High Levels of Syndemics and Their Association with Adherence, Viral Non-suppression, and Biobehavioral Transmission Risk in Miami, a U.S. City with an HIV/AIDS Epidemic

Syndemic Theory and Its Use in Developing Health Interventions and Programming: A Scoping Review

PURPOSE OF REVIEW

The central tenet of syndemics theory is that disease interactions are driven by social factors, and that these factors have to be understood in order to reduce the health burdens of local populations. Without an understanding of the theory and how it is being put into practice, there is a strong possibility of losing the potential for syndemic theory to positively impact change at community and individual level.

METHODS

Following an initial database search that produced 921 articles, we developed a multi-stage scoping review process identifying invention studies that employ syndemic theory. Inclusion was defined as the presence of healthcare interventions examining multiple social-biological outcomes, refering to a specific (local) at risk population, developing or attempting to develop interventions impacting upon multiple health and/or social targets, and explicit employment of syndemic theory in developing the intervention.

RESULTS

A total of 45 articles contained a substantial engagement with syndemic theory and an original healthcare intervention. However, only eleven studies out of all 921 articles met the inclusion criteria.

DISCUSSION/CONCLUSION

It is strongly suggested that when employing syndemic theory researchers focus close attention to demonstrating disease interactions, providing evidence of the social drivers of these disease interactions, and constructing interventions grounded in these analytical findings. We conclude that although frequently referred to, syndemic theory is rarely employed in its entirety and recommend that interventions be developed using a more thorough grounding in this important and powerful theory.

Provider perspectives on screening and treatment for opioid use disorder and mental health in HIV care: A qualitative study

BACKGROUND

HIV, opioid use disorder (OUD), and mental health challenges share multiple syndemic risk factors. Each can be effectively treated with routine outpatient appointments, medication management, and psychosocial support, leading implementers to consider integrated screening and treatment for OUD and mental health in HIV care. Provider perspectives are crucial to understanding barriers and strategies for treatment integration.

METHODS

We conducted in-depth qualitative interviews with 21 HIV treatment providers and social services providers (12 individual interviews and 1 group interview with 9 participants) to understand the current landscape, goals, and priorities for integrated OUD, mental health, and HIV care. Providers were purposively recruited from known clinics in Mecklenburg County, North Carolina, U.S.A. Data were analyzed using applied thematic analysis in the NVivo 12 software program and evaluated for inter-coder agreement.

RESULTS

Participants viewed substance use and mental health challenges as prominent barriers to engagement in HIV care. However, few organizations have integrated structured screening for substance use and mental health into their standard of care. Even fewer screen for opioid use. Although medication assisted treatment (MAT) is effective for mitigating OUD, providers struggle to connect patients with MAT due to limited referral options, social barriers such as housing and food insecurity, overburdened staff, stigma, and lack of provider training. Providers believed there would be clear benefit to integrating OUD and mental health treatment in HIV care but lacked resources for implementation.

CONCLUSIONS

Integration of screening and treatment for substance use and mental health in HIV care could mitigate many current barriers to treatment for all three conditions. Efforts are needed to train HIV providers to provide MAT, expand resources, and implement best practices.

Factors associated with antiretroviral treatment adherence among people living with HIV in Guangdong Province, China: a cross sectional analysis

BACKGROUND

Understanding factors associated with antiretroviral treatment (ART) adherence is crucial for ART success among people living with HIV (PLHIV) in the "test and treat" era. Multiple psychosocial factors tend to coexist and have a syndemic effect on ART adherence. We aimed to explore factors associated with ART adherence and the syndemic effect of multiple psychosocial factors on ART adherence among PLHIV newly starting ART in Guangdong Province, China.

METHODS

Newly diagnosed PLHIV from six cities in Guangdong Province were recruited between May 2018 and June 2019, and then followed up from May 2019 to August 2020. Baseline and follow-up data were collected from a questionnaire and the national HIV surveillance system, the follow-up data of which were analyzed in this study. A Center for Adherence Support Evaluation (CASE) index > 10 points was defined as optimal ART adherence, which was measured via participants' self-reported adherence during follow-up survey. Multivariable logistic regression was used to identify factors associated with ART adherence. Exploratory factor analysis (EFA) and multi-order latent variable structural equation modeling (SEM) were performed to explore the syndemic effect of multiple psychosocial factors on ART adherence.

RESULTS

A total of 734 (68.53%) follow-up participants were finally included in this study among the 1071 baseline participants, of whom 91.28% (670/734) had self-reported optimal ART adherence. Unemployment (aOR = 1.75, 95%CI: 1.01-3.02), no medication reminder (aOR = 2.28, 95%CI: 1.09-4.74), low medication self-efficacy (aOR = 2.28, 95%CI: 1.27-4.10), low social cohesion (aOR = 1.82, 95%CI: 1.03-3.19), no social participation (aOR = 5.65, 95%CI: 1.71-18.63), and ART side effects (aOR = 0.46, 95%CI: 0.26-0.81) were barriers to optimal ART adherence. The EFA and second-order latent variable SEM showed a linear relationship (standardized coefficient = 0.43, P < 0.001) between ART adherence and the latent psychosocial (syndemic) factor, which consisted of the three latent factors of medication beliefs and self-efficacy (standardized coefficient = 0.65, P < 0.001), supportive environment (standardized coefficient = 0.50, P < 0.001), and negative emotions (standardized coefficient=-0.38, P < 0.01). The latent factors of medication beliefs and self-efficacy, supportive environment, and negative emotions explained 42.3%, 25.3%, and 14.1% of the variance in the latent psychosocial factor, respectively.

CONCLUSIONS

About nine out of ten PLHIV on ART in Guangdong Province self-reported optimal ART adherence. However, more efforts should be made to address barriers to optimal ART adherence.

The impact of syndemic burden, age, and sexual minority status on internalized HIV stigma among people living with HIV in South Florida

Internalized HIV stigma has been associated with several poor mental and physical health outcomes among people living with HIV (PLWH); yet, little research has explored how internalized HIV stigma may be affected by syndemic burden. This study sought to examine the relationship between syndemic conditions and HIV stigma over and above the potential effects of two social determinants of health, age and sexual minority status, using a linear regression approach (N = 1343). Syndemic burden was significantly positively associated with internalized HIV stigma above and beyond the effects of age and sexual minority status (b = 0.23). Additionally, age (b = -0.02) and being a sexually minority (b = -0.31) were significantly negatively associated with internalized HIV stigma. Findings should inform future treatment targets for this population by specifically working to reduce internalized HIV stigma for people with a greater syndemic burden and, potentially, among young adults and heterosexual PLWH.

Developing an mHealth program to improve HIV care continuum outcomes among young Black gay and bisexual men

BACKGROUND

Young Black gay and bisexual men (YBGBM) in the United States face significant disparities in HIV care outcomes. Mobile health (mHealth) interventions have shown promise with improving outcomes for YBGBM across the HIV care continuum.

METHODS

We developed an mHealth application using human-centered design (HCD) from 2019-2021 in collaboration with YBGBM living with HIV and with HIV service providers. Our HCD process began with six focus groups with 50 YBGBM and interviews with 12 providers. These insights were used to inform rapid prototyping, which involved iterative testing and refining of program features and content, with 31 YBGBM and 12 providers. We then collected user feedback via an online survey with 200 YBGBM nationwide and usability testing of a functional prototype with 21 YBGBM.

RESULTS

Focus groups and interviews illuminated challenges faced by YBGBM living with HIV, including coping with an HIV diagnosis, stigma, need for social support, and a dearth of suitable information sources. YBGBM desired a holistic approach that could meet the needs of those newly diagnosed as well as those who have been living with HIV for many years. Program preferences included video-based content where users could learn from peers and experts, a range of topics, a community of people living with HIV, and tools to support their health and well-being. Providers expressed enthusiasm for an mHealth program to improve HIV care outcomes and help them serve clients. Rapid prototyping resulted in a list of content topics, resources, video characteristics, community features, and mHealth tools to support adherence, retention, goal setting, and laboratory results tracking, as well as tools to help organization staff to support clients. Online survey and usability testing confirmed the feasibility, acceptability, and usability of the content, tools, and features.

CONCLUSIONS

This study demonstrates the potential of a video-based mHealth program to address the unique needs of YBGBM living with HIV, offering support and comprehensive information through a user-friendly interface and videos of peers living with HIV and of experts. The HCD approach allowed for continuous improvements to the concept to maximize cultural appropriateness, utility, and potential effectiveness for both YBGBM and HIV service organizations.

