Longitudinal analysis of syndemic psychosocial problems predicting HIV risk behavior among a multicity prospective cohort of sexually active young transgender women in the United States

Abstract

Background:

Worldwide, young transgender women (YTW) contend with exceptionally high-risks for HIV infection. Cross-sectional studies have suggested that co-occurring epidemics or “syndemics” of psychosocial problems may accelerate HIV acquisition and transmission via elevated sexual risk behavior among transgender women. We aimed to examine how a syndemic of seven psychosocial problems potentiates HIV sexual risk behavior among a multicity, longitudinal cohort of sexually active YTW in the United States.

Methods:

Between 2012 and 2015, 233 YTW from Boston, MA and Chicago, IL completed behavioral surveys at baseline, 4-, 8-, and 12-months. We used generalized estimating equations to examine the prospective relationship of overlapping psychosocial problems and HIV sexual risk behavior (i.e., condomless anal or vaginal sex (CAVS)) among YTW.

Results:

The prevalence of seven psychosocial syndemic problems was substantial at baseline and remained high at each time point: 6.4% polydrug use past 4 months (excluding stimulants); 7.7% heavy alcohol use past 4 months; 10% history of childhood sexual abuse; 15.9% stimulant use past 4 months; 41.7% experiencing lifetime intimate partner violence; 42.1% clinically significant depressive symptoms; and 68.6% lifetime transgender specific victimization. We identified a statistically significant positive “dose-response” relationship between the number of psychosocial syndemic problems and CAVS over time.

Conclusion:

The accumulation of “syndemic” psychosocial problems predicted HIV sexual risk behavior in a prospective cohort of YTW. Given the high prevalence of psychosocial problems and HIV sexual risk behavior, as well as having the highest HIV incidence among any risk group, the HIV prevention agenda requires a shift toward improved assessment of psychosocial comorbidities as well as stronger integration with gender-affirming and supportive mental health, violence recovery, and addiction treatment services for this population.

INTRODUCTION

Worldwide, young transgender women (YTW) contend with exceptionally high-risks for HIV infection. The prevalence of HIV among transgender women—individuals assigned a male sex at birth who identify as girls, women, transgender women, trans-female, male-to-female, or another diverse transfeminine gender identity—is disproportionately high relative to cisgender populations. A meta-analysis of the global burden of HIV infection in transgender women found HIV prevalence was 19.1% (95% CI=17.4–20.7); transgender women had a 49-fold increased odds of HIV infection compared with adults of reproductive age.¹ A meta-analysis of 29 studies focused on U.S. transgender women found a prevalence of 27.7% lab-confirmed HIV infection (four studies) and 11.8% self-reported (18 studies).² This elevated HIV burden is facilitated by risky sex including condomless anal and vaginal sex (CAVS).²

There is mounting evidence that psychosocial and cultural context is associated with HIV infection and adverse HIV-related outcomes among YTW.³ For young transgender women, discrimination, mistreatment, violence and adversity in the form of rejection from friends, family and society, can become a central part of young adulthood,^4,5 affecting the ability to secure housing, employment, social services, and healthcare.^4,6,7 This struggle for survival undermines YTW’s ability to prioritize and avoid HIV risk.^8,9 Indeed, YTW are disproportionately represented among homeless people, often a result of estrangement from families of origin.¹⁰ In addition, transgender women experience discrimination in seeking housing and have trouble finding a job.^7,11–13 This socioeconomic marginalization may force young transgender women to earn money to support themselves through sex work;^10,12,14 across three studies, the prevalence ranged from 33% to 67%.^4,14,15 Transactional sex is related to CAVS and HIV because economic pressures often result in compromising safer sex practices for monetary incentives.^12,16–18 In addition to providing an economic incentive, sex work may serve to validate feminine gender roles.¹⁹ “Passing” or the extent to which individuals have a gender conforming visual gender expression may facilitate the ability of YTW to exchange sex for money.^10,11 Lastly, transgender women experience elevated levels of depression/distress, trauma, stigma, victimization, and intimate partner violence (IPV),⁵ which may drive high levels of HIV-related risk among this group,^20–23 and may interact with drug and heavy alcohol use,^24,25 to produce additive or multiplicative effects on sexual risk.^26–31 Over the past decade, research on sexual and gender minorities has suggested that these psychosocial problems—co-occurring epidemics—may be intertwined, representing a “syndemic.”^26,28–33

