Impact of Syndemics on People Living with HIV/AIDS in San Francisco Priscilla Lee Chu, DrPH, MPH San Francisco Department of Public Health XIX International AIDS Conference July 23, 2012 Washington, DC Impact of Syndemics on People Living with HIV/AIDS in San Francisco Impact of Syndemics on People Living with HIV/AIDS in San Francisco For submission to the International AIDS conference Due: February 14 Track C: Epidemiology and Prevention Science Authors: Priscilla Lee Chu, Glenn-Milo Santos, Annie Vu, Israel Nieves-Rivera, Grant Colfax, Jennifer Grinsdale, Sandra Huang, Susan Philip, Susan Scheer, Tomas Aragon Introduction. Syndemics are the presence of two or more diseases interacting synergistically to exacerbate health outcomes within a population. In San Francisco (SF), the Program Collaboration and Service Integration (PCSI) project has prioritized the integrated monitoring of syndemics among four communicable disease registries: HIV, tuberculosis (TB), Viral Hepatitis (VH), and sexually transmitted diseases (STD). We assessed the prevalence of co-occurring infections within these registries and their impact on persons living with HIV/AIDS (PLWHA). Methods. Living SF HIV/AIDS cases were matched against seven diseases (active TB, latent TB, hepatitis B, hepatitis C (HCV), syphilis, gonorrhea, and chlamydia). Using chi-square, t-test, and Kruskal-Wallis tests, we assessed demographic, HIV health status, and neighborhood differences between those with HIV only versus HIV plus at least one co-infection. Results. Among PLWHA, syndemics were highest among: injection drug users (27%, p<0.0001), those with very high (>100000) viral loads (VLs) (26%, p=0.0001), those not virologically suppressed (23%, p<0.0001), homeless (23%, p<0.0001), African-Americans (21%, p<0.0001), women, transgender (both 18%, p<0.0001), and ages 20-29 (16%, p=0.0003). Co-infected PLWHA affected diverse geographic areas, regardless of socioeconomic status. Syndemic rates per 100000 population were highest in Castro (1219), South of Market (670), and Tenderloin (665) neighborhoods (p<0.001) (Figure 1). The mean VLs for PLWHA with syphilis, chlamydia, gonorrhea, HCV, or latent TB were higher than for PLWHA with HIV only (all p<0.001). There was a significant correlation with increasing number of co-infections and increasing mean VLs (p<0.001) (Table 1). Conclusion. Syndemics are associated with poorer HIV health outcomes among PLWHA. We found a significant “dose-response relationship” between the number of co-infections and mean VLs. Greater numbers of co-infections, demographic subgroups, and certain geo-clusters were associated with poorer health outcomes, underscoring the need to address multiple conditions in tandem in an integrated health system.

Introduction: PCSI Program Collaboration and Service Integration (PCSI) has prioritized the integrated monitoring of syndemics among four communicable disease registries: HIV Tuberculosis Viral Hepatitis STDs All United States initiatives at the federal level: expand collaboration and increase integration In San Francisco, Program Collaboration and Service Integration (PCSI) is a CDC demonstration project Purpose: to implement a syndemic approach to the prevention of HIV, viral hepatitis, STDs and TB Goal: to develop system level changes that can be sustained over time In SF, we have prioritized the integrated monitoring of syndemics among the separately housed four communicable disease registries

Introduction: Syndemics Syndemics are the presence of two or more diseases interacting synergistically to exacerbate health outcomes within a population “…two or more afflictions (diseases), interacting synergistically, contributing to increase transmission and/or worsen outcomes of either or all diseases in a population” ~ CDC’s definition Syndemics become more than the sum of their epidemic parts

Introduction: Purpose To assess the prevalence of co-occurring infections within the four registries and their impact on persons living with HIV/AIDS (PLWHA)