Intersectional stigma and the non-communicable disease syndemic in the context of HIV: protocol for a multisite, observational study in the USA

INTRODUCTION

The increasing burden of non-communicable diseases, such as hypertension, diabetes and dyslipidaemia, presents key challenges to achieving optimal HIV care outcomes among ageing people living with HIV. These diseases are often comorbid and are exacerbated by psychosocial and structural inequities. This interaction among multiple health conditions and social factors is referred to as a syndemic. In the USA, there are substantial disparities by social position (ie, racial, ethnic and socioeconomic status) in the prevalence and/or control of non-communicable diseases and HIV. Intersecting stigmas, such as racism, classism and homophobia, may drive these health disparities by contributing to healthcare avoidance and by contributing to a psychosocial syndemic (stress, depression, violence victimisation and substance use), reducing success along the HIV and non-communicable disease continua of care. Our hypothesis is that marginalised populations experience disparities in non-communicable disease incidence, prevalence and control, mediated by intersectional stigma and the psychosocial syndemic.

METHODS AND ANALYSIS

Collecting data over a 4 year period, we will recruit sexual minority men (planned n=1800) enrolled in the MACS/WIHS Combined Cohort Study, a long-standing mixed-serostatus observational cohort in the USA, to investigate the following specific aims: (1) assess relationships between social position, intersectional stigma and the psychosocial syndemic among middle-aged and ageing sexual minority men, (2) assess relationships between social position and non-communicable disease incidence and prevalence and (3) assess relationships between social position and HIV and non-communicable disease continua of care outcomes, mediated by intersectional stigma and the psychosocial syndemic. Analyses will be conducted using generalised structural equation models using a cross-lagged panel model design.

ETHICS AND DISSEMINATION

This protocol is approved as a single-IRB study (Advarra Institutional Review Board: Protocol 00068335). We will disseminate results via peer-reviewed academic journals, scientific conferences, a dedicated website, site community advisory boards and forums hosted at participating sites.

Nurse-led approaches to address social determinants of health and advance health equity: A new framework and its implications

BACKGROUND

The U.S. health care system is burdened by inefficiencies, longstanding health inequities, and unstainable costs. Within the nursing profession and the broader health care sector, there is growing recognition of the need for a paradigm shift that addresses persistent structural problems and advances health equity.

PURPOSE

Despite evidence of the importance of the social determinants of health (SDOH) in shaping inequitable health outcomes, practical tools for applying SDOH theory in the development of effective nurse-led programs to mitigate harmful SDOH remain scarce.

METHODS

We synthesize extant SDOH literature into a heuristic framework for conceptualizing core SDOH mechanisms, constructs, and principles.

FINDINGS

To illustrate how nurse scientists can use the framework to guide the development of programs for SDOH mitigation, we outline a three-step exemplar application to the U.S. Latino HIV epidemic.

DISCUSSION

Our framework can inform a paradigm shift toward nurse-led, multi-level SDOH mitigation across practice, education, and research.

Methodologies used in studies examining substance abuse, violence and HIV/AIDS (SAVA) constructs using a syndemic framework: a scoping review

The syndemic theoretical framework has been used in health disparities research to explain several co-occurring epidemics, particularly in populations facing disparate health conditions. A prominent example of this is seen in Singer's Substance Abuse, Violence and HIV/AIDS (SAVA) syndemic theory. However, even though numerous studies support some of the theoretical underpinnings of the SAVA syndemic, the empirical applications of the theory remain methodologically underdeveloped. The current review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review (PRISMA-ScR), to present the state of the science of methodologies examining SAVA constructs using the syndemic framework. Seven bibliographic databases were searched with no language or date restrictions. Studies were synthesized by author, year of publication, study location, total sample size, study population, SAVA outcomes, analytic method of SAVA measurement, intervention type, level of influence, disease interaction and concentration, main findings of the study, and possible future areas of research. Our search yielded a total of 967 articles, and 123 were included in the review. Methodologic and statistical innovation is needed to elevate the impact of syndemic theory for elucidating the synergistic effects of determinants leading to health disparities.

A Trauma-Informed, Geospatially Aware, Just-in-Time Adaptive mHealth Intervention to Support Effective Coping Skills Among People Living With HIV in New Orleans: Development and Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

In 2020, Greater New Orleans, Louisiana, was home to 7048 people living with HIV-1083 per 100,000 residents, 2.85 times the US national rate. With Louisiana routinely ranked last in indexes of health equity, violent crime rates in Orleans Parish quintupling national averages, and in-care New Orleans people living with HIV surviving twice the US average of adverse childhood experiences, accessible, trauma-focused, evidence-based interventions (EBIs) for violence-affected people living with HIV are urgently needed.

OBJECTIVE

To meet this need, we adapted Living in the Face of Trauma, a well-established EBI tailored for people living with HIV, into NOLA GEM, a just-in-time adaptive mobile health (mHealth) intervention. This study aimed to culturally tailor and refine the NOLA GEM app and assess its acceptability; feasibility; and preliminary efficacy on care engagement, medication adherence, viral suppression, and mental well-being among in-care people living with HIV in Greater New Orleans.

METHODS

The development of NOLA GEM entailed identifying real-time tailoring variables via a geographic ecological momentary assessment (GEMA) study (n=49; aim 1) and place-based and user-centered tailoring, responsive to the unique cultural contexts of HIV survivorship in New Orleans, via formative interviews (n=12; aim 2). The iOS- and Android-enabled NOLA GEM app leverages twice-daily GEMA prompts to offer just-in-time, in-app recommendations for effective coping skills practice and app-delivered Living in the Face of Trauma session content. For aim 3, the pilot trial will enroll an analytic sample of 60 New Orleans people living with HIV individually randomized to parallel NOLA GEM (intervention) or GEMA-alone (control) arms at a 1:1 allocation for a 21-day period. Acceptability and feasibility will be assessed via enrollment, attrition, active daily use through paradata metrics, and prevalidated usability measures. At the postassessment time point, primary end points will be assessed via a range of well-validated, domain-specific scales. Care engagement and viral suppression will be assessed via past missed appointments and self-reported viral load at 30 and 90 days, respectively, and through well-demonstrated adherence self-efficacy measures.

RESULTS

Aims 1 and 2 have been achieved, NOLA GEM is in Beta, and all aim-3 methods have been reviewed and approved by the institutional review board of Tulane University. Recruitment was launched in July 2023, with a target date for follow-up assessment completion in December 2023.

CONCLUSIONS

By leveraging user-centered development and embracing principles that elevate the lived expertise of New Orleans people living with HIV, mHealth-adapted EBIs can reflect community wisdom on posttraumatic resilience. Sustainable adoption of the NOLA GEM app and a promising early efficacy profile will support the feasibility of a future fully powered clinical trial and potential translation to new underserved settings in service of holistic survivorship and well-being of people living with HIV.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05784714; https://clinicaltrials.gov/ct2/show/NCT05784714.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/47151.

The impact of multiple-behavior HIV interventions as a function of regional disadvantages: An analysis of syndemics

OBJECTIVE

Disadvantaged populations, including inhabitants of developing countries as well as racial/ethnic and sexual minorities in the United States, are disproportionally burdened by human immunodeficiency virus (HIV) infection, delayed HIV diagnosis, and unfavorable HIV-treatment outcomes. HIV interventions targeting single behaviors (e.g., testing) in these populations have shown to be efficacious at producing behavioral and clinical change but have been unable to eliminate the social health disparities associated with syndemics (i.e., a set of connected risks, interacting synergistically, and contributing to excess burden of disease in a population).

METHOD

This meta-analysis of 331 reports (clusters; number of effect sizes [k] = 1,364) assessed whether multiple-behavior interventions that target clusters of syndemic risks are more efficacious for those in disadvantaged regions and social groups.

RESULTS

Across the board, multiple-behavior interventions were more efficacious than single-behavior ones as well as passive control groups among samples from countries with lower log gross domestic product (GDP), lower Human Development Index (HDI), and lower Healthcare Access and Quality (HAQ) Index.

CONCLUSIONS

Within the United States, the efficacy of multiple-behavior interventions was similar across different levels of representation of racial/ethnic and sexual minorities. The analyses used robust variance estimation with small-sample corrections to assess the differential effects of multiple-behavior interventions and Egger Sandwich test with the multilevel meta-analysis approach to detect selection biases. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Stimulant use, HIV, and immune dysregulation among sexual minority men

BACKGROUND

Sexual minority men (SMM) report high rates of stimulant use (e.g., crystal methamphetamine, cocaine) and HIV infection. Stimulant use contributes to immune dysfunction, which enhances risk for HIV acquisition and pathogenesis. Research is needed to examine the independent and interactive relationships of stimulant use and HIV infection with systemic immune dysregulation among SMM, especially during the COVID-19 pandemic.

METHODS

From 2020-2022, 75 SMM in Miami, Florida with and without HIV completed an online survey and provided biospecimens to assess HIV status and viral load (VL), recent stimulant use, and soluble markers of immune activation and inflammation in plasma, including soluble CD14 (sCD14) and elevated high-sensitivity C-reactive protein (hs-CRP > 1.0mg/L). Sociodemographics and prior SARS-CoV-2 infection were compared across HIV status/stimulant use groups. Moderation models examined the independent and interactive associations of stimulant use and HIV status with sCD14 and elevated hs-CRP.

