Using Syndemics Theory to Investigate Risk and Protective Factors Associated with Condomless Sex Among Youth Living with HIV in 17 U.S. Cities

Intervening on the Intersecting Issues of Intimate Partner Violence, Substance Use, and HIV: A Review of Social Intervention Group's (SIG) Syndemic-Focused Interventions for Women

Intimate partner violence (IPV), HIV, and substance use are serious intersecting public health issues. This paper aims to describe the Social Intervention Group (SIG)'s syndemic-focused interventions for women that address the co-occurrence of IPV, HIV, and substance use, referred to as the SAVA syndemic. We reviewed SIG intervention studies from 2000 to 2020 that evaluated the effectiveness of syndemic-focused interventions which addressed two or more outcomes related to reducing IPV, HIV, and substance use among different populations of women who use drugs. This review identified five interventions that co-targeted SAVA outcomes. Of the five interventions, four showed a significant reduction in risks for two or more outcomes related to IPV, substance use, and HIV. The significant effects of SIG's interventions on IPV, substance use, and HIV outcomes among different populations of women demonstrate the potential of using syndemic theory and methods in guiding effective SAVA-focused interventions.

Prevalence and predictors of HIV and sexually transmitted infections among vulnerable women engaged in sex work: Findings from the Kyaterekera Project in Southern Uganda

INTRODUCTION

Women engaged in sex work (WESW) have an elevated risk of the human immunodeficiency virus (HIV) and sexually transmitted infections (STI). Estimates are three times higher than the general population. Understanding the predictors of HIV and STI among WESW is crucial in developing more focused HIV and STI prevention interventions among this population. The study examined the prevalence and predictors of HIV and STI among WESW in the Southern part of Uganda.

METHODOLOGY

Baseline data from the Kyaterekera study involving 542 WESW (ages 18-55) recruited from 19 HIV hotspots in the greater Masaka region in Uganda was utilized. HIV and STI prevalence was estimated using blood and vaginal fluid samples bioassay. Hierarchical regression models were used to determine the predictors of HIV and STI among WESW.

RESULTS

Of the total sample, 41% (n = 220) were found to be HIV positive; and 10.5% (n = 57) tested positive for at least one of the three STI (Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis) regardless of their HIV status. Older age (b = 0.09, 95%CI = 0.06, 0.13, p≤0.001), lower levels of education (b = -0.79, 95%CI = -1.46, -0.11, p≤0.05), fewer numbers of children in the household (b = -0.18, 95%CI = -0.36, -0.01), p≤0.05), location (i.e., fishing village (b = 0.51, 95%CI = 0.16, 0.85, p≤0.01) or small town (b = -0.60, 95%CI = -0.92, -0.28, p≤0.001)), drug use (b = 0.58, 95%CI = 0.076, 1.08, p≤0.05) and financial self-efficacy (b = 0.05, 95%CI = -0.10, 0.00, p≤0.05), were associated with the risk of HIV infections among WESW. Domestic violence attitudes (b = -0.24, 95%CI = -0.42, -0.07, p≤0.01) and financial distress (b = -0.07, 95%CI = -0.14, -0.004, p≤0.05) were associated with the risk of STI infection among WESW.

CONCLUSION

Study findings show a high prevalence of HIV among WESW compared to the general women population. Individual and family level, behavioural and economic factors were associated with increased HIV and STI infection among WESW. Therefore, there is a need for WESW focused HIV and STI risk reduction and economic empowerment interventions to reduce these burdens.

Running with Scissors: a Systematic Review of Substance Use and the Pre-exposure Prophylaxis Care Continuum Among Sexual Minority Men

Purpose of Review

Patterns of sexualized drug use, including stimulants (e.g., methamphetamine) and chemsex drugs, are key drivers of HIV incidence among sexual minority men (SMM). Although pre-exposure prophylaxis (PrEP) mitigates HIV risk, there is no consensus regarding the associations of substance use with the PrEP care continuum.

