AIDS and Behavior

, Volume 18, Issue 11, pp 2089–2096 | Cite as

Psychosocial Health Conditions and HIV Prevalence and Incidence in a Cohort of Men Who have Sex with Men in Bangkok, Thailand: Evidence of a Syndemic Effect

  • T. E. Guadamuz
  • K. McCarthy
  • W. Wimonsate
  • W. Thienkrua
  • A. Varangrat
  • S. Chaikummao
  • A. Sangiamkittikul
  • R. D. Stall
  • F. van Griensven
Original Paper


Men who have sex with men (MSM) in Bangkok may experience multiple psychosocial health conditions, such as substance use, suicidality, and a history of sexual abuse. These factors may contribute to HIV vulnerability in a syndemic way. A syndemic is defined as a number of synergistically interacting health conditions producing excess disease in a population. The objective of this study is to examine whether psychosocial health conditions among MSM have a syndemic association with HIV prevalence and HIV incidence. To do this, we evaluated psychosocial health conditions and their associations with unprotected sex, HIV prevalence and HIV incidence in a cohort of Thai MSM (N = 1,292). There was a positive and significant association between the number of psychosocial health conditions and increased levels of unprotected sex and HIV prevalence at study baseline. The number of psychosocial health conditions at baseline was also associated with increased HIV incidence during follow-up (no conditions, HIV incidence = 15.3 %; one to three conditions, 23.7 %; four to five conditions, 33.2 %). The number of psychosocial health conditions was positively associated with HIV risk behavior and HIV prevalence and incidence. Prevention efforts among MSM need to address the existence of multiple psychosocial health conditions and their synergy to effectively decrease the spread of HIV infection.


Syndemics HIV/AIDS Men who have sex with men Thailand 



The authors would like to thank the participants in the Bangkok MSM Cohort Study, the staff of the Silom Community Clinic, the HIV STD Research Program and the Thailand Ministry of Public Health—U.S. Centers for Disease Control and Prevention Collaboration for their contributions to the study. We would like to also acknowledge the leadership of the Thai Red Cross AIDS Research Center for granting the time needed to complete the study and to finalize the manuscript for publication. K. McCarthy was supported by the ASPPH/CDC Allan Rosenfield Global Health Fellowship and TE Guadamuz was supported by a Mentored Research Scientist Development Award from the U.S. National Institute of Mental Health (K01MH085567). The study was funded by the Division of HIV/AIDS Prevention, U.S. Centers for Disease Control and Prevention. The findings and conclusions in this manuscript are those of the authors and do not necessary represent the views of the U.S. Centers for Disease Control and Prevention.


