Journal of Community Health

, Volume 41, Issue 6, pp 1204–1211 | Cite as

The Utility of a Syndemic Framework in Understanding Chronic Disease Management Among HIV-Infected and Type 2 Diabetic Men Who Have Sex with Men

  • Blaire Byg
  • Angela Robertson Bazzi
  • Danielle Funk
  • Bonface James
  • Jennifer Potter
Original Paper


Syndemic theory posits that epidemics of multiple physical and psychosocial problems co-occur among disadvantaged groups due to adverse social conditions. Although sexual minority populations are often stigmatized and vulnerable to multiple health problems, the syndemic perspective has been underutilized in understanding chronic disease. To assess the potential utility of this perspective in understanding the management of co-occurring HIV and Type 2 diabetes, we used linear regression to examine glycemic control (A1c) among men who have sex with men (MSM) with both HIV and Type 2 diabetes (n = 88). Bivariable linear regression explored potential syndemic correlates of inadequate glycemic control. Compared to those with adequate glycemic control (A1c ≤ 7.5 %), more men with inadequate glycemic control (A1c > 7.5 %) had hypertension (70 vs. 46 %, p = 0.034), high triglycerides (93 vs. 61 %, p = 0.002), depression (67 vs. 39 %, p = 0.018), current substance abuse (15 vs. 2 %, p = 0.014), and detectable levels of HIV (i.e., viral load ≥75 copies per ml blood; 30 vs. 10 %, p = 0.019). In multivariable regression controlling for age, the factors that were independently associated with higher A1c were high triglycerides, substance use, and detectable HIV viral load, suggesting that chronic disease management among MSM is complex and challenging for patients and providers. Findings also suggest that syndemic theory can be a clarifying lens for understanding chronic disease management among sexual minority stigmatized populations. Interventions targeting single conditions may be inadequate when multiple conditions co-occur; thus, research using a syndemic framework may be helpful in identifying intervention strategies that target multiple co-occurring conditions.