Recent Findings

SMM who use substances are as likely or more likely to use PrEP. Although SMM who use stimulants experience greater difficulties with daily oral PrEP adherence, some evidence shows that SMM who use stimulants or chemsex drugs may achieve better adherence in the context of recent condomless anal sex. Finally, SMM who use substances may experience greater difficulties with PrEP persistence (including retention in PrEP care).

Summary

SMM who use stimulants and other substances would benefit from more comprehensive efforts to support PrEP re-uptake, adherence, and persistence, including delivering behavioral interventions, considering event-based dosing, and providing injectable PrEP.

The COVID-19 Pandemic Seen from a Syndemic Perspective: The LGBTQIA2SP+ Community

An adverse condition or a disease can (either directly or indirectly) interact in a synergistic fashion with other adverse conditions or diseases/maladies, and co-cluster together with them: this fundamental observation is at the basis of the term "syndemic" (a portmanteau for "synergistic epidemic") [...].

Barriers and Facilitators to Promoting Resilience to HIV/AIDS: A Qualitative Study on the Lived Experiences of HIV-Positive, Racial and Ethnic Minority, Middle-Aged and Older Men Who Have Sex with Men from Ontario, Canada

Evidence-based research has highlighted the need for exploring factors that support the mental health of men who have sex with men living with HIV/AIDS (MSMLWH), and environmental influences that promote their resilience to HIV/AIDS. This exploratory study utilized a community-based participatory research approach to investigate barriers and facilitators to promoting resilience to HIV/AIDS, specifically among racial and ethnic minority, middle-aged and older MSMLWH, a population that continues to be significantly impacted by HIV/AIDS today. This collaborative, qualitative study recruited participants who identified as racial or ethnic minority MSMLWH, were aged 40 or older, and resided in Ontario, Canada. Participants (n = 24) discussed in their interviews barriers and facilitators to promoting resilience to HIV/AIDS, which they recognized from their lived experiences. Utilizing thematic analysis, themes related to barriers and facilitators to promoting resilience to HIV/AIDS were identified. Themes related to identified barriers included: (1) language proficiency, (2) racism, (3) pernicious norms in North American gay culture, and (4) HIV stigma. Themes related to identified facilitators included: (1) compartmentalization, (2) perseverance, and (3) community-based health and social services. This article discusses the implications of the study’s findings, particularly on how they may influence the development of future services for racial and ethnic minority, middle-aged and older MSMLWH.

Addressing Syndemics and Self-care in Individuals with Uncontrolled HIV: An Open Trial of a Transdiagnostic Treatment

Interventions addressing syndemics and ART adherence are needed for individuals with uncontrolled HIV and psychosocial problems. Twenty-seven participants with detectable HIV plasma viral load (PVL) or recent STI participated in an open trial of transdiagnostic adherence counseling and cognitive behavioral therapy. Outcomes were collected at baseline, 4-, and 8-months. Log PVL improved from baseline to 4-month (γ = - 1.13, 95% CI - 1.72, - 0.55, p < 0.001) and 8-month (γ = - 0.93, 95% CI - 1.57, - 0.30, p = 0.006), with more participants suppressed at 4- (χ2(1) = 9.09, p = 0.001) and 8-month (χ2(1) = 5.14, p = 0.016). Self-reported adherence improved across major assessments (γ = 0.87, 95% CI 0.28, 1.46, p = .005); Wisepill adherence did not. Negative affect declined during treatment (γ = - 0.28, 95% CI - 0.40, - 0.16, p < 0.001), with improvement at 4- (γ = - 4.34, 95% CI - 6.99, - 1.69, p = 0.002) but not 8-month. Positive affect trended positively during treatment and from baseline to 4-month, with significant 8-month improvement (γ = 3.84, 95% CI 0.33, 7.44, p = 0.04). Depressive symptoms did not change. In a complicated sample of participants selected for uncontrolled HIV, the intervention yielded improved PVL and self-reported adherence. Efforts to end HIV should improve upon strategies such as these, addressing syndemics. Registration: clinicaltrial.gov: NCT02696681.

