Stigma and the non-communicable disease syndemic in aging HIV positive and HIV negative MSM

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ABSTRACT Over the next decade, more than 70% of people living with HIV (PWH) will be older than 50. The increasing burden of the non-communicable diseases (NCDs) hypertension, diabetes, and dyslipidemia has al-ready begun to present key challenges to effective HIV care among aging PLWH, including sexual minority men (SMM). Because these NCDs often present together as comorbid conditions, interact with each other adversely, and are inflected by social and structural inequities, they may comprise a synergistic epidemic (syndemic). In the U.S., there are substantial racial, ethnic, and socioeconomic disparities in the prevalence and/or control of NCDs and HIV. Intersecting stigmas, such as racism, classism, and homophobia, may drive these health disparities through direct and indirect mechanisms. Directly, intersectional stigma in healthcare settings may contribute to healthcare avoidance, decreasing success rates along HIV and NCD syndemic continua of care domains of retention, treatment, adherence, and disease control. Indirectly, experiencing intersectional stigma may lead to a psychosocial syndemic of stress, depression, violence, and substance use, thereby contributing to HIV and NCD incidence, prevalence, and poorer disease control. Very few if any studies have prospectively assessed the contribution of intersectional stigma to social disparities in NCD syndemic incidence, prevalence, and control among PWH; and few if any studies have rigorously assessed how the psychosocial syndemic may mediate pathways between social position and syndemic NCD and HIV outcomes. Collecting data over a four-year period, we will utilize the MACS/WIHS Combined Cohort Study, the longest-running cohort study of HIV+ and HIV- SMM in the U.S., to assess the following specific aims: 1) assess relationships between social position, intersectional stigma, and the psychosocial syndemic among middle-aged and aging HIV+ and HIV- SMM; 2) assess relationships between social position and NCD syndemic incidence and prevalence; and 3) assess relationships between social position and HIV and NCD syndemic continua of care outcomes, mediated by intersectional stigma and the psychosocial syndemic. Our scientific premise is that multiply marginalized populations experience disparities in NCD syndemic incidence, prevalence, and control, which are mediated by intersectional stigma and the psychosocial syndemic. The proposed work will extend intersectional stigma and psychosocial syndemics research on the HIV continuum of care to the NCD syndemic continuum of care. This proposal aligns with NIH high priority AIDS research areas outlined in NOT-OD-15-137 (“addressing the impact of HIV-associated comorbidities”) and with NHLBI RFA-HL-21-018, which calls for multifactorial research using syndemics frameworks to characterize clustering of heart, lung, blood, and sleep conditions within PWH. This study will provide critical data for informing the development of integrated, multilevel interventions intended to remediate disparities in NCD incidence, prevalence, and control among middle-aged and aging SMM, particularly SMM of color and PWH.