Syndemics HIV Diabetes MSM Chronic disease management 


Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    HIV Incidence. (2015). Centers for disease control and prevention web site. Accessed 13 July 2015.
  2. 2.
    Mayer, K. H., Bradford, J. B., Makadon, H. J., et al. (2008). Sexual and gender minority health: What we know and what needs to be done. American Journal of Public Health, 98, 989–995.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Brown, T. T., Cole, S. R., Xiuhong, L., et al. (2005). Antiretroviral therapy and the prevalence and incidence of diabetes mellitus in the Multicenter AIDS Cohort Study. Archives of Internal Medicine, 165, 1179–1184.CrossRefPubMedGoogle Scholar
  4. 4.
    Cochran, S. D., & Mays, V. M. (2000). Lifetime prevalence of suicide symptoms and affective disorders among men reporting same-sex sexual partners: Results from NHANES III. American Journal of Public Health, 90(4), 573–578.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Cochran, S. D., Mays, V. M., & Sullivan, J. G. (2003). Prevalence of mental disorders, psychological distress, and mental health services use among lesbian, gay, and bisexual adults in the United States. Journal of Consulting and Clinical Psychology, 71(1), 53–61.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Mustanski, B., Garofalo, R., Herrick, A., & Donenberg, G. (2007). Psychosocial health problems increase risk for HIV among urban young men who have sex with men: preliminary evidence of a syndemic in need of attention. Annals of Behavioral Medicine, 34(1), 37–45.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Stall, R., Mills, T. C., Williamson, J., et al. (2003). Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. American Journal of Public Health, 93(6), 939–942.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Mimiaga, M. J., O’Cleirigh, C., Biello, K. B., Robertson, A. M., & Safren, S. A. (2015). The effect of psychosocial syndemic production on 4-year HIV incidence and risk behavior in a large cohort of men who have sex with men. Journal of Acquired Immune Deficiency Syndromes, 68(3), 329–336.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Singer, M., & Clair, S. (2003). Syndemics and public health: Reconceptualizing disease in bio-social context. Medical Anthropology Quarterly, 17(4), 423–441.CrossRefPubMedGoogle Scholar
  10. 10.
    Mimiaga, M. J., Noonan, E., Donnell, D., et al. (2009). Childhood sexual abuse is highly associated with HIV risk-taking behavior and infection among MSM in the EXPLORE Study. Journal of Acquired Immune Deficiency Syndromes, 51(3), 340–348.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Safren, S. A., Reisner, S. L., Herrick, A., Mimiaga, M. J., & Stall, R. D. (2010). Mental health and HIV risk in men who have sex with men. Journal of Acquired Immune Deficiency Syndromes, 55(Suppl 2), S74–S77.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Stall, R., Friedman, M., & Catania, J. (2008). Interacting epidemics and gay men’s health: A theory of syndemic production among urban gay men. In R. J. Wolitski, R. Stall, & R. O. Valdiserri (Eds.), Unequal opportunity: Health disparities affecting gay and bisexual men in the United States (p. 251). New York: Oxford University Press.Google Scholar
  13. 13.
    Dyer, T. P., Shoptaw, S., Guadamuz, T. E., et al. (2012). Application of syndemic theory to black men who have sex with men in the multicenter AIDS cohort study. Journal of Urban Health : Bulletin of the New York Academy of Medicine, 89(4), 697–708.CrossRefGoogle Scholar
  14. 14.
    Herrick, A. L., Lim, S. H., Plankey, M. W., et al. (2012). Adversity and syndemic production among men participating in the multicenter AIDS cohort study: A life-course approach. American Journal of Public Health, 103(1), 79–85.CrossRefPubMedGoogle Scholar
  15. 15.
    Parsons, J. T., Grov, C., & Golub, S. A. (2012). Sexual compulsivity, co-occurring psychosocial health problems, and HIV risk among gay and bisexual men: Further evidence of a syndemic. American Journal of Public Health, 102(1), 156–162.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Friedman, M. R., Stall, R., & Silvestre, A. J. (2015). Effects of syndemics on HIV viral load and medication adherence in the multicentre AIDS cohort study. AIDS, 29(9), 1087–1096.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Wawrzyniak, A. J., Rodriguez, A. E., Falcon, A. E., Chakrabarti, A., & Parra, A. (2015). Association of individual and systemic barriers to optimal medical care in people living with HIV/AIDS in Miami-Dade County. Journal of Acquired Immune Deficiency Syndromes, 69(1), 63–72.CrossRefGoogle Scholar
  18. 18.
    Sullivan, K. A., Messer, L. C., & Quinlavin, E. B. (2015). Substance abuse, violence, and HIV/AIDS (SAVA) syndemic effects on viral suppression among HIV positive women of color. AIDS Patient Care and STDS, 29(1), 42–48.CrossRefGoogle Scholar
  19. 19.
    Frederiksen-Goldsen, K., Hyun-Jun, K., Barkan, S. E., et al. (2013). Health disparities among lesbian, gay, and bisexual older adults: Results from a population-based study. American Journal of Public Health, 103(10), 1802–1809.CrossRefGoogle Scholar
  20. 20.
    Mason, S. M., Wright, R. J., Hibert, E. N., et al. (2013). Intimate partner violence and incidence of type 2 diabetes in women. Diabetes Care, 36, 1159–1165.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Musselman, D. L., Ziemer, D. C., McNutt, M. D., et al. (2014). Depression, deficits in functional capacity, and impaired glycemic control in urban African-Americans with type 2 diabetes. Journal of Psychiatric Research, 52, 21–27.CrossRefPubMedGoogle Scholar
  22. 22.
    Wilson, P. A., Nanin, J., Amesty, S., et al. (2014). Using syndemic theory to understand vulnerability to HIV-infection among black and Latino men in New York City. J Urban Health, 91(5), 983–998.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Gilbert, L., Raj, A., & Hien, D. (2015). Targeting the SAVA (substance abuse, violence, and AIDS) among women and girls: A global review of epidemiology and integrated interventions. Journal of Acquired Immune Deficiency Syndromes, 69, S118–S127.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Kalra, S., & Agrawal, N. (2013). Diabetes and HIV: Current understanding and future perspectives. Current Diabetes Reports, 13, 419–427.CrossRefPubMedGoogle Scholar