Work2Prevent, an Employment Intervention Program as HIV Prevention for Young Men Who Have Sex With Men and Transgender Youth of Color (Phase 3): Protocol for a Single-Arm Community-Based Trial to Assess Feasibility and Acceptability in a Real-World Setting

BACKGROUND

In the United States, young cisgender men who have sex with men (YMSM), young transgender women (YTW), and gender nonconforming (GNC) youth face elevated rates of HIV infection. However, racial and ethnic disparities in adolescent HIV infection cannot be attributed to individual-level factors alone and are situated within larger social and structural contexts that marginalize and predispose sexual and gender minority youth of color to HIV. Addressing broader ecological factors that drive transmission requires interventions that focus on the distal drivers of HIV infection, including violence exposure, housing, food insecurity, educational attainment, and employment. Given the ways that economic instability may make YMSM, YTW, and GNC youth of color vulnerable to HIV exposure, this study focuses on employment as an HIV prevention intervention. More specifically, the intervention, called Work2Prevent (W2P), targets economic stability through job readiness and employment as a means of preventing behaviors and factors associated with adolescent and young adult HIV, such as transactional sex work and homelessness. The intervention was adapted from iFOUR, an evidence-based employment program for HIV-positive adults in phase 1 of this study, and pilot tested in a university-based setting in phase 2.

OBJECTIVE

This paper aims to describe the protocol for the community-based test phase of W2P. The purpose of this phase was to pilot test a tailored, theoretically informed employment intervention program among YMSM, YTW, and GNC youth of color within a lesbian, gay, bisexual, transgender, and queer (LGBTQ) community setting.

METHODS

The employment intervention was pilot tested using a single-arm pretest-posttest trial design implemented among a sample of vulnerable YMSM, YTW, and GNC youth of color using services within a community-based LGBTQ center. Assessments will examine intervention feasibility, acceptability, and preliminary estimates of efficacy.

RESULTS

Phase 3 of W2P research activities began in May 2019 and was completed in December 2019. Overall, 41 participants were enrolled in the community-based pilot.

CONCLUSIONS

This study will assess intervention feasibility and acceptability in the target populations and determine preliminary efficacy of the intervention to increase employment and reduce vulnerability to HIV when implemented in a community-based setting serving LGBTQ youth of color. Testing the intervention in a community setting is an opportunity to evaluate how recruitment, retention, and other outcomes are impacted by delivery in a venue akin to where this intervention could eventually be used by nonresearchers. If W2P demonstrates feasibility and acceptability, a larger multisite trial implemented in multiple community settings serving YMSM, YTW, and GNC youth of color is planned.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03313310; https://clinicaltrials.gov/ct2/show/NCT03313310.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18051.

A Syndemic Model of Exchange Sex Among HIV-Positive Men Who Have Sex With Men

Exchange sex is a behavior associated with HIV transmission risk among men who have sex with men (MSM). Few studies have examined exchange sex among HIV-positive MSM. We utilize a syndemic framework to account for co-occurring psychosocial problems that suggest the presence of intertwining epidemics (i.e., syndemics), which have not been examined within the context of exchange sex among HIV-positive MSM. In 2015, MSM were recruited via online sexual networking Web site and app advertisements for Sex Positive!^[+], a video-based online intervention that aimed to improve health outcomes for men living with HIV. Participants completed surveys every three months for a year. Surveys covered demographics, drug use, exchange sex, intimate partner violence (IPV), and past 2-week depressive symptoms. We conducted three logistic regression models to assess syndemic factors associated with exchange sex in the past 3 months. Of the 722 HIV-positive MSM included in the sample, 59 (8%) reported exchange sex in the past 3 months at 12-month follow-up. HIV-positive MSM who had more syndemic factors had greater odds of exchange sex. Exchange sex was associated with being African-American/Black, age 18-29 years, past and present experiences with IPV, stimulant use, polysubstance use, and depressive symptoms. Exchange sex was associated with multiple psychosocial factors, indicating exchange sex may be part of a syndemic involving substance use, depression, HIV, and IPV. Interventions should address the social and behavioral circumstances that perpetuate environments that can foster multiple negative health outcomes.

