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AIDS and Behavior

, Volume 23, Issue 6, pp 1518–1529 | Cite as

Syndemic Classes, Stigma, and Sexual Risk Among Transgender Women in India

  • Venkatesan ChakrapaniEmail author
  • Tiara C. Willie
  • Murali Shunmugam
  • Trace S. Kershaw
Original Paper

Abstract

Syndemic theory could explain the elevated HIV risk among transgender women (TGW) in India. Using cross-sectional data of 300 TGW in India, we aimed to: identify latent classes of four syndemic conditions (Depression-D, Alcohol use-A, Violence victimization-V, HIV-positive status), test whether syndemic classes mediate the association between stigma and sexual risk, and test whether social support and resilient coping moderate the association between syndemic classes and sexual risk. Four distinct classes emerged: (1) DAV Syndemic, (2) AV Syndemic, (3) DV Syndemic, and (4) No Syndemic. TGW in the DAV Syndemic (OR 9.80, 95% CI 3.45, 27.85, p < 0.001) and AV Syndemic classes (OR 2.74, 95% CI 1.19, 6.32, p < 0.01) had higher odds of inconsistent condom use in the past month than the No Syndemic class. Social support significantly moderated the effect of DAV Syndemic class on inconsistent condom use. DAV Syndemic was found to be a significant mediator of the effect of transgender identity stigma on sexual risk. HIV prevention programs among TGW need to: (a) incorporate multi-level multi-component interventions to address syndemic conditions, tailored to the nature of syndemic classes; (b) reduce societal stigma against TGW; and (c) improve social support to buffer the impact of syndemics on sexual risk.

Keywords

Syndemics Transgender women Social support Resilience Stigma HIV/AIDS 

Notes

Acknowledgments

Venkatesan Chakrapani was supported, in part, by senior fellowship from the Wellcome Trust/DBT India Alliance. Tiara C. Willie was supported, in part, by grants from the National Institute of Mental Health (T32MH02003118 and F31MH11350801A1). For successful implementation of this study, we thank our study partner agencies: The Humsafar Trust, Social Welfare Association for Men, Lotus Integrated AIDS Awareness Sangam, Mooknayak, Pahal Foundation, and Solidarity and Action Against The HIV Infection in India. 

Funding

This research study was funded by Indian Council of Medical Research (RHN/Adhoc/21/2010–11).

Compliance with Ethical Standards

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Humsafar Trust, Mumbai, and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

