Syndemics among individuals enrolled in the PrEP Brasil Study

Highlights

• The prevalence of syndemics on the Preexposure Prophylaxis (PrEP) Brasil Study was 24.2%.

• Syndemics was driven by polysubstance use (22.8%) and binge drinking (51.1%).

• PrEP delivery is an opportunity to provide substance use interventions.

Abstract

Background

Concurrent psychosocial problems may synergistically increase the risk of HIV infection (syndemics), representing a challenge for prevention. We aimed to evaluate the prevalence and associated factors of syndemics among men who have sex with men (MSM) and transgender women (TGW) enrolled in the Brazilian pre-exposure prophylaxis demonstration study (PrEP Brasil Study).

Methods

Secondary cross-sectional analysis of the PrEP Brasil Study was performed. Of 450 HIV-seronegative MSM/TGW enrolled in the PrEP Brasil Study– conducted at Rio de Janeiro and São Paulo, Brazil– 421 participants with complete data were included in the present analysis. Syndemics was defined as occurrence of ≥2 of the following conditions: polysubstance (≥2) use, binge drinking, positive depression screen, compulsive sexual behavior, and intimate partner violence (IPV).

Results

The prevalence of recent polysubstance use was 22.8%, binge drinking 51.1%, positive depression screening 5.2%, compulsive sexual behavior 7.1%, and IPV 7.3%. Syndemics prevalence was 24.2%, and associated factors were younger age (adjusted Odds Ratio (aOR) 0.95, 95% Confidence Interval (95% CI) 0.92–0.98 per year increase), TGW vs. MSM (aOR 3.09, 95% CI: 1.2–8.0), some college education or more vs. less than college (aOR 2.49, 95% CI: 1.31–4.75), and multiple male sexual partners in prior 3 months (aOR 1.69, 95% CI: 0.92–3.14).

Conclusion

Given the high prevalence of syndemics, particularly of polysubstance use and binge drinking, PrEP delivery offers an opportunity to diagnose and intervene in mental and social well-being.

Introduction

The HIV epidemic in Brazil, as in other Latin America countries, is concentrated in key populations such as men who have sex with men (MSM) and transgender women (TGW), making targeted prevention strategies fundamental to achieve the 90-90-90 goal (De Boni et al., 2014; Kerr et al., 2013). Pre-exposure prophylaxis (PrEP) is an effective, feasible, and cost-effective biomedical strategy for HIV prevention among individuals at high risk for infection (Anderson et al., 2012; Caceres et al., 2015; Drabo et al., 2016; Liu et al., 2015; Nichols et al., 2016; Schneider et al., 2014). However, considering syndemics theory (Halkitis et al., 2013; Singer et al., 2017), MSM and TGW are vulnerable to co-occurring psychosocial problems that may interact to increase HIV risk and worsen other health outcomes (Singer, 1994).

Syndemics, understood as the cumulative and synergistic presence of psychosocial and other health conditions, has been associated with different outcomes such as reporting a higher number of sexual partners (Martinez et al., 2016), condomless anal intercourse (CAI) (Biello et al., 2014; Dyer et al., 2012; Ferlatte et al., 2014; Guadamuz et al., 2014; Jie et al., 2012; Mimiaga et al., 2015a), increased risk for HIV infection (Santos et al., 2014; Guadamuz et al., 2014; Mimiaga et al., 2015b), lack of HIV medication adherence (Biello et al., 2016; Blashill et al., 2015; Friedman et al., 2015), and increased risk for suicide (Ferlatte et al., 2015). It is hard to compare the prevalence of syndemics across populations due to differences in how authors operationalize the definitions. Still, the prevalence of two or more syndemic conditions was higher than 40% among US black MSM living with HIV/AIDS (Dyer et al., 2012) and male sex workers from Vietnam (Biello et al., 2014), for example.

Some of the individual psychosocial conditions previously described as clustering among MSM and associated with increasing the likelihood of risky sexual behavior and HIV prevalence/incidence include substance use, depression, intimate partner violence (IPV), child abuse, and, more recently, compulsive sexual behavior (CSB) (Parsons et al., 2012; Stall et al., 2003). As only 25% of studies on syndemics were conducted outside the US (Tsai et al., 2017), little is known about syndemics in Latin America. A noteworthy web survey of over 20,000 HIV-negative MSM showed that the prevalence of two or more conditions was at 43% in the region (Mimiaga et al., 2015a). The most frequent conditions were childhood or adolescent sexual abuse (41.75%) and IPV in the last 5 years (35.7%).

Considering the high social vulnerability of MSM and TGW, as well as the recent implementation of PrEP in the Brazilian public health system, to evaluate the occurrence of syndemics among MSM and TGW in the context of PrEP delivery programs may represent an additional benefit of PrEP. These services may provide an opportunity for screening and intervening in underdiagnosed mental health and social issues, and understanding the characteristics and behavior of individuals presenting higher likelihood of syndemics may be useful for targeting limited resources. In the present study, we aimed to describe the prevalence of psychosocial conditions and their clustering (syndemics), as well as factors associated with syndemics, among MSM and TGW enrolled in the PrEP Brasil Study.