Transmission Risk Among Youth Living With HIV in the U.S

PURPOSE

HIV treatment as prevention is effective for reducing the risk of HIV transmission and the messaging campaign, undetectable = untransmittable, is gaining recognition. As youth living with HIV (YLWH) who have condomless sex may acquire and potentially transmit other sexually transmitted infections (STIs), the purpose of this study was to assess potential differences in transmission risk of HIV and other STIs among YLWH to inform subsequent HIV and STI prevention efforts.

METHODS

A cohort of 600 HIV behaviorally infected youth aged 13-24 years who were engaged in medical care completed an audio computer-assisted self-interview including questions about demographics, HIV disclosure, mental health, substance use, and sexual behaviors and beliefs. HIV viral loads and the presence of other STIs were abstracted from medical records. A viral load <200 copies/mL was considered undetectable. Univariate and bivariate analyses were conducted to examine differences by viral load and STIs.

RESULTS

Participants were categorized into four groups: (1) undetectable without STIs (55.2%); (2) undetectable with STIs (14.2%); (3) detectable without STIs (22.8%); and (4) detectable with STIs (7.8%). In comparison to the other three groups, youth in the undetectable group with STIs reported more favorable sexual risk reduction attitudes and beliefs, internet use for finding sex partners, anal sex with male partners, and condomless anal sex with male partners.

CONCLUSIONS

YLWH with undetectable viral loads and other STIs engaged in higher risk behaviors. To realize the promise of the messaging campaign, undetectable = untransmittable, efforts must focus on sustained viral suppression and prevention of STIs among YLWH.

Effects of HIV-Related Discrimination on Psychosocial Syndemics and Sexual Risk Behavior among People Living with HIV

In the context of HIV-related stigma and discrimination, people living with HIV (PLHIV) might be vulnerable to a ‘syndemic’ of co-occurring psychosocial challenges that can affect sexual behavior. The present study examined how HIV-related discrimination contributes to co-occurring psychosocial syndemic problems and results in inconsistent condom use among PLHIV in Hong Kong. Two-hundred and ninety-one PLHIV were recruited to complete a self-report questionnaire. More than one-quarter of the sample experienced two or more psychosocial syndemic problems, and 74.1% of the participants who had sex with steady partners reported inconsistent condom use over the past three months. The results indicated that HIV-related discrimination was positively predictive of the number of psychosocial syndemic problems. HIV-related discrimination and psychosocial syndemics were associated with increased odds of inconsistent condom use with steady partners (AOR = 5.40 and AOR = 3.09 respectively). Findings from structural equation modeling showed that psychosocial syndemics mediated the effect of HIV-related discrimination on condom use consistency with steady partners. PLHIV in Hong Kong suffered from the syndemic effects of stigma, social isolation, and poor mental health, which rendered them vulnerable to condomless sex. In order to curb the rapidly increasing incidence of HIV, multi-level strategies should be adopted to concurrently address the structural inequities and psychosocial syndemics faced by PLHIV.

Longitudinal Effects of Syndemics on HIV-Positive Sexual Minority Men's Sexual Health Behaviors