References

  1. 1.
    Poteat T, Scheim A, Xavier J, Reisner S, Baral S. Global Epidemiology of HIV Infection and Related Syndemics Affecting Transgender People. J Acquir Immune Defic Syndr. 2016;72(Suppl 3):S210–9.PubMedPubMedCentralGoogle Scholar
  2. 2.
    Poteat T, German D, Flynn C. The conflation of gender and sex: gaps and opportunities in HIV data among transgender women and MSM. Glob Public Health. 2016;11(7–8):835–48.PubMedPubMedCentralGoogle Scholar
  3. 3.
    Parker R, Aggleton P, Perez-Brumer AG. The trouble with ‘Categories’: rethinking men who have sex with men, transgender and their equivalents in HIV prevention and health promotion. Glob Public Health. 2016;11(7–8):819–23.PubMedGoogle Scholar
  4. 4.
    NACO. National IBBS 2014–15: Hijras/Transgender people. New Delhi: National AIDS Control Organization (NACO); 2016.Google Scholar
  5. 5.
    NACO. Annual Report: 2016–17. National AIDS Control Organization (NACO). New Delhi: 2017.Google Scholar
  6. 6.
    Singer M, Clair S. Syndemics and public health: reconceptualizing disease in bio-social context. Med Anthropol Q. 2003;17(4):423–41.PubMedGoogle Scholar
  7. 7.
    Singer M, Bulled N, Ostrach B, Mendenhall E. Syndemics and the biosocial conception of health. Lancet. 2017;389(10072):941–50.Google Scholar
  8. 8.
    Singer MC, Erickson PI, Badiane L, Diaz R, Ortiz D, Abraham T, et al. Syndemics, sex and the city: understanding sexually transmitted diseases in social and cultural context. Soc Sci Med. 2006;63(8):2010–21.PubMedGoogle Scholar
  9. 9.
    Parsons JT, Grov C, Golub SA. Sexual compulsivity, co-occurring psychosocial health problems, and HIV risk among gay and bisexual men: further evidence of a syndemic. Am J Public Health. 2012;102(1):156–62.PubMedPubMedCentralGoogle Scholar
  10. 10.
    Stall R, Mills TC, Williamson J, Hart T, Greenwood G, Paul J, et al. Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. Am J Public Health. 2003;93(6):939–42.PubMedPubMedCentralGoogle Scholar
  11. 11.
    Brennan J, Kuhns LM, Johnson AK, Belzer M, Wilson EC, Garofalo R. Syndemic theory and HIV-related risk among young transgender women: the role of multiple, co-occurring health problems and social marginalization. Am J Public Health. 2012;102(9):1751–7.PubMedPubMedCentralGoogle Scholar
  12. 12.
    Operario D, Nemoto T. HIV in transgender communities: syndemic dynamics and a need for multicomponent interventions. J Acquir Immune Defic Syndr. 2010;55(Suppl 2):S91–3.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Himmelgreen DA, Romero-Daza N, Turkon D, Watson S, Okello-Uma I, Sellen D. Addressing the HIV/AIDS-food insecurity syndemic in sub-Saharan Africa. Afr J AIDS Res. 2009;8(4):401–12.PubMedGoogle Scholar
  14. 14.
    Sullivan LE, Saitz R, Cheng DM, Libman H, Nunes D, Samet JH. The impact of alcohol use on depressive symptoms in HIV-infected patients. Addiction (Abingdon, England). 2008;103(9):1461–7.Google Scholar
  15. 15.
    Egbe CO, Dakum PS, Ekong E, Kohrt BA, Minto JG, Ticao CJ. Depression, suicidality, and alcohol use disorder among people living with HIV/AIDS in Nigeria. Bmc Public Health. 2017;17(1):542.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Tsai AC, Burns BF. Syndemics of psychosocial problems and HIV risk: a systematic review of empirical tests of the disease interaction concept. Soc Sci Med. 2015;139:26–35.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Shaw SY, Lorway R, Bhattacharjee P, Reza-Paul S, du Plessis E, McKinnon L, et al. Descriptive epidemiology of factors associated with hiv infections among men and transgender women who have sex with men in South India. LGBT Health. 2016;3(4):292–9.PubMedPubMedCentralGoogle Scholar
  18. 18.
    Shaw SY, Lorway RR, Deering KN, Avery L, Mohan HL, Bhattacharjee P, et al. Factors associated with sexual violence against men who have sex with men and transgendered individuals in Karnataka, India. PLoS ONE. 2012;7(3):e31705.PubMedPubMedCentralGoogle Scholar
  19. 19.
