Substance use and HIV epidemics have disproportionately impacted sexual and gender minoritized (SGM) communities. The burden of substance use within SGM communities is disproportionately high and has increased precipitously during the COVID-19 pandemic [1]. Although there have been decreases in illicit substance use and sexual risk behaviors among the general population, associations between the two have persisted among SGM communities [1]. Men who have sex with men (MSM) of color and transgender women of color face heightened vulnerability to concurrent epidemics of poverty, poor mental health, discrimination, and substance use, each constituting a unique barrier to engagement in health care that perpetuates a cycle of neglect [2]. Researchers investigating factors associated with substance use and HIV found that Black MSM experienced an 8% decrease in the odds of reporting viral suppression for every unit increase in the substance abuse and mental illness symptoms [3]. A study in Massachusetts found a higher prevalence of homonegativity among MSM of color, suggesting that internalized stigma may be racialized [1]. Research on adherence to HIV treatment describes how HIV-related stigma and substance use stigma drive poor HIV care outcomes [4,5].

The confluence of these factors has created a unique environment for digital health interventions to become a vital tool for an evolving public health landscape. Digital health interventions may better serve SGM communities faced with complex decisions that limit their access to essential health services [6,7]. For example, researchers issued a self-administered survey to students and faculty in Oklahoma, Wyoming, and Texas, asking whether respondents had ever needed to visit a health care provider but did not in the last 6 months [8]. Their analysis found that SGM respondents experienced a higher likelihood of forgoing care compared to their non-SGM counterparts, suggesting that SGM communities disproportionately experience unmet health care needs [8]. Digital health interventions have been effective in addressing poor mental health among people living with HIV, especially for younger participants [9]. Digital health interventions have demonstrated potential in overcoming barriers rooted in complex stigma and isolation and mitigate stigma as a barrier to accessing health care [9].

Not only that but digital health interventions can also reach SGM populations where they are using online methods and having greater presence in online community spaces [10]. The AFFIRM study delivered cognitive behavioral therapy by using virtual conference technology to overcome traditional in-person barriers and was effective in improving the mental health of SGM youth [11]. Social networking apps have become digital spaces that lead to real-world connections for SGM communities. This can include strengthening community ties, forming relationships, and seeking sexual partners. Yet, these digital spaces can also facilitate sexual and substance use risk behaviors [12,13]. Studies have found that risk behaviors vary for SGM communities depending on the digital space or virtual platform [14,15]. This study seeks to examine the social correlates of substance use and sexual risk perception in an online sample of help-seeking MSM and transgender women in San Francisco, California. These data may inform public health strategies and future interventions to serve SGM communities at risk of and desiring help for substance use and HIV-related services.

Table 1 describes participants’ demographics, knowledge and utilization of testing and preventive services, and perceptions of harm attributed to substance use behaviors. Almost a third of participants (117/409, 28.61%) were aged 50 years or older, and 27.38% (112/409) were aged 30-39 years. The majority (327/409, 79.95%) identified as a cisgender man, and 20.05% (82/409) identified as a transgender women or other gender. Most participants identified as White or Latino/a/x/e racial/ethnic (169/409, 41.32% and 113/409, 27.63%, respectively). Approximately 17.60% (72/409) of the participants reported having unstable housing, and 17.36% (71/409) reported an annual income below the 2022 federal poverty line. Utilization of testing resources for HIV and hepatitis was high among our participants, with 98.04% (401/409) having previously been tested for HIV and 88.02% (360/409) for hepatitis. Knowledge of HIV or other sexually transmitted infection health services was also high (379/409, 92.67%). However, participants were less knowledgeable about substance use–related services, with 64.55% (264/409) of the participants reporting they were aware of the resources.

Overall, participants frequently reported that using substances posed high risk of harm. Approximately 97.07% (397/409) of the participants perceived sharing needles and using nonprescription opioid drugs as high risk, followed by prescription opioid drugs without a prescription, substance use during sex, and condomless sex (368/409, 89.98%, 349/409, 85.33%, and 287/409, 70.17%, respectively). Conversely, almost a third (122/409, 29.83%) perceived engaging in condomless sex as low risk. One in ten (41/409, 10.02%) perceived using prescription opioid drugs without a prescription as low risk, and 14.67% (60/409) perceived using substances during sex as low risk.

Table 2 describes the associations between social factors and low risk perception of harm attributed to substance use and HIV risk behaviors. We assessed the following social factors: race, housing stability, and socioeconomic status, history of receiving testing services, and knowledge of substance use and HIV-related services. Odds ratios and 95% CIs are presented, adjusted for age, gender, and sexual orientation.