The term “syndemic” was first developed to describe the co-occurring and mutually reinforcing epidemics of substance use, violence, and AIDS in poor urban communities³⁴ and emphasizes how disadvantageous social conditions interact to adversely affect health outcomes within marginalized communities. The limited number of published studies specific to transgender women that have examined syndemics in relation to sexual risk have relied on cross-sectional data.^21,27,35 Despite this expanding evidence, research is needed to examine the syndemic production of HIV risk behavior longitudinally among this group. Thus, we drew from a large, multicity, prospective cohort of sexually active YTW (ages 16-to-29) enrolled in behavioral HIV prevention intervention in the United States to assess the interplay between multiple psychosocial problems and to determine the extent to which these psychosocial problems result in additive effects on sexual risk (i.e., CAVS) over follow-up. Based on previous work (with other high-risk populations) supporting the centrality of syndemics in heightening HIV risk longitudinally, specifically among men who have sex with men (MSM),²⁶ we hypothesized that psychosocial problems [i.e., clinically significant depressive symptoms; stimulant use; polydrug use (3 or more drugs used, excluding stimulants); heavy alcohol use (≥ 4 drinks every day or ≥ 6 drinks on a typical day when drinking); history of childhood sexual abuse (CSA); experiencing lifetime IPV; and lifetime transgender-specific victimization] would result in multiplicative effects on sexual risk (i.e., a “dose response” relationship such that the additive effects of psychosocial problems increases the odds of engaging in CAVS) over time among this cohort of YTW. The overarching goal of this analysis is to refine and specify current HIV prevention intervention targets for this group.

METHODS

Between 2012 and 2015, 300 YTW from Boston, MA (49%) and Chicago, IL (51%) were enrolled in Project LifeSkills, a randomized controlled efficacy trial of an empowerment-based, group-delivered HIV prevention intervention for YTW compared to a standard of care (SOC) only arm (i.e., HIV and sexually transmitted infection testing and counseling).^36,37

Study population

Participants were recruited using non-probability sampling strategies grounded in community-based participatory research principles,³⁸ including outreach to community-based organizations and other venues. Eligibility criteria of participants included those (1) aged 16 through 29 years; (2) assigned male sex at birth who now self-identify as female, transgender women, or on the transfeminine spectrum; (3) who are English-speaking; (4) who had no plan to move from the local area during the 12-month study period; and (5) who had self-reported sexual risk in the preceding 4-months (i.e., CAVS; anal or vaginal intercourse with more than one sexual partner; anal or vaginal sex in exchange of money, food, shelter; or diagnosis with HIV or another sexually transmitted infection). HIV serostatus was not a criterion for eligibility.

Procedures

The study was approved by institutional review boards at Ann & Robert H. Lurie Children’s Hospital and The Fenway Institute, Fenway Health. Study staff obtained written informed consent for each participant with parental consent waived for minors (aged 16–17 years). Following informed consent, participants completed a baseline assessment via a computer-assisted self-interviewing (CASI) system. Follow-up assessments were conducted at 4-, 8-, and 12-months. Only participants who were randomized (67 not randomized) were included in the analytic sample (N=233). Detailed information on the study design, procedures and intervention have been previously reported.^36,37

Measures

Sociodemographic characteristics.

