title: Syndemic conditions associated with increased HIV risk in a global sample of men who have sex with men.
abstract: OBJECTIVE
  We evaluated the relationship among syndemic conditions (defined as a cluster of interconnected psychosocial health conditions), sexual behaviours and self-reported HIV infection in a global sample of men who have sex with men (MSM).
  
  
  METHODS
  We used generalised estimating equations logistic regression models with robust SEs to assess the relationships among cumulative number of syndemic conditions--including depression, substance use, violence, sexual stigma and homelessness--and unprotected anal intercourse (UAI) and HIV infection, while accounting for clustering within-country in a global cross-sectional survey of 3934 MSM across 151 countries.
  
  
  RESULTS
  We observed parallel, significant dose-response associations between the number of syndemic conditions and UAI, as well as number of syndemic conditions and HIV infection. Compared with participants without syndemics, the adjusted OR (aOR) for UAI among those with 1, 2 and 3 or more syndemic conditions were 1.44 (Bonferroni-adjusted 95% CI 1.23 to 1.68), 1.89 (1.51 to 2.36) and 2.03 (1.43 to 2.89), respectively. Compared with participants without syndemics, the aOR for HIV infection among those with 1, 2 and 3 or more syndemic conditions were 1.67 (1.24 to 2.26), 2.02 (1.44 to 2.85) and 2.35 (1.31 to 4.21), respectively.
  
  
  CONCLUSIONS
  This analysis provides evidence of intertwining syndemics that may operate synergistically to increase HIV risk among MSM globally. To curb HIV effectively and advance the health of MSM, multiple conditions must be addressed concurrently using multi-level approaches that target both individual and structural risk factors.
authors.affiliation: HIV Prevention, , San Francisco Department of Public Health, San Francisco, California, USA.
authors.forename: Glenn-Milo
authors.initials: GM
authors.lastname: Santos
authors.forename: Tri
authors.initials: T
authors.lastname: Do
authors.forename: Jack
authors.initials: J
authors.lastname: Beck
authors.forename: Keletso
authors.initials: K
authors.lastname: Makofane
authors.forename: Sonya
authors.initials: S
authors.lastname: Arreola
authors.forename: Thomas
authors.initials: T
authors.lastname: Pyun
authors.forename: Pato
authors.initials: P
authors.lastname: Hebert
authors.forename: Patrick A
authors.initials: PA
authors.lastname: Wilson
authors.forename: George
authors.initials: G
authors.lastname: Ayala
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D003430:Cross-Sectional Studies; D003863:Depression / Q000453:epidemiology*; D014943:Global Health; D015658:HIV Infections / Q000453:epidemiology* / Q000517:prevention & control / Q000523:psychology*; D006703:Ill-Housed Persons / Q000523:psychology / Q000706:statistics & numerical data*; D018451:Homosexuality, Male; D006801:Humans; D007398:Interpersonal Relations; D008297:Male; D008875:Middle Aged; D012309:Risk-Taking; D012747:Sexual Partners / Q000523:psychology; D012931:Social Environment; D057545:Social Stigma; D047568:Unsafe Sex; D014754:Violence / Q000523:psychology / Q000706:statistics & numerical data*
keywords: Drug Misuse; Epidemiology (General); Gay Men; HIV; Sexual Behaviour