RESULTS

Thirty participants were persons living with HIV (PWH) (50% with stimulant use), and 45 were HIV-negative (44% with stimulant use). SARS-CoV-2 infection was not associated with stimulant use/HIV groups or immune outcomes. HIV-negative SMM without stimulant use had lower sCD14 compared to other SMM, as well as lower odds of elevated hs-CRP compared to PWH who used stimulants. Stimulant use showed independent associations with immune dysregulation that persisted after controlling for HIV status and VL, whereas HIV status was only independently associated with elevated hs-CRP in one model not controlling for VL.

CONCLUSIONS

Among SMM, stimulant use was independently associated with elevated immune activation and inflammation.

Factors Associated with Antiretroviral Therapy Adherence Among a Community-Based Sample of Sexual Minority Older Adults with HIV

Older sexual minorities (e.g., gay, bisexual) living with HIV are at risk for poor HIV outcomes due to their frequent experience with both psychosocial challenges and structural barriers to care. This study utilized a stochastic search variable selection (SVSS) approach to explore potential psychosocial and structural factors associated with HIV-related health outcomes among a community-based sample of older sexual minorities (N = 150) in South Florida, an U.S. HIV-epidemic epicenter. After SVSS, a forward entry regression approach suggested unstable housing, illicit substance use, current nicotine use, and depression were all associated with poorer ART adherence among older sexual minority adults living with HIV. No associations between potential correlates and biological measures of HIV disease severity were observed. Findings highlight a need to focus on multiple levels of intervention that target a combination of psychosocial and structural factors to improve HIV-care outcomes among older sexual minorities and achieve Ending the HIV Epidemic goals.

Amphetamine use and its associations with antiretroviral adherence and viral load among sexual minority men and transgender women living with HIV

Substance use has complex associations to HIV disease progression. The current study tested the associations between several substances and HIV viral load while accounting for confounders relevant to HIV disease progression and substance use. Young sexual minority men and transgender women living with HIV (LWH) in Georgia (N = 385) completed measures and biological tests for HIV viral load and substance use. Multivariable regression models tested the role of specific drugs (i.e., alcohol, cannabis/THC, cocaine, and combined amphetamine and methamphetamine) directly on viral load and indirectly through antiretroviral (ART) adherence. ART adherence and HIV care self-efficacy were consistently associated with greater HIV suppression. Alcohol and cocaine were not associated with ART adherence or viral load. Cannabis was negatively associated with ART adherence (B = -.053, p = .037) but not viral load. Amphetamine/methamphetamine demonstrated significant direct effects on higher viral load (B = .708, p = .010) while indirectly influencing viral load through a negative association with ART adherence. Our findings support previous research demonstrating amphetamine/methamphetamine use impacts viral load both directly and indirectly through ART adherence. Interventions addressing amphetamine/methamphetamine use by young sexual minority men and transgender women LWH are urgently needed, and future research should focus on determining the mechanisms by which formulations of amphetamine impact HIV replication.Trial registration: ClinicalTrials.gov identifier: NCT03665532.

"What's Sex and Gender Got to Do With It?" A Scoping Review of Sex- and Gender-Based Analysis in Pharmacoepidemiologic Studies of Medication Adherence

OBJECTIVES

Medication taking is a complex multidimensional behavior that may be impeded by a range of biological and psychosocial factors, including sex and gender. We aimed to synthesize how sex and gender have been reported and analyzed in pharmacoepidemiologic studies of medication.

METHODS

We searched for English-language peer-reviewed articles of observational studies (eg, cross-sectional, cohort, and case-control) that examined medication adherence among adults and included sex or gender in their reporting.

RESULTS

We included 937 studies among 530 537 287 participants published between the year 1979 and 2021. Most studies were cross-sectional (47%), lasted ≤ 1 year (35%), examined self-reported adherence (53%), did not assess specific adherence problem(s) (40%), and included medications for cardiovascular conditions (24%) or systemic infections (24%). A quarter of studies (25%) used sex and gender interchangeably, more than one third of studies (36%) that reported gender data likely collected data on sex, and < 1% of studies described sex and gender as distinct variables. Studies of cisgender participants more often reported that females/women experienced greater adherence problems often than males/men (31% vs 20%), particularly discontinuation and cost-related nonadherence. Only 21 studies (2%) reported on transgender individuals, and these predominantly examined antiretroviral medications for HIV.

CONCLUSIONS

Our review revealed substantial conflation of sex and gender in studies of medication adherence and a paucity of research among transgender individuals. Moreover, our synthesis showed sex/gender disparities in medication taking with studies reporting greater medication adherence problems among cisgender women and transgender participants than cisgender men.

PrEP awareness and use among reproductive age women in Miami, Florida

BACKGROUND

Miami, Florida is an epicenter of the HIV epidemic in the US, with 20% of new HIV infections occurring in women. Despite effectiveness of Pre-Exposure Prophylaxis (PrEP) in preventing HIV, only 10% of eligible women benefit from its use.

SETTING

This study evaluates PrEP awareness and use, and factors associated with PrEP awareness among sexually active women in Miami, Florida.

METHODS

Results reported in this study included cross-sectional data that were collected as part of a baseline visit from a parent study. Cis-gender, HIV-negative, 18-45-year-old, sexually active women were recruited as part of a study evaluating recurrent bacterial vaginosis and HIV risk. Participants completed questionnaires assessing socio-demographics, HIV risk factors, prior history of HIV testing and reproductive tract infections, PrEP awareness and use. Relationships between variables and PrEP awareness were analyzed and multivariable logistic regression identified variables strongly associated with PrEP awareness.

RESULTS

Among the 295 women enrolled, median age was 31 (24-38) years, 49% Black, 39% White, and 34% Hispanic. Of 63% who knew about PrEP, only 5% were on PrEP. Women with income below poverty line (OR = 2.00[1.04,3.87];p = 0.04), more male sexual partners in past month (OR = 1.30[1.01,1.68];p = 0.04), lifetime HIV testing (OR = 6.42[2.83,14.52];p<0.01), and current bacterial vaginosis (OR = 2.28[1.18,4.40];p = 0.01) were more likely to be aware of PrEP. Lower odds of PrEP awareness were associated with being Black (OR = 0.38[0.15,0.96];p = 0.04), Hispanic (OR = 0.18[0.08,0.39];p<0.01), heterosexual (OR = 0.29[0.11,0.77];p<0.01), and reporting inconsistent condom use during vaginal sex (OR = 0.21[0.08,0.56];p<0.01).

CONCLUSION

PrEP awareness is low among reproductive age women in a high-risk setting. Culturally tailored interventions are needed to increase PrEP awareness and uptake, especially among Black and Hispanic women with inconsistent condom use during vaginal sex with male partners.

Intersecting Relationships of Psychosocial and Structural Syndemic Problems Among People with HIV in South Africa: Using Network Analysis to Identify Influential Problems

In South Africa, little is known about interrelationships between syndemic problems among people with HIV (PWH). A better understanding of syndemic problems may yield important information regarding factors amenable to mitigation. We surveyed 194 PWH in Khayelitsha, outside of Cape Town, South Africa. We used network analysis to examine the frequency of 10 syndemic problems and their interrelationships. Syndemic problems among PWH in South Africa were common; 159 (82.8%) participants reported at least 2 co-occurring syndemic problems and 90 (46.9%) endorsed 4 or more. Network analysis revealed seven statistically significant associations. The most central problems were depression, substance use, and food insecurity. Three clusters of syndemics were identified: mood and violence; structural factors; and behavioral factors. Depression, substance use, and food insecurity commonly co-occur among PWH in sub-Saharan Africa and interfere with HIV outcomes. Network analysis can identify intervention targets to potentially improve HIV treatment outcomes.

Intersectional stigma and gender non-affirmation hinder HIV care engagement among transgender women living with HIV in India

Among transgender women living with HIV (TGWLH) in India, little is understood about the mechanisms through which multiple intersecting stigmas impact HIV care engagement, or intervention strategies that might mitigate this impact. We conducted focus groups with TGWLH (N = 30) in three Indian cities and analysed data using theoretical frameworks related to HIV stigma, gender affirmation, and syndemics. Findings revealed that enacted and anticipated stigma due to transgender identity, HIV, or sex work status, and lack of gender affirmation (e.g., misgendering) in healthcare settings delayed ART initiation and promoted care disengagement. Having supportive physicians and counsellors within ART centres and peer outreach workers facilitated ART initiation, adherence, and retention. Findings also revealed that HIV stigma within TGW communities led to concealment of HIV status or syndemic conditions such as depression and alcohol use, thereby affecting care engagement. However, the TGW community itself was also described as a resilience resource, offering emotional, psychological and tangible support that decreased the impact of discrimination on care engagement. HIV care engagement efforts among Indian TGWLH could be strengthened by reducing intersecting stigmas in healthcare settings and within TGW communities, providing gender-affirming and culturally competent healthcare, addressing psychosocial syndemic conditions, and strengthening support within transgender communities.

