Abstract
Syndemic factors tend to co-occur and increase the risks of condomless anal intercourse (CAI), multiple sexual partners (MSP) and HIV vulnerability among men who have sex with men (MSM). This study aimed to test the synergistic effects of syndemic factors on HIV risk and to further explore the moderators between syndemics and HIV risk among Chinese MSM. A cross-sectional study was conducted to recruit MSM in Guangzhou to collect data on syndemic factors (depression, intimate partner violence, childhood sexual abuse [CSA], alcohol, and rush popper use before anal sex). The relative excess risk due to interactions (RERIs) was calculated to test the synergy in adjusted regression models. A moderated analysis was conducted to test the buffer effects of potential resilience factors (education and income). Among the 976 included MSM, individuals experiencing more syndemic factors were more likely to have CAI (odds ratio [OR]= 1.26, 95% confidence interval [CI] 1.11–1.44), MSP (OR= 1.33, 95% CI 1.16–1.52), and HIV infection (OR= 1.46, 95% CI 1.12–1.90). RERIs showed a synergy of depression and rush popper use prior to sex for MSP (1.17, 95% CI 0.03–2.03) and CSA and rush popper use prior to sex for HIV infection (1.72, 95% CI 0.05–3.43). However, no significant association was found for the interaction between the number of syndemic factors and education or income. Our findings support the synergy approach in syndemic studies and highlight the need for comprehensive and multifactorial intervention strategies on sexual health of MSM. Future studies are needed to identify potential resilience factors among Chinese MSM.
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Beyrer, C., Baral, S. D., Collins, C., Richardson, E. T., Sullivan, P. S., Sanchez, J., … Mayer, K. H. (2016). The global response to HIV in men who have sex with men. Lancet,388(10040), 198–206. https://doi.org/10.1016/S0140-6736(16)30781-4.
Beyrer, C., Baral, S. D., van Griensven, F., Goodreau, S. M., Chariyalertsak, S., Wirtz, A. L., & Brookmeyer, R. (2012). Global epidemiology of HIV infection in men who have sex with men. Lancet,380(9839), 367–377. https://doi.org/10.1016/S0140-6736(12)60821-6.
Cheng, W., Tang, W., Zhong, F., Babu, G. R., Han, Z., Qin, F., … Wang, M. (2014). Consistently high unprotected anal intercourse (UAI) and factors correlated with UAI among men who have sex with men: Implication of a serial cross-sectional study in Guangzhou, China. BMC Infectious Diseases,14, 696. https://doi.org/10.1186/s12879-014-0696-8.
Dunkle, K. L., Wong, F. Y., Nehl, E. J., Lin, L., He, N., Huang, J., & Zheng, T. (2013). Male-on-male intimate partner violence and sexual risk behaviors among money boys and other men who have sex with men in Shanghai, China. Sexually Transmitted Diseases,40(5), 362–365. https://doi.org/10.1097/OLQ.0b013e318283d2af.
Dyer, T. P., Shoptaw, S., Guadamuz, T. E., Plankey, M., Kao, U., Ostrow, D., … Stall, R. (2012). Application of syndemic theory to black men who have sex with men in the Multicenter AIDS Cohort Study. Journal of Urban Health,89(4), 697–708. https://doi.org/10.1007/s11524-012-9674-x.
Ferlatte, O., Salway, T., Samji, H., Dove, N., Gesink, D., Gilbert, M., … Wong, J. (2018). An application of syndemic theory to identify drivers of the syphilis epidemic among gay, bisexual, and other men who have sex with men. Sexually Transmitted Diseases,45(3), 163–168. https://doi.org/10.1097/OLQ.0000000000000713.
Friedman, M. R., Stall, R., Silvestre, A. J., Wei, C., Shoptaw, S., Herrick, A., … Plankey, M. W. (2015). Effects of syndemics on HIV viral load and medication adherence in the multicentre AIDS cohort study. AIDS,29(9), 1087–1096. https://doi.org/10.1097/QAD.0000000000000657.