Age was assessed in years. Participants were coded according to study site: Boston, MA or Chicago, IL. Participants were asked to indicate their primary race/ethnicity (white; black/African American; Spanish/Hispanic/Latina; Asian; American Indian/Alaskan Native; Native Hawaiian or other Pacific Islander; other race/ethnicity). Race/ethnicity was dichotomized as white vs. racial/ethnic minority. Participants were asked their highest level of education completed and whether or not they were a current student (categories included: high school equivalent or less; some college; college degree; some graduate school or more; or current student). Employment was assessed as either employed full-time, employed part-time, or unemployed. HIV status was assessed via pre-posttest counseling coupled with HIV screening (i.e., third generation testing algorithms at each site for those reporting HIV-negative or unknown status) at baseline, per the RESPECT-2 protocol.³⁹

Syndemic psychosocial problems.

(1) Clinically significant depressive symptoms were assessed in the past seven days at each time point using six items from the Brief Symptom Inventory (BSI; Cronbach’s alpha=0.90).⁴⁰ The items were summed and dichotomized based on a standard cutoff score of 63 indicating current clinically significant depressive symptoms. (2) Polydrug use in the past 4-months was defined as using ≥ 3 non-prescription drugs (marijuana, heroin, GHB, LSD/hallucinogens, pain medication, tranquilizers, amyl nitrite “poppers”) excluding stimulants. (3) Stimulant use was separated from the polydrug use variable due to its strong independent association with CAVS ²⁶; this included any use of cocaine, crack, or crystal methamphetamine in the past 4-months. (4) Heavy alcohol use in the past 4-months was defined as having ≥ 4 drinks every day or ≥ 6 drinks on a typical day when drinking. (5) CSA was assessed at a single time point and defined as having been forced to engage in unwanted sexual behavior with an adult or caregiver before age 18.²³ (6) Lifetime IPV (Cronbach’s alpha=0.88) was assessed at a single time point via a five-item scale developed for transgender youth assessing the frequency with which participants reported experiencing various forms of partner violence (e.g., sexual, physical, and emotional-control).¹⁴ Participants reporting having experienced any form of partner violence were considered to have experienced IPV. (7) Transgender-specific victimization (Cronbach’s alpha=0.95). was assessed at a single time point via a nine-item scale assessing the frequency with which participants reported experiencing victimization due to being transgender.⁴¹ Victimization included being verbally threatened or insulted, being chased, followed or suffering property damage, and being physically assaulted or spat on. Participants reporting having experienced any form of transgender specific victimization were considered to have experienced this in their lifetime.

The syndemic measure was calculated as a count score based on the number of psychosocial problems endorsed, resulting in scores ranging from 0–5 (note: category 5 includes those who reported experiencing 5 (n=5) or 6 (n=1) psychosocial problems; zero participants had all 7). If participants were missing data on any of the items, the scale was not scored.

HIV sexual risk behavior.

We assessed participants’ sexual behaviors over the past 4-months at baseline and at their 4-, 8- and 12-month follow-up visits. For each time point, individuals who reported having any CAVS were dichotomized as having engaged in HIV sexual risk vs. those reporting no CAVS.

Data Analysis

Statistical analyses were conducted in SAS 9.4. Means and frequencies were calculated to describe participant characteristics at baseline and syndemic psychosocial problems over time adjusting for randomization arm. For the time varying syndemic variable and individual psychosocial problems (i.e., depressive symptoms, polydrug use, stimulant use, and heavy alcohol use) generalized estimating equations (GEE) were used to examine whether the frequency of each variable changed over time, adjusting for randomization arm. Each model used time as the predictor and a multinomial link function was used for the nominal syndemic measure as an outcome and a logit link function was used for the individual binary syndemic psychosocial problems. Congruent with the syndemic framework, we also examined interrelationships between psychosocial problems at baseline via several multivariable logistic regression models with each psychosocial problem as the outcome, adjusting for randomization arm, site, age, race/ethnicity, education, employment, and HIV-serostatus.

Using GEE with an unstructured covariance matrix and a binary distribution, we then tested whether the number of psychosocial problems increased the odds of past 4-month CAVS over time adjusting for randomization arm, site, age, race/ethnicity, education, employment and HIV-serostatus. Since the lifetime CSA and IPV measures were only assessed at a single time point, the value for these measures was carried across all time points.