Critical Perspectives on Expanding Racial/Ethnic Diversity in the HIV Research Workforce: Comorbidities and Mentoring

HIV-related comorbidities in underrepresented minority populations are reframed to include the co-occurring problems of systemic and structural barriers, within the mentoring context as a buffer and as action-oriented. This framework is discussed to improve racial and ethnic minority diversity in the research workforce from the perspectives of HIV comorbidities and mentoring. An integrated and coordinated approach to HIV-related comorbidities and inequities may be helpful when combined with research on the social-structural contributions as drivers to diversify the research workforce. We emphasize how these key research issues (a) provide a platform for training and retraining a highly motivated, diverse workforce and (b) facilitate the empowerment of these trained individuals to conduct rigorous scientific research on social-structural factors to mitigate the effects of these comorbidities. We conclude that a diverse research workforce is necessary but insufficient for improving training-related outcomes or reducing comorbidity effects. Additional considerations are warranted that include systemic approaches and changes at the structural and institutional levels.

Structural violence and the uncertainty of viral undetectability for African, Caribbean and Black people living with HIV in Canada: an institutional ethnography

Biomedical advances in healthcare and antiretroviral treatment or therapy (ART) have transformed HIV/AIDS from a death sentence to a manageable chronic disease. Studies demonstrate that people living with HIV who adhere to antiretroviral therapy can achieve viral suppression or undetectability, which is fundamental for optimizing health outcomes, decreasing HIV-related mortality and morbidity, and preventing HIV transmission. African, Caribbean, and Black (ACB) communities in Canada remain structurally disadvantaged and bear a disproportionate burden of HIV despite biomedical advancements in HIV treatment and prevention. This institutional ethnography orients to the concept of 'structural violence' to illuminate how inequities shape the daily experiences of ACB people living with HIV across the HIV care cascade. We conducted textual analysis and in-depth interviews with ACB people living with HIV (n = 20) and health professionals including healthcare providers, social workers, frontline workers, and health policy actors (n = 15). Study findings produce a cumulative understanding that biomedical HIV discourses and practices ignore structural violence embedded in Canada's social fabric, including legislation, policies and institutional practices that produce inequities and shape the social world of Black communities. Findings show that inequities in structural and social determinants of health such as food insecurity, financial and housing instability, homelessness, precarious immigration status, stigma, racial discrimination, anti-Black racism, criminalization of HIV non-disclosure, health systems barriers and privacy concerns intersect to constrain engagement and retention in HIV healthcare and ART adherence, contributing to the uncertainty of achieving and maintaining undetectability and violating their right to health. Biomedical discourses and practices, and inequities reduce Black people to a stigmatized, pathologized, and impoverished detectable viral underclass. Black people perceived as nonadherent to ART and maintain detectable viral loads are considered "bad" patients while privileged individuals who achieve undetectability are considered "good" patients. An effective response to ending HIV/AIDS requires implementing policies and institutional practices that address inequities in structural and social determinants of health among ACB people.

Efficacy of an mHealth self-management intervention for persons living with HIV: the WiseApp randomized clinical trial

IMPORTANCE

Progression of HIV disease, the transmission of the disease, and premature deaths among persons living with HIV (PLWH) have been attributed foremost to poor adherence to HIV medications. mHealth tools can be used to improve antiretroviral therapy (ART) adherence in PLWH and have the potential to improve therapeutic success.

OBJECTIVE

To determine the efficacy of WiseApp, a user-centered design mHealth intervention to improve ART adherence and viral suppression in PLWH.

DESIGN, SETTING, AND PARTICIPANTS

A randomized (1:1) controlled efficacy trial of the WiseApp intervention arm (n = 99) versus an attention control intervention arm (n = 101) among persons living with HIV who reported poor adherence to their treatment regimen and living in New York City.

INTERVENTIONS

The WiseApp intervention includes the following components: testimonials of lived experiences, push-notification reminders, medication trackers, health surveys, chat rooms, and a "To-Do" list outlining tasks for the day. Both study arms also received the CleverCap pill bottle, with only the intervention group linking the pill bottle to WiseApp.

RESULTS

We found a significant improvement in ART adherence in the intervention arm compared to the attention control arm from day 1 (69.7% vs 48.3%, OR = 2.5, 95% CI 1.4-3.5, P = .002) to day 59 (51.2% vs 37.2%, OR = 1.77, 95% CI 1.0-1.6, P = .05) of the study period. From day 60 to 120, the intervention arm had higher adherence rates, but the difference was not significant. In the secondary analyses, no difference in change from baseline to 3 or 6 months between the 2 arms was observed for all secondary outcomes.

CONCLUSIONS

The WiseApp intervention initially improved ART adherence but did not have a sustained effect on outcomes.

Differential Effects of Patient Navigation across Latent Profiles of Barriers to Care among People Living with HIV and Comorbid Conditions

Engaging people living with HIV who report substance use (PLWH-SU) in care is essential to HIV medical management and prevention of new HIV infections. Factors associated with poor engagement in HIV care include a combination of syndemic psychosocial factors, mental and physical comorbidities, and structural barriers to healthcare utilization. Patient navigation (PN) is designed to reduce barriers to care, but its effectiveness among PLWH-SU remains unclear. We analyzed data from NIDA Clinical Trials Network's CTN-0049, a three-arm randomized controlled trial testing the effect of a 6-month PN with and without contingency management (CM), on engagement in HIV care and viral suppression among PLWH-SU (n = 801). Latent profile analysis was used to identify subgroups of individuals' experiences to 23 barriers to care. The effects of PN on engagement in care and viral suppression were compared across latent profiles. Three latent profiles of barriers to care were identified. The results revealed that PN interventions are likely to be most effective for PLWH-SU with fewer, less severe healthcare barriers. Special attention should be given to individuals with a history of abuse, intimate partner violence, and discrimination, as they may be less likely to benefit from PN alone and require additional interventions.

Anterior Insula Activation During Cardiac Interoception Relates to Depressive Symptom Severity in HIV-Positive and HIV-Negative Postmenopausal Women

OBJECTIVE

This study aimed to determine whether subclinical symptoms of depression in postmenopausal women are associated with blood oxygen level-dependent (BOLD) activity within the anterior insula during cardiac interoceptive awareness and whether this association differs for persons living with the human immunodeficiency virus (PWH).

METHOD

Twenty-three postmenopausal (mean [standard deviation] age = 56.5 [4.8] years) and 27 HIV-negative women (mean [standard deviation] age = 56.4 [8.0]) underwent functional magnetic resonance imaging while performing a heartbeat detection task. BOLD activation within the bilateral anterior insula based on the contrast of a heartbeat detection condition with and without a distracting tone was entered along with age, HIV status, and psychological stress into two multivariate regression models with self-reported depressive symptom severity as the outcome.

RESULTS

Depressive symptoms did not vary by HIV status, nor was there a main effect or interaction for PWH on insula BOLD activation. Depressive symptoms were positively associated with psychological stress for the left ( β = 0.310, t (49) = 2.352, p = .023) and right brain models ( β = 0.296, t (49) = 2.265, p = .028) as well as the magnitude of BOLD activation in the left insula ( β = 0.290, t (49) = 2.218, p = .032) and right insula ( β = 0.318, t (49) = 2.453, p = .018), respectively. Exploratory analyses revealed that greater magnitude of BOLD activation attributed to exteroceptive noise (tone) was also correlated with self-reported distrust and preoccupation with interoceptive sensations.

CONCLUSIONS

Results support an active interference model for interoceptive awareness wherein greater BOLD signal in the anterior insula in the presence of distracting exteroceptive stimuli may reflect greater prediction error, a feature of depression.

A Syndemic Approach to Explore Factors Associated with Bacterial Vaginosis

Bacterial vaginosis (BV) is the most common genital infection in women and is associated with an increased risk of sexually transmitted infections and HIV. This study uses a syndemic approach to evaluate factors associated with BV. Non-pregnant, HIV-negative, sexually active, cis-gender women aged 18-45 years living in Miami, Florida were recruited from Nov.2018- Jun.2021. Participants completed a sociodemographic and behavioral questionnaire along with gynecological examinations. BV was diagnosed by Amsel criteria and confirmed by a Nugent score ≥ 4. A syndemic score was calculated as the sum of factors associated with BV. The association between syndemic score and BV was assessed using logistic regression. Of 166 women included, 60.2% had BV. Race, ethnicity, education, vaginal sex, recent cannabis use, and reasons for intravaginal practices were included in the syndemic score. Higher odds of BV were found in women with a score of ≥ 3 compared to women with a score of 0/1. A higher syndemic score was associated with increased odds of having BV. Multilevel interventions to decrease BV are needed to decrease women's risk of acquiring HIV.

