Pushing the syndemic research agenda forward: a comment on Pitpitan et al

The syndemic effects of mental ill health, household hunger, and intimate partner violence on adherence to antiretroviral therapy among pregnant women living with HIV in Yaoundé, Cameroon

Background

This research advances understanding of interrelationships among three barriers to adherence to antiretroviral therapy (ART) among pregnant women living with HIV (WLWH) in Cameroon: probable common mental disorders (CMD), intimate partner violence (IPV), and hunger.

Methods

The sample included 220 pregnant WLWH in Cameroon. Multivariable modified Poisson regression was conducted to assess the relationship between IPV, hunger, and CMD on ART adherence.

Results

Almost half (44%) of participants recently missed/mistimed an ART dose. Probable CMD was associated with greater risk of missed/mistimed ART dose (aRR 1.5 [95% CI 1.1, 1.9]). Hunger was associated with greater risk of missed/mistimed ART dose among those who reported IPV (aRR 1.9 [95% CI 1.2, 2.8]), but not among those who did not (aRR 0.8 [95% CI 0.2, 2.3]).

Conclusion

Suboptimal ART adherence, CMD, and IPV were common among pregnant WLWH in Cameroon. Pregnant WLWH experiencing IPV and hunger may be especially vulnerable to suboptimal ART adherence.

The impact of a syndemic theory-based intervention on HIV transmission risk behaviour among men who have sex with men in India: Pretest-posttest non-equivalent comparison group trial

This study aimed to examine the effect of a syndemic theory-based intervention to reduce condomless anal intercourse among men who have sex with men (MSM) in India. In 2016/17, a pre- and post-test comparison group design was used to implement a syndemic theory-based intervention among 459 MSM (229, intervention; 230, standard-of-care comparison) recruited through non-governmental organizations in Chandigarh, India. The intervention group received two-session peer-delivered motivational interviewing-based HIV risk reduction counselling and skills training to improve sexual communication/negotiation and condom use self-efficacy, and screening/management of psychosocial health problems. The intervention's effect on consistent condom use was estimated using difference-in-differences (DiD) approach. Mediation analysis assessed the extent to which intervention effects on the outcome were mediated by changes in psychosocial health problems and condom use self-efficacy. A process evaluation assessed implementation fidelity and intervention acceptability. Baseline consistent condom use was 43% in the intervention group and 46% in the standard-of-care group. Baseline survey findings demonstrated that a psychosocial syndemic of problematic alcohol use, internalised homonegativity and violence victimisation synergistically increased condomless anal intercourse. Using DiD, we estimated that the intervention increased consistent condom use with male partners by 16.4% (95% CI: 7.1, 25.7) and with female partners by 28.2% (95% CI: 11.9, 44.4), and decreased problematic alcohol use by 24.3% (95%CI: -33.4, -15.3), depression by 20.0% (95% CI: -27.6, -12.3) and internalised homonegativity by 34.7% (95% CI: -43.6%, -25.8%). The mediation analysis findings suggested that the intervention might have improved consistent condom use by decreasing internalised homonegativity and by increasing condom use self-efficacy. The process evaluation showed high levels of acceptability/satisfaction among participants and high levels of implementation fidelity. A syndemic theory-based intervention tailored for MSM in India is feasible, acceptable, and can reduce HIV transmission risk behaviour as well as problematic alcohol use, depression and internalised homonegativity.

Syndemic Classes, Stigma, and Sexual Risk Among Transgender Women in India

Syndemic theory could explain the elevated HIV risk among transgender women (TGW) in India. Using cross-sectional data of 300 TGW in India, we aimed to: identify latent classes of four syndemic conditions (Depression-D, Alcohol use-A, Violence victimization-V, HIV-positive status), test whether syndemic classes mediate the association between stigma and sexual risk, and test whether social support and resilient coping moderate the association between syndemic classes and sexual risk. Four distinct classes emerged: (1) DAV Syndemic, (2) AV Syndemic, (3) DV Syndemic, and (4) No Syndemic. TGW in the DAV Syndemic (OR 9.80, 95% CI 3.45, 27.85, p < 0.001) and AV Syndemic classes (OR 2.74, 95% CI 1.19, 6.32, p < 0.01) had higher odds of inconsistent condom use in the past month than the No Syndemic class. Social support significantly moderated the effect of DAV Syndemic class on inconsistent condom use. DAV Syndemic was found to be a significant mediator of the effect of transgender identity stigma on sexual risk. HIV prevention programs among TGW need to: (a) incorporate multi-level multi-component interventions to address syndemic conditions, tailored to the nature of syndemic classes; (b) reduce societal stigma against TGW; and (c) improve social support to buffer the impact of syndemics on sexual risk.