To examine whether certain psychosocial problems played a larger role in the syndemic–CAVS relationship, we examined the association between each psychosocial problem and CAVS over time adjusting for randomization arm, site, age, race/ethnicity, education, employment and HIV-serostatus. Because stimulant use (past 4-months) was the strongest predictor (largest statistically significant corresponding odds ratio) of CAVS, we were interested in whether or not this variable was “driving” the relationship between the syndemic measure and CAVS. To test this, we first re-coded the syndemic measure to exclude stimulant use. We then included the recoded syndemic variable and the stimulant use (past 4-months) variable as separate predictor variable in a GEE model (adjusting for randomization arm, site, age, race/ethnicity, education, employment, and HIV-serostatus) to examine whether or not stimulant use attenuated the relationship between the syndemic measure and CAVS over time.

RESULTS

Participants’ mean age was 23.4 years (SD: 3.6; range 16–29); 25.8% were white and 74.2% were racial/ethnic minorities (47.2% black/African American; 11.6% Hispanic/Latina; 15.5% mixed race/other); 45.1% had a high school education or less; 30.5% were current students; and 75.1% were unemployed (note: current students were included in all of the employment variable response options). At the baseline assessment, 20.6% of participants were living-with-HIV.

Psychosocial problems prevalent at baseline were high: 6.4% polydrug use in the past 4-months (3 or more drugs used, excluding stimulants); 7.7% heavy alcohol use in the past 4-month (≥ 4 drinks every day or ≥ 6 drinks on a typical day when drinking); 10% reported a history of CSA; 15.9% reported stimulant use in the past 4-months; 41.7% reported experiencing IPV in their lifetime; 42.1% had clinically significant depressive symptoms; and 74.9% reported transgender-specific victimization in their lifetime. Looking at the number of syndemic psychosocial problems experienced among the sample, 12.3%=zero psychosocial problems, 29.4%=one, 25.7%=two, 20.3%= three, 9.1%=four, and 3.2%=five or more.

There was not a statistically significant change in prevalence of the count of the syndemic measure or the individual psychosocial problems over follow-up, adjusting for randomized arm (Table 2). After adjusting for baseline covariates, with the exception of transgender-related victimization and polydrug use, each baseline psychosocial problem was positively and significantly associated with all other psychosocial problems or at least trending in the expected direction (Supplemental Table 1).

Table 2.

Descriptive analyses of changes in syndemic psychosocial problems over time among YTW (N = 233).^*

	Baseline N=233		4 Month N=204		8 Month N=201		12 Month N=199		P-Value c
	N	%	N	%	N	%	N	%
Syndemics
Missing a	46	19.7	17	8.3	29	14.4	29	14.6	0.16
0	23	25.8	24	11.8	26	12.9	24	12.1
1	55	22.6	55	27.0	49	24.4	52	26.1
2	48	28.0	49	24.0	50	24.9	41	20.6
3	38	15.1	34	16.7	28	13.9	34	17.1
4	17	8.6	17	8.3	12	6.0	13	6.5
5+	6	2.6	8	3.9	7	3.5	6	3.0
Depression - Past 7 Day
No	135	57.9	124	60.8	120	59.7	120	60.3	0.49
Yes	98	42.1	80	39.2	81	40.3	79	39.7
Poly-Drug Use - Past 4-Months
No	218	93.6	193	94.6	190	94.5	183	92.0	0.48
Yes	15	6.4	11	5.4	11	5.5	16	8.0
Stimulant Use - Past 4-Months
No	196	84.1	163	79.9	177	88.1	175	87.9	0.08
Yes	37	15.9	41	20.1	24	11.9	24	12.1
Heavy Alcohol Use - Past 4-Months
No	215	92.3	192	94.1	194	96.5	189	95.0	0.10
Yes	18	7.7	12	5.9	7	3.5	10	5.0
Child Sexual Abuse - Lifetime
Missing b	---	---	19	9.3	---	---	---	---
No	---	---	126	61.8	---	---	---	---
Yes	---	---	14	6.9	---	---	---	---
IPV - Lifetime
Missing b			17	8.3
No	---	---	109	53.4	---	---	---	---
Yes	---	---	78	38.2	---	---	---	---
Transgender Victimization - Lifetime
Missing b	---	---	17	8.3	---	---	---	---
No	---	---	47	23.0	---	---	---	---
Yes	---	---	140	68.6	---	---	---	---

Note.