    Willie TC, Chakrapani V, Hughto JMW, Kershaw TS. Victimization and human immunodeficiency virus-related risk among transgender women in India: a latent profile analysis. Violence Gend. 2017;4(4):121–9.PubMedPubMedCentralGoogle Scholar
  20. 20.
    Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex. 2017;19(8):903–17.PubMedPubMedCentralGoogle Scholar
  21. 21.
    Chakrapani V, Shunmugam M, Newman PA, Kershaw T, Dubrow R. HIV status disclosure and condom use among hiv-positive men who have sex with men and Hijras (male-to-female transgender people) in India: implications for Prevention. J HIV/AIDS Soc Serv. 2015;14(1):26–44.Google Scholar
  22. 22.
    Chakrapani V, Newman PA, Shunmugam M, Logie CH, Samuel M. Syndemics of depression, alcohol use, and victimisation, and their association with HIV-related sexual risk among men who have sex with men and transgender women in India. Glob Public Health. 2017;12(2):250–65.PubMedGoogle Scholar
  23. 23.
    Tsai AC, Venkataramani AS. Syndemics and health disparities: a methodological note. AIDS Behav. 2016;20(2):423–30.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Starks TJ, Millar BM, Eggleston JJ, Parsons JT. Syndemic factors associated with HIV risk for gay and bisexual men: comparing latent class and latent factor modeling. AIDS Behav. 2014;18(11):2075–9.PubMedGoogle Scholar
  25. 25.
    Stall R, Friedman M, Catania JA. Interacting epidemics and gay men’s health: a theory of syndemic production among urban gay men. In: Wolitski RJ, Stall R, Valdiserri RO, editors. Unequal opportunity: health disparities affecting gay and bisexual men in the United States. New York: Oxford University Press; 2008.Google Scholar
  26. 26.
    Chakrapani V, Kaur M, Newman PA, Mittal S, Kumar R. Syndemics and HIV-related sexual risk among men who have sex with men in India: influences of stigma and resilience. Cult Health Sex. 2018;20:1–16.Google Scholar
  27. 27.
    Herrick A, Stall R, Egan J, Schrager S, Kipke M. Pathways towards risk: syndemic conditions mediate the effect of adversity on HIV risk behaviors among young men who have sex with men (YMSM). J Urban Health. 2014;91(5):969–82.PubMedPubMedCentralGoogle Scholar
  28. 28.
    Chakrapani V, Vijin PP, Logie CH, Newman PA, Shunmugam M, Sivasubramanian M, et al. Understanding how sexual and gender minority stigmas influence depression among trans women and men who have sex with men in India. LGBT Health. 2017;4(3):217–26.PubMedGoogle Scholar
  29. 29.
    Sevelius JM. Gender affirmation: a framework for conceptualizing risk behavior among transgender women of color. Sex Roles. 2013;68(11–12):675–89.PubMedGoogle Scholar
  30. 30.
    Herrick AL, Stall R, Goldhammer H, Egan JE, Mayer KH. Resilience as a research framework and as a cornerstone of prevention research for gay and bisexual men: theory and evidence. AIDS Behav. 2014;18(1):1–9.PubMedGoogle Scholar
  31. 31.
    Kurtz SP, Buttram ME, Surratt HL, Stall RD. Resilience, syndemic factors, and serosorting behaviors among HIV-positive and HIV-negative substance-using MSM. AIDS Educ Prev. 2012;24(3):193–205.PubMedPubMedCentralGoogle Scholar
  32. 32.
    Aburn G, Gott M, Hoare K. What is resilience? An integrative review of the empirical literature. J Adv Nurs. 2016;72(5):980–1000.PubMedGoogle Scholar
  33. 33.
    Woodward EN, Banks RJ, Marks AK, Pantalone DW. Identifying resilience resources for hiv prevention among sexual minority men: a systematic review. AIDS Behav. 2017;21(10):2860–73.PubMedGoogle Scholar
  34. 34.
    Chakrapani V, Vijin PP, Logie CH, Newman PA, Shunmugam M, Sivasubramanian M, et al. Assessment of a “Transgender Identity Stigma” scale among trans women in India: findings from exploratory and confirmatory factor analyses. Int J Transgend. 2017;18(3):271–81.Google Scholar
  35. 35.