Participants who reported experiencing unstable housing were more likely to report perceiving sharing needles (adjusted odds ratio [aOR] 7.20, 95% CI 1.99-27.80) and nonprescription opioid use (aOR 4.02, 95% CI 1.08-14.90) as low risk. Participants who reported an income below the federal poverty level were more likely to report perceiving sharing needles (aOR 6.35, 95% CI 1.84-23.40), prescription opioid use (aOR 2.89, 95% CI 1.32-6.18), and substance use during sex (aOR 2.29, 95% CI 1.14-4.48) as low risk. Participants who have not been tested for hepatitis in the past have 3.31 times the odds of perceiving prescription opioid use as low risk compared to counterparts who have been tested for hepatitis before (95% CI 1.36-7.68).

This study examines how SGM people seeking help for substance use–related services online perceive substance use risk and harms. We found that the highest proportion of participants perceived sharing needles and nonprescription opioid use as high risk, followed by prescription opioid drugs without a prescription, substance use during sex, and condomless sex. On the surface, these data demonstrate that participants are actively engaged in assessing risk and harms related to using specific substances and appropriately ascribe high risk to substances that have severe health consequences. For example, needle sharing is a mode of transmission for HIV acquisition [21], and use of nonprescription opioids like fentanyl could lead to life-threatening overdose [22]. Yet, for other behaviors like prescription opioid drug use without a prescription, condomless sex, and substance use during sex, more participants perceive these behaviors as less risky.

Our study finds that low risk perception is unevenly distributed, revealing that some people are more likely to perceive substance use behaviors as low risk. For example, although we found that while more than 95% of the participants perceived sharing needles as high risk, participants experiencing unstable housing and those with an income less than the federal poverty level are more likely to perceive sharing needles as low risk compared to their respective counterparts. Similarly, while most participants perceived nonprescription opioid drug use as high risk, people experiencing unstable housing were more likely to perceive this behavior as low risk.

These findings can inform how public health sectors ought to tailor interventions to reach communities who perceive substance use behaviors as low risk. We found that participants who reported an income below the federal poverty level were more likely to report perceiving prescription opioid use as low risk. Integrating substance use prevention and health education into employment programs and social welfare and other benefit programs may improve risk assessment and decision-making skills. For example, Bosk et al [23] describe opportunities for child welfare programs to integrate addiction treatment, education, and prevention among parents of families involved in the child welfare system. Additionally, we found that participants who have not been tested for hepatitis in the past are more likely to perceive prescription opioid use as low risk. Scaling up and enhancing viral hepatitis testing could act as a feasible conduit for health education about substance use disorder and prescription opioid use.

Our study is not without limitations. There is limited generalizability of our findings due to the cross-sectional study design and the unique sociohistorical environment and communities of the San Francisco Bay Area and its public health institutions. Although existing scientific literature suggests that social factors may influence substance use behaviors [24-26], our study cannot definitively establish causality or determine the direction of influence between these social factors and risk perception [27]. Historically, San Francisco has been a center of civil rights and public health movements for SGM communities—from HIV to harm reduction to transgender health to ending the syndemic of hepatitis C virus/HIV/sexually transmitted infections. As a result, not only have many SGM folks relocated to San Francisco to live in an environment less adverse to SGM people, the public health infrastructure has evolved to specifically meet the needs of SGM communities [28]. Despite these limitations, this study is unique in that the sample is comprised of SGM individuals seeking help online. Stigma can deter people from seeking help for substance use, mental health, and HIV services in-person [29], and creating entry points into the public health service system that interface with people seeking help online is critical to overcoming stigma and communities hardly reached by traditional methods [30]. Another limitation to our study may include how response categories were recoded to characterize low risk perception. Although many participants in our study reported knowledge of HIV/sexually transmitted infection services, more than a third were unaware of substance use services; reaching these individuals is critical to addressing gaps in substance use disorder service utilization, and increasing research find that it is important to reach people who use substances online [31,32]. Future research examining pre-exposure prophylaxis for HIV and sexually transmitted infections may be important factors in assessing sexual risk and vulnerability for people who use substances. Although our study examines perceptions of risk of harm to oneself related to substance use quantitatively, we understand that the dynamic processes of cognition and risk assessment in the lived experiences of vulnerable communities may perhaps be best investigated by employing qualitative methodologies. For example, phenomenology and repeated in-depth interviews over time may reveal critical insights into the lived experiences and meaning behind understanding risks related to substance use and decision-making.

This study underscores the importance of social determinants in shaping the low risk perception of harm associated with substance use behaviors among online help–seeking SGM people in San Francisco. These systemic inequities structure participants’ perceptions, access, and utilization of preventive and public health services. Our findings identify critical opportunities for outreach and preventative efforts needed to serve vulnerable populations. Addressing the substance use and HIV syndemic requires public health interventions that seek to overcome structural barriers and leverage digital technology to meet people where they are. Although our study provides valuable insights, further research is needed to understand the influence of social determinants in digital spaces and facilitate the development of effective and inclusive interventions in the future.