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Abstract
Background: The MSM (Men who have sex with men) population suffers from very high rates of concurrent psychosocial
problems. Together, these problems comprise a syndemic that increases the risk of HIV infection for this community. The
precise mechanisms through which this syndemic can raise the likelihood of HIV infection warrant further exploration.
Methodology/Principal Findings: A total of 522 MSM were enrolled via a multiframe sampling approach and were asked to
report psychosocial problems, risky sexual behaviors and HIV test results. A count of psychosocial health problems was
calculated to test the additive relationship of these factors on HIV risk. Adjusting analysis and restriction analysis were used
to determine a proposed intermediate pathway. Psychosocial health problems are highly concurrent and intercorrelated
among urban MSM. Greater numbers of health problems are significantly and positively associated with HIV infection, which
is mediated, at least partially, by risky sexual behaviors.
Conclusions/Significance: MSM experience concurrent psychosocial health problems that correlate with HIV infection in
this community. We recommend the development of coping strategies for this population to deal with these psychosocial
problems, both in prevention research and health policy.
Citation: Jie W, Ciyong L, Xueqing D, Hui W, Lingyao H (2012) A Syndemic of Psychosocial Problems Places the MSM (Men Who Have Sex with Men) Population at
Greater Risk of HIV Infection. PLoS ONE 7(3): e32312. doi:10.1371/journal.pone.0032312
Editor: Vittoria Colizza, INSERM & Universite Pierre et Marie Curie, France
Received July 4, 2011; Accepted January 26, 2012; Published March 30, 2012
Copyright: 2012 Jie et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This study was supported by the Sun Yat-sen University Faculty Research Grant. The funders had no role in study design, data collection and analysis,
decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: luciyong@yahoo.cn
Introduction
Men who have sex with men (MSM) have been disproportionately affected by the human immunodeficiency virus (HIV) and
continue to be major drivers of the HIV/AIDS epidemic
throughout the world. Recent data indicate an emerging HIV
epidemic among MSM in metropolitan areas of China [14]. By
the end of 2007, it was estimated that 77,000 MSM were living
with HIV/AIDS, accounting for 11% of the total number of
estimated HIV cases in China [5]. MSM have recently emerged as
a high-risk group in China.
As alarming as these epidemiological data are, even more
disturbing is the lack of preparedness to address HIV risk and
prevention in this population. Modifying the health behaviors of
individuals at risk is a complex challenge. Not only are there
interpersonal challenges and life experiences to overcome, but
there are also social, psychological and cultural obstacles to
surmount in curtailing the epidemic.
In certain areas, homosexuality has traditionally been stigmatized. Therefore, MSM in these locations are vulnerable to a
variety of psychosocial difficulties [6], and researchers have
suggested that homophobia and prejudice contribute to these
psychosocial difficulties through a process termed minority stress.
This model incorporates various psychological and stress theories
28(1868)
Ethnicity
Han
507
97.1
others
15
2.9
Household registration
local
248
47.7
other
274
52.3
SES
low
87
16.7
middle
309
59.2
high
126
24.1
399
76.4
123
23.6
gay
378
72.4
bisexual
96
18.4
uncertain
48
9.2
Full/part time
448
85.8
unemployed
74
14.2
Education
Methods
Sexual orientation
employment
Marital status
Married
68
13.0
Unmarried
454
87.0
HIV
Positive
18
3.4
Negative
504
96.6
Ethics
The Sun Yat-sen University Institutional Review Board approved the study, and each study participant provided written
informed consent with a trained researcher.
Measures
Demographic and background characteristics. Participants were asked to report their age, ethnicity, educational
level, employment status, marital status and sexual orientation. All
other variables used in the analysis are described in Table 1.
PLoS ONE | www.plosone.org
Characteristics
4.9
(1.121.7)
2.7
(1.17.1)
8
Note. Dash indicates odd ratio is nonsignificant. All odds ratios shown, two-tailed p,.05.
doi:10.1371/journal.pone.0032312.t002
3.8
(1.410.2)
2.6
(1.06.8)
4.4
(1.414.2)
2.1
(1.23.6)
2.0
(1.04.0)
7
1.5
(1.02.2)
6
5.0
(1.517.3)
4.5
(1.513.3)
3.8
(1.311.6)
5
1.6
(1.12.3)
4
2.8
(1.17.1)
2
62.8%
54.3%
8.HIV positive
7.Unprotected Anal Sex
5.Partner violence
2.7%
15.1%
33%
3.8%
A total of 530 MSM were recruited for the study, and 522
(95.4%) completed the questionnaire and provided blood samples.
