Policy Implications of Adopting a Syndemics Approach to Overcoming Barriers to HIV/AIDS Testing and Treatment among Vulnerable Populations Merrill Singer, PhD University of Connecticut

“When one tugs at a single thing in nature, he finds it attached to the rest of the world.” –John Muir Syndemic: the concentration and deleterious interaction of two or more diseases or other health conditions in a population, especially as a consequence of social conditions that promote disease clustering.

We need to assess the nature of the specific interconnections and pathways of influence among the parts, –including the intricate ways in which they foster and reinforce each other and –thereby create complex, burdensome and challenging webs of entwined health and social problems.

HIV/AIDS Studying this history-changing disease and responding to it within public health frameworks, as though it were separate from other diseases is a distortion. As it exists in the world, HIV/AIDS is never separate from other diseases, –nor is it detached from social structures and social environments –that channel the lived experiences and health and mental states of infected individuals

CDC: “research protocols, prevention programs, policy interventions, and other aspects of public health practice [is that they] have focused on one disease at a time, leaving other health problems to be addressed by parallel enterprises.” Using the term epidemic to describe HIV/AIDS does not adequately describe this public health crisis, –which involves the transmission of this disease in close conjunction with a set of opportunistic diseases but also with many non-opportunistic health conditions.

Syndemic perspective The multiple contemporary threats to the health of disadvantaged and marginalized populations are not concurrent epidemics in that they are not completely separable phenomena. They constitute sets of enmeshed and mutually enhancing synergistic health problems that, working together in a context of noxious social and physical conditions, can significantly affect the overall disease burden and access to services of a population

Structural violence The “host of offenses against human dignity” including significant social disadvantage, discrimination, and stigmatization suffered by the poor, people of color, documented and undocumented immigrants from developing countries, women, the homeless, and sexual minorities. Latent or hidden and delayed or sequential consequences.

Hidden & Delayed Consequences Housing –Housing directly contributes to a debilitating lack of a sense of safety and to feelings of hopelessness, –poor physical and emotional health –exhaustion of social capital –resulting weakened social support networks –poor education –diminished life opportunities

Immigration –those with lower acculturation scores were more than twice as likely to test positive for HIV/AIDS –more than twice as likely never to have been tested for hepatitis C –documented immigrants were twice as likely as their undocumented counterparts to have been tested for HIV and hepatitis C –each measure of lowered acculturation contributed to a 6% decline in chances that a participant would have access to health care

Drug users in New England –25% of our participants were infected with HIV –Of these, over 90% reported suffering from at least one other major disease, including hepatitis, tuberculosis, endocarditis, STDs, diabetes, liver disease, or mental illness. –Almost half of HIV-infected participants reported three or more of these diseases. –Most participants in this and our drug user studies reported lifetime and enduring experiences with violence in various forms

Female Drug users in New York –over 80% reported drug use during the incident. –In 40% of cases, both partners were using drugs –20% of the women in this study reported that they used drugs immediately after an episode of partner violence had ended as a means of coping with their emotional upset and physical pain. –a similar proportion of the women reported that they had been forced to have unprotected sex either during the most recent episode of violence they had endured or just after it concluded.

“There is a critical need for [longitudinal] research on (a) causal pathways and cumulative effects of the syndemic issues of violence, HIV, and substance abuse and (b) interventions that target [intimate partner violence] victims at risk for HIV, as well as HIV- positive [individuals] who may be experiencing [violence].” -- Andrea Gielen

Challenges & Barriers 1.finding hidden populations of people living with HIV-related syndemic health and social burdens 2.addressing issues of the availability, accessibility, and acceptability of testing, treatment and care programs for this vulnerable population based on syndemic health and social assessment; 3.attending to the challenges of sustaining people in treatment by insuring the coordination, integration, and comprehensiveness of services

New resources for meeting challenges 1.improved methodologies for finding and engaging hidden and hard-to-reach populations 2.availability of community-based rapid assessment strategies for identifying local structural and situational barriers to testing and care 3.growing recognition of the value of community-based participatory approaches and the availability of local networks 4.enhanced awareness of the importance of cultural factors and the role of stigmatization in avoiding or delaying help-seeking 5.expanding understanding of HIV/AIDS syndemics and the challenges of treatment adherence for vulnerable populations 6.recognition of the significant cost savings, both in terms of human suffering and monetary expenditure, of early as opposed to late intervention

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