GBD 2015 HIV Collaborators. (2016). Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2015: The Global Burden of Disease Study 2015. Lancet HIV,3(8), e361–e387. https://doi.org/10.1016/S2352-3018(16)30087-X.
Guadamuz, T. E., McCarthy, K., Wimonsate, W., Thienkrua, W., Varangrat, A., Chaikummao, S., … van Griensven, F. (2014). Psychosocial health conditions and HIV prevalence and incidence in a cohort of men who have sex with men in Bangkok, Thailand: Evidence of a syndemic effect. AIDS and Behavior,18(11), 2089–2096. https://doi.org/10.1007/s10461-014-0826-8.
Halkitis, P. N., Kapadia, F., Bub, K. L., Barton, S., Moreira, A. D., & Stults, C. B. (2015). A longitudinal investigation of syndemic conditions among young gay, bisexual, and other MSM: The P18 cohort study. AIDS and Behavior,19(6), 970–980. https://doi.org/10.1007/s10461-014-0892-y.
Herrick, A. L. (2011). Syndemic processes among young men who have sex with men (MSM): Pathways toward risk and resilience. Doctoral dissertation, University of Pittsburgh.
Herrick, A. L., Lim, S. H., Wei, C., Smith, H., Guadamuz, T., Friedman, M. S., & Stall, R. (2011). Resilience as an untapped resource in behavioral intervention design for gay men. AIDS and Behavior,15(Suppl. 1), S25–S29. https://doi.org/10.1007/s10461-011-9895-0.
Hirshfield, S., Schrimshaw, E. W., Stall, R. D., Margolis, A. D., Downing, M. J., Jr., & Chiasson, M. A. (2015). Drug use, sexual risk, and syndemic production among men who have sex with men who engage in group sexual encounters. American Journal of Public Health,105(9), 1849–1858. https://doi.org/10.2105/AJPH.2014.302346.
Jie, W., Ciyong, L., Xueqing, D., Hui, W., & Lingyao, H. (2012). A syndemic of psychosocial problems places the MSM (men who have sex with men) population at greater risk of HIV infection. PLoS ONE,7(3), e32312. https://doi.org/10.1371/journal.pone.0032312.
Kroger, H., Pakpahan, E., & Hoffmann, R. (2015). What causes health inequality? A systematic review on the relative importance of social causation and health selection. European Journal of Public Health,25(6), 951–960. https://doi.org/10.1093/eurpub/ckv111.
Li, R., Cai, Y., Wang, Y., Sun, Z., Zhu, C., Tian, Y., … Gan, F. (2016). Psychosocial syndemic associated with increased suicidal ideation among men who have sex with men in Shanghai, China. Health Psychology,35(2), 148–156. https://doi.org/10.1037/hea0000265.
Martinez, O., Arreola, S., Wu, E., Munoz-Laboy, M., Levine, E. C., Rutledge, S. E., … Sandfort, T. (2016). Syndemic factors associated with adult sexual HIV risk behaviors in a sample of Latino men who have sex with men in New York City. Drug and Alcohol Dependence,166, 258–262. https://doi.org/10.1016/j.drugalcdep.2016.06.033.
Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin,129(5), 674–697. https://doi.org/10.1037/0033-2909.129.5.674.
Mimiaga, M. J., O’Cleirigh, C., Biello, K. B., Robertson, A. M., Safren, S. A., Coates, T. J., … Mayer, K. H. (2015). The effect of psychosocial syndemic production on 4-year HIV incidence and risk behavior in a large cohort of sexually active men who have sex with men. Journal of Acquired Immune Deficiency Syndromes,68(3), 329–336. https://doi.org/10.1097/QAI.0000000000000475.
Mustanski, B., Andrews, R., Herrick, A., Stall, R., & Schnarrs, P. W. (2014). A syndemic of psychosocial health disparities and associations with risk for attempting suicide among young sexual minority men. American Journal of Public Health,104(2), 287–294. https://doi.org/10.2105/AJPH.2013.301744.
