Integrating Intersectional and Syndemic Frameworks for Ending the US HIV Epidemic

In the US HIV epidemic, intersectional stigma research illustrates how multiple interlocking systems of oppression (e.g., classism, racism, misogyny, drug use stigma) amplify HIV vulnerability and related health inequities.¹ Michele Tracey Berger¹ first coined the term intersectional HIV stigma, grounding the core of this intersectional approach in Black feminist theory to articulate individual and collective experiences of status-based oppression and to advance liberation.^2,3 To date, intersectional HIV-related stigma research has focused largely on understanding how stigma is experienced among populations with multiple interlocking stigmatized statuses in relation to a single health condition, HIV.⁴ In contrast, the past decade of HIV research has leveraged the theory of syndemics to understand how the co-occurrence of multiple health conditions (and their interactions) amplifies HIV vulnerability and related health inequities.⁵

Integrating the foci of these frameworks can better target efforts to end the HIV epidemic (EHE) in the United States. Recently, HIV scholars have explored the usefulness of coapplying intersectionality and syndemic analytic frameworks.^6–8 We briefly review each framework’s theoretical foundations to provide an integrated understanding of the sociostructural processes through which US HIV disparities are amplified. Finally, we explore community-led efforts to disrupt the paths through which intersectional stigma cultivates domestic HIV-related syndemics.

INTERSECTIONALITY

Through its formal articulation in legal and sociological studies by Crenshaw and Collins, respectively,^2,3 the concept of intersectionality was developed to specify how systems of power and privilege are experienced through multiple interlocking social statuses in ways that reinforce inequalities.⁹ Intersectionality is articulated as an analytical lens and as a praxis of social justice that calls for the redistribution of power and liberation to be rooted in marginalized communities.¹⁰

Intersectional researchers have encouraged scholars to consider how health disparities, including HIV vulnerability, are shaped by systems of power (e.g., racial segregation, carceral systems, poverty, criminalization of drug use and sex work) that are grounded in anti-Blackness, racism, classism, and various manifestations of misogyny (e.g., sexism, transphobia, homonegativity).^4,9 An intersectional lens can further challenge the dominant stigma paradigm, which siloes experiences of stigma within distinct social positions, to address the interconnected nature of stigmas and elevate the agency of groups of people who experience intersectional stigmas (i.e., resilience and resistance).¹⁰

SYNDEMICS

The theory of syndemics reflects on larger sociostructural environmental contexts (e.g., poverty, urbanicity) in which multiple health and social conditions (e.g., sexual violence, drug use, HIV) interact synergistically to amplify disease burden in a population. Singer emphasized that this interrelationship of “complex health and social crises”^5(p99) emerges among high-risk groups “because they are subject to social discrimination, stigmatization, and subordination.”^11(p39)

The empirical foundations of syndemic theory rest largely on associations between cumulative exposure to individual psychosocial (e.g., depression, violence) and behavioral health conditions (e.g., substance use, sexual compulsivity) and poor individual health outcomes.¹² Stigma, when accounted for, is articulated as an additional syndemic exposure.¹² Such analyses pushed HIV intervention science to acknowledge and address co-occurring conditions that affect vulnerability to HIV acquisition and poorer health outcomes among people living with HIV. Still, future work must address the core theoretical tenet of syndemics (i.e., the synergistic interactions between epidemics driven by sociostructural contexts).¹²

Integrating sociostructural processes

In brief, intersectionality specifies how interlocking systems of power and privilege produce the sociostructural environmental contexts that promote syndemic conditions. These processes not only amplify disease burden but also restrict access to effective interventions and attenuate treatment efficacy when care is accessed. Box 1 outlines examples of how these sociostructural processes synergistically interact to amplify HIV inequities in the United States and can inform intersectional HIV-related stigma research. Applying an intersectional lens to syndemics draws attention to these systems to illustrate how the “same syndemic exposures” (e.g., drug use stigma, misogyny, police violence) reflect heterogeneity in interconnected health inequities across interlocking social positions (e.g., age, race, gender).⁷ When an individual-level focus is applied, syndemic research reflects the by-product of this sociostructural process (i.e., exposure to social and health conditions), and applications of intersectionality risk simply enumerating “multiple” identities (versus specifying socially structured positions of power or disadvantage) of populations most impacted by this process.^10,12 Such siloed applications ignore the underlying power dynamics that produce intersectional HIV-related stigma and discrimination and codify health inequities.¹ It is a fallacy to believe that research grounded in either theory can produce a meaningful end to the HIV epidemic by ignoring the sociostructural systems upholding US HIV disparities in exchange for an easier operationalization of complex phenomena (e.g., cumulative conditions or identities that explain enough variance in HIV outcomes). Rather, we echo previous calls for research to inform how to change these sociostructural processes when applying either framework or both of them.^9,12

BOX 1—

Integrating Intersectional and Syndemic Sociostructural Processes Applied to Populations Inequitably Served by the US HIV Response