This study examined the longitudinal effects of co-occurring psychosocial concerns, or syndemics, on HIV-positive sexual minority men's likelihood of engaging in serodiscordant condomless anal sex (CAS), a health behavior with implications for personal and public health. Participants included 390 HIV-positive sexual minority men from two prior secondary prevention trials. Over the course of the 1-year data collection period (up to 5 observations per participant), participants completed self-report measures of CAS, as well as six syndemic factors: post-traumatic stress disorder, childhood sexual abuse, depression, anxiety, alcohol abuse, and polysubstance/stimulant use. We employed multilevel modeling to examine the longitudinal additive effect of syndemics on serodiscordant CAS (binary) over the 1-year period. The number of syndemic conditions was a significant predictor of CAS, with each additional syndemic associated with 1.41 greater odds of CAS (p = .0004; 95% CI [1.16, 1.70]). Both the between-person (p = .0121, 95% CI [1.07, 1.69]) and within-person (p = .01, 95% CI [1.11, 2.10]) effects of syndemics were significant predictors, showing that an increase in the number of syndemic conditions across person and time both increased odds of CAS. Interventions addressing HIV-positive sexual minority men's sexual health behaviors should address the potential impact of co-occurring psychosocial concerns that affect these behaviors. This will benefit this population's personal sexual health and reduce transmission of HIV and STIs among sexual minority men.

Applying resilience theory models to contextualize economic-dependent partnerships as a risk factor for HIV among young men who have sex with men

Economic-dependent partnerships (EDP) are an understudied HIV risk correlate among young men who have sex with men (YMSM) in the U.S. We explored whether YMSM's psychological resilience buffered against the effect of socioeconomic disadvantage on EDPs, after accounting for other psychosocial risks. Data come from an observational study assessing YMSM's HIV vulnerabilities. We developed indices for socioeconomic disadvantage, psychosocial profiles, and cumulative promotive factors. Multivariable logistic regressions tested the main associations of these indices on EDPs. Protective models tested whether psychosocial profiles exacerbated and cumulative promotive factors buffered the effects of socioeconomic disadvantage on EDPs. 31% and 23% of YMSM reported EDPs with main and casual partners, respectively. For both outcomes, we found support for adjusted compensatory models. Socioeconomic disadvantage was associated with increased odds of EDPs with main (AOR = 1.45, p < .001) and casual (AOR = 1.47, p < .001) partners. Psychosocial profiles were also associated with increased odds of EDPs with main (AOR = 1.53, p = .001) and casual (AOR = 1.67, p < .001) partners. Cumulative promotive factors was associated with decreased odds of EDPs with main (AOR = 0.66, p = .003) and casual (AOR = 0.72, p = .035) partners. Our findings elucidate the need for multilevel interventions that provide opportunities for socioeconomic advancement and improve psychosocial/psychological functioning for at-risk YMSM.

Are trajectories of a syndemic index in adolescence linked to HIV vulnerability in emerging and young adulthood?

OBJECTIVES

To examine trajectories of adolescent psychosocial risk - drug use, depressive and anxiety symptoms, and violence victimization and observation - and the longitudinal relationship between psychosocial risk trajectories during adolescence and HIV risk behaviors in adulthood.

METHODS

The 18-year longitudinal study was conducted from September 1994 through May 2013, in Michigan. Eight hundred and fifty predominantly (80%) African-American adolescents completed demographics and measures of drug use, depressive and anxiety symptoms, violence victimization and observation at Times 1-4, sexual risk behaviors at Times 5 and 6, and social conditions (i.e. family, peer, and community-level factors) between 14.9 and 32.0 years of age.

RESULTS

Growth mixture modeling revealed two trajectories of psychosocial risk factors which can be characterized as a syndemic index: high-frequency and low-frequency. The high-frequency class was more likely to report HIV risk behaviors, including condomless sex at last sexual intercourse with their primary and secondary partner, sexual intercourse with someone they just met, at least four sexual partners, and licit and illicit drug use prior to sexual intercourse at Time 5 (mean age 23.1). At Time 6 (mean age 32.0), the high-frequency class was more likely to report sexual intercourse with someone they just met and at least four sexual partners, relative to the low-frequency class. In addition, the high-frequency class was linked to peer and family-level indicators of social conditions.

CONCLUSION

A syndemic index comprised of co-occurring psychosocial risk factors in adolescence seem to have lasting effects on the vulnerability to engage in HIV risk behaviors in emerging adulthood, some of which extend into young adulthood.