O’Leary, A., Jemmott, J. B., 3rd, Stevens, R., Rutledge, S. E., & Icard, L. D. (2014). Optimism and education buffer the effects of syndemic conditions on HIV status among African American men who have sex with men. AIDS and Behavior,18(11), 2080–2088. https://doi.org/10.1007/s10461-014-0708-0.
Oldenburg, C. E., Perez-Brumer, A. G., & Reisner, S. L. (2014). Poverty matters: Contextualizing the syndemic condition of psychological factors and newly diagnosed HIV infection in the United States. AIDS,28(18), 2763–2769. https://doi.org/10.1097/QAD.0000000000000491.
Parsons, J. T., Antebi-Gruszka, N., Millar, B. M., Cain, D., & Gurung, S. (2018). Syndemic conditions, HIV transmission risk behavior, and transactional sex among transgender women. AIDS and Behavior,22(7), 2056–2067. https://doi.org/10.1007/s10461-018-2100-y.
Parsons, J. T., Grov, C., & Golub, S. A. (2012). Sexual compulsivity, co-occurring psychosocial health problems, and HIV risk among gay and bisexual men: Further evidence of a syndemic. American Journal of Public Health,102(1), 156–162. https://doi.org/10.2105/AJPH.2011.300284.
Parsons, J. T., Millar, B. M., Moody, R. L., Starks, T. J., Rendina, H. J., & Grov, C. (2017). Syndemic conditions and HIV transmission risk behavior among HIV-negative gay and bisexual men in a US national sample. Health Psychology,36(7), 695–703. https://doi.org/10.1037/hea0000509.
Parsons, J. T., Rendina, H. J., Moody, R. L., Ventuneac, A., & Grov, C. (2015). Syndemic production and sexual compulsivity/hypersexuality in highly sexually active gay and bisexual men: further evidence for a three group conceptualization. Archives of Sexual Behavior,44(7), 1903–1913. https://doi.org/10.1007/s10508-015-0574-5.
Pitpitan, E. V., Smith, L. R., Goodman-Meza, D., Torres, K., Semple, S. J., Strathdee, S. A., & Patterson, T. L. (2016). “Outness” as a moderator of the association between syndemic conditions and HIV risk-taking behavior among men who have sex with men in Tijuana, Mexico. AIDS and Behavior,20(2), 431–438. https://doi.org/10.1007/s10461-015-1172-1.
Richardson, D. B., & Kaufman, J. S. (2009). Estimation of the relative excess risk due to interaction and associated confidence bounds. American Journal of Epidemiology,169(6), 756–760. https://doi.org/10.1093/aje/kwn411.
Salganik, M. J. (2006). Variance estimation, design effects, and sample size calculations for respondent-driven sampling. Journal of Urban Health,83(6 Suppl.), i98–112. https://doi.org/10.1007/s11524-006-9106-x.
Sandfort, T., Bos, H., Knox, J., & Reddy, V. (2016). Gender nonconformity, discrimination, and mental health among black South African men who have sex with men: A further exploration of unexpected findings. Archives of Sexual Behavior,45(3), 661–670. https://doi.org/10.1007/s10508-015-0565-6.
Singer, M., Bulled, N., Ostrach, B., & Mendenhall, E. (2017). Syndemics and the biosocial conception of health. Lancet,389(10072), 941–950. https://doi.org/10.1016/S0140-6736(17)30003-X.
Stall, R., Mills, T. C., Williamson, J., Hart, T., Greenwood, G., Paul, J., … Catania, J. A. (2003). Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. American Journal of Public Health,93(6), 939–942.
Stoicescu, C., Ameilia, R., Irwanto, Praptoraharjo, I., & Mahanani, M. (2019). Syndemic and synergistic effects of intimate partner violence, crystal methamphetamine, and depression on HIV sexual risk behaviors among women who inject drugs in Indonesia. Journal of Urban Health,96, 477–496. https://doi.org/10.1007/s11524-019-00352-6.
