The impact of a syndemic theory-based intervention on HIV transmission risk behaviour among men who have sex with men in India: Pretest-posttest non-equivalent comparison group trial

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Highlights

  • Syndemic alcohol use, depression & internalised homonegativity increased HIV risk.

  • A syndemic theory-based intervention significantly increased condom use among MSM.

  • Syndemic intervention significantly reduced psychosocial syndemic conditions.

  • Managing psychosocial syndemic conditions led to more consistent condom use.

  • HIV interventions for MSM should screen for & treat psychosocial syndemic conditions.

Abstract

This study aimed to examine the effect of a syndemic theory-based intervention to reduce condomless anal intercourse among men who have sex with men (MSM) in India. In 2016/17, a pre- and post-test comparison group design was used to implement a syndemic theory-based intervention among 459 MSM (229, intervention; 230, standard-of-care comparison) recruited through non-governmental organizations in Chandigarh, India. The intervention group received two-session peer-delivered motivational interviewing-based HIV risk reduction counselling and skills training to improve sexual communication/negotiation and condom use self-efficacy, and screening/management of psychosocial health problems. The intervention's effect on consistent condom use was estimated using difference-in-differences (DiD) approach. Mediation analysis assessed the extent to which intervention effects on the outcome were mediated by changes in psychosocial health problems and condom use self-efficacy. A process evaluation assessed implementation fidelity and intervention acceptability. Baseline consistent condom use was 43% in the intervention group and 46% in the standard-of-care group. Baseline survey findings demonstrated that a psychosocial syndemic of problematic alcohol use, internalised homonegativity and violence victimisation synergistically increased condomless anal intercourse. Using DiD, we estimated that the intervention increased consistent condom use with male partners by 16.4% (95% CI: 7.1, 25.7) and with female partners by 28.2% (95% CI: 11.9, 44.4), and decreased problematic alcohol use by 24.3% (95%CI: −33.4, −15.3), depression by 20.0% (95% CI: −27.6, −12.3) and internalised homonegativity by 34.7% (95% CI: −43.6%, −25.8%). The mediation analysis findings suggested that the intervention might have improved consistent condom use by decreasing internalised homonegativity and by increasing condom use self-efficacy. The process evaluation showed high levels of acceptability/satisfaction among participants and high levels of implementation fidelity. A syndemic theory-based intervention tailored for MSM in India is feasible, acceptable, and can reduce HIV transmission risk behaviour as well as problematic alcohol use, depression and internalised homonegativity.

Introduction

The HIV epidemic in India is concentrated among marginalised communities such as men who have sex with men (MSM), transgender people, people who inject drugs, and sex workers. Among MSM, the national average HIV prevalence is reported between 4.3% (NACO, 2015) and 7% (Solomon et al., 2015), 15 to 25 times higher than that among the general population (0.26%) (NACO, 2017). Furthermore, while the HIV prevalence among the general population has shown a decreasing trend, HIV prevalence among MSM has plateaued, rather than decreased, over the past decade. Several regions of high HIV prevalence among MSM ranging from 6.8% to 10.1% were reported in the 2014 national survey (NACO, 2015). Consistent with the continuing HIV epidemic, a large-scale survey conducted by India's National AIDS Control Organisation (NACO) reported that consistent condom use among MSM ranges between 50% and 55%, depending on the type of male partner (NACO, 2015). These rates are moderate despite prevailing high levels of HIV knowledge (NACO, 2015) and easy access to condoms, including free distribution of condoms through HIV prevention interventions supported by NACO (NACO, 2017). According to a NACO survey, 69% of MSM reported having received condoms from peer educators (NACO, 2015).

Syndemic theory may help to explain the factors that contribute to persistently high levels of inconsistent condom use and HIV risk, and could offer potential solutions to preventing the secondary transmission of HIV. A syndemic is conceptualized as a population-level phenomenon in which two or more psychosocial health problems co-occur or cluster together and have synergistic (more than additive) effects on negative health outcomes, such as inconsistent condom use and HIV infection (Chakrapani et al., 2019; Singer, 1996; Tsai, 2018; Tsai et al., 2017). Several studies conducted among MSM in predominantly North American countries have documented the presence of co-occurring psychosocial health problems that increase risk for HIV, including depression, problematic alcohol use, violence victimisation, sexual compulsivity, and childhood sexual abuse (Mustanski et al., 2007; Stall et al., 2003; A. C. Tsai and Burns, 2015). The presence of co-occurring psychosocial health problems (Chakrapani et al., 2017) and their synergistic effects (Chakrapani et al., 2019; Tomori et al., 2018) on transmission risk of HIV or sexually transmitted infections have been documented among MSM in India. An intervention strategy motivated by syndemic theory, such as screening and management of co-occurring psychosocial health problems, may contribute to reducing the risk of HIV transmission or acquisition.

Despite the burgeoning literature on compounding effects of HIV and other health risks, and despite explicit calls for “syndemically-oriented” HIV interventions among marginalised populations (Gonzalez-Guarda, 2013; Operario and Nemoto, 2010; Singer et al., 2012), globally there has been little progress in designing and testing syndemic theory-based HIV prevention interventions for MSM. Almost all published “syndemic interventions” have been implemented primarily at the individual level, by simultaneously addressing two or more conditions comprising the putative syndemic. Nevertheless, such individual-level syndemic interventions have been shown to be efficacious in improving HIV-related prevention and treatment outcomes among women (Gilbert et al., 2015; Jemison et al., 2019; Pitpitan et al., 2015) and among people living with HIV (Carey et al., 2004). However, among MSM, there have been no empirical tests of interventions effectively addressing two or more psychosocial health problems in order to reduce their impact on HIV risk among MSM, except a recently published protocol (Achterbergh, van der Helm, van den Brink and de Vries, 2017). Singular interventions have been conducted among MSM to reduce HIV transmission risk behaviour (Hergenrather et al., 2016; Johnson et al., 2008), alcohol use (Wray et al., 2016), depressive symptoms (Safren et al., 2010) or sexual stigma (Safren et al., 2014).