Development of an Implementation Facilitation Strategy to Link Mental Health Screening and eHealth Intervention for Clients in Ryan White-Funded Clinics in Chicago

BACKGROUND

To reduce the impact of depression on people living with HIV, we are implementing a clinic-based behavioral health screener and referral to Optimizing Resilience and Coping with HIV through Internet Delivery, an evidenced-based intervention. We used the Consolidated Framework for Implementation Research to identify contextual barriers and facilitators in advance of implementation.

SETTING

Sixteen Chicagoland area Ryan White Medical Case Management sites.

METHODS

We conducted a sequential mixed-methods study with medical case managers and supervisors. Participants completed an online survey assessing Consolidated Framework for Implementation Research domains, scored on a 1 (strongly disagree) to 5 (strongly agree) scale. Survey results informed a purposive sampling frame and interview protocol. Interviews were analyzed by rapid qualitative analysis.

RESULTS

On average, survey respondents (n = 58) slightly agreed with positive views of team culture, learning climate, and implementation readiness (mean = 3.80-3.87). Potential barriers included intervention complexity (mean = 3.47), needed human resources (mean = 2.71-3.33), and only slight agreement with relative advantage over existing screening/referral systems (mean = 3.09-3.71). Qualitative results (n = 15) identified low advantage for clinics with robust behavioral health systems but strong advantage in clinics without these services. Respondents identified system-wide training and monitoring strategies to facilitate implementation.

CONCLUSIONS

Ryan White Medical Case Management sites are a generally favorable context for the implementation of the interventions. As illustrated in an implementation research logic model, barriers will be addressed through deploying strategies proposed to impact clinic- and individual-level outcomes, including electronic prompts (reduce complexity), training on Optimizing Resilience and Coping with HIV through Internet Delivery as a complement to other behavioral health services (increase relative advantage), and feedback during implementation (strengthen rewards/incentives).

The role of health facility and individual level characteristics on medication adherence among PLHIV on second-line antiretroviral therapy in Northeast Ethiopia: use of multi-level model

BACKGROUND

Medication adherence plays a pivotal role in achieving the desired treatment outcomes. The proportion of HIV patients on second-line antiretroviral therapy is becoming a growing public health concern. However, to date, little attention has been given to second-line antiretroviral medication adherence. Moreover, the association between health facility characteristics and medication adherence has yet not been tested. Thus, this research was conducted to determine the magnitude of medication adherence and examine the role of facility-level determinants among HIV patients on second-line ART.

METHODS

A cross-sectional study was conducted on 714 HIV patients on second-line therapy who were selected via systematic random sampling in twenty public health facilities. Medication adherence was measured using the six-item Simplified Medication Adherence Questionnaire (SMAQ) tool. Data were collected in a personal interview as well as document reviews. A multi-level binary logistic regression was used to uncover individual and facility-level determinants. The effect size was presented using an adjusted odds ratio (AOR), and statistical significance was declared at a P value less than 0.05.

RESULTS

The magnitude of optimal medication adherence among HIV patients on second-line antiretroviral therapy was 69.5% (65.9-72.7%). Medication adherence was positively associated with the use of adherence reminder methods [AOR = 3.37, (95% CI 2.03-5.62)], having social support [AOR = 1.11, (95% CI 1.02-1.23)], and not having clinical depression [AOR = 3.19, (95% CI 1.93-5.27). The number of adherence counselors [AOR = 1.20, (95% CI 1.04-1.40)], teamwork for enhanced adherence support [AOR = 1.82, (95% CI 1.01-3.42)], and caseloads at ART clinics were all significantly correlated with ARV medication adherence at the facility level.

CONCLUSIONS

A large proportion of HIV patients on second-line antiretroviral therapy had adherence problems. Both facility-level and individual-level were linked with patient medication adherence. Thus, based on the identified factors, individual and system-level interventions should be targeted.

Social Determinants of Disease: HIV and COVID-19 Experiences

PURPOSE OF REVIEW

The differential impact of the COVID-19 and HIV pandemics on marginalized communities has renewed calls for more robust and deeper investigation into structural and social causes of health inequities contributing to these infections, including underlying factors related to systematic racism. Using the Social Determinants of Health (SDOH) framework, we analyzed parallel and divergent factors associated with COVID-19 and HIV/AIDS and the prevalence of disparate disease in diverse communities. We utilized PRISMA guidelines to identify relevant literature (N = 210 articles) that resulted in a review of 125 articles included in our synthesis.

RECENT FINDINGS

With racial health inequities as a core contributor to disease vulnerability, we also identified other factors such as economic stability, social and community support, the neighborhood and built environment, healthcare access and quality, and education access and quality as important socioecological considerations toward achieving health equity. Our review identifies structural and systematic factors that drive HIV and COVID-19 transmission. Our review highlights the importance of not solely focusing on biomedical interventions as solutions to ending HIV and COVID-19, but rather call for building a more just public health and social service safety net that meets the needs of people at the intersection of multiple vulnerabilities.

Relationship Power and Intimate Partner Violence in Sexual Minority Male Couples

Objective: The objective of the present study was to test pathways implied by Disempowerment Theory to predict intimate partner violence (IPV) among men in a same-sex relationship. Background: Sexual minority men in relationships experience rates of IPV comparable with heterosexual women, yet most research on IPV focuses on heterosexual couples. Disempowerment Theory suggests that a range of individual, family-of-origin, and intimate relationship risk factors predict the use of violence to re-establish power in a relationship. Method: Data for the present study were gathered from an online survey completed by sexual minority men currently in a same-sex relationship (n = 339). Analysis of data included two steps: (a) we tested the direct effect of individual, family, and relational predictors on the odds of IPV and (b) we calculated a path model that included relationship power as a link between the predictors (individual, family, and relational) and IPV. Results: In line with Disempowerment Theory, relationship power was negatively associated with IPV. Bivariate analysis indicated an association between childhood sexual abuse and IPV, but childhood sexual abuse was not predictive of IPV through relationship power. Other individual (depression) and relationship-specific (sexual communication and relationship satisfaction) risk factors were associated with IPV indirectly through relationship power. Conclusion: Disempowerment Theory may provide a useful framework for understanding the occurrence of IPV in sexual minority male couples. It may also provide a starting point for the development of multi-component interventions to reduce violence in these couples.

The Impact of COVID-19 on Sexual Behavior and Psychosocial Functioning in a Clinical Sample of Men who have Sex with Men Using HIV Pre-exposure Prophylaxis

The purpose of this study was to evaluate the impact of the Coronavirus Disease 2019 (COVID-19) pandemic on sexual behavior, mental health, and substance use among men who have sex with men (MSM) engaged in pre-exposure prophylaxis (PrEP) care. Generalized linear mixed models and logistic mixed-effect models examined change over time for number of sexual partners, mood, and alcohol consumption. From February 29, 2020 to July 31, 2020, 177 MSM actively engaged in PrEP care were evaluated. The median age was 37 [interquartile range (IQR 30, 51]. Patients in the sample were largely representative of the clinic population and identified as White (73.0%), Black/African American (9.2%), and other race (17.2%), and 11.8% identified as Hispanic/Latino ethnicity. Men reported an average of 2.60 fewer sexual partners (95% CI −4.04, −1.40) during the pandemic compared to pre-COVID-19. Rates of depressive symptoms and alcohol use remained stable and few patients reported substance use. The reduced number of sexual partners may be explained by patients’ efforts to reduce risk of exposure to COVID-19 and low rates of psychosocial symptoms may be indicative of only the highest functioning patients continuing to engage in care. Reductions in sexual partners may offset reduced engagement in care and help mitigate risk of HIV and other sexually transmitted infections (STIs).

Structural Syndemics and Antiretroviral Medication Adherence Among Black Sexual Minority Men Living With HIV

BACKGROUND

Although HIV antiretroviral treatment (ART) access and uptake have increased among racial/ethnic minority individuals, lower rates of ART adherence and viral suppression persist, especially among Black men who have sex with men (BMSM) compared with their White counterparts.

SETTING

Black men who have sex with men living with HIV (BMSM+) residing in Los Angeles County (N = 124) were recruited in-person (eg, clinic) and online (eg, social networking apps).

METHODS

Participants completed a cross-sectional survey measuring demographic characteristics, structural syndemics (poverty, criminal justice involvement, and housing instability), and psychosocial syndemics (mental health and substance use). A text message survey assessed missed doses of ART over the past week. Zero-inflated Poisson regression models were used to evaluate variables associated with the number of missed doses of ART.

RESULTS

On average, participants missed 1.30 doses of ART (SD = 2.09) and reported structural syndemics: poverty (56.1%), criminal justice involvement (36.6%), housing instability (26.3%), and psychosocial syndemics: childhood sexual abuse (51.8%), intimate partner violence (16.9%), depression (39%), and problem alcohol use (15.5%). After controlling for employment, age, education, and psychosocial syndemics, participants with a one-point increase in structural syndemic indicators were found to be 1.63 times more likely to have missed a dose of ART.