Syndemics and HIV-related sexual risk among men who have sex with men in India: influences of stigma and resilience

Using syndemics theory as a framework, we explored the experience of men who have sex with men in India in relation to four syndemic conditions (depression, alcohol use, internalised homonegativity and violence victimisation) and to understand their resilience resources. Five focus groups were conducted among a purposive sample of diverse men along with seven key informant interviews with HIV service providers. Participants' narratives suggested various pathways by which syndemic conditions interact with one another to sequentially or concurrently increase HIV risk. Experiences of discrimination and violence from a range of perpetrators (family, ruffians and police) contributed to internalised homonegativity and/or depression, which in turn led some men to use alcohol as a coping strategy. Stigma related to same-sex sexuality, gender non-conformity and sex work contributed to the production of one or more syndemic conditions. While rejection by family and male regular partners contributed to depression/alcohol use, support from family, regular partners and peers served as resources of resilience. In India, HIV prevention and health promotion efforts among men who have sex with men could be strengthened by multi-level multi-component interventions to reduce intersectional/intersecting stigma, address syndemic conditions and foster resilience - especially by promoting family acceptance and peer support.

Persistent Food Insecurity Is Associated with Adverse Mental Health among Women Living with or at Risk of HIV in the United States

BACKGROUND

Food insecurity and mental health negatively affect the lives of women in the United States. Participants in the Women's Interagency HIV Study (WIHS) provided the opportunity to understand the association of food insecurity with depression and mental well-being over time.

OBJECTIVE

We investigated the association between current and persistent food insecurity and depression among women at risk of or living with HIV in the United States.

METHODS

We used longitudinal data from the WIHS, a prospective cohort study in women at risk of or living with HIV from multiple sites in the United States. Participants completed 6 semiannual assessments from 2013 to 2016 on food security (FS; high, marginal, low, and very low) and mental health (i.e., depressive symptoms and mental well-being). We used multiple regression analysis to estimate the association between these variables.

RESULTS

Among 2551 participants, 44% were food insecure and 35% reported depressive symptoms indicative of probable depression. Current marginal, low, and very low FS were associated with 2.1-, 3.5-, and 5.5-point (all P < 0.001) higher depression scores, respectively. In models adjusting for both current and previous FS, previous marginal, low, and very low FS were associated with 0.2-, 0.93-, and 1.52-point higher scores, respectively (all P < 0.001). Women with very low FS at both time points (persistent food insecurity) had a 6.86-point higher depression score (P < 0.001). In the mental health models, there was a dose-response relation between current FS and worse mental health even when controlling for previous FS (all P < 0.001). Previous low FS was associated with worse mental health. These associations did not differ by HIV status.

CONCLUSIONS

Food insecurity placed women at risk of depression and poor mental well-being, but the risk was substantially higher for women experiencing persistent food insecurity. Future interventions to improve women's mental health call for multilevel components that include addressing food insecurity.

Diabetic Retinopathy and the Cascade into Vision Loss

Vision loss from diabetic retinopathy should be unnecessary for patients with access to diabetic retinopathy screening, yet it still occurs at high rates and in varied contexts. Precisely because vision loss is only one of many late-stage complications of diabetes, interfering with the management of diabetes and making self-care more difficult, Vision Threatening Diabetic Retinopathy (VTDR) is considered a "high stakes" diagnosis. Our mixed-methods research addressed the contexts of care and treatment seeking in a sample of people with VTDR using safety-net clinic services and eye specialist referrals. We point to conceptual weaknesses in the single disease framework of health care by diagnosis, and we use the framework of "cascades" to clarify why and how certain non-clinical factors come to bear on long-term experiences of complex chronic diseases.

Buffering Syndemic Effects in a Sexual Risk-Reduction Intervention for Male Clients of Female Sex Workers: Results From a Randomized Controlled Trial

OBJECTIVES

We sought to test the efficacy of a sexual risk intervention for male clients of female sex workers (FSWs) and examine whether efficacy was moderated by syndemic risk.

METHODS

From 2010 to 2014, we conducted a 2-arm randomized controlled trial (60-minute, theory-based, safer sex intervention versus a didactic time-equivalent attention control) that included 400 male clients of FSWs on the US-Mexico border with follow-up at 4, 8, and 12 months. We measured 5 syndemic risk factors, including substance use and depression. Primary outcomes were sexually transmitted infections incidence and total unprotected sex with FSWs.

RESULTS

Although participants in both groups became safer, there was no significant difference in behavior change between groups. However, baseline syndemic risk moderated intervention efficacy. At baseline, there was a positive association between syndemic risk and unprotected sex. Then at 12 months, longitudinal analyses showed the association depended on intervention participation (B = -0.71; 95% confidence interval [CI] = -1.22, -0.20; P = .007). Among control participants there still existed this modest association (B = 0.36; 95% CI = -0.49, 1.22; P = .09); among intervention participants there was a significant negative association (B = -0.35; 95% CI = -0.63, -0.06; P = .02).

CONCLUSION

A brief intervention might attenuate syndemic risks among clients of FSWs. Other populations experiencing syndemic problems may also benefit from such programs.