Eight refused to finish the questionnaire but consented to give
blood for the HIV test. The most common reason for refusing the
questionnaire was that the participant was too busy to complete it.
Table 1 describes the demographic characteristics and HIV
infection status of this sample. The age of the participants ranged
from 18 to 68 years, with a median age of 28 years. More than half
(55%) of the participants were between 26 and 35 years of age.
The majority were educated beyond junior college (76.4%) and
were employed. Eighty-four percent of participants were unmarried. Most participants identified themselves as gay (72.4%), and a
minority identified as bisexual (18.4%). The remainder were
uncertain about their sexual orientation (9.2%). The overall
prevalence of HIV in this sample was 3.4%.
2.Drug abuse
Results
35.6%
Table 2. Logistic regression model to evaluated the association between psychosocial health problems.
1.Binge drinking
Statistical analysis
Prevalence
3.4%
Table 3. Logistic regression models to evaluate the association between syndemic and HIV infection.
items
Age
1.0(0.91.1)
1.0(0.91.1)
1.0(0.91.1)
SES
low
1.0
1.0
1.0
middle
0.5(0.11.6)
0.4(0.11.5)
0.6(0.22.5)
high
0.7(0.22.8)
0.7(0.22.7)
0.9(0.24.2)
Syndemic#
1.8(1.13.0)
1.5(1.02.9)
1.4(0.92.8)
Unconditional logistic regression. CI, confidence interval; OR, odds ratio. SES, socioeconomic status.
a
Adjusted for sexual risk behaviours; having sex with multiple partners, anal sex without a condom or with partial condom use.
b
Restricted to 432 men who engaged in the highest risk behaviours; having sex with multiple partners, anal sex without a condom or with partial condom use.
#OR refers to each unit increase of the syndemic score confers approximately corresponding increase in odds of HIV infection compared to the previous syndemic
score.
doi:10.1371/journal.pone.0032312.t003
Discussion
Our study supports the previous evidence that additive
psychosocial health problemscollectively known as a syndemicexist among urban MSM. In our study the interconnection
of these psychosocial problems magnified the effects of the HIV/
AIDS epidemic in this population. In addition, we found that this
effect is at least partially mediated by high-risk sexual behavior. We
found that not only is sexual risk behavior an important mechanism
underlying the relationship between the syndemic of psychosocial
problems and HIV infection for gay and bisexual men, but it also
partially mediates the syndemic effects of psychosocial problems on
HIV infection.
Given the cross-sectional nature of the study design, some
results should be interpreted with caution; for instance, depression
and substance-use may be the result of HIV-infection in some men
rather than a cause. All relationships identified in this study are
restricted to bidirectional relationships, not causality.
In the mediation analysis, the size of the syndemic effect was not
attenuated to one after adjusting for sexual risk behaviors, which
may be explained by incomplete adjustment and residual
confounding by unmeasured sexual behaviors. Another possible
explanation is that the syndemic of psychosocial problems acts as a
Table 4. Logistic regression models to evaluate the association between syndemic components and HIV infection.
Substance abuse
0.8(0.32.3)
0.8(0.32.3)
0.9(0.32.4)
depression
2.9(1.17.6)
2.9(1.17.6)
3.3(1.24.3)
trauma
3.5(1.39.4)
3.1(1.18.6)
2.8(0.98.0)
Unconditional logistic regression. CI, confidence interval; OR, odds ratio. SES, socioeconomic status.
a
Adjusted for sexual risk behaviours; having sex with multiple partners, anal sex without a condom or with partial condom use.
b
Restricted to 432 men who engaged in the highest risk behaviours; having sex with multiple partners, anal sex without a condom or with partial condom use.
doi:10.1371/journal.pone.0032312.t004
Acknowledgments
We are very grateful to the men who participated in this study. The authors
would also like to thank the Lingnan Partner Support Center (LPSC) and
local CDC who helped with the referral of respondents.
Author Contributions
Conceived and designed the experiments: LCY WJ. Performed the
experiments: LCY WJ DXQ. Analyzed the data: WJ. Contributed
reagents/materials/analysis tools: WH. Wrote the paper: WJ. Academic
counseling: HLY.
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