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

摘要 在未来十年，超过70%的艾滋病毒感染者（PWH）将超过50岁。日益 高血压、糖尿病和血脂异常等非传染性疾病的负担已经 开始对老年艾滋病毒感染者（包括性少数男性）的有效艾滋病毒护理提出关键挑战 （SMM）。由于这些非传染性疾病通常作为共病一起出现， 如果它们是不利的，并受到社会和结构不平等的影响， （syndemic）.在美国，有大量的种族，民族和社会经济差异， 预防和/或控制非传染性疾病和艾滋病毒。交叉的耻辱，如种族主义，阶级歧视， 同性恋恐惧症可能通过直接和间接的机制推动这些健康差距。直接， 医疗机构中的交叉污名可能会导致医疗回避，降低成功率 保持、治疗、依从性等护理领域的艾滋病毒和非传染性疾病综合征连续性的沿着率， 疾病控制。间接地，经历交叉的耻辱感可能会导致心理社会的压力， 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， 疾病控制较差。很少有研究前瞻性地评估了 非传染性疾病发病率、流行率和控制的社会差异的交叉污名， 很少有研究严格评估心理社会综合症如何介导 社会地位与非传染性疾病和艾滋病毒结果之间的联系。收集了四年的数据 在此期间，我们将利用MACS/WIHS联合队列研究，这是运行时间最长的HIV+ 和HIV- SMM在美国，评估以下具体目标：（1）评估社会 立场，交叉污名，以及中老年艾滋病毒+和 艾滋病毒- SMM; 2）评估社会地位与非传染性疾病综合征发病率之间的关系， 流行率;和3）评估社会地位与艾滋病毒和非传染性疾病综合征之间的关系， 护理结果，介导的交叉污名和心理社会综合症。我们的科学前提是 许多边缘化人群在非传染性疾病的发病率、流行率和 控制，这是介导的交叉污名和心理社会综合症。拟议工作 将把艾滋病毒持续护理的交叉污名和心理社会综合症研究扩大到 非传染性疾病综合症连续护理。该提案符合NIH的高优先艾滋病研究领域， NOT-OD-15-137（“解决HIV相关合并症的影响”）和NHLBI RFA-HL-21-018， 这就要求使用综合征框架进行多因素研究，以表征心脏的聚集， PWH内的肺、血液和睡眠状况。这项研究将提供关键数据， 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尤其是有色人种和PWH的患病率和控制率。

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.