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

Abstract

<jats:p>The HIV epidemic has dramatically changed over the past 30 years; there are now fewer newly infected people (especially children), fewer AIDS-related deaths, and more people with HIV (PWH) receiving treatment. However, the HIV epidemic is far from over. Despite the tremendous advances in anti-retroviral therapies (ART) and the implementation of ART regimens, HIV incidence (number of new infections over a defined period of time) and prevalence (the burden of HIV infection) in certain regions of the world and socio-economic groups are still on the rise. HIV continues to disproportionally affect highly marginalized populations that constitute higher-risk and stigmatized groups, underserved and/or neglected populations. In addition, it is not uncommon for PWH to suffer enhanced debilitating conditions resulting from the synergistic interactions of both communicable diseases (CDs) and non-communicable diseases (NCDs). While research utilizing only a comorbidities framework has advanced our understanding of the biological settings of the co-occurring conditions from a molecular and mechanistic view, harmful interactions between comorbidities are often overlooked, particularly under adverse socio-economical and behavioral circumstances, likely prompting disease clustering in PWH. Synergistic epidemics (syndemics) research aims to capture these understudied interactions: the mainly non-biological aspects that are central to interpret disease clustering in the comorbidities/multi-morbidities only framework. Connecting population-level clustering of social and health problems through syndemic interventions has proved to be a critical knowledge gap that will need to be addressed in order to improve prevention and care strategies and bring us a step closer to ending the HIV epidemic.</jats:p>

“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

“…stigma) and structural conditions (e.g. poverty) create and perpetuate vulnerabilities placing PLHIV at a higher risk for comorbidities [ 16 ]. Research has provided compelling evidence for the important role of the “risk environment” and elucidated how contextual factors produce harm for PLHIV who use illicit drugs (hereafter referred to as PLHIV who use drugs) [ 17 , 18 ].…”

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

“…Implementation research can be used to adapt strategies to deliver evidence-based smoking cessation interventions shown to be effective in other settings. These parallel research programs will benefit from adopting a syndemic framework to decipher and disentangle the social, behavioral, and biological linkages among HIV, smoking, and cardiopulmonary disease in Africa [ 97 ].…”

“…However, the mental, environmental, and economic circumstances that predispose PWH to smoke at high rates compared to the general population cannot be addressed solely with smoking cessation programs. We therefore advocate for both biomechanistic and implementation research to strengthen prevention and care strategies by considering the full scope of vulnerabilities, rather than treating the disorders individually and ignoring the complex contexts in which they occur ( Figure 1 ) [ 97 ]. Syndemics, or “synergistic epidemics,” describes the complex interaction between two or more epidemics with consideration for the multilevel social and environmental context in which they arise [ 98 ].…”

“…cART can also cause mood changes and anxiety, contributing to the higher prevalence of depression among PWH [ 103 , 104 , 105 ]. In addition, the physical ailments associated with HIV can have a negative effect on everyday mood, which can keep an individual in a state of depression, as many describe the symptoms as a constant reminder of their infection [ 97 ]. Moreover, the economic burden associated with comorbid conditions and the accompanying healthcare costs can threaten the financial stability of individuals, families, and communities and can cause significant stress for PWH.…”

“…In LMICs, the economic burden of comorbidities impacts not only the patients, but also their family members and caretakers. The time commitment required of family members to care for PWH often results in lost wages and reduced productivity, both of which can have detrimental effects on the larger economy [ 97 ].…”