Methods 1/2 HIV STD Syphilis Gonorrhea Chlamydia Viral Hepatitis Chronic Hepatitis B Hepatitis C TB Active TB Latent TB HIV/AIDS cases were matched against seven diseases from three other registries HIV/AIDS cases were matched against seven diseases from three other registries We developed distinct case inclusion criteria appropriate to each disease registry and used this to generate a list of cases for the match: VH registry included all cases because of the difficulty in determining a current case; TB registry included all active and latent cases from their registry because latent TB is more prevalent than active TB. HIV registry chose cases living as of December 31, 2009. STD registry selected cases who had a reportable STD in 2009. Variables to match: exact last name, first name, date of birth

Methods 2/2 Chi-square, t-test, and Kruskal-Wallis tests were used to assess differences between those with HIV only versus HIV plus at least one co-infection by: Demographics Health status Neighborhood

Results: Syndemics with HIV 14% Syphilis 1% Gonorrhea 2% Chlamydia 2% HCV 4% HBV 4% LTBI 2% Active TB 1% HIV N=15,056 N=2,050 (14%) with one or more infection in addition to HIV Syndemic rate 13,616 per 100,000 HIV cases Highest co-morbidities: HCV, HBV, Chlamydia, and latent TB HIV N=15,056 N=2,050 (14%) with one or more infection in addition to HIV Syndemic rate 13,616 per 100,000 HIV cases Highest co-morbidities: HCV, HBV, Chlamydia, and latent TB

Results: Characteristics of PLWHA with at least one other disease Among PLWHA, syndemics were highest among (chi-square test): injection drug users (27%, p<0.0001) those with very high (>100000) viral loads (VLs) (26%, p=0.0001), those not virologically suppressed (23%, p<0.0001), homeless (23%, p<0.0001), African-Americans (21%, p<0.0001) women, transgender (both 18%, p<0.0001) ages 20-29 (16%, p=0.0003)

Results: Mean viral load by specific co-infection The mean viral loads for PLWHA with co-infections (except for viral hepatitis) were higher than for PLWHA with HIV only p<0.05 for all by t-test

Results: Suppression rates by specific co-infection People with HIV disease only had a higher percentage of viral suppression than HIV plus another disease. (chi-square p<0.01 for all except HBV and Active TB not significant)

Results: Mean viral load by number of co-infections There was a significant correlation with increasing number of co-infections and increasing mean viral loads P<0.01 by chi-square HIV only N=13006 HIV+1 N=1716 HIV+2 N=303 HIV+3 or more N=31

Results: Viral suppression rates by number of co-infections Similarly, increasing co-infections also demonstrated significantly less viral suppression p<0.01 by Kruskal-Wallis

Results: PLWHA syndemics and poverty, San Francisco, 2009 The darkest green areas show neighborhoods with the highest rates of poverty The darker red circles show a larger number of co-infections per 100k population Co-infected PLWHA affected diverse geographic areas, regardless of socioeconomic status Syndemic rates per 100,000 population were highest in the following neighborhoods: Castro South of Market Tenderloin

Conclusion 1/3 Syndemics are associated with poorer HIV health outcomes among PLWHA Significant “dose-response relationship” between the number of co-infections and mean VLs Syndemics are associated with poorer HIV health outcomes among PLWHA We found a significant “dose-response relationship” between the number of co-infections and mean VLs Greater numbers of co-infections, demographic subgroups, and certain geo-clusters were associated with poorer health outcomes, underscoring the need to address multiple conditions in tandem in an integrated health system

Conclusion 2/3 In addition to numbers of co-infections, particular demographic subgroups, and certain geo-clusters were also associated with poorer health outcomes, underscoring the need to address multiple conditions in tandem in an integrated health system In addition to numbers of co-infections, particular demographic subgroups, and certain geo-clusters were also associated with poorer health outcomes, underscoring the need to address multiple conditions in tandem in an integrated health system

Conclusion 3/3 Finally, I’d like to end with a historical poster that I saw at the National Air and Space museum this week. We encourage other local jurisdictions to better understand the syndemics that happen with HIV so that they can more effectively address not only HIV, but also health and well-being with an integrated approach

Thanks & Acknowledgements Glenn-Milo Santos Annie Vu Israel Nieves-Rivera Grant Colfax Jennifer Grinsdale Sandra Huang Susan Philip Susan Scheer Tomas Aragon Thank you for your time. I would like to acknowledge the aid and support of my colleagues