Motivational interviewing (MI) is one potential modality of implementing syndemic interventions to reduce HIV transmission risk among MSM. MI refers to a client-centred counselling approach that is focused on eliciting and strengthening the client's intrinsic motivation in such a way that behaviour change emerges from the client rather than being imposed or recommended by the counsellor. There is conflicting evidence on the effectiveness of MI in reducing high-risk sexual behaviours among MSM. Although a systematic review (Naar-King et al., 2012) has reported that MI can be effective in reducing condomless anal intercourse among HIV-positive male youth, another systematic review of 10 randomized controlled trials among MSM reported the effectiveness of MI-based HIV interventions as being “uncertain” (Berg et al., 2011), noting that MI was relatively more effective in reducing other risk behaviours (such as alcohol use) than HIV transmission risk behaviours and calling for more studies to be done. More recent evidence shows that MI-based interventions are effective in reducing HIV transmission risk behaviour (Rongkavilit et al., 2014, 2015), alcohol use (Chen et al., 2011; Murphy et al., 2018; Murphy et al., 2012; Naar-King et al., 2009), and depression (Naar-King et al., 2010) among HIV-positive MSM in the U.S. and Thailand. Taken together, these findings suggest that MI-based counselling may be a viable strategy for delivering a syndemic theory-based intervention among MSM in India.

Previous MI-based HIV interventions among MSM and other populations have primarily focused on addressing key theoretical constructs, such as condom use self-efficacy and condom attitudes, based on social cognitive theory (Bandura, 1986; Wulfert and Wan, 1993). Several behavioural interventions for MSM and other populations have shown that improving condom use self-efficacy was associated with reduction in HIV transmission risk (Johnson et al., 2008). Studies among MSM in India have provided evidence that lower condom use self-efficacy is associated with condomless anal intercourse (Chakrapani et al., 2013; Chakrapani et al., 2008; Chakrapani et al., 2015; Hemmige et al., 2011; Solomon et al., 2010). Accordingly, this study tested the effectiveness of a syndemic theory-guided, MI-based HIV prevention intervention among MSM, which aimed to reduce condomless anal intercourse by improving condom use self-efficacy as well as by addressing co-occurring psychosocial health problems.

Section snippets

Study design and study setting

From October 13, 2016 to October 29, 2017, a study with a pretest-posttest non-equivalent comparison group design (Gravetter and Forzano, 2012; Shadish et al., 2002) was conducted with an intervention group of 229 MSM and a standard-of-care comparison group of 230 MSM. Participants were recruited through three non-governmental organisations (NGOs) that implement HIV prevention interventions in the city of Chandigarh in north India. These NGOs have been providing HIV-related services to nearly

Baseline characteristics

Table 1 shows characteristics of participants by intervention condition. Participants' median age was 26 years and the median monthly income was INR 8000 (approximately $120 USD at the time of the study); 237 (51%) had up to secondary education, 332 (72%) were single, and 57 (12%) engaged in sex work. Diverse self-identities were represented: 177 kothis (39%), 82 giriyas/panthis (18%), 75 double-deckers (16%), 37 gay (8%), 55 bisexual (12%), and 23 straight/heterosexual (5%). MSM in the

Discussion

This study provides preliminary evidence of the feasibility, acceptability, and impact of a syndemic theory-based HIV intervention for MSM in India, contributing to limited literature in this domain (Gonzalez-Guarda, 2013; Operario and Nemoto, 2010). As hypothesised, the syndemic theory-based intervention significantly increased consistent condom use among MSM, with both male and female partners, compared with a non-randomized standard-of-care condition. Mediation analyses demonstrated that the

Conclusions

This controlled intervention study among MSM has demonstrated the feasibility, acceptability, and effectiveness of a syndemic theory-based brief intervention using MI techniques to reduce HIV transmission risk behaviour as well as problematic alcohol use, depression and internalised homonegativity. The findings show that screening for and addressing psychosocial health conditions can be successfully integrated into existing condom promotion-based and HIV-focused prevention interventions to

CRediT authorship contribution statement

Venkatesan Chakrapani: Conceptualization, Methodology, Investigation, Data curation, Formal analysis, Writing - original draft, Writing - review & editing. Manmeet Kaur: Methodology, Resources, Supervision, Writing - review & editing. Alexander C. Tsai: Methodology, Writing - review & editing. Peter A. Newman: Supervision, Writing - review & editing. Rajesh Kumar: Conceptualization, Methodology, Supervision, Resources, Writing - review & editing.

Acknowledgments

The study was supported by ‘PGI research fellowship’ awarded to Dr. Chakrapani by the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. Further, he was in part supported by the Wellcome Trust/DBT India Senior Alliance fellowship (IA/CPHS/16/1/502667) awarded to him. Dr. Newman was supported by a Social Sciences and Humanities Research Council of Canada Partnership Grant (MFARR-Asia; 895-2019-1020). For the support towards successful implementation of the

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