  25. 25.
    Murata, H., Hruz, P. W., & Mueckler, M. (2000). The mechanism of insulin resistance caused by HIV protease inhibitor therapy. Journal of Biological Chemistry, 275, 20251–20254.CrossRefPubMedGoogle Scholar
  26. 26.
    Noor, M. A., Parker, R. A., O’Mara, E., Grasela, D. M., Currie, A., & Hodder, S. L. (2004). The effects of HIV protease inhibitors atazanavir and lopinavir/ritonavir on insulin sensitivity in HIV-seronegative healthy adults. AIDS, 18, 2137–2144.CrossRefPubMedGoogle Scholar
  27. 27.
    De Wit, S., Sabin, C. A., Weber, R., et al. (2008). Incidence and risk factors for new onset diabetes in HIV-infected patients. Diabetes Care, 31(6), 1224–1229.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Paik, I. J., & Kotler, D. P. (2011). The prevalence and pathogenesis of diabetes mellitus in treated HIV-infection. Best Practice & Research Clinical Endocrinology & Metabolism, 25, 469–478.CrossRefGoogle Scholar
  29. 29.
    Satlin, M. J., Hoover, D. R., & Glesby, M. J. (2011). Glycemic control in HIV-infected patients with diabetes mellitus and rates of meeting American diabetes association management guidelines. AIDS Patient Care and STDs, 25(1), 5–12.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Davies, M. L., Johnson, M. D., Brown, J. N., et al. (2015). Predictors of glycaemic control among HIV-positive veterans with diabetes. International Journal of STDs and AIDS, 26(2), 262–267.CrossRefGoogle Scholar
  31. 31.
    Adeyemi, O., Vibhaker, S., & Max, B. (2009). Are we meeting the American diabetes association goals for HIV-infected patients with diabetes mellitus? Clinical Infectious Diseases, 49, 799–802.CrossRefPubMedGoogle Scholar
  32. 32.
    Bury, J. E., Stroup, J. S., Stephens, J. R., et al. (2007). Achieving American diabetes association goals in HIV-seropositive patients with diabetes mellitus. Proceedings (Baylor University Medical Center)., 20(2), 118–123.PubMedCentralGoogle Scholar
  33. 33.
    Candib, L. M. (2007). Obesity and diabetes in vulnerable populations: proximal and distal causes. Annals of Family Medicine, 5, 547–556.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Hein, C., & Small, D. (2006). Combating diabetes, periodontal disease, and interrelated inflammatory conditions with a syndemic approach. Grand Rounds in Oral-Systemic Medicine, 1(2), 36–47.Google Scholar
  35. 35.
    Greenland, S. (1989). Modeling and variable selection in epidemiologic analysis. American Journal of Public Health, 79(3), 340–349.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Akaike, H. (1974). A new look at the statistical model identification. IEEE Transactions on Automatic Control, 19(6), 716–723.CrossRefGoogle Scholar
  37. 37.
    Tsai, A. C., & Burns, B. F. (2015). Syndemics of psychosocial problems and HIV risk: A systematic review of empirical tests of the disease interaction concept. Social Science and Medicine, 139, 26–35.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Stark Casagrande, S., Fradkin, J. E., Saydah, S. H., et al. (2013). The prevalence of meeting A1C, blood pressure, and LDL goals among people with diabetes, 1988–2010. Diabetes Care, 36(8), 2271–2279.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Ali, M.K., Bullard, K.M., Imperatore G, et al. (2012). Characteristics associated with poor glycemic control among adults with self-reported diabetes diagnosis. National Health and Nutrition Examination Survey, United States, 2007–2010, 61(02) 32–37.Google Scholar
  40. 40.
    Halkitis, P. N., Wolitski, R. J., & Millett, G. A. (2013). A holistic approach to addressing HIV infection disparities in gaybisexualand other men who have sex with men. The American Psychologist, 68(4), 261–273.CrossRefPubMedGoogle Scholar
  41. 41.
    Herbst, J. H., Beeker, C., Mathew, A., et al. (2007). The effectiveness of individual-, group-, and community-level HIV behavioral risk-reduction interventions for adult men who have sex with men: A systematic review. American Journal of Preventive Medicine, 32(4 Suppl), 38–67.CrossRefGoogle Scholar
  42. 42.
    Herbst, J. H., Sherba, R. T., Crepaz, N., et al. (2005). A meta-analytic review of HIV behavioral interventions for reducing sexual risk behavior of men who have sex with men. Journal of Acquired Immune Deficiency Syndromes, 39(2), 228–241.PubMedGoogle Scholar
  43. 43.
    Johnson, W.D., Diaz, R.M., Flanders, W.D., et al. (2008). Behavioral interventions to reduce risk for sexual transmission of HIV among men who have sex with men. Cochrane Database Syst Rev, 3.Google Scholar
  44. 44.
    Johnson, W.D., Hedges, L.V., Diaz, R.M. (2003). Interventions to modify sexual risk behaviors for preventing HIV infection in men who have sex with men. Cochrane Database System Rev, 1.Google Scholar
  45. 45.
    Johnson, W. D., Holtgrave, D. R., McClellan, W. M., Flanders, W. D., Hill, A. N., & Goodman, M. (2005). HIV intervention research for men who have sex with men: A 7-year update. AIDS Education and Prevention, 17(6), 568–589.CrossRefPubMedGoogle Scholar
  46. 46.
    Axelrad, J. E., Mimaga, M. J., Grasso, C., & Mayer, K. H. (2013). Trends in the spectrum of engagement in HIV care and subsequent clinical outcomes among men who have sex with men (MSM) at a Boston community health center. AIDS Patient Care STDS, 27(5), 287–296.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Chrvala CA, Sherr D, Lipman RD. (2015). Diabetes self-management education for adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic control. Patient Education Counseling, 15.Google Scholar
  48. 48.
    Meyer, Ilan H. (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36(1), 38–56.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Blaire Byg
    • 1
  • Angela Robertson Bazzi
    • 1
    • 3
  • Danielle Funk
    • 1
  • Bonface James
    • 1
    • 2
  • Jennifer Potter
    • 1
    • 2
    • 4
  1. 1.Fenway Community Health CenterBostonUSA
  2. 2.Harvard Medical SchoolBostonUSA
  3. 3.Department of Community Health Sciences, School of Public HealthBoston UniversityBostonUSA
  4. 4.Beth Israel Deaconess Medical CenterBostonUSA

Personalised recommendations