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
The end