Deconstructing Syndemics: The Many Layers of Clustering Multi-Comorbidities in People Living with HIV

Co-designing strategies to implement long-acting injectable PrEP for sexual minority men in Chicago: a study protocol for an innovation tournament and implementation mapping

BACKGROUND

Participatory design approaches can improve successful selection and tailoring of implementation strategies by centering the voices of key constituents. To reduce incidence of the human immunodeficiency virus (HIV) in the USA, co-design of implementation strategies is needed for long-acting injectable cabotegravir (CAB-LA), a new form of HIV pre-exposure prophylaxis, among the disproportionately impacted population of sexual minority men (SMM). This manuscript describes the protocol for participatory design approaches (i.e., innovation tournament and implementation mapping) to inform implementation of CAB-LA among SMM (≥ 12 years), particularly Black and Latino populations, in Chicago.

METHODS

This research incorporates innovative methods to accomplish two objectives: (1) to crowdsource ideas for the design of implementation strategies for CAB-LA through a virtual innovation tournament and (2) to leverage the ideas from the innovation tournament to operationalize implementation strategies for CAB-LA thorough the systematic process of implementation mapping. A committee of constituents with diverse expertise and perspectives (e.g., SMM, implementation scientists, HIV clinicians, public health leadership, and community partners) will provide input throughout the design process.

DISCUSSION

This research will produce a menu of co-designed implementation strategies, which can guide plans for CAB-LA integration in Chicago and provide insights for other EHE regions. Further, as the first innovation tournament focused on HIV prevention, this research can provide a framework for participatory approaches across the care continuum. Given that the co-design of implementation strategies often does not involve the participation of individuals with lived experiences, this work will center the voices of those who will benefit most.

Psychosocial Syndemic Classes and Longitudinal Transition Patterns Among Sexual Minority men Living with or Without HIV in the Multicenter AIDS Cohort Study (MACS)

Mental health and substance use epidemics interact to create psychosocial syndemics, accelerating poor health outcomes. Using latent class and latent transition analyses, we identified psychosocial syndemic phenotypes and their longitudinal transition pathways among sexual minority men (SMM) in the Multicenter AIDS Cohort Study (MACS, n = 3,384, mean age 44, 29% non-Hispanic Black, 51% with HIV). Self-reported depressive symptoms and substance use indices (i.e., smoking, hazardous drinking, marijuana, stimulant, and popper use) at the index visit, 3-year and 6-year follow-up were used to model psychosocial syndemics. Four latent classes were identified: "poly-behavioral" (19.4%), "smoking and depression" (21.7%), "illicit drug use" (13.8%), and "no conditions" (45.1%). Across all classes, over 80% of SMM remained in that same class over the follow-ups. SMM who experienced certain psychosocial clusters (e.g., illicit drug use) were less likely to transition to a less complex class. These people could benefit from targeted public health intervention and greater access to treatment resources.

Factors affecting ability of TB patients to follow treatment guidelines - applying a capability approach

BACKGROUND

Negotiating anti-Tuberculosis treatment is a complicated process comprising daily consumption of multiple medications at stipulated times and dosages, as well as periodic follow-ups and investigations, may not be uniform for all Tuberculosis (TB) patients and some may perform better than others. In this context, we conducted a study in Thiruvananthapuram district, Kerala to ascertain the ability of those suffering from TB to follow treatment guidelines.

METHODS

This study used an embedded mixed methods design. We collected cross-sectional data from 135 drug sensitive pulmonary TB patients aged 18 years or above in Thiruvananthapuram, Kerala using a structured questionnaire to get the proportion of patients following all treatment guidelines. We also did eight in-depth interviews (four men and four women) from within the survey sample. The in-depth interviews were inductively analysed for getting deeper insights about reasons for the choices people made regarding the treatment guidelines. Written informed consent was taken from all participants and the study was implemented after the necessary programmatic and ethical clearances.

RESULTS

Of the 105 men and 30 women studied, uninterrupted daily drug consumption was reported by 80 persons (59.3%, 95% Confidence Intervals (CI) 50.8-67.2%). Overall, 38 (28.2%, 95% CI 21.3%-36.3%) persons were able to follow all seven aspects of advised guidelines. Living in an extended/ joint family (Adjusted Odds ratio (AOR) 2.6, 95% CI 1.1-6.0), approximate monthly household expenditure of over rupees 13,500 (AOR 2.9, 95% CI 1.3-6.7) and no perceived delay in seeking initial care (AOR 3.2, 95% CI 1.2-8.7) were significantly associated with following all aspects of treatment guidelines. In-depth interviews revealed reflective treatment related behaviours were influenced by bodily experiences, moral perceptions, social construct of TB, programmatic factors and substance use. Sometimes behaviours were non-reflective also. Programmatic stress was on individual agency for changing behaviour but capability and opportunity for these were influenced social aspects like stigma, gender roles and poverty.