^*All analyses adjusted for randomization arm.

⁺includes individuals with 5 or 6 syndemic psychosocial problems; Violence questions only assessed at one time point. These variables were carried backward/forward to the baseline and 8- and 12-month assessments.

^aIf a participant was missing data for any individual syndemic variable than they were set to missing for the categorical syndemic variable.

^bViolence questions were not assessed among the 17 people who took the remote visit at the 4-month follow-up.

^cP-Value represents the value for the adjusted regression analyses examining whether there was a significant change in the variable over time, adjusting for randomization arm. Since the lifetime variables were only assessed at one time point, it was not possible to examine change over time.

The odds of CAVS is highest for those with more psychosocial problems over follow-up, with a trend toward a lower odds of engaging in CAVS for fewer psychosocial problems reported (Table 3). Specifically, in both unadjusted and adjusted models, compared to those with no psychosocial problems (referent), those with five or more psychosocial problems had more than 3 times the odds of engaging in CAVS over follow-up (aOR=3.27, 95% CI: 1.14–9.41); those with four psychosocial problems also had more than 3 times the odds of engaging in CAVS over follow-up (aOR=3.05, 95% CI: 1.48–6.31); those with three psychosocial problems had 2.6 times the odds of engaging in CAVS over follow-up (aOR=2.59, 95% CI: 1.37–4.86); those with two psychosocial problems had 1.8 times the odds of engaging in CAVS over follow-up (aOR=1.77, 95% CI: 1.05–2.99); and finally those with one psychosocial problem had 1.6 times the odds of engaging in CAVS over follow-up (aOR=1.62, 95% CI: 1.01–2.61). All models were adjusted for randomization arm, site, age, race/ethnicity, education, employment and HIV-serostatus.

Table 3.

Longitudinal syndemic psychosocial problems as a predictor of condomless anal or vaginal sex (CAVS) among YTW (N = 233).

	CAVS
	Bivariate				Multivariable
	aORa	95% CI		P-Value	aORb	95% CI		P-Value
Syndemics
0	1.00	---	---	---	1.00	---	---	---
1	1.63	0.99	2.67	0.05	1.62	1.01	2.61	0.047
2	1.81	1.05	3.13	0.03	1.77	1.05	2.99	0.03
3	2.63	1.38	5.01	0.003	2.59	1.37	4.86	0.003
4	3.18	1.56	6.47	0.002	3.05	1.48	6.31	0.003
5+	3.43	1.32	8.89	0.01	3.27	1.14	9.41	0.03
COVARIATES
Age					1.00	0.94	1.06	0.95
Study Site
Boston					1.00	---	---	---
Chicago					0.88	0.57	1.36	0.58
Race
White					1.00	---	---	---
Person of color					0.68	0.40	1.15	0.15
Educational Attainment
High school/equivalent or less					1.00	---	---	---
Some college					1.03	0.57	1.87	0.91
College					0.71	0.31	1.63	0.42
Some graduate school or more					1.25	0.12	13.01	0.85
Current student					0.88	0.54	1.43	0.64
Employment
Unemployed					1.00	---	---	---
Part-time					1.29	0.91	1.82	0.15
Full-time					1.10	0.63	1.93	0.74
HIV Status
Positive					1.00	---	---	---
Negative					1.53	0.90	2.60	0.11
Unknown					0.87	0.40	1.88	0.73

Note. aOR = adjusted odds ratio; 95% CI = Confidence Interval; + includes individuals with 5 or 6 syndemic psychosocial problems.

^aThe first, “bivariate” model only adjusted for randomization arm.

^bThe second, “multivariable” model and the test for trend (below) adjusted for randomization arm and all covariates shown.