Tomori, C., McFall, A. M., Solomon, S. S., Srikrishnan, A. K., Anand, S., Balakrishnan, P., … Celentano, D. D. (2018). Is there synergy in syndemics? Psychosocial conditions and sexual risk among men who have sex with men in India. Social Science and Medicine,206, 110–116. https://doi.org/10.1016/j.socscimed.2018.03.032.
Tsai, A. C., & Burns, B. F. (2015). Syndemics of psychosocial problems and HIV risk: A systematic review of empirical tests of the disease interaction concept. Social Science and Medicine,139, 26–35. https://doi.org/10.1016/j.socscimed.2015.06.024.
Tsai, A. C., & Venkataramani, A. S. (2016). Syndemics and health disparities: A methodological note. AIDS and Behavior,20(2), 423–430. https://doi.org/10.1007/s10461-015-1260-2.
Tsuyuki, K., Pitpitan, E. V., Levi-Minzi, M. A., Urada, L. A., Kurtz, S. P., Stockman, J. K., & Surratt, H. L. (2017). Substance use disorders, violence, mental health, and HIV: Differentiating a syndemic factor by gender and sexuality. AIDS and Behavior,21(8), 2270–2282. https://doi.org/10.1007/s10461-017-1841-3.
Wang, Y., Wang, Z., Jia, M., Liang, A., Yuan, D., Sun, Z., … Zhang, Z. (2017). Association between a syndemic of psychosocial problems and unprotected anal intercourse among men who have sex with men in Shanghai, China. BMC Infectious Diseases,17(1), 46. https://doi.org/10.1186/s12879-016-2132-8.
Wang, Z., Zhao, X., Zhang, Z., Luo, M., Shen, Q., Dong, Y., … Cai, Y. (2018). Co-occurring psychosocial problems and multiple sexual partners among men who have sex with men in Shanghai, China: A syndemic approach. Journal of Sex Research,55(7), 892–901. https://doi.org/10.1080/00224499.2017.1399333.
Williams, J. K., Wilton, L., Magnus, M., Wang, L., Wang, J., Dyer, T. P., … HIV Prevention Trials Network 061 Study Team. (2015). Relation of childhood sexual abuse, intimate partner violence, and depression to risk factors for HIV among black men who have sex with men in 6 US cities. American Journal of Public Health,105(12), 2473–2481. https://doi.org/10.2105/AJPH.2015.302878.
Zung, W. W. (1965). A self-rating depression scale. Archives of General Psychiatry,12, 63–70.
Acknowledgements
The authors would like to thank the staff in the voluntary counseling and testing clinics of Baiyun, Conghua, Panyu, Huadu, Huangpu, Zengcheng District CDC, Lingnan Partners, and Zhitong Charity to help collect the data in this study.
Funding
This study was funded by the Young Scientists Fund (81703282) from the National Natural Science Foundation of China (http://www.nsfc.gov.cn/), the “13th Five-Year” plan for the development of philosophy and social sciences in Guangzhou (2018GZGJ67) from the Guangzhou Association of Social Science Societies (http://www.gzsk.org.cn/), Special Funds for Provincial Health and Family Planning Development of Guangdong in China in 2016 (AIDS prevention Project: 2100409) from the Department of Finance of Guangdong Province (http://www.gdczt.gov.cn/) and the Medical Scientific Research Foundation of Guangdong Province, China (A2017036), from the Health and Family Planning Commission of Guangdong Province (http://www.gdwst.gov.cn/).
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Jiang, H., Li, J., Tan, Z. et al. Syndemic Factors and HIV Risk Among Men Who Have Sex with Men in Guangzhou, China: Evidence from Synergy and Moderated Analyses. Arch Sex Behav 49, 311–320 (2020). https://doi.org/10.1007/s10508-019-01488-x
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DOI: https://doi.org/10.1007/s10508-019-01488-x