CONCLUSION

TB patients live amidst a syndemic of biomedical and social problems. These problems influence the capabilities and opportunities of such TB patients to follow treatment guidelines. Interventions should balance focus on individual agency and social abd economic factors.

Can we better understand severe mental illness through the lens of Syndemics?

Current health care systems do not sufficiently address contributors, also known as modifiable behavior factors, to severe mental illnesses (SMI). Instead treatment is focused on decreasing symptom-experience rather than reducing the detrimental effect of biological predisposition and behavioral influences on illness. Health care services and patients alike call for a more comprehensive, individual approach to mental health care, especially for people with SMI. A Syndemics framework has been previously used to identify ecological and social contributors to an HIV epidemic in the 1990s, and the same framework is transferable to mental health research to identify the relationship between contributing factors and the outcomes of SMI. Using this approach, a holistic insight into mental illness experience could inform more effective health care strategies that lessen the burden of disease on people with SMI. In this review, the components of a Syndemic framework, the scientific contributions to the topic so far, and the possible future of mental health research under the implementation of a Syndemic framework approach are examined.

Are There Global Syndemics?

In this article, we address the nature of syndemics and whether, as some have asserted, these epidemiological phenomena are global configurations. Our argument that syndemics are not global rests on recognition that they are composed of social/environment contexts, disease clusters, demographics, and biologies that vary across locations. These points are illustrated with the cases of syndemics involving COVID-19, diabetes mellitus, and HIV/AIDS. We draw on theoretical discourse from epidemiology, biology, and anthropology to present what we believe is a more accurate framework for thinking about syndemics with shared elements.

"It's a burden, it's a nuisance. I wish I didn't have these other ailments": a qualitative exploration of comorbidities management among older people living with HIV who use drugs in Vancouver, British Columbia

Introduction

People living with HIV (PLHIV) who use illicit drugs (other than or in addition to cannabis) are living longer due to antiretroviral therapy (ART). Older PLHIV who use drugs have an increased risk for comorbidities, and managing multiple health conditions is a growing concern among this population. However, in‐depth understandings of the lived realities and complexities of living with HIV alongside comorbidities among older PLHIV who use drugs remain limited. We sought to explore how older PLHIV who use drugs manage their comorbid conditions in a setting with universal ART access.

Methods

Between January 2019 and March 2020, semi‐structured, in‐depth interviews were conducted in Vancouver, Canada with 42 older PLHIV who use drugs and were living with at least one comorbidity. All participants were currently on ART, and had initiated treatment at least 2 years prior to the interviews. Data were analysed using inductive and deductive approaches.

Results

Several themes were identified through this analysis. First, comorbidities were perceived as more urgent health concerns and prioritized over HIV. Second, stigma and discrimination hindered access to care for comorbidities. Third, the concurrent management of HIV and comorbidities was often challenging due to unmanaged or poorly managed comorbidities. Fourth, the potential impact of ART on the development of comorbidities was a source of concern and frustration. Finally, integrated treatment approaches facilitated engagement with HIV and comorbidities care.

Conclusions

Our findings underscore the need for HIV care to shift from a primary focus on managing HIV to an integrated, patient‐centred approach that addresses both HIV and non‐HIV‐related health needs, as well as an equitable and non‐judgemental delivery of such care for an ageing population of PLHIV who use drugs.

An Emerging Syndemic of Smoking and Cardiopulmonary Diseases in People Living with HIV in Africa

Background: African countries have the highest number of people living with HIV (PWH). The continent is home to 12% of the global population, but accounts for 71% of PWH globally. Antiretroviral therapy has played an important role in the reduction of the morbidity and mortality rates for HIV, which necessitates increased surveillance of the threats from pernicious risks to which PWH who live longer remain exposed. This includes cardiopulmonary comorbidities, which pose significant public health and economic challenges. A significant contributor to the cardiopulmonary comorbidities is tobacco smoking. Indeed, globally, PWH have a 2–4-fold higher utilization of tobacco compared to the general population, leading to endothelial dysfunction and atherogenesis that result in cardiopulmonary diseases, such as chronic obstructive pulmonary disease and coronary artery disease. In the context of PWH, we discuss (1) the current trends in cigarette smoking and (2) the lack of geographically relevant data on the cardiopulmonary conditions associated with smoking; we then review (3) the current evidence on chronic inflammation induced by smoking and the potential pathways for cardiopulmonary disease and (4) the multifactorial nature of the syndemic of smoking, HIV, and cardiopulmonary diseases. This commentary calls for a major, multi-setting cohort study using a syndemics framework to assess cardiopulmonary disease outcomes among PWH who smoke. Conclusion: We call for a parallel program of implementation research to promote the adoption of evidence-based interventions, which could improve health outcomes for PWH with cardiopulmonary diseases and address the health inequities experienced by PWH in African countries.