Test for trend was significant (aOR = 1.27; 95% CI = 1.09–1.48, p=0.002)

To assess if a specific psychosocial problem was driving the syndemic–CAVS relationship, we examined whether each individual variable predicted CAVS over time. Because stimulant use (past 4-months) was the strongest predictor (largest statistically significant corresponding odds ratio) of CAVS (aOR=1.77, 95% CI: 1.13–2.77), we were interested in whether or not this variable was “driving” the main effect between the syndemic measure and CAVS. To assess this, we conducted post-hoc analyses with stimulant use removed from the syndemic index, but included in the model as a covariate, in an adjusted multivariable GEE model. With stimulant use removed from the syndemic index, at baseline, 21.5% of the sample had zero psychosocial problems, 31.3% had one, 24.9% had two, 16.3% had three, 5.1% had four or more (4.3% had four and 1.7% had five). In this model, the syndemic variable remained positively and significantly associated with CAVS (four vs. none: aOR=2.77, 95% CI: 1.13–6.74; three vs. none: aOR=2.53, 95% CI: 1.34–4.78; two vs. none: aOR=1.89, 95% CI: 1.10–3.24; one vs. none; aOR=1.77, 95% CI: 1.07–2.92); however, stimulant use was no longer significant (aOR=1.44; 95% CI: 0.90–2.32). The longitudinal relationship between syndemic psychosocial problems and engaging in CAVS was therefore attenuated but remained large when controlling for stimulant use. The association between each level of the syndemic variable and engaging in CAVS was also larger than any individual syndemic psychosocial problem alone, even after accounting for stimulant use.

DISCUSSION

This study prospectively demonstrates that the accumulation of “syndemic” or overlapping psychosocial problems predicts HIV sexual risk (i.e., CAVS) among YTW. In particular, we found that clinically significant depressive symptoms, polydrug use in the past 4-months, stimulant use in the past 4-months, heavy alcohol use in the past 4-months, history of CSA, lifetime IPV, and lifetime transgender-specific victimization produced additive effects on engaging in CAVS over 12-months of follow-up, greatly extending prior cross-sectional research.^21,27,35,42 We identified a dose-response relationship between increasing numbers of syndemic psychosocial problems and elevated HIV risk (i.e., those with five or more psychosocial problems had more than 3 times the odds of engaging in CAVS over follow-up). Our study provides compelling evidence for the directionality of the effect of syndemic psychosocial problems on increased HIV sexual risk among YTW.

Much of the empirical research applying syndemic theory to HIV risk among sexual and gender minority populations has largely been conducted with MSM.^{26,28–33,43–45} These studies have shown that overlapping depression, polydrug use, stimulant use, heavy alcohol use, IPV, and CSA, which were all positively correlated with each other, additively increase the odds of sexual risk, increase the hazard of HIV-infection, and, may potentiate the odds of transmission to sexual partners among those living-with-HIV. While transgender woman may face some of the same social stressors as MSM, they also experience unique stressors due to their gender minority status.⁵ As such, the relationship between overlapping psychosocial problems and sexual risk for HIV faced by YTW are unique to this population and will necessitate distinct intervention targets. In order to be successful, HIV prevention services and risk reduction interventions will need to be gender-affirming and foster supportive environments in which to disclose one’s sexual risk behavior and learn about available HIV prevention modalities such as PrEP.