CONCLUSIONS

Structural syndemic were associated with ART nonadherence among BMSM+ after adjusting for demographic and psychosocial factors. HIV treatment interventions that incorporate financial incentives, legal support, and housing may help improve ART adherence among BMSM+. Findings suggest that key priorities to ending the HIV epidemic must include structural interventions that alleviate poverty, eliminate disproportionate policing and criminalization, and end homelessness.

Evaluating the effects of two alcohol reduction counseling interventions on intimate partner violence perpetration: secondary analysis of a three-arm randomized controlled trial among Vietnamese men with HIV

BACKGROUND AND AIMS

Evidence suggests that alcohol reduction interventions decrease intimate partner violence (IPV) perpetration, although this remains untested in low- and middle-income countries and among men with human immunodeficiency virus (HIV). This study evaluates the effectiveness of alcohol reduction counseling interventions on IPV perpetration among men on anti-retroviral therapy (ART) and tests whether alcohol use explains the intervention effects.

DESIGN

Secondary analysis of data from a three-arm randomized controlled trial among ART patients with hazardous alcohol use. Participants were recruited from March 2016 to May 2017.

SETTING

Thai Nguyen, Vietnam.

PARTICIPANTS, INTERVENTIONS AND COMPARATORS

Male participants (n = 426). Participants received a two-session brief intervention (BI), a six-session combined intervention (CoI) or the standard of care (SOC), comprising alcohol treatment referrals. Alcohol reduction counseling interventions were guided by cognitive-behavioral therapy and motivational enhancement therapy delivered by psychosocial counselors over 3 months.

MEASUREMENTS

IPV perpetration was measured using the shortened Conflict Tactics Scale 2 and alcohol use was measured using timeline followback.

FINDINGS

BI and CoI participants reported reduced IPV perpetration at 3 months compared with SOC participants [BI: adjusted odds ratio (aOR) = 0.27, 95% confidence interval (CI) = 0.11, 0.65; CoI: aOR = 0.50, 95% CI = 0.22, 1.13]; the association was only significant for the BI group. Intervention effects were not sustained at 6 and 12 months. There was little evidence that alcohol use acted as a mediator (indirect effect, BI: aOR = 0.84, 95% CI = 0.63, 1.04; indirect effect, CoI: aOR = 0.86, 95% CI = 0.66, 1.03).

CONCLUSIONS

Among Vietnamese men receiving anti-retroviral therapy, alcohol reduction counseling interventions appeared to reduce intimate partner violence perpetration immediately post-intervention, but reductions were not sustained at 6 and 12 months and were not explained by alcohol reduction.

Longitudinal Associations of Syndemic Conditions with Antiretroviral Therapy Adherence and HIV Viral Suppression Among HIV-Infected Patients in Primary Care

Psychosocial syndemic conditions have received more attention regarding their deleterious effects on HIV acquisition risk than for their potential impact on HIV treatment and viral suppression. To examine syndemic conditions' impact on the HIV care continuum, we analyzed data collected from people living with HIV (N = 14,261) receiving care through The Centers for AIDS Research Network of Integrated Clinical Systems at seven sites from 2007 to 2017 who provided patient-reported outcomes ∼4-6 months apart. Syndemic condition count (depression, anxiety, substance use, and hazardous drinking), sexual risk group, and time in care were modeled to predict antiretroviral therapy (ART) adherence and viral suppression (HIV RNA <400 copies/mL) using multilevel logistic regression. Comparing patients with each other, odds of ART adherence were 61.6% lower per between-patient syndemic condition [adjusted odds ratio (AOR) = 0.384; 95% confidence interval (CI), 0.362-0.408]; comparing patients with themselves, odds of ART adherence were 36.4% lower per within-patient syndemic condition (AOR = 0.636 95% CI, 0.606-0.667). Odds of viral suppression were 29.3% lower per between-patient syndemic condition (AOR = 0.707; 95% CI, 0.644-0.778) and 27.7% lower per within-patient syndemic condition (AOR = 0.723; 95% CI, 0.671-0.780). Controlling for the effects of adherence (AOR = 5.522; 95% CI, 4.67-6.53), each additional clinic visit was associated with 1.296 times higher odds of viral suppression (AOR = 1.296; 95% CI, 1.22-1.38), but syndemic conditions were not significant. Deploying effective interventions within clinics to identify and treat syndemic conditions and bolster ART adherence and continued engagement in care can help control the HIV epidemic, even within academic medical settings in the era of increasingly potent ART.

Cumulative Burden of Mental Health Factors and Engagement in HIV Care in Argentina

BACKGROUND

Cumulative burden of multiple mental health conditions may worsen physical health outcomes in vulnerable populations. Accordingly, identifying cumulative burdens of mental health conditions that may affect HIV treatment and care can guide public health strategies to reduce their impact on HIV-related health outcomes. This study examined the relationship between the cumulative burden of mental health conditions and factors associated with engagement in HIV care in Argentina.

METHOD

Data for this study was obtained at baseline from Conexiones y Opciones Positivas en la Argentina 2 (COPA2). Participants (N = 360) were cisgender patients living with HIV who were lost to care, recruited from seven clinics serving people living with HIV in four Argentine urban centers. Cumulative burden of mental health conditions (i.e., depressive symptoms, problematic substance use, unhealthy alcohol use, and psychotic symptoms) was assessed.

RESULTS

Every one-point increase in the number of mental health conditions present was associated with a decrement in patient-provider communication (b = - 0.22, p < .001), self-efficacy (b = - 0.13, p = .012), and motivation for adherence (b = - 0.11, p = .039).

CONCLUSION

This study found cumulative burden of depression, problematic substance use, unhealthy alcohol use, and psychotic symptoms to be negatively associated with factors related to engagement in HIV care. Results highlight the importance of identification and treatment of challenges to mental health, in order to ameliorate their influence on engagement in HIV care.

Association between depression and HIV treatment outcomes in a US military population with HIV infection

Background

Depression is common among HIV-infected individuals and may contribute to suboptimal adherence to antiretroviral therapy (ART) and subsequent inability to attain viral load (VL) suppression. We evaluated associations between depression, self-reported adherence, and longitudinal HIV treatment outcomes in US Military HIV Natural History Study (NHS) participants with and without depression.

Methods

Male NHS participants with available ICD-9 data for mental health diagnoses, Center for Epidemiological Studies Depression (CES-D) measures, and self-reported adherence (SRA) were included. ART use was defined as ART initiation between 2006 and 2010, with follow-up through 2015. SRA was defined as taking 95% of ART doses and continuous ART was defined as longitudinal ART use with gaps  < 30 days. Continuous VL suppression was defined as maintaining VLs  < 200 c/mL on ART. To analyse the association between depression and HIV treatment outcomes, latent class analysis was used to create classes of depression trajectories: low depression (LD), recent onset depression (ROD) and high Depression (HD).

Results

Participants had a mean age of 32 (± 8.3) years at HIV diagnosis, and similar proportions were Caucasian (44.3%) or African American (40.8%). Overall, older participants at HIV diagnosis had greater odds of having 95% self-reported adherence (OR 1.06, 95% CI 1.02–1.12), and African Americans had lower odds (OR 0.41, 95% CI 0.22–0.76) compared to Caucasians (OR 1.49, 95% CI 0.52–4.28). However, there was no difference in SRA by depression trajectory. Participants with HD had an increased odds of taking ART continuously (OR 1.75, 95% CI 0.99–3.09), and those with ROD had significantly higher odds of virologic failure (OR 0.58, 95% CI 0.38–0.91).

Conclusions

Although there was no observed association between depression and SRA, participants with ROD had lower odds of attaining the HIV treatment goal of VL suppression. Continued efforts to identify and aggressively manage mental health disorders is important to success along the HIV care continuum.

Syndemics and salivary inflammation in people living with HIV/AIDS

OBJECTIVE

People living with HIV/AIDS (PLWHA) are disproportionally exposed to a host of structural, community, and individual-level physical and psychosocial stressors also termed 'syndemic conditions.' The current study aimed to examine the association between experiencing syndemic conditions and physiological stress response and be associated with bodily inflammation, including Interlekin-6 (IL-6) and C-reactive protein (CRP) in PLWHA.

DESIGN

Participants (N = 103) were recruited from a public HIV clinic. They provided saliva samples of IL-6 and CRP and completed psychosocial measures.

MAIN OUTCOME MEASURES

Levels of circulating salivary IL-6 and CRP.

RESULTS

When predictors (birth country, recent housing instability, and incarceration history) were simultaneously entered into a regression model, only incarceration history was negatively associated with IL-6 [b = -.27, t(98) = -3.11, p = .002]. For CRP, the resulting regression model was not significant, [F(3, 98) = 2.23, p = .090].

