Taking responsibility: how syndemic theory could shift the HIV response
We know that HIV does not exist in a social, political or economic vacuum, yet we often fail to think broadly about the wider context of the life of a person living with HIV. Can syndemic theory provide us with an HIV response that goes deeper?
HIV epidemics are complex and don’t occur in controlled environments. A diverse range of social, economic and political factors can drive vulnerability not just to HIV, but multiple diseases.
This idea of synergistic epidemics – known as syndemics – while not a new concept, was a major talking point at the International AIDS Conference (AIDS 2018) in Amsterdam in July. Many saw ‘syndemic thinking’ as being a way to move away from the siloed working of ‘AIDS exceptionalism’, which has long characterised the HIV response.
Until now, ‘AIDS exceptionalism’, where HIV was responded to separately and above other diseases and STIs, has been useful in fast-tracking access to HIV treatment and care. But today the HIV response is in danger of stagnating, and is falling behind in the goal to end AIDS by 2030. Has this ‘exceptionalist’ mentality held back progress, encouraging an emphasis on quick wins and low-hanging fruit?
Focusing on the 10-10-10
Peter Piot, Director of the London School of Hygiene and Tropical Medicine, noted in his plenary address at AIDS 2018 that the UNAIDS 90-90-90 ‘Fast-Track’ targets – which call for 90% of people living with HIV diagnosed, 90% of those on treatment, and 90% of people on treatment virally suppressed – have inadvertently made us target resources to those easiest to reach. He warned that it is those with the most compounded disadvantage who will be in the last ‘10-10-10’. It is “the people who, for whatever reason, we can’t reach, who are dying still, that we should be concentrating on,” he said.
In another AIDS 2018 session, Tonia Poteat of Johns Hopkins University echoed this concern, arguing that because “inequitable distribution of power is the source of an inequitable distribution of disease,” the HIV response must orient itself towards those who are most vulnerable and develop “multi-level, integrated interventions that target the mechanisms that drive epidemics” in communities.
Also at the conference, Steven Safren and Mathew Mimiaga presented their findings from ‘Project IMPACT’ conducted with the Fenway Institute in Boston. They showed how their work with high-risk men who have sex with men could reduce new HIV infections by focusing on treating syndemic mental health conditions. The project targeted depressive symptoms through counselling and behavioural activation interventions, designed to re-engage men in pleasurable, goal-orientated activities. At six months, intervention participants had less risky condomless sex and had more meth-free days.
In a similar study, Venkatesen Chakrapani from the Postgraduate Institute of Medical Education and Research (PGIMER) in India showed how screening for and addressing syndemic conditions such as frequent alcohol and drug use as well as violence towards men who have sex with men in India can substantially reduce sexual risk.
A broader perspective
The results of these studies show that we can increase the success of our sexual health services by engaging with the broader aspects of a person’s life. Understanding the other factors that make safer-sex difficult, for example, means that we can offer more support, helping people to stay HIV-negative.
The preventative effects demonstrated by these syndemic-focused interventions, strongly counter arguments that addressing violence, depression or other syndemic conditions falls outside the remit of the HIV response.
In his plenary speech, David Malebranche from the Morehouse School of Medicine, argued that for too long our approach to public health has involved “simply blaming the victim”. He argued that to make real progress, we need to acknowledge that “medical communities are microcosms of larger society, and if societal stigmas and other institutional issues are plaguing us as gatekeepers to scientific advances, we won’t get to zero new infections anytime soon.”
Syndemic theory has application beyond prevention. Emily Hyle, from Harvard University, argued in her AIDS 2018 presentation that it’s not enough for HIV care to solely focus on providing treatment, and screening for common co-infections (such as TB and hepatitis), now that non-communicable diseases, such as diabetes, cardiovascular disease and mental illness, are playing such a significant role in the lives of those with HIV. To properly care for people with HIV we need to increase the diagnoses, treatment and control of syndemic non-communicable diseases.
It’s clear ‘syndemic thinking’ pushes us to take responsibility not only for driving down new HIV infections or increasing the number of people on antiretroviral treatment, but to look beyond this at the other factors impacting the lives of those living with HIV. If we want to reach the final ‘10-10-10’ and move away from ‘blaming the victim’, we need to broaden our own sense of responsibility, including syndemic conditions as new areas of need.
As Tonia Poteat put it, “how we think about disease pathologies affects how we design policies and deliver care to those most affected by social and economic inequities.” Broadening our understanding of HIV from a single epidemic to a component of wider syndemics, will help us to get back on track and reach those left behind.