Short communicationSyndemics among individuals enrolled in the PrEP Brasil Study
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.
Section snippets
Methods
PrEP Brasil is a 48-week long demonstration study where oral daily emtricitabine/tenofovir was provided at no cost for PrEP in two Brazilian cities (Rio de Janeiro and São Paulo). Study details are described elsewhere (Hoagland et al., 2017a; Hoagland et al., 2017b). Briefly, 1270 individuals who were either self or clinic-referred (when looking for HIV testing or post-exposure prophylaxis –PEP) were pre-screened. MSM and TGW, 18 years or more, who were HIV-seronegative and presented high risk
Results
Of the 450 participants enrolled in PrEP Brasil, 421 participants had complete data and were included in the present analysis. The median age was 29 years (IQR 24–35), 54.4% (n = 229) self-identified as white, 74.6% (n = 314) had at least some college education, 5.7% (n = 24) self-identified as TGW, 53% had a steady partner, and 59.4% (n = 250) were enrolled in São Paulo. Regarding risky sexual behavior in prior 3 months, 45% (n = 189/421) reported condomless receptive anal sex, 50%
Discussion
About a quarter (24.2%) of the MSM and TGW enrolled into the PrEP Brasil Study reported the co-occurrence of at least two psychosocial conditions, i.e., syndemics. These participants were more likely to be young, TGW, more educated, and have multiple male sexual partners. Syndemics prevalence in the PrEP Brasil Study was lower than the 43% found in an online survey (Mimiaga et al., 2015a). Although data may not be entirely comparable, given that only 14% of the included MSM in the online survey
Contributors
RBDB conceived the study and wrote the first draft. IKM and MTLV analyzed the data. PML supervised data analysis and writing. RIM was responsible for data management. BH, EK, JVM, NBC, SPG, VGV, BG were responsible for PrEP Brasil design and implementation. All authors have read the manuscript and provided important intellectual content. All authors have read and approved the text as submitted.
Funding
The authors acknowledge funding from the Brazilian Ministry of Health (#01/2013 BRA/650 K57), CNPq ((#476333/2013-0, #402004/2012-4, # 454931/2014-0, # 476024/2013-7) SVS (#281/2013), FAPERJ (#E- 26/110.261/2014) and FAPESP (<gn4>#2012/51743-</gn4 > 0). PML and BG acknowledge funding from the National Council of Technological and Scientific Development and the Research Funding Agency the State of Rio de Janeiro. EGK acknowledges funding from the Sao Paulo State Funding Agency. Gilead Sciences
Conflict of interest
Authors have no conflict to declare.
Acknowledgements
The authors would like to thank the entire PrEP Brasil Study team and the participants who made this study possible.
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