HIV Sexual Risk and Syndemics among Women in Three Urban Areas in the United States: Analysis from HVTN 906

Abstract

on behalf of the HVTN 906 study team ABSTRACT Limited data are available on the longitudinal occurrence of syndemic factors among women at risk for HIV infection in the USA and how these factors relate to sexual risk over time. HVTN 906 was a longitudinal study enrolling 799 HIV-uninfected women in three cities. Assessments were done at baseline, 6, 12, and 18 months to assess syndemic factors (low education, low income, unemployment, lack of health insurance, housing instability, substance use, heavy alcohol use, partner violence, incarceration) and sexual risk outcomes. For each sexual risk outcome, a GEE model was fit with syndemic factors or syndemic score (defined as sum of binary syndemics, ranging from 0 to 9), visit, study site, age and race/ethnicity as predictors to examine the multivariable association between syndemic factors and outcomes over time. Odds of unprotected sex while drunk or high were significantly higher when women reported lack of health insurance, substance and heavy alcohol use and partner violence. Housing instability, substance and heavy alcohol use, partner violence and recent incarceration were associated with higher odds of having multiple sexual partners. Odds of sex exchange were significantly higher in the presence of unemployment, housing instability, low education, lack of health insurance, substance and heavy alcohol use, partner violence and incarceration. Housing instability, substance and heavy alcohol use, and partner violence were significantly associated with higher odds of unprotected anal sex. Odds of having a recent STI were significantly higher when women reported housing instability and partner violence. There were significantly higher odds of the reporting of any risk outcomes during follow-up with higher syndemic score. This study highlights a group of women experiencing multiple poor social and health outcomes who need to be the focus of comprehensive interventions.

Importance of substance use and violence in psychosocial syndemics among women with and at-risk for HIV

“…Consistent with prior literature, number of syndemic conditions was positively and incrementally associated with number of types of sexual risk behaviors among women living with and at-risk for HIV (Koblin et al, 2015; Meyer et al, 2011). Similar to Koblin et al’s 2015 findings, substance use was more strongly associated with sexual risk behaviors, compared to other syndemic conditions.…”

“…The additive relationship between number of syndemic conditions and sexual risk, despite the lack of expected bivariate associations, emphasizes the importance of the co-occurrence these syndemic conditions. Additionally, we identified an interaction between substance use and violence, consistent with syndemic theory and other syndemic research focused on urban women (Koblin et al, 2015; Singer, 1992; Singer & Clair, 2003). Together, these findings indicate that while an additive framework may be associated with sexual risk behaviors, investigation of specific syndemic conditions using multivariable models is needed to identify which conditions are most associated with sexual risk behaviors and should be prioritized.…”

“…Similar to Koblin et al’s 2015 findings, substance use was more strongly associated with sexual risk behaviors, compared to other syndemic conditions. Paralleling previously published literature- CSA and adult violence were each associated with sexual risk behaviors (Illangasekare, Burke, McDonnell, & Gielen, 2013; Kelly, Cheng, Spencer-Carver, & Ramaswamy, 2014).…”

“…Stall and others (Mustanki, Garofalo, Herrick, & Donenberg, 2007; Stall et al, 2003) have described syndemics among men who have sex with men, including childhood sexual abuse (CSA) and depression. Similar syndemics exist among low-income women that increase risk of HIV (Koblin et al, 2015; Meyer, Springer, & Altice, 2011). As the majority of HIV infections among women are attributable to heterosexual sex (CDC, 2015), a greater understanding of how psychosocial conditions including poverty, violence, and substance use relate to sexual risk behaviors among women is needed (Krishnan et al, 2008; Oldenburg, Perez-Brumer, & Reisner, 2014; Ostrach & Singer, 2012).…”

The Influence of Relationship Power and Partner Communication on the Syndemic Factor among Hispanic Women

“…A syndemic is comprised of co-occurring epidemics (e.g., substance abuse and HIV) that have synergistic effects on health outcomes (Singer, 1996; Singer & Clair, 2003). There is increasing empirical support for the substance abuse, violence, HIV and AIDS, and depression (SAVA) syndemic among women (Gilbert et al, 2015; Koblin et al, 2015; Meyer et al 2011). Although several risk and protective factors contributing to this syndemic have been identified, less is known about the effects of the quality of intimate relationships.…”