Investigating possible syndemic relationships between structural and drug use factors, sexual HIV transmission and viral load among men of colour who have sex with men in Los Angeles County

Abstract

Introduction and Aims. Past research investigating syndemic factors and HIV-related outcomes has overlooked the impact of structural conditions on behaviours linked with HIV transmission and disease progression. Given prevalent substance use among our sample, we explored whether four structural conditions indicative of social marginalisation and previously correlated with increased risk for HIV infection demonstrated syndemic (additive/synergistic) effects on: (i) HIV viral suppression; and (ii) self-reported involvement in sexual HIV transmission behaviours among a prospective cohort mostly comprising men of colour who have sex with men (MCSM; i.e. Latino/Hispanic and African American/black men) in Los Angeles County. Design and Methods. Data were collected between August 2014 and March 2017. The structural conditions of interest were: current unemployment, recent (≤6 months) incarceration history, 'unstable' accommodation (past month) and remote (>6 months) contact with health-care providers. Generalised estimating equations assessed possible additive effects of experiencing multiple structural conditions, and possible synergistic effects on the HIVrelated outcomes. Results. Of 428 participants, nearly half (49%) were HIV-positive at baseline. Involvement in sexual HIV transmission risk behaviours varied over follow-up (22-30%). Reporting ≥2 structural syndemic conditions was significantly associated with reporting sexual HIV transmission risk behaviours among HIV-negative participants, and detectable viral load among HIV-positive participants. Frequent methamphetamine use was consistently associated with the HIV-related outcomes across the final multivariate models. Discussion and Conclusions. When developing initiatives to address HIV transmission among marginalised sub-populations including MCSM, we must holistically consider systemic and structural issues (e.g. unemployment and homelessness), especially in the context of prevalent substance use. [Quinn B, Gorbach PM, Okafor CN, Heinzerling KG, Shoptaw S. Investigating possible syndemic relationships between structural and drug use factors, sexual HIV transmission and viral load among men of colour who have sex with men in Los Angeles County. Drug Alcohol Rev 2020;39:116-127]

Structural Syndemics and Antiretroviral Medication Adherence Among Black Sexual Minority Men Living With HIV

“…25 However, researchers have identified structural factors to be critical in understanding syndemics and their impact on HIV treatment engagement, particularly within communities often left vulnerable to societal forces such as poverty, homelessness, and unemployment. 29,30 Yet only a handful of studies have examined these relations directly. 22 A qualitative study examining HIV treatment engagement among 23 Black men who have sex with men living with HIV (BMSM+) found that poverty, depression, substance use, and intersectional stigma, defined in this study as the overlapping stigmas associated with race, gender, sexual orientation, HIV status, and other marginalized identities, affected HIV treatment engagement decisions of young BMSM+.…”

“…31 Quantitative studies assessing the role of multiple structural factors in treatment behaviors focused on select populations of PLWH, including women of color, 32 young people, 33 injection drug users, 34 and men of color who have sex with men. 30 These studies broadened the examination of syndemics to include previously defined psychosocial factors and structural factors, including unemployment, poverty, incarceration history, housing instability, and HIV stigma. Structural indicators, counted alongside psychosocial factors, were found to be associated with poor ART adherence, detectable viral load, 33,35 and being interrelated, demonstrating a syndemic relationship.…”

“…34 Similarly, a recent study among men of color who have sex with men living in Los Angeles County that focused only on structural syndemic conditions, such as current unemployment, housing instability, incarceration history, and remote contact with health care providers, demonstrated that the number of structural syndemic factors experienced were associated with higher odds of sexual HIV transmission risk behaviors and having a detectable viral load for participants living with HIV. 30 There is strong evidence that psychosocial syndemics are associated with treatment behaviors and a growing understanding of the role that structural conditions might play in these relations. Yet the differentiation between psychosocial factors and structural conditions, along with its effect on HIV outcomes, is limited.…”

“…Yet the differentiation between psychosocial factors and structural conditions, along with its effect on HIV outcomes, is limited. 29,30 Therefore, a better understanding of the prevalent structural conditions and psychosocial factors that affect the HIV treatment engagement of BMSM+ is warranted. This study hypothesizes that psychosocial and structural factors would be negatively associated with ART adherence among BMSM+ in LA County.…”

Mapping the current knowledge in syndemic research applied to men who have sex with men: a scoping review protocol

“…7 Moreover, all of these negative and often avoidable health outcomes are associated with experiences of homophobic violence, stigma, discrimination, internalisation of negative assumptions and attitudes about MSM by MSM themselves [8][9][10][11][12] as well as with poverty, unemployment, unstable housing and poor healthcare access. [13][14][15][16] Unfortunately, social factors such as these are often overlooked in the conventional frameworks of comorbidity and multimorbidity 17 even though our understanding of diseases clustering demonstrates the need to incorporate social and environmental elements. 18 To offer meaningful improvements to the health of marginalised populations, public health researchers and clinicians must move beyond a reductionist understanding of disease causation to more complex models of diseases interaction taking into account the social forces driving health inequalities.…”