Didactic Series. How Psychosocial Syndemics Perpetuate the HIV Epidemic

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1 Didactic Series How Psychosocial Syndemics Perpetuate the HIV Epidemic David J. Grelotti, MD University of California, San Diego November 10,

2 Disclosures Pharmaceutical industry: Travel support (2014) from unrestricted educational grant to Kocaeli University School of Medicine from Novo Nordisk Saglik Urunleri Tic. Ltd. Sti.; Travel support (2016) from Braeburn Pharmaceuticals to learn how to use the new buprenorphine implant Government grants: NIMH (T32); NIDA (R21); NIAID/Harvard University Center for AIDS Research (Scholar Award) 2

3 Learning Objectives 1) To define and identify psychosocial syndemics 2) To evaluate the relevance of psychosocial syndemics to the HIV epidemic 3) To apply one evidence-based approach to treating a syndemic that has been shown to improve HIV outcomes 3

4 Question 1 Please select the best response to complete this sentence: People with HIV have higher rates of A. Depression B. Heavy alcohol use C. Illicit drug use D. Both A and C E. A, B, and C 4

5 Psychiatric comorbidity General population a HIV-infected men and women a Depression 7.6% 36.0% 47.3% Heavy alcohol 4.7% 18.5% 10.5% use Illicit drug use 10.3% (any illicit drug) 50.1% (any illicit drug) a. US sample b. Urban US sample of men who have sex with men in an RCT HIV-uninfected MSM b 25.1% (stimulants) 13.7% ( 3 other illicit drugs) Grant et al. 2004; Bynum et al. 2010; Bing et al. 2001; Mimiaga et al

6 Comorbidity: HIV outcomes Depression and substance use: Increase risk of HIV infection Act as barriers to accessing treatment services and delay in initiating ART Are associated with suboptimal adherence to ART, treatment failure, poorer viral suppression Are associated with greater HIV-related morbidity and mortality 6

7 Comorbidity: Concepts Multimorbidity, dual diagnosis, and other notions of disease concentration Health disparities, social and historical influences on HIV risk Syndemics 7

8 Syndemics A syndemic is a set of intertwined and mutually enhancing epidemics involving disease interactions at the biological level that develop and are sustained in a community/population because of harmful social conditions and injurious social connections. - Singer & Clair 2003 Disease concentration: Co-occurrence of disease due to harmful conditions Disease interaction: Mutually reinforcing harmful effects on health Singer & Clair 2003; Tsai & Burns

9 Populations and conditions Psychosocial Syndemics Depression and other mental health problems Substance use Intimate partner violence Childhood sexual abuse Sexual compulsivity High-risk sexual behavior Populations studied MSM, including African American and Latino MSM MSMW MSW Lesbian women Bisexual women Transgender men and women Stall et al. 2003; Brennan et al ; Friedman et al. 2014; Mustanski et al. 2014; Coulter et al

10 Syndemics model for HIV Early life adversity Bullying Physical or sexual abuse Harassment Psychosocial epidemics Violence victimization Depression Substance use Sexual compulsivity HIV vulnerability Stall et al

11 Syndemics: HIV transmission EXPLORE Study 4395 uninfected MSM Longitudinal 4- year study SYNDEMICS: Depression, Alcohol, Stimulant, Other polysubstance use, Childhood sexual abuse Probability of remaining HIV negative 0 syndemics 1 syndemic 2 syndemics 3 syndemics 4 or 5 syndemics Mimiaga et al Time (days) 11

12 Syndemics: Adherence Primary care HIV clinic 333 HIV+ men and women MEMS cap monitoring of adherence SYNDEMICS: Childhood abuse; Current violence; Alcohol or substance abuse/ dependence; PTSD, Mood, and other psychiatric disorders Blashill et al

13 Syndemics: Viral suppression Multicenter AIDS Cohort Study 766 HIV+ MSM Prospective / longitudinal SYNDEMICS: Depression, Polysubstance use, Unprotected anal intercourse 70% 60% 50% 40% 30% 20% 10% 0% Detectable viral load (%) 34% 38% 45% 66% Friedman et al

14 Question 2 Psychosocial syndemics perpetuate the HIV epidemic through a negative association with A. HIV transmission risk B. HIV prevention through treatment as prevention C. Adherence to PrEP D. Both A and B E. A, B, and C 14

15 Syndemics: What to do? Prevention of early life adversity through structural interventions (e.g., community mobilization, service integration, economic interventions, funding reform) Promoting resilience (e.g., education) Targeted prevention efforts (e.g., encourage condom use) Treat the syndemics Single component, Multicomponent, or transdiagnostic Psychosocial (e.g., community, family, group, individual) or biomedical Gilbert et al. 2015; O Leary et al. 2014; Pitpitan et al. 2015; Pachankis 2015; Blank et al. 2013; Operario and Nemoto 2010; Rotheram-Borus et al

