Inter-connecting health problems increase HIV risk for MSM

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Intertwining health problems – syndemics – are associated with higher viral load and poorer adherence in HIV-positive men who have sex with men (MSM) taking antiretroviral treatment (ART), investigators from the United States report in the online edition of AIDS.

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

They believe their findings have important implications for current treatment as prevention strategies to control the HIV epidemic, as every increase in the number of epidemics was associated with higher viral load and therefore transmission risk.



The co-occurrence of several diseases and social problems which combine together to have an especially negative impact on risk behaviour and health. For example, researchers have described syndemics of drug use, mental health problems and sexual risk behaviour.


A mental health problem causing long-lasting low mood that interferes with everyday life.

treatment as prevention (TasP)

A public health strategy involving the prompt provision of antiretroviral treatment in people with HIV in order to reduce their risk of transmitting the virus to others through sex.

detectable viral load

When viral load is detectable, this indicates that HIV is replicating in the body. If the person is taking HIV treatment but their viral load is detectable, the treatment is not working properly. There may still be a risk of HIV transmission to sexual partners.

drug interaction

A risky combination of drugs, when drug A interferes with the functioning of drug B. Blood levels of the drug may be lowered or raised, potentially interfering with effectiveness or making side-effects worse. Also known as a drug-drug interaction.

Men who have sex with men account for approximately two-thirds of new HIV diagnoses in the United States. There are great hopes that the use of antiretroviral treatment as prevention will help curtail the epidemic in this population. However, only 28% of people with HIV in the US have an undetectable viral load.

Investigators from the Multicentre AIDS Cohort Study (MACS) were concerned that there were significant barriers preventing MSM with HIV from achieving and maintaining an undetectable viral load.

It is possible that syndemics (intertwining health problems) such as adversity and trauma in early life are associated with depression and substance abuse in young adulthood, which in turn leads to sexual risk-taking.

To see if this is the case, investigators assessed the association of syndemics on adherence and viral load in 766 MSM living with HIV who received care between 2003 and 2009.

Their research addressed three questions:

  • Is a higher syndemics count – number of syndemic conditions experienced concomitantly – associated with poorer control of viral load?
  • Are higher syndemics counts associated with poorer ART adherence?
  • Does adherence mediate the relationship between syndemics count and viral load?

Results showed that syndemics count was significantly associated with poorer adherence to ART (p < 0.0001). Racial/ethnic minority status and low income were also associated with lower adherence levels.

There was also evidence that the number of concomitant syndemics predicted poorer adherence. Individuals with one syndemic condition had poorer adherence compared to individuals with none; individuals with two syndemic conditions were less likely to adhere than individuals with only one condition; and those with three conditions had significantly poorer treatment adherence than those with two conditions.

Syndemics count was also associated with viral load (p < 0.001), as was racial/ethnic minority status (p < 0.0001) and lower income (p < 0.0001).

People with one syndemic condition had a median viral load of 248 copies/ml, significantly higher than the count of 191 copies/ml observed in people with no conditions. People with two conditions had a median viral load of 376 copies/ml and viral load was on average 1197 copies/ml for those with three conditions.

The likelihood of having a detectable viral load increased with syndemics count.

Higher syndemics count was associated with lower ART adherence (p < 0.01) and, for the most part, higher syndemics count was associated with higher viral load.

There was a significant interaction between syndemics. Polysubstance use was correlated with depressive symptoms (p < 0.0001) and unprotected anal sex (p < 0.0001). Depressive symptoms were related to polysubstance use (p < 0.0001) and unprotected sex (p < 0.0001); unprotected anal intercourse was significantly associated with polysubstance use (p < 0.0001) and depression (p < 0.0001).

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


Friedman MR et al. Effects of syndemics on HIV viral load and medication adherence in the multicentre AIDS cohort study. AIDS, online edition. DOI: 10.1097/QAD.0000000000000657, 2015.