    Go VF, Solomon S, Srikrishnan AK, Sivaram S, Johnson SC, Sripaipan T, et al. HIV rates and risk behaviors are low in the general population of men in Southern India but high in alcohol venues: results from 2 probability surveys. J Acquir Immune Defic Syndr. 2007;46(4):491–7.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Yadav D, Chakrapani V, Goswami P, Ramanathan S, Ramakrishnan L, George B, et al. Association between alcohol use and HIV-related sexual risk behaviors among men who have sex with men (MSM): findings from a multi-site bio-behavioral survey in India. AIDS Behav. 2014;18(7):1330–8.PubMedPubMedCentralGoogle Scholar
  37. 37.
    Logie CH, Newman PA, Chakrapani V, Shunmugam M. Adapting the minority stress model: associations between gender non-conformity stigma, HIV-related stigma and depression among men who have sex with men in South India. Soc Sci Med. 2012;74(8):1261–8.PubMedGoogle Scholar
  38. 38.
    Zimet GD, Dahlem NW, Zimet SG, Farley GK. The multidimensional scale of perceived social support. J Pers Assess. 1988;52(1):30–41.Google Scholar
  39. 39.
    Sinclair VG, Wallston KA. The development and psychometric evaluation of the Brief Resilient Coping Scale. Assessment. 2004;11(1):94–101.PubMedGoogle Scholar
  40. 40.
    Akaike H. Factor analysis and AIC. Psychometrika. 1987;52(3):317–32.Google Scholar
  41. 41.
    Hu LT, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equ Model. 1999;6(1):1–55.Google Scholar
  42. 42.
    Lanza ST, Collins LM, Lemmon DR, Schafer JL. PROC LCA: A SAS Procedure for Latent Class Analysis. Struct Equ Model. 2007;14(4):671–94.Google Scholar
  43. 43.
    Muthen LK, Muthen B. Mplus user's guide: statistical analysis with latent variables. 7th ed. Los Angeles, CA: Muthén & Muthén; 2012.Google Scholar
  44. 44.
    Nemoto T, Bodeker B, Iwamoto M. Social support, exposure to violence and transphobia, and correlates of depression among male-to-female transgender women with a history of sex work. Am J Public Health. 2011;101(10):1980–8.PubMedPubMedCentralGoogle Scholar
  45. 45.
    Beach D, Pedersen RB. Process-tracing methods : foundations and guidelines. Ann Arbor: The University of Michigan Press; 2016.Google Scholar
  46. 46.
    Earnshaw VA, Smith LR, Cunningham CO, Copenhaver MM. Intersectionality of internalized HIV stigma and internalized substance use stigma: implications for depressive symptoms. J Health Psychol. 2015;20(8):1083–9.PubMedGoogle Scholar
  47. 47.
    Logie CH, James L, Tharao W, Loutfy MR. HIV, gender, race, sexual orientation, and sex work: a qualitative study of intersectional stigma experienced by HIV-positive women in Ontario, Canada. PLoS Med. 2011;8(11):e1001124.PubMedPubMedCentralGoogle Scholar
  48. 48.
    Sugano E, Nemoto T, Operario D. The impact of exposure to transphobia on HIV risk behavior in a sample of transgendered women of color in San Francisco. AIDS Behav. 2006;10(2):217–25.PubMedGoogle Scholar
  49. 49.
    Roberts T, Esponda GM, Krupchanka D, Shidhaye R, Patel V, Rathod S. Factors associated with health service utilisation for common mental disorders: a systematic review. BMC Psychiatry. 2018;18(1):262.PubMedPubMedCentralGoogle Scholar
  50. 50.
    Schmidt LA. Recent developments in alcohol services research on access to care. Alcohol Res. 2016;38(1):27–33.PubMedPubMedCentralGoogle Scholar
  51. 51.
    Singer M. A dose of drugs, a touch of violence, a case of AIDS: conceptualizing the SAVA syndemic. Free Inq Creat Sociol. 1996;24(2):99–110.Google Scholar
  52. 52.
    Reisner SL, White Hughto JM, Pardee D, Sevelius J. Syndemics and gender affirmation: HIV sexual risk in female-to-male trans masculine adults reporting sexual contact with cisgender males. Int J STD AIDS. 2016;27(11):955–66.PubMedGoogle Scholar
  53. 53.
    Gonzalez-Guarda RM. Pushing the syndemic research agenda forward: a comment on Pitpitan et al. Ann Behav Med. 2013;45(2):135–6.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.School of Public HealthPostgraduate Institute of Medical Education and Research (PGIMER)ChandigarhIndia
  2. 2.Centre for Sexuality and Health Research and Policy (C-SHaRP)ChennaiIndia
  3. 3.Department of Chronic Disease EpidemiologyYale School of Public HealthNew HavenUSA
  4. 4.Yale Center for Interdisciplinary Research on AIDSNew HavenUSA

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