Sociostructural Processes Exacerbating the US HIV Epidemic	Applications of Intersectional HIV Stigma Research
1. Production of disproportionate disease burden: Interlocking systems of oppression cultivate and concentrate environmental stressors (e.g., political, economic, physical, psychological) that directly increase vulnerability to syndemic conditions and amplify HIV transmission and poorer HIV and overall health outcomes.
Applied example: Among Black and Latina/x transgender women, systemic racism and anti-trans legislation legitimize discrimination in gender-affirming care and employment, stripping access to care to meet basic needs. This can increase reliance on informal economies such as sex work, where criminalization (rooted in anti-Blackness and misogyny) increases exposure to interpersonal and structural violence. The absence of legislation protecting the rights of transgender people permits and amplifies exposure to violence and its sequelae across the life course (poorer mental health, increased substance use).	Research application: Identify mechanisms to increase agency and reduce synergies between syndemic conditions. • Study the effects of upstream intervention efforts that protect against violence and facilitate access to safe and stable housing and employment for transgender women. • Examine the role of social networks within the transgender community on mitigating the synergies between mental health, substance use, and vulnerability to HIV.
2. Restricted access to effective interventions: The same interlocking systems of oppression limit access to interventions for HIV (and related syndemic conditions) by producing environments with fewer (and less equipped) geographic, economic, and interpersonal health care resources.
Applied example: Among persons who inject drugs, classism and racism fundamentally limit proximity and access to evidence-based substance use and HIV interventions (e.g., syringe service programs, medications for opioid use disorder, ART, PrEP) among the rural and urban poor. Drug use stigma further limits access via restrictive policies misaligned with the chronic nature of substance use care (e.g., restrictions on syringe distribution locations/volume, lifetime or annual caps on drug treatment coverage). Race- and gender-based discrimination can further amplify the punitive consequences of interactions with health care providers (and law enforcement), deterring service access.	Research application: Develop strategies to increase equity in service access and mitigate punitive norms and interactions. • Investigate how technology can bridge geographic and economic barriers to accessing quality services, integrating evidence-based HIV and substance use services. • Assess the impact of programs that aim to decriminalize substance use or restore or sustain access to services across periods of active use and abstinence.
3. Attenuation of available evidence-based treatments: Intervention and treatment efficacy is impacted by co-occurring syndemic conditions (and their interactions) initially cultivated by the same interlocking systems of oppression.
Applied example: Among Black women accessing evidence-based interventions, disparities in HIV outcomes persist (e.g., proportion of new HIV diagnoses, linkage to care, viral suppression when receiving ART, PrEP persistence). The social and health care needs of Black women are also more likely to go undiagnosed and undertreated due to ways racism, misogyny, and classism affect providers’ dismissal of their symptom severity and/or expectations of treatment noncompliance. Both undertreatment and mistreatment of co-occurring conditions likely attenuate HIV outcomes in critical ways (e.g., competing family planning priorities or caregiver responsibilities; resource insecurity; neglected and/or siloed treatment plans for trauma, substance use, poor mental health).	Research application: Assess treatment models targeting the collective impact of and interactions between co-occurring conditions. • Develop methods to monitor and correct for inequity in provider adherence to treatment guidelines in the United States. • Assess the impact of syndemic-responsive treatment guidelines that integrate care for co-occurring conditions on ART and PrEP persistence and viral load. • Evaluate strategies that promote the agency of Black women and other patients to make treatment decisions and address unmet needs across co-occurring conditions.

Note. ART = antiretroviral therapy; PrEP = preexposure prophylaxis.

Amplifying sociostructural responses

Attaining EHE endpoints will require sociostructural change within existing health care, carceral, and community environments, among others.¹⁰ Increasing the availability of condoms and biomedical interventions will fail to achieve the desired public health impact if interlocking systemic oppression and syndemic health inequities remain unaddressed. This final section illustrates how EHE efforts dovetail with ongoing social justice movements led by and for affected communities.^1,10 Although not an exhaustive list, we highlight organizations working to disrupt the paths through which intersectional stigma cultivates domestic HIV-related syndemics among communities inequitably served 40 years into the US epidemic.

Accounting for Medical Injustice

Past (and ongoing) medical injustices sought to control and exploit the sexual and reproductive lives of Black women in the United States. Groups such as SisterLove Inc. and the Black Women’s Health Imperative are forging paths to destigmatize and empower Black women’s sexual and reproductive health. They have developed multidimensional strategies via health policy, research, health education, and leadership development initiatives that integrate HIV prevention and treatment into the broader context of sexual and reproductive autonomy and liberation. Bringing these strategies to scale via implementation science could advance the dissemination and impact of effective biomedical interventions among Black women within EHE jurisdictions.

Decriminalization and Deservingness

Policing and immigration systems reinforce interlocking inequities by chronically destabilizing family, social, economic, and housing environments along axes of race, class, and gender. Access to lifesaving treatment and life-stabilizing services largely requires passing measures of “deservingness” (e.g., drug screening, background checks). Criminalization of drug use, sex work, and gender-affirming care further concentrates these harms within specific subpopulations. Efforts led by the Black Harm Reduction Network and Sex Workers Outreach Project USA to legalize or decriminalize drug use and sex work can help to mitigate the direct harms of these power structures, affording members of these affected populations greater stability to engage in evidence-based HIV interventions and treatment.

Overcoming Misogyny and its Sequelae

Many social syndemic exposures (e.g., trauma, violence, mental illness, substance use) are rooted in racialized manifestations of misogyny, reinforcing social norms that promote or permit physical and sexual violence toward LGBTQAI+ communities of color. Black- and Latinx-led groups such as the Counter Narrative Project and the TransLatin@ Coalition are working to dismantle these norms and shift power structures toward liberation by making visible authentic Black and Brown expressions of love, self-care, sexuality, and gender expression. Empowerment and other resilience-based intervention strategies might build on this work to promote and sustain preexposure prophylaxis and antiretroviral therapy adherence within LGBTQAI+ communities of color (see related readings in Appendix A, available as a supplement to the online version of this article at http://www.ajph.org).

CONCLUSION

To better inform sociostructural change and paths toward liberation, HIV researchers—and health disparity scholars and interventionists more broadly—must account for how mutually reinforcing systems of oppression interact to produce and reinforce overlapping HIV-related syndemic health crises.