Syndemics and clinical impact of HIV and mental health conditions among people living with HIV: a systematic review and meta-analysis

Abstract

Introduction People living with HIV (PLWH) may be exposed to harmful political, social, economic and environmental factors that exacerbate their risk of mental health conditions. Such factors can interact synergistically to worsen HIV and mental health-related outcomes, creating a syndemic. This study aims to review existing literature on mental health-related syndemics and their impact on HIV and mental health outcomes. Methods CINAHL, Embase, MEDLINE, PsycInfo, Scopus and ProQuest were searched. We included observational studies that investigated a potential mental health-related syndemic and/or reported the impact of a syndemic on HIV outcomes (antiretroviral therapy [ART] adherence or viral suppression), or mental health outcomes (mental health-related quality of life, depression, anxiety, schizophrenia, bipolar disorder, post-traumatic stress disorder or psychological distress) among PLWH. Screening, data extraction and quality assessment were conducted by two independent reviewers. The Newcastle-Ottawa Scale (NOS) was used to assess the quality and risk of bias. The impact of syndemic count on ART adherence and viral suppression was pooled using random effects using STATA and the remaining findings were synthesised narratively. PRISMA guidelines were followed. Results 32 studies were included with sample sizes ranging from 51 participants to 14,261. Six studies reported on mental health-related syndemics among PLWH, four of which found depression or distress to be the most influential syndemic factor. Mental health conditions within syndemics often cluster and are significantly associated with socioeconomic factors such as food insecurity, stigma and violence. Fifteen of 16 studies found a significant association between adherence and the number of mental health-related syndemics. Pooled odds ratio of seven studies showed a significant reduction in adherence ( OR = 0.73; 95% CI = 0.55 – 0.96); heterogeneity was high ( I 2 = 98.58%). Eleven of 13 studies found a significant association between the number of mental health-related syndemics and being virally suppressed. Four studies resulted in a significant pooled odds ratio for having detectable viral load ( OR = 1.26; 95% CI = 1.10 - 1.44); heterogeneity was moderate ( I 2 = 52.38%). Conclusion Despite wide variation in how syndemics were defined and measured across studies, our findings suggest that mental health conditions, particularly depression, strongly influence synergising syndemics among PLWH, and mental health-related syndemics negatively impact ART adherence and viral load. These findings underscore the need for syndemic-informed holistic care models to address the intersecting burden of mental health conditions and psychosocial factors among PLWH.