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Inter-connecting health problems increase HIV risk for MSM
Michael Carter, 2015-05-19 06:30:00
Intertwining health problems – syndemics - are associated with higher viral load and poorer adherence in HIV-positive men who have sex with men (MSM) taking antiretroviral therapy (ART), investigators from the United States report in the online edition of AIDS.
“Higher HIV viral load and lower ART adherence are, respectively, associated with increased syndemics count,” explain the authors. “These findings indicate that combinations of depression symptoms, polysubstance use and sexual risk behaviour function as profound barriers to fully reaping the benefits of successful HIV care and that, as these conditions snowball, their impact on HIV outcomes is exacerbated.”
They believe their findings have important implications for current treatment as prevention strategies to control to HIV epidemic, as every increase in the number of epidemics was associated with higher viral load and therefore transmission risk.
MSM account for approximately two-thirds of new HIV diagnoses in the United States. There are great hopes that the use of ART as prevention will help curtail the epidemic in this population. However, only 28% of HIV-infected individuals in the United States have an undetectable viral load.
Investigators from the Multicentre AIDS Cohort Study (MACS) were concerned that there were significant barriers preventing HIV-positive MSM achieving and maintaining an undetectable viral load.
It’s possible that syndemics (intertwining health problems) such as adversity and trauma in early life are associated with depression and substance abuse in young adulthood, which in turn leads to sexual risk taking.
To see if this is the case, investigators assessed the association of syndemics on adherence and viral load in 766 HIV-positive MSM who received care between 2003 and 2009.
Their research addressed three questions:
- Is higher syndemics count – number of syndemic conditions experienced concomitantly – associated with poorer control of viral load?
- Are higher syndemics counts associated with poorer ART adherence?
- Does adherence mediate the relationship between syndemics count and viral load?
Results showed that syndemics count was significantly associated with poorer adherence to ART (p < 0.0001). Racial/minority status and low income were also associated with lower adherence levels.
There was also evidence that the number of concomitant syndemics predicted poorer adherence. Patients with one syndemic condition had poorer adherence compared to individuals with no conditions; individuals with two syndemic conditions were less likely to adhere than patients with only one condition; and those with three conditions had significantly poorer treatment adherence than patients with two conditions.
Syndemics count was also associated with viral load (p < 0.001), as was racial/ethnic minority status (p < 0.0001) and lower income (p < 0.0001).
Patients with one syndemic condition had a median viral load of 248 copies/ml, significantly higher than the count of 191 copies/ml observed in patients with no conditions. Patients with two conditions had a median viral load of 376 copies/ml and viral load was on average 1197 copies/ml for those with three conditions.
The likelihood of having a detectable viral load increased with syndemics count.
Higher syndemics count was associated with lower ART adherence (p < 0.01), and for the most part, higher syndemics count as associated with higher viral load.
There was a significant interaction between syndemics. Polysubstance use was correlated with depressive symptoms (p < 0.0001) and unprotected anal sex (p < 0.0001). Depressive symptoms were related to polysubstance use (p < 0.0001) and unprotected sex (p < 0.0001); unprotected anal intercourse was significantly associated with polysubstance use (p < 0.0001) and depression (p < 0.0001).
“Our findings provide support for integrating structural and behavioural approaches to address syndemics among MSM receiving HIV care in the US,” comment the authors. “We strongly recommend the diffusion of HIV clinical care models that provide highly connected, preferably internally delivered mental health, sexual risk behaviour prevention and substance use treatment to optimize viral load suppression among HIV-positive MSM.”
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