CONCLUSION

Although we had expected higher levels of syndemics to be associated with higher levels of circulating inflammation, in our sample, length of incarceration was associated with lower levels of circulating IL-6. Findings are therefore suggestive of a stress response disruption resulting in a negative feedback loop as the long-term impact of chronic stress on inflammation.

Estimating HIV transmissions in a large U.S. clinic-based sample: effects of time and syndemic conditions

INTRODUCTION

Little is known about onward HIV transmissions from people living with HIV (PLWH) in care. Antiretroviral therapy (ART) has increased in potency, and treatment as prevention (TasP) is an important component of ending the epidemic. Syndemic theory has informed modelling of HIV risk but has yet to inform modelling of HIV transmissions.

METHODS

Data were from 61,198 primary HIV care visits for 14,261 PLWH receiving care through the Centers for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS) at seven United States (U.S.) sites from 2007 to 2017. Patient-reported outcomes and measures (PROs) of syndemic conditions - depressive symptoms, anxiety symptoms, drug use (opiates, amphetamines, crack/cocaine) and alcohol use - were collected approximately four to six months apart along with sexual behaviours (mean = 4.3 observations). Counts of syndemic conditions, HIV sexual risk group and time in care were modelled to predict estimated HIV transmissions resulting from sexual behaviour and viral suppression status (HIV RNA < 400/mL) using hierarchical linear modelling.

RESULTS

Patients averaged 0.38 estimated HIV transmissions/100 patients/year for all visits with syndemic conditions measured (down from 0.83, first visit). The final multivariate model showed that per 100 patients, each care visit predicted 0.05 fewer estimated transmissions annually (95% confidence interval (CI): 0.03 to 0.06; p < 0.0005). Cisgender women, cisgender heterosexual men and cisgender men of undisclosed sexual orientation had, respectively, 0.47 (95% CI: 0.35 to 0.59; p < 0.0005), 0.34 (95% CI: 0.20 to 0.49; p < 0.0005) and 0.22 (95% CI: 0.09 to 0.35; p < 0.005) fewer estimated HIV transmissions/100 patients/year than cisgender men who have sex with men (MSM). Each within-patient syndemic condition predicted 0.18 estimated transmissions/100 patients/year (95% CI: 0.12 to 0.24; p < 0.0005). Each between-syndemic condition predicted 0.23 estimated HIV transmissions/100 patients/year (95% CI: 0.17 to 0.28; p < 0.0005).

CONCLUSIONS

Estimated HIV transmissions among PLWH receiving care in well-resourced U.S. clinical settings varied by HIV sexual risk group and decreased with time in care, highlighting the importance of TasP efforts. Syndemic conditions remained a significant predictor of estimated HIV transmissions notwithstanding the effects of HIV sexual risk group and time in care.

Conceptualizing the Effects of Continuous Traumatic Violence on HIV Continuum of Care Outcomes for Young Black Men Who Have Sex with Men in the United States

The United States (US) is on track to achieve the 90-90-90 targets set forth by UNAIDS and the National HIV/AIDS strategy, yet significant racial disparities in HIV care outcomes remain, particularly for young Black men who have sex with men (YBMSM). Research has demonstrated that various types of violence are key aspects of syndemics that contribute to disparities in HIV risk. However, little research has looked collectively at cumulative violent experiences and how those might affect HIV treatment and care outcomes. Drawing on extant literature and theoretical underpinnings of syndemics, we provide a conceptual model that highlights how continuous traumatic violence experienced by YBMSM may affect HIV outcomes and contribute to racial disparities in HIV outcomes. The findings of this focused review suggest a need for research on how continuous exposure to various types of violence influence HIV prevention and treatment outcomes for young Black MSM.

A Descriptive Study of HIV Patients Highly Adherent to Antiretroviral

HIV medication adherence is a topic of major public health concern in the United States. Adherent patients may be less likely to experience treatment failure, AIDS presentations and extreme medical costs. We evaluate a cohort of highly adherent Medicare beneficiaries to establish if the out of pocket costs of HIV medications are an inherent barrier to adherence. We analyzed a 100% sample of Medicare Part-D prescription medications. The drug and out ofpocket costs for HIV and non-HIV medications of highly adherent cohort were extracted and analyzed. The average gross drug cost per beneficiary was $34,029for HIV medications and $11,439for non-HIV medications. Average out of pocket costs per beneficiary was $454for HIV medications and $129 for non-HIV medications. Out of pocket costs do not reasonably appear to be a barrier to adherence for Part-D beneficiaries.

Recruitment of Youth Living With HIV to Optimize Adherence and Virologic Suppression: Testing the Design of Technology-Based Community Health Nursing to Improve Antiretroviral Therapy (ART) Clinical Trials

Background

Despite advances in HIV diagnosis and treatment, adolescents and young adults 12-25 years old have high HIV incidence, poor engagement and retention in treatment, and low rates of adherence and virologic suppression when compared to their older counterparts. HIV has emerged as a chronic disease for which antiretroviral therapy (ART) adherence is critical for virologic suppression and long-term survival. Virologic suppression has been elusive for many youth with HIV (YHIV). Novel strategies designed to facilitate health care systems’ support for YHIV between medical visits are essential for improving ART adherence, virologic suppression, and long-term survival.

Objective

The aim of this study is to compare the effectiveness of a technology-enhanced community health nursing intervention (TECH2CHECK) to a standard of care (SOC) control group for improving ART adherence and subsequent viral suppression using a randomized trial design. The objectives are to assess the feasibility, acceptability, and cost-effectiveness of TECH2CHECK as compared to SOC for management of HIV in the outpatient setting and to examine the sustainability of self-care behavior, adherence, and virologic suppression among youth following the intervention period.

Methods

We will recruit 120 adherence-challenged YHIV being followed at clinics specializing in HIV care in the Baltimore-Washington metropolitan area and in Jacksonville. Eligible participants complete an audio, computer-assisted self-interview and are randomized to either TECH2CHECK intervention or the SOC (60 participants in each arm). The primary outcome of interest is virologic suppression (viral load <20 copies/mL) and improved treatment adherence. Participants in the intervention arm receive community health nursing visits at 2 weeks, 6 weeks, 10 weeks, 14 weeks, and 26 weeks. The intervention arm also receives SMS messaging comprising daily adherence and appointment reminders and positive reinforcement for medication adherence daily for 2 weeks, on alternate days for 2 weeks, thrice weekly for 1 month, weekly for 3 months, and every 2 weeks for the rest of the study duration. The control group receives appointment reminders and SOC per clinic protocol. Exploratory analysis will be conducted to determine differences in medication adherence and virologic suppression in the 2 arms and to assess cost-effectiveness and study feasibility and acceptability.

Results

In the first 23 months of the study (July 2018-April 2020), 56 (55%) of 102 eligible patients were enrolled and randomized. At present, participating youths are primarily African American (53/56, 95%), male (37/56, 66%), and ≥18 years old (53/56, 95%). Follow-up study visits, as required per the protocol, have been completed by 77% (43/56), 94% (45/48), 95% (37/39), 96% (24/25), and 100% (10/10) of participants at the 1-month, 3-month, 6-month, 12-month, and 18-month follow-ups, respectively.

Conclusions

Preliminary accrual and retention data suggest that TECH2CHECK is feasible and acceptable.

Trial Registration

ClinicalTrials.gov NCT03600103 https://clinicaltrials.gov/ct2/show/NCT03600103

International Registered Report Identifier (IRRID)

DERR1-10.2196/23480

Improvements in Retention in Care and HIV Viral Suppression Among Persons with HIV and Comorbid Mental Health Conditions: Patient-Centered HIV Care Model

The Patient-centered HIV Care Model (PCHCM) integrated community-based pharmacists with medical providers and required sharing of patient clinical information and collaborative therapy-related action planning. We determined the proportions of participants with HIV and mental health conditions who were retained in care and the proportion virally suppressed, pre- and post-implementation. Overall, we found a relative 13% improvement in both retention [60% to 68% (p = 0.009)] and viral suppression [79% to 90% (p < 0.001)]. Notable improvements were seen among persons triply diagnosed with HIV, mental illness and substance use [+ 36% (50% to 68%, p = 0.036) and + 32% (66% to 86%, p = 0.001) in retention and viral suppression, respectively]. There were no differences in the proportions of persons adherent to psychiatric medications, pre- to post-implementation, nor were there differences in the proportions of persons retained in care or virally suppressed by psychiatric medication adherence, post-implementation. PCHCM demonstrated that collaborations between community-based pharmacists and medical providers can improve HIV care continuum outcomes among persons with mental health conditions.

