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Depression, Substance Use, Poverty & Minority Status Exacerbate HIV Outcomes

Depression, Substance Use, Poverty & Minority Status Exacerbate HIV Outcomes


A study shows interconnected health issues snowball negative outcomes. Oh yeah, poverty and minority status do the same.

A new study in the online edition of AIDS  raises issues about treatment as prevention as a strategy for ending the HIV epidemic while showing that interconnected health issues are tied with negative health outcomes.

The results indicate that intertwining health problems — as well as poverty and minority racial/ethnic background —  are associated with higher viral loads and poorer antiretroviral treatment adherence among HIV-positive men who have sex with men.

These intersecting health problems, also known as syndemics, include depression, substance use, and “sexual risk behavior.”

“Higher HIV viral load and lower ART adherence are, respectively, associated with increased syndemics count,” explain the authors, including M. Reuel Friedman of the University of Pittsburgh. “These findings indicate that combinations of depression symptoms, polysubstance use, and sexual risk behavior 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.”

In other words, the more of these health problems one has, the less likely a person is able to achieve a positive outcome, even if they have access to HIV treatment. Although it was not what they set out to examine, the authors also discovered that poverty and racial background had similar negative impacts on HIV outcomes.

The authors findings have implications for current treatment as prevention  strategies as a way to control to the HIV epidemic among gay and bisexual men. They argue that too many of those currently HIV-positive have high viral loads and therefore are at a higher risk of transmitting the virus.

A poz person’s viral load is the amount of HIV in a sample of your blood. When the viral load is high, there is more HIV in one’s body, and that means their immune system isn’t working as well amd it is more likely to transmit the virus. On the opposite end of the scale, when the viral load becomes undetectable, it is very unlikely that person could transmit the virus to a sexual partner (about 1 percent).

According to AIDS Map, only 28 percent of HIV-positive Americans have an undetectable viral loads. The other 72 percent remain likely to transmit the disease. Investigators from the Multicentre AIDS Cohort Study were reportedly concerned about potential barriers preventing HIV-positive MSM from achieving and maintaining an undetectable viral load.

To see what role intertwining health problems (called syndemics) had on adherence and viral load, the researchers examined the medical files of 766 HIV-positive gay and bi men who had received care between 2003 and 2009.

They hoped to answer the following questions:
* Is a higher syndemics count (aka the number of health problems that one has concurrently) associated with higher viral loads?
* Are higher syndemics counts associated with poorer adherence to antiretroviral therapy?
* Does taking antiretroviral medication as prescribed alter the relationship between syndemics count and viral load?

The study showed that a higher syndemics count was associated with significantly lower adherence to antiretroviral therapy. Researchers also stumbled on the results showing racial/minority status and low income were also associated with lower adherence levels. There was also evidence in the study results that the number of concurrent health issues one had the less likely the patient was to adhere to their treatment. Patients with one condition had poorer adherence compared to individuals with none. Those with two syndemic conditions were less likely to adhere to treatment than patients with only one; and patients with three conditions had even worse treatment adherence than those with two.

Having concurrent health issues was also associated with higher viral load (as was racial/ethnic minority status and lower income). Patients with one syndemic condition had an average viral load of 248 copies/ml, significantly higher than the count of 191 copies/ml observed in patients with no conditions. Patients with two health conditions had a median viral load of 376 copies/ml and those with three conditions had average viral load was on average 1197 copies/ml for those with three conditions. 

Higher interconnected health conditions count was also associated with lower antiretroviral therapy adherence.

The researcher also found significant interactions between syndemics. In other words, those who used substances were more likely to be depressed and to have unprotected anal sex. Likewise, those who engaged in unprotected anal intercourse were significantly more likely to also have polysubstance use and depression.

“Our findings provide support for integrating structural and behavioural approaches to address syndemics among [men who have sex with men] receiving HIV care in the US,” noted the authors. “We strongly recommend the diffusion of HIV clinical care models that provide highly connected, preferably internally delivered mental health, sexual risk behavior prevention, and substance use treatment to optimize viral load suppression among HIV-positive MSM.”

This is one of the first studies to make it clear that mental health, substance abuse, and risky sexual behavior are more than tangential to positive HIV outcomes. This research indicates these three issues are entwined and must be dealt with inorder to stop the HIV epidemic.

And even if it wasn't the authors’ focus, this study reiterates that poverty and racial heritage can themselves lead to poor HIV health outcomes — even before adding other factors to the mix suggesting that until systemic poverty and institutionalized racism are addressed it will not be possible to end HIV.

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Jacob Anderson-Minshall