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

摘要 在接下来的十年里，超过70%的艾滋病毒携带者(PWH)将超过50岁。不断增长的 非传染性疾病(NCDs)、高血压、糖尿病和血脂异常的负担已经显现 开始对包括性少数男性在内的老年妇女保健中心的艾滋病毒有效护理提出重大挑战 (SMM)。因为这些非传染性疾病经常以共病状态出现，彼此相互作用 不利，并受到社会和结构性不平等的影响，它们可能构成一种协同作用的流行病 (Syndemic)。在美国，存在着巨大的种族、民族和社会经济差距 非传染性疾病和艾滋病毒的流行和/或控制。相互交叉的污名，如种族主义、分类主义和 同性恋恐惧症，可能通过直接和间接机制推动这些健康差距。直接， 医疗保健环境中的跨部门污名可能会导致医疗回避，降低成功率 保留、治疗、依从性、依从性和 疾病控制。间接地，经历跨部门的耻辱可能会导致压力的心理社会综合征， 抑郁、暴力和药物使用，从而导致艾滋病毒和非传染性疾病的发病率、流行率和 更差的疾病控制。很少有研究，如果有的话，前瞻性地评估 对非传染性疾病发病率、患病率和控制率的社会差异的跨界别污名 几乎没有任何研究严格评估了心理社会综合征如何可能起到中介作用 社会地位与非传染性疾病和艾滋病毒结果之间的路径。在四年内收集数据 期间，我们将利用MACS/WIHS联合队列研究，这是运行时间最长的HIV+队列研究 和美国的艾滋病毒-SMM，以评估以下具体目标：1)评估社会之间的关系 中老年HIV阳性和老年患者的位置、交叉耻辱和心理社会症状 HIV-SMM；2)评估社会地位与非传染性疾病发病率和 流行率；以及3)评估社会地位与HIV和NCD之间的关系 护理结果，由跨部门污名和心理社会综合征调节。我们的科学前提是 倍增的边缘化人群在非传染性疾病的发病率、患病率和 控制，这是由跨部门污名和心理社会综合征调节的。拟议中的工作 将把关于艾滋病毒连续护理的跨部门污名和心理社会综合体研究扩展到 非传染性疾病共同护理的连续体。这项建议与美国国立卫生研究院重点艾滋病研究领域相一致。 NOT-OD-15-137(“应对艾滋病毒相关共病的影响”)和NHLBI RFA-HL-21-018， 它要求使用综合框架进行多因素研究，以表征心脏聚集， 威尔斯亲王医院内的肺部、血液和睡眠状况。这项研究将提供关键数据，以告知 制定旨在纠正非传染性疾病发病率差异的综合、多层次干预措施， 中老年SMM的患病率和控制情况，特别是有色性和PWH的SMM。

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.