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
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
References (101)
Testing mediating mechanisms in theory-based interventions: contributions to efficacy research
J. Adolesc. Health
(2007)- et al.
The syndemic of violence victimisation, drug use, frequent alcohol use, and HIV transmission risk behaviour among men who have sex with men: cross-sectional, population-based study in India
SSM Popul. Health
(2019) - et al.
A clinic-based motivational intervention improves condom use among subgroups of youth living with HIV
J. Adolesc. Health
(2011) - et al.
Mechanisms of change within motivational interviewing in relation to health behaviors outcomes: a systematic review
Patient Educ. Counsel.
(2015) - et al.
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) - et al.
A randomized clinical trial of motivational enhancement therapy for alcohol problems in partner violent men
J. Subst. Abuse Treat.
(2018) - et al.
A multisite randomized trial of a motivational intervention targeting multiple risks in youth living with HIV: initial effects on motivation, self-efficacy, and depression
J. Adolesc. Health
(2010) - et al.
A feasibility study of motivational interviewing for health risk behaviors among Thai youth living with HIV
J. Assoc. Nurses AIDS Care
(2014) - et al.
Is there synergy in syndemics? Psychosocial conditions and sexual risk among men who have sex with men in India
Soc. Sci. Med.
(2018) Syndemics: a theory in search of data or data in search of a theory?
Soc. Sci. Med.
(2018)
Syndemics of psychosocial problems and HIV risk: a systematic review of empirical tests of the disease interaction concept
Soc. Sci. Med.
Co-occurring epidemics, syndemics, and population health
Lancet
Design of a syndemic based intervention to facilitate care for men who have sex with men with high risk behaviour: the syn.bas.in randomized controlled trial
BMC Infect. Dis.
Exploring the question-behaviour effect: randomized controlled trial of motivational and question-behaviour interventions
Br. J. Health Psychol.
AUDIT, the Alcohol Use Disorders Identification Test : Guidelines for Use in Primary Care
Social Foundations of Thought and Action : a Social Cognitive Theory
Planning Health Promotion Programs: an Intervention Mapping Approach
The effectiveness of MI4MSM: how useful is motivational interviewing as an HIV risk prevention program for men who have sex with men? A systematic review
AIDS Educ. Prev.
Measuring stigma in people with HIV: psychometric assessment of the HIV stigma scale
Res. Nurs. Health
Measurement of stigma in people with HIV: a reexamination of the HIV Stigma Scale
AIDS Educ. Prev.
Reducing HIV-risk behavior among adults receiving outpatient psychiatric treatment: results from a randomized controlled trial
J. Consult. Clin. Psychol.
Methodological problems in AIDS behavioral research: influences on measurement error and participation bias in studies of sexual behavior
Psychol. Bull.
Contextual influences on condom use among men who have sex with men in India: subjectivities, practices and risks
Cult. Health Sex.
Syndemics and HIV-related sexual risk among men who have sex with men in India: influences of stigma and resilience
Cult. Health Sex.
Secondary HIV prevention among kothi-identified MSM in Chennai, India
Cult. Health Sex.
Barriers to free antiretroviral treatment access among kothi-identified men who have sex with men and aravanis (transgender women) in Chennai, India
AIDS Care
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
Global Publ. Health
Structural violence against Kothi-identified men who have sex with men in Chennai, India: a qualitative investigation
AIDS Educ. Prev.
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.
Integrated Counselling & Testing Centre (ICTC DATA), STI Data and Blood Bank
Manual for Health Counselors: the MANAS Program
The Healthy Activity Program lay counsellor delivered treatment for severe depression in India: systematic development and randomised evaluation
Br. J. Psychiatry
Motivational interviewing, enhancement, and brief interventions over the last decade: a review of reviews of efficacy and effectiveness
Psychol. Addict. Behav.
National Institute of mental health multisite eban HIV/STD prevention intervention for African American HIV serodiscordant couples: a cluster randomized trial
Arch. Intern. Med.
Targeting the SAVA (substance abuse, violence, and aids) syndemic among women and girls: a global review of epidemiology and integrated interventions
J. Acquir. Immune Defic. Syndr.
Sometimes people let love conquer them': how love, intimacy, and trust in relationships between men who have sex with men influence perceptions of sexual risk and sexual decision-making
Cult. Health Sex.
Pushing the syndemic research agenda forward: a comment on Pitpitan et al
Ann. Behav. Med.
Research Methods for the Behavioral Sciences
Propensity Score Analysis : Statistical Methods and Applications
Assessing mediation in HIV intervention studies
Publ. Health Rep.
Sex position, marital status, and HIV risk among Indian men who have sex with men: clues to optimizing prevention approaches
AIDS Patient Care STDS
A meta-analytic review of HIV behavioral interventions for reducing sexual risk behavior of men who have sex with men
J. Acquir. Immune Defic. Syndr.
Correlates of internalized homophobia in a community sample of lesbians and gay men
J. Gay Lesb. Med. Assoc.
Enhancing HIV prevention among young men who have sex with men: a systematic review of HIV behavioral interventions for young gay and bisexual men
AIDS Educ. Prev.
Resilience as a research framework and as a cornerstone of prevention research for gay and bisexual men: theory and evidence
AIDS Behav.
Counselling Manual for Parents of LGBT
Pilot randomized controlled trial of a syndemics intervention with HIV-positive, cocaine-using women
AIDS Behav.
On the efficacy and mediation of a one-on-one HIV risk-reduction intervention for African American men who have sex with men: a randomized controlled trial
AIDS Behav.
HIV epidemic among men who have sex with men in India: national scenario of an unfinished agenda
HIV AIDS (Auckl)
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2022, Social Science and MedicineCitation Excerpt :The findings of Chakrapani and colleagues support the three models of interacting epidemics (synergistically interacting epidemics, serially causal epidemics, and mutually causal epidemics) with the strongest support for the model of synergistically interacting epidemics (Chakrapani et al., 2019b). These findings are supported by other studies that found synergy through departure from additivity, by using measures such as RERI, AP or S, or through a departure from multiplicativity by using significant product terms in the multiplicative scale (Bulled, 2021; Chakrapani et al., 2020; Chandler et al., 2020b, 2020c; Chuang et al., 2021; Tomori et al., 2018). However, other studies found no synergy between the syndemic conditions using the same statistical approach (Batchelder et al., 2019; Ferlatte et al., 2018a; Shuper et al., 2020).
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