  1. 1.
    Bartholow BN, Doll LS, Joy D, et al. Emotional, behavioral, and HIV risks associated with sexual abuse among adult homosexual and bisexual men. Child Abuse Negl. 1994;18:747–61.PubMedCrossRefGoogle Scholar
  2. 2.
    Chesney MA, Barrett DC, Stall R. Histories of substance use and risk behavior: precursors to HIV seroconversion in homosexual men. Am J Public Health. 1998;88:113–6.PubMedCrossRefPubMedCentralGoogle Scholar
  3. 3.
    Cochran SD, Mays VM. Lifetime prevalence of suicide symptoms and affective disorders among men reporting same-sex sexual partners: results from NHANES III. Am J Public Health. 2000;90:573–8.PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    He Q, Wang Y, Lin P, et al. High prevalence of risk behaviour concurrent with links to other high-risk populations: a potentially explosive HIV epidemic among men who have sex with men in Guangzhou. China Sex Transm Infect. 2009;85:383–90.CrossRefGoogle Scholar
  5. 5.
    Koblin BA, Husnik MJ, Colfax G, et al. Risk factors for HIV infection among men who have sex with men. AIDS. 2006;20:731–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Remafedi G. Suicidality in a venue-based sample of young men who have sex with men. J Adolesc Health. 2002;31:305–10.PubMedCrossRefGoogle Scholar
  7. 7.
    Van Tieu H, Koblin BA. HIV, alcohol, and noninjection drug use. Curr Opin HIV AIDS. 2009;4:314–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Walkup J, Blank MB, Gonzales JS, et al. The impact of mental health and substance abuse factors on HIV prevention and treatment. J Acquir Immun Defic Syndr. 2008;47(Suppl 1):S15–9.CrossRefGoogle Scholar
  9. 9.
    Singer M. AIDS and the health crisis of the U.S. urban poor: the perspective of critical medical anthropology. Soc Sci Med. 1994;39:931–48.PubMedCrossRefGoogle Scholar
  10. 10.
    Kwan CK, Ernst JD. HIV and tuberculosis: a deadly human syndemic. Clin Microbiol Rev. 2011;24:351–76.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Candib LM. Obesity and diabetes in vulnerable populations: reflection on proximal and distal causes. Ann Fam Med. 2007;5:547–56.PubMedCrossRefPubMedCentralGoogle Scholar
  12. 12.
    Bulled N, Singer M. Syringe-mediated syndemics. AIDS Behav. 2011;15:1539–45.PubMedCrossRefGoogle Scholar
  13. 13.
    Gielen AC, Burke JG, Mahoney P, et al. HIV/AIDS and intimate partner violence: intersecting women’s health issues in the United States. Trauma Violence Abuse. 2007;8:178–98.PubMedCrossRefGoogle Scholar
  14. 14.
    Kurtz SP. Arrest histories of high-risk gay and bisexual men in Miami: unexpected additional evidence for syndemic theory. J Psychoact Drugs. 2008;40:513–21.CrossRefGoogle Scholar
  15. 15.
    Mustanski B, Garofolo R, Herrick A, Donenberg G. Psychosocial health problems increase risk for HIV among urban young men who have sex with men: preliminary evidence of a syndemic in need of attention. Ann Behav Med. 2007;34:37–45.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Salomon EA, Mimiaga MJ, Husnik MJ, et al. Depressive symptoms, utilization of mental health care, substance use and sexual risk among young men who have sex with men in EXPLORE: implications for age-specific interventions. AIDS Behav. 2009;13:811–21.PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Stall R, Mills TC, Williamson J, et al. Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. Am J Public Health. 2003;93:939–42.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Braitstein P, Asselin JJ, Schilder A, et al. Sexual violence among two populations of men at high risk of HIV infection. AIDS Care. 2006;18:681–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Houston E, McKirnan DJ. Intimate partner abuse among gay and bisexual men: risk correlates and health outcomes. J Urb Health. 2007;84:681–90.CrossRefGoogle Scholar
  20. 20.