Among the few published studies that exist, there are inconsistent findings examining the relationship between syndemic psychosocial factors and HIV sexual risk among transgender women. One cross-sectional study found that among YTW (N=282) in San Francisco an index of psychosocial problems, including clinically significant depressive symptoms, trauma, transgender-related discrimination, bullying, unstable housing, and parental rejection was not significantly associated with CAVS.³⁵ However, a cross-sectional study conducted in Los Angeles and Chicago among YTW (N=151) found that syndemic psychosocial factors, inclusive of low self-esteem, polydrug use, victimization, and IPV, were significantly associated with unprotected anal intercourse.²⁷ Further, in a sample of transgender women in San Francisco, a syndemic index of alcohol intoxication, drug use, and condomless anal sex was shown to be significantly associated with stigma,²¹ but not self-reported HIV infection. Lastly, with data from a sample of transgender women (N=117) in Richmond, VA and Washington, DC, researchers found that syndemic psychosocial problems, such as drug and alcohol use, mediated the relationship between stigma and HIV sexual risk.⁴² While these early studies offer important insights into the associations between psychosocial problems and HIV sexual risk, a major limitation is that they relied on cross-sectional data. Given that syndemic psychosocial problems in YTW may vary over time, in this prospective study we are able to learn more about cause and effect relationships by having repeated measures, allowing us to establish directionality in the relationship between syndemics and HIV risk. A prospective understanding of syndemic psychosocial problems specific to YTW can help to inform culturally-tailored HIV prevention interventions that adequately target these underlying conditions driving sexual risk and the broader social contexts from which they originate.

The plurality of co-occurring psychosocial problems identified in our large sample of YTW in two U.S. cities likely reflects the extent of mental health and substance use disparities in this population.^5,46 Despite the fact that YTW are a key population at high-risk of HIV infection,² with HIV prevalence estimates among urban YTW ranging from 19–22%,^6,7 only recently have investigators begun to link these syndemic vulnerabilities—many of which can be traced back to socioeconomic marginalization and disadvantage—to the sexual health of this population. That coinciding syndemic psychosocial problems persist into adulthood would contribute to HIV disparities among gender minorities is broadly consistent with the minority stress model.^47,48 This model argues that stressors associated with gender minority status produce external and internal stress processes (e.g., transgender-prejudice, discrimination, expectations of rejection) that contribute to mental health and substance use problems later in life. In support of this model, the LifeSkills intervention, conducted by Garofalo et al., 2018, is the first evidence-based, sexual risk-reduction intervention for HIV prevention among YTW with demonstrated efficacy that specifically targets expectations of rejection, discrimination, and victimization among YTW.³⁷ Conceptualizing the production of syndemic psychosocial problems in this way helps maintain focus on these important targets of the broader HIV prevention agenda.

Findings indicate a need for more refined, comprehensive, clinical assessments of psychosocial comorbidities in YTW. Diagnostic assessments would allow greater specification of treatment targets to support referrals or linkage-to-care for individuals at heightened HIV risk or YTW who are living-with-HIV. Key syndemic indicators among YTW, including those identified in our study, are typically assessed via self-report. However, the use of clinician-administered diagnostic assessments would help identify those who meet diagnostic criteria for particular disorders or have characteristics of significant functional impairment (e.g., depressive disorders, stimulant use disorder). Improved specification of adolescent and young adult mental health and substance abuse treatment targets may be particularly helpful for HIV prevention because there are established, efficacious behavioral and psychopharmacological treatments for many of these disorders (e.g., depression, substance abuse).⁴⁹

These findings should be understood within the context of some limitations. First, our syndemic indicators were based upon self-report; thus, the extent of the impairment or distress associated with these measures is unknown. Convenience-sampling was used in this study and occurred in large U.S. cities, and participants were those willing to join an HIV prevention study, possibly preventing the generalizability of our findings to all YTW. In addition, we selected one specific syndemic-cluster a priori; there are likely multiple syndemics associated with HIV risk (i.e. not just the indicators included in this study) and additional research is necessary to elucidate these. Lastly, some syndemic variables differed with respect to lifetime vs. past 4-months, namely done to maintain the integrity of how each scale was previously validated.

Despite limitations, this study is an important contribution to the literature in that it establishes the prospective relationship between syndemic psychosocial problems and subsequent CAVS in a large sample of YTW in the U.S. In addition to addressing the common socioeconomic and structural causes of these co-occurring psychosocial problems, HIV prevention efforts will require greater integration of risk reduction counseling into existing mental health and substance abuse treatment services. The efficacy of HIV prevention interventions will be enhanced by incorporating treatment modules designed to address the specific presenting syndemic psychosocial problems among YTW.

Table 1.

Baseline sociodemographic characteristics, psychosocial problems, and condomless anal or vaginal sex among a multicity sample of YTW (N = 233).

