured given the young age of the sample is the ability to be maintained on parents’ insurance plans. It should also be noted that the Patient Protection and Affordable Care Act was signed into law on March 23rd, 2010, and implementation began in late 2013 –coinciding with HMP enrollment (2013–2015). Indeed, the overall percentage of U.S. adults who were uninsured dropped from 18% in the third quarter of 2013 to 11% in the first quarter of 2016 [49]. Given that having insurance was associated with greater engagement in care and ART uptake in this sample, continued efforts to ensure HIV-positive young men have access to insurance or provision of ART benefits through other means is critical.

This exploratory study has some important limitations. Study outcomes were not rare (i.e., <10%) so odds and odds ratios should not be interpreted as risks. The data included in these analyses are from the baseline survey for an online intervention and are thus cross-sectional in nature, limiting our ability to determine causality. Our engagement and viral suppression measures were assessed via self-report, thus introducing the possibility of both recall and reporting bias [50]. However, all our surveys were conducted online which has been shown to be a reliable and valid method for collecting sensitive information among young adults [51, 52]. Finally, as mentioned above, many of the HIV-positive participants in the intervention were recruited from HIV clinics and community based organizations and thus may not be reflective of the population of those YBMSM who are out of care.

Findings from this study have implications for both future research as well as intervention development for HIV-positive YBMSM. The high rates of depression, social isolation and substance use behaviors seen in this study have been found in other work focused on YBMSM, including those who are HIV-positive [53–55]. These psychosocial conditions, particularly in combination are likely to have an additive impact on continuum of care outcomes for YBMSM. While prior work has established the impact of syndemics on heightened risk for HIV infection among BMSM [55–58], longitudinal studies that not only address the combined impact of syndemics over time, but also provide guidance on how to effectively intervene as early as possible in these men’s lives are needed. Validated clinical screening tools for mental health [59, 60] and substance use disorders [61, 62] should be administered upon initial care engagement and at regular intervals to identify those YBMSM in need of additional services [63]. Given the high reported rates of social isolation experienced by YBMSM in this study, network based interventions, such as Project nGage, which focuses on helping YBMSM identify supportive relationships as a mechanism to promote retention in care, could be beneficial [64].