    Ratner PA, Johnson JL, Shoveller JA, et al. Non-consensual sex experienced by men who have sex with men: prevalence and association with mental health. Patient Educ Couns. 2003;49:67–74.PubMedCrossRefGoogle Scholar
  21. 21.
    Stall R, Friedman MS, Catania JA. Interacting epidemics and gay men’s health: a theory of syndemic production among urban gay men. In: Wolitski RJ, Stall R, Valdiserri RO, editors. Unequal opportunity: health disparities affecting gay and bisexual men in the United States. Oxford: Oxford University Press; 2008. p. 251–74.Google Scholar
  22. 22.
    Mustanski B, Andrews R, Herrick A, Stall R, Schnarrs PW. A syndemic of psychosocial health disparities and associations with risk for attempting suicide among young sexual minority men. Am J Public Health. 2014;104:287–94.PubMedCrossRefGoogle Scholar
  23. 23.
    Santos GM, Do T, Beck J, Makofane K, Arreola S, Pyun T, Hebert P, Wilson PA, Ayala G. Syndemic conditions associated with increased HIV risk in a global sample of men who have sex with men. Sex Transm Infect. 2014;90:250–3.PubMedCrossRefGoogle Scholar
  24. 24.
    Singer M, Clair S. Syndemics and public health: reconceptualizing disease in bio-social context. Med Anthropol Q. 2003;17:423–41.PubMedCrossRefGoogle Scholar
  25. 25.
    Dyer TP, Shoptaw S, Guadamuz TE, Plankey M, Kao U, Ostrow D, Chmiel JS, Herrick A, Stall R. Application of syndemic theory to black men who have sex with men in the Multicenter AIDS Cohort Study. J Urb Health. 2012;89:697–708.CrossRefGoogle Scholar
  26. 26.
    Guadamuz TE, Friedman, Marshal MP, Herrick AL, Lim SH, Wei C, Stall R. Health, sexual health, and syndemics: toward a better approach to STI and HIV preventive interventions for men who have sex with men (MSM) in the United States. In: Aral SO, Fenton KA, Lipshutz JA, editors. The new public health and STI/HIV prevention: personal, public, and health systems approaches. New York: Springer Science+Business Media, LLC; 2013.Google Scholar
  27. 27.
    Marshal MP, Friedman MS, Stall R, et al. Sexual orientation and adolescent substance use: a meta-analysis and methodological review. Addiction. 2008;103:546–56.PubMedCrossRefPubMedCentralGoogle Scholar
  28. 28.
    Friedman MS, Marshal MP, Guadamuz TE, et al. A meta-analysis of disparities in childhood sexual abuse, parental physical abuse, and peer victimization among sexual minority and sexual nonminority individuals. Am J Public Health. 2011;101:1481–94.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Herrick AL, Marshal MP, Smith HA, Sucato G, Stall RD. Sex while intoxicated: a meta-analysis comparing heterosexual and sexual minority youth. J Adolesc Health. 2011;48:306–9.PubMedCrossRefPubMedCentralGoogle Scholar
  30. 30.
    van Griensven F, Kilmarx PH, Jeeyapant S, et al. The prevalence of bisexual and homosexual orientation and related health risks among adolescents in northern Thailand. Arch Sex Behav. 2004;33:137–47.PubMedCrossRefGoogle Scholar
  31. 31.
    Chemnasiri T, Netwong T, Visarutratana S, et al. Inconsistent condom use among young men who have sex with men, male sex workers, and transgenders in Thailand. AIDS Educ Prev. 2010;22:100–9.PubMedCrossRefGoogle Scholar
  32. 32.
    van Griensven F, Thienkrua W, McNicholl J, et al. Evidence of an explosive epidemic of HIV infection in a cohort of men who have sex with men in Thailand. AIDS. 2013;27:825–32.PubMedCrossRefGoogle Scholar
  33. 33.
    Wangroongsarb Y, Weniger BG, Wasi C, et al. Prevalence of HTLV-III/LAV antibody in selected populations in Thailand. Southeast Asian J Trop Med Public Health. 1985;16:517–20.PubMedGoogle Scholar
  34. 34.
    Gouws E, White PJ, Stover J, Brown T. Short term estimates of adult HIV incidence by mode of transmission: Kenya and Thailand as examples. Sex Transm Infect. 2006;82:51–5.CrossRefGoogle Scholar
  35. 35.