	Mean	SD
Age (range 16–29)	23.4	3.6
Study Site	N	%
Boston	116	49.8
Chicago	117	50.2
Race
White	60	25.8
Racial/Ethnic Minority	173	74.2
Education
High school/equivalent or less	105	45.1
Some college	43	18.5
College	8	3.4
Some graduate school or more	6	2.6
Current student	71	30.5
Employment
Unemployed	175	75.1
Part-time	36	15.5
Full-time	22	9.4
HIV Status
Positive	48	20.6
Negative	183	78.5
Unknown	2	0.9
Syndemic Psychosocial Problems (n = 187)
0	23	12.3
1	55	29.4
2	48	25.7
3	38	20.3
4	17	9.1
5+	6	3.2
5	5	2.7
6	6	0.5
7	0	0.0
Depression - Past 7 Days
No	135	57.9
Yes	98	42.1
Poly-Drug Use - Past 4-Months
No	218	93.6
Yes	15	6.4
Stimulant Use - Past 4-Months
No	196	84.1
Yes	37	15.9
Heavy Alcohol Use - Past 4-Months
No	215	92.3
Yes	18	7.7
Child Sexual Abuse - Lifetime (n = 140)
No	126	90.0
Yes	14	10.0
IPV - Lifetime (n = 187)
No	109	58.3
Yes	78	41.7
Transgender Victimization - Lifetime (n = 187)
No	47	25.1
Yes	140	74.9
CAVS Any
No	91	39.1
Yes	142	60.9

Note. Racial/ethnic minority includes 47.2% black/African American, 11.6% Hispanic/Latina, and 15.5% mixed race/other; + includes individuals with 5 or 6 syndemic psychosocial problems; CAVS = Condomless anal or vaginal sex

Lifetime discrimination and violence variables were assessed at the 4-month visit and carried forward to baseline

Table 4.

Adjusted longitudinal models examining the predictive relationship between each syndemic psychosocial problem and condomless anal and/or vaginal sex (CAVS) over time; and an examination of stimulant use as a “driver” of the overall syndemic psychosocial problems variable and CAVS relationship over time among YTW (N = 233).

	CAVS
	Bivariatea				Multivariableb
	aOR	95% CI		P-Value	aOR	95% CI		P-Value
Syndemics
0					1.00	---	---	---
1					1.77	1.07	2.92	0.03
2					1.89	1.10	3.24	0.02
3					2.53	1.34	4.78	0.004
4+					2.77	1.13	6.74	0.03
Depression - Past 7 Days
No	1.00	---	---	---
Yes	1.03	0.78	1.37	0.83
Poly-Substance Use - Past 4-Months
No	1.00	---	---	---
Yes	1.81	0.88	3.69	0.10
Stimulant Use - Past 4-Months
No	1.00	---	---	---	1.00	---	---	---
Yes	1.77	1.13	2.77	0.01	1.44	0.90	2.32	0.13
Heavy Alcohol Use - Past 4-Months
No	1.00	---	---	---
Yes	1.79	0.94	3.41	0.08
Child Sexual Abuse - Lifetime
No	1.00	---	---	---
Yes	1.18	0.43	3.26	0.75
IPV - Lifetime
No	1.00	---	---	---
Yes	1.54	1.01	2.36	0.05
IPV - Lifetime
No	1.00	---	---	---
Yes	1.56	1.02	2.40	0.04

Note. aOR=adjusted odds ratio (adjusted for randomization arm, study site, age, race/ethnicity, education, employment and HIV-serostatus); 95% CI = Confidence Interval; + includes individuals with 4 or 5 syndemic psychosocial problems, excluding stimulant use;

^a“Bivariate” = the association between each individual syndemic psychosocial problem and CAVS adjusting for randomization arm, study site, age, race/ethnicity, education, employment and HIV-serostatus.

^b“Multivariable” = the association between syndemics, stimulant use, and CAVS adjusting for randomization arm, study site, age, race/ethnicity, education, employment and HIV-serostatus.