16 Antidepressants and HIV Himelhoch & Madoff

17 Depression treatment and HIV Meta-analysis of 12,243 persons from 29 studies Antidepressant studies targeting depression (10) Psychosocial interventions targeting depression (6) Psychosocial interventions targeting other issues (13) 1.83 (95% CI: 1.27, 2.55) greater odds of adherence with depression treatment Studies targeting depression (predominantly antidepressant trials) showed a greater impact on adherence than those targeting other issues Sin & DiMatteo

18 Syndemic depression Diagnoses of HIV-infected patients referred for mental health services at London clinic Number of patients Adams et al

19 Depression treatment barriers Perception of providers that on average only 50% of their patients with recognized depression were receiving treatments. Depression went undiagnosed in 54% of HIVinfected patients with depression National sample of HIV-infected persons from Persons with less perceived need, less than high school education, and private insurance were less likely to be diagnosed Bess et al. 2013; Asch et al. 2003; Taylor et al

20 Antidepressants and HIV HIV provider routine practices and beliefs % Belief that treating depression is part of their role 77% How depression is assessed: Screening 32% Observation or patient discloses 61% Confidence in prescribing: Prescribing an initial antidepressant 59% Use of full dose ranges 45% Changing or augmenting antidepressants 14% Follow up within 4 weeks 37% Bess et al

21 SLAM-DUNC Algorithm Measurement-Based Care (MBC) for depression Captures best practice: Treatment algorithms Defined windows for follow up Systematic screening for depressive symptoms and side effects Uses a Depression Care Manager to provide data and recommendations to providers Pence et al

22 Owen Prescribing Guide 1. Recommended firstline therapy 2. Dosing and titrating 3. Side effects to warn people about 4. Interactions with HIV medications DEPRESSION Depression (uncomplicated) Depression and smoking cigarettes Depression and pain Depression and difficulty sleeping and/or weight loss ANXIETY Anxiety disorders As needed medication INSOMNIA BENZODIAZEPINES ADHD NIGHTMARES IN SETTING OF PTSD 22

23 Question 3 Which of the following is NOT a treatment for depression? A. Sertraline B. Trazodone C. Bupropion D. Alprazolam E. Electroconvulsive therapy F. Cognitive behavioral therapy G. Amitriptyline H. Venlafaxine I. Interpersonal therapy 23

24 Summary Depression and other psychosocial syndemics are a group of co-occurring, mutually reinforcing conditions that perpetuate the HIV epidemic by increasing the risk of HIV transmission and worsening HIV treatment outcomes Psychosocial syndemics will impair our ability to achieve goals Depression treatment improves adherence to HIV treatment and indirectly improves HIV treatment outcomes 24

25 Selected references Adams, C., Zacharia, S., Masters, L., Coffey, C., & Catalan, P. (2016). Mental health problems in people living with HIV: changes in the last two decades: the London experience AIDS Care, Bing, E. G., Burnam, M. A., Longshore, D., Fleishman, J. A., Sherbourne, C. D., London, A. S., Shapiro, M. (2001). Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Archives of General Psychiatry, 58(8), Blashill, A. J., Bedoya, C. A., Mayer, K. H., O Cleirigh, C., Pinkston, M. M., Remmert, J. E., Safren, S. A. (2015). Psychosocial Syndemics are Additively Associated with Worse ART Adherence in HIV-Infected Individuals. AIDS and Behavior, 19(6), Friedman, M. R., Stall, R., Plankey, M., Wei, C., Shoptaw, S., Herrick, A., Silvestre, A. J. (2015). Effects of syndemics on HIV viral load and medication adherence in the multicentre AIDS cohort study. AIDS (London, England), 29(9), Mimiaga, M. J., OʼCleirigh, 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. JAIDS Journal of Acquired Immune Deficiency Syndromes, 68(3), Pence, B. (2011). Improving HAART Adherence in Depressed HIV Clinic Patients : A Real World RCT Study Protocol Updated August 31, 2011, Singer, M., & Clair, S. (2003). Syndemics and public health: reconceptualizing disease in bio-social context. Medical Anthropology Quarterly, 17(4), Stall, R., Coulter, R. W. S., Friedman, M. R., & Plankey, M. W. (2015). Commentary on Syndemics of psychosocial problems and HIV risk: A systematic review of empirical tests of the disease interaction concept by A. Tsai and B. Burns. Social Science and Medicine, 145, Tsai, A. C., & Venkataramani, A. S. (2015). Syndemics and Health Disparities: A Methodological Note. AIDS and Behavior. 25