Trauma exposure, PTSD, and suboptimal HIV medication adherence among marginalized individuals connected to public HIV care in Miami

Individuals living with HIV report disproportionately high levels of trauma exposure and PTSD symptoms, both which have been associated with suboptimal ART adherence. Often conflated, the question arises as to which construct is driving subsequent HIV self-care behavior. Given the HIV disparities among Black and Hispanic/Latinx individuals, and that Miami is a geographic region with a high racial/ethnic minority make up and a unique socioeconomic environment, it is important to explore factors related to HIV outcomes in Miami to mitigate its uncontrolled epidemic. This study aimed to examine the association of trauma exposure, PTSD symptoms, and relevant additional key factors with adherence to ART among a sample of majority Black and Hispanic/Latinx individuals who are economically marginalized receiving public HIV care in Miami, FL (N = 1237) via a cross-sectional survey. Sequential linear regression was used to examine the study aim in four blocks: (1) trauma, (2) PTSD symptoms, and key covariates of ART adherence including (3) depression and substance use (potential psychological covariates), and (4) indicators of socioeconomic status (potential structural covariates). In the first block, trauma exposure was associated with worse adherence. However, in the second block, the association with trauma dropped and PTSD was significantly associated with worse adherence. Of note, for those experiencing high levels of trauma exposure, adherence was negatively impacted regardless of PTSD. When other key factors associated with adherence were entered in the third and fourth blocks, neither trauma exposure nor PTSD were uniquely significant. In this final model, depression, substance use, and unstable housing were uniquely associated with worse adherence. Trauma-informed models of HIV care that holistically address co-occurring factors are warranted to cater to communities with HIV health disparities and keep them from falling off the HIV care continuum.

Alcohol use, depressive symptoms, and intimate partner violence perpetration: A longitudinal analysis among men with HIV in northern Vietnam

Background

While the link between alcohol use and male-perpetrated intimate partner violence (IPV) has been well-established, research is needed to test whether psychosocial factors interact with alcohol use to exacerbate IPV perpetration. We tested whether depressive symptoms influenced the strength and/or direction of the alcohol-IPV relationship among men with HIV in Vietnam.

Methods

This study is a secondary analysis using data from a randomized controlled trial conducted in Thai Nguyen, Vietnam. Participants were clinic patients with HIV and hazardous alcohol use. Questionnaires were administered at baseline, three, six, and 12 months. Alcohol use was assessed as proportion of days alcohol abstinent. Analyses were restricted to males who reported being married/cohabitating at baseline (N = 313). Multilevel growth models were used to test whether time-varying depressive symptoms modified the time-varying effect of alcohol use on IPV perpetration.

Results

Time-varying depressive symptoms modified the effect of proportion of days alcohol abstinent on IPV perpetration. However, the pattern of effect modification was not as expected, as reporting depressive symptoms weakened the alcohol-IPV relationship. At times when participants screened negative for depressive symptoms, those who reported higher proportion of days alcohol abstinent than usual had significantly lower odds of IPV perpetration (Odds Ratio [OR] = 0.17, 95% Confidence Interval 0.06, 0.45, p = 0.0004). At times when participants screened positive for depressive symptoms, there was no observed effect of alcohol use on IPV perpetration (OR = 4.28, 95% CI 0.80, 22.78, p = 0.09).

Conclusion

The findings highlight the complex nature of the alcohol-IPV relationship and the need to investigate the intersection between hazardous drinking, mental health, and IPV. Men who concurrently report depressive symptoms and heightened alcohol use may be socially isolated from an intimate partner or experiencing fatigue, leading to less alcohol-related IPV perpetration. Mental health interventions addressing depression and alcohol misuse integrated into HIV services may reduce IPV perpetration.

The People Living with HIV Stigma Index 2.0: generating critical evidence for change worldwide

OBJECTIVE(S)

To describe the process of updating the People Living with HIV (PLHIV) Stigma Index (Stigma Index) to reflect current global treatment guidelines and to better measure intersecting stigmas and resilience.

DESIGN

Through an iterative process driven by PLHIV, the Stigma Index was revised, pretested, and formally evaluated in three cross-sectional studies.

METHODS

Between March and October 2017, 1153 surveys (n = 377, Cameroon; n = 390, Senegal; n = 391, Uganda) were conducted with PLHIV at least 18 years old who had known their status for at least 1 year. PLHIV interviewers administered the survey on tablet computers or mobile phones to a diverse group of purposively sampled respondents recruited through PLHIV networks, community-based organizations, HIV clinics, and snowball sampling. Sixty respondents participated in cognitive interviews (20 per country) to assess if questions were understood as intended, and eight focus groups (Uganda only) assessed relevance of the survey, overall.

RESULTS

The Stigma Index 2.0 performed well and was relevant to PLHIV in all three countries. HIV-related stigma was experienced by more than one-third of respondents, including in HIV care settings. High rates of stigma experienced by key populations (such as MSM and sex workers) impeded access to HIV services. Many PLHIV also demonstrated resilience per the new PLHIV Resilience Scale.

CONCLUSION

The Stigma Index 2.0 is now more relevant to the current context of the HIV/AIDS epidemic and response. Results will be critical for addressing gaps in program design and policies that must be overcome to support PLHIV engaging in services, adhering to antiretroviral therapy, being virally suppressed, and leading healthy, stigma-free lives.

Psychosocial Well-Being and HIV-Related Immune Health Outcomes among HIV-Positive Older Adults: Support for a Biopsychosocial Model of HIV Stigma and Health

Evidence suggests that psychosocial stress negatively impacts immunological health in HIV-positive individuals. However, few studies have explored this association in substance-using older adults living with HIV (OALWH). We evaluated the effect of depression, loneliness, substance use problems, and HIV stigma on primary markers of immune function in a sample of 120 OALWH with substance-related issues. HIV stigma correlated with the greatest number of factors, including depression, loneliness, and substance use problems. Older age and antiretroviral adherence were associated with viral suppression, which was in turn associated with higher percentage of CD4 count. Multivariate path analyses demonstrated that lower HIV stigma and viral suppression were the only factors independently associated with higher percentage of CD4 count, with a significant indirect effect of adherence on CD4 through viral suppression. HIV stigma emerged as the most salient factor associated with both psychosocial well-being and immune health in the current study, suggesting that it is a critical factor to consider in future interventions for the rapidly growing population of OALWH.

Longitudinal analysis of alcohol use and intimate partner violence perpetration among men with HIV in northern Vietnam

BACKGROUND

Alcohol use is a known risk factor for male-perpetrated intimate partner violence (IPV), although few studies have been conducted globally and among men with HIV (MWH). We estimated the longitudinal effects of alcohol use on IPV perpetration among MWH.

METHODS

This study is a secondary analysis of randomized controlled trial data among male and female antiretroviral treatment patients with hazardous alcohol use in Thai Nguyen, Vietnam. Analyses were restricted to male participants who were married/cohabitating (N = 313). Alcohol use was assessed as proportion days alcohol abstinent, heavy drinking, and alcohol use disorder (AUD) using the Timeline Followback and Mini International Neuropsychiatric Interview questionnaire. Multilevel modeling was used to estimate the effects of higher versus lower average alcohol use on IPV perpetration (between-person effects) and the effects of time-specific deviations in alcohol use on IPV perpetration (within-person effects).

RESULTS

Participants with higher average proportion days alcohol abstinent had decreased odds of IPV perpetration (adjusted Odds Ratio [aOR] = 0.43, p = 0.03) and those with higher average heavy drinking and AUD had increased odds of IPV perpetration (Heavy drinking: aOR = 1.05, p = 0.002; AUD: aOR = 4.74, p < 0.0001). Time-specific increases in proportion days alcohol abstinent were associated with decreased odds of IPV perpetration (aOR = 0.39, p = 0.02) and time-specific increases in AUD were associated with increased odds of IPV perpetration (aOR = 2.95, p = 0.001). Within-person effects for heavy drinking were non-significant.

CONCLUSIONS

Alcohol use is associated with IPV perpetration among Vietnamese men with HIV. In this context, AUD and frequent drinking are stronger correlates of IPV perpetration as compared to heavy drinking.

The contribution of syndemic conditions to cardiovascular disease risk

The syndemic conditions of low education, childhood maltreatment, depression, HIV, alcohol and cocaine use, and obesity have been established as independent risk factors for cardiovascular risk, but research examining the association between syndemic conditions and cardiovascular risk in high-risk populations is lacking. A total of N = 503 participants underwent an ultrasound of the carotid artery to assess for atherosclerotic plaque. Participants, HIV-infected (n = 202) and HIV-uninfected (n = 301) with and without a history of cocaine use, were a mean age of 36.13 years (SD = 9.51); 50% were male, and 62% were African-American. Each syndemic condition was associated with 8% greater odds of atherosclerotic plaque (OR = 1.08), 9% greater odds of systolic blood pressure (OR = 1.09), and 10% greater odds of diastolic blood pressure (OR = 1.10). Multilevel research, interventions, and public policy initiatives are needed to activate stakeholders at each level to maximize their impact at a community level among populations with high rates of syndemic conditions.