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.

Interorganizational relationships among HIV/AIDS service organizations in Baltimore: a network analysis

A wide variety of organizations has become involved in providing medical and social services to people living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Although there is much interest among policymakers, service providers, and clients in coordination among HIV/AIDS service organizations, few studies have used network analytic tools to examine existing systems of HIV-related care. In an effort to fill this gap, this study used network analysis methods to describe several aspects of the interorganizational relationships among 30 HIV/AIDS service agencies in Baltimore, Maryland. Client referrals to other organizations, client referrals from other organizations, exchange of information about shared clients, formal written linkage agreements for client referrals, and joint programs were each examined as a distinct type of network tie, with each the basis of a separate network among these 30 organizations. All of the networks except the one based on joint programs were relatively well connected, with most organizations either directly or indirectly linked. Most of the interorganizational collaboration occurred on a rather ad hoc basis for the purposes of meeting the more immediate needs presented by clients. Highly structured coordination involving substantial investment of resources and ongoing interagency activities appeared to be less common. The findings from this study also suggest that the providers in Baltimore tend to work directly with others as client needs arise rather than negotiating through "clearinghouse" types of organizations. Of the 30 HIV/AIDS service organizations, 5 were highly central in at least four of the five different types of networks. These five organizations--each having a critical role in the continuum of care--may be considered the most central core of the HIV/AIDS service delivery network in Baltimore. These organizations tend to be those that have been created specifically to provide HIV-related services or that specialize in HIV/AIDS care. This research can help policymakers understand how an HIV-related service delivery network may function and delineate key features of a network. In all communities, this type of assessment is critical to designing interventions to promote collaboration that are feasible within the context of existing interorganizational relationships. This type of data also has implications for informing activities to build the capacity of HIV/AIDS service organizations.