    van Griensven F, Varangrat A, Wimonsate W, et al. Trends in HIV prevalence, estimated HIV incidence, and risk behavior among men who have sex with men in Bangkok, Thailand, 2003-2007. J Acquir Immune Defic Syndr. 2010;53:234–9.CrossRefGoogle Scholar
  36. 36.
    Yu F, Nehl EJ, Zheng T, He N, Berg CJ, Lemieux AF, Lin L, Tran A, Sullivan PS, Wong FY. A syndemic including cigarette smoking and sexual risk behaviors among a sample of MSM in Shanghai. China Drug Alcohol Depend. 2013;132:265–70.CrossRefGoogle Scholar
  37. 37.
    Biello KB, Colby D, Closson E, Mimiaga MJ. The syndemic condition of psychosocial problems and HIV risk among male sex workers in Ho Chi Minh City, Vietnam. AIDS Behav. 2013 [Epub ahead of print].Google Scholar
  38. 38.
    Sungkanuparph S, Techasathit W, Utaipiboon C, Chasombat S, Bhakeecheep S, Leechawengwongs M, Ruxrungtham K, Phanuphak P. Thai national guidelines for antiretroviral therapy in HIV-1 infected adults and adolescents. Asian Biomed. 2010;4:515–28.Google Scholar
  39. 39.
    Guadamuz TE, Wimonsate W, Varangrat A, et al. Correlates of forced sex among populations of men who have sex with men in Thailand. Arch Sex Behav. 2011;40:259–66.PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Dowshen N, Binns HJ, Garofalo R. Experiences of HIV-related stigma among young men who have sex with men. AIDS Patient Care STDS. 2009;23:371–6.PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    Colfax G, Vittinghoff E, Husnik MJ, et al. Substance use and sexual risk: a participant- and episode-level analysis among a cohort of men who have sex with men. Am J Epidemiol. 2004;159:1002–12.PubMedCrossRefGoogle Scholar
  42. 42.
    Stall R, Paul JP, Greenwood G, et al. Alcohol use, drug use and alcohol-related problems among men who have sex with men: the urban men’s health Study. Addiction. 2001;96:1589–601.PubMedCrossRefGoogle Scholar
  43. 43.
    Aynalem G, Smith L, Bemis C, et al. Commercial sex venues: a closer look at their impact on the syphilis and HIV epidemics among men who have sex with men. Sex Transm Infect. 2006;82:439–43.PubMedCrossRefPubMedCentralGoogle Scholar
  44. 44.
    MacKellar D, Valleroy L, Karon J, Lemp G, Janssen R. The Young Men’s Survey: methods for estimating HIV seroprevalence and risk factors among young men who have sex with men. Public Health Rep. 1996;111:138–44.PubMedPubMedCentralGoogle Scholar
  45. 45.
    Mansergh G, Naorat S, Jommaroeng R, Jenkins RA, Jeeyapant S, Kanggarnrua K, Phanuphak P, Tappero JW, van Griensven F. Adaptation of venue-day-time sampling in Southeast Asia to access men who have sex with men for HIV assessment in Bangkok. Field Methods. 2006;18:135–52.CrossRefGoogle Scholar
  46. 46.
    Stall R, Herrick A, Guadamuz TE, Friedman MS. Updating HIV prevention with gay men: Current challenges and opportunities to advance health among gay men. In: Mayer KH, Pizer H, editors. HIV prevention: a comprehensive approach. London: Academic Press; 2009. p. 267–80.CrossRefGoogle Scholar
  47. 47.
    Blume J, Douglas SD, Evans DL. Immune suppression and immune activation in depression. Brain Behav Immun. 2011;25:221–9.PubMedCrossRefPubMedCentralGoogle Scholar
  48. 48.
    Sharan P, Levav I, Olifson S, de Francisco A, Saxena S, editors. Research capacity for mental health in low- and middle-income countries: results of a mapping project. Geneva: World Health Organization & Global Forum for Health Research; 2007.Google Scholar
  49. 49.
    Horton R. Launching a new movement for mental health. Lancet. 2007;370:806.PubMedCrossRefGoogle Scholar
  50. 50.
    Herrick AL, Lim SH, Wei C, et al. Resilience as an untapped resource in behavioral intervention design for gay men. AIDS Behav. 2011;15:S25–9.PubMedCrossRefGoogle Scholar
  51. 51.
    Gwadz MV, Clatts MC, Yi H, et al. Resilience among young men who have sex with men in New York City. Sex Res Social Policy. 2006;3:13–21.PubMedCrossRefPubMedCentralGoogle Scholar
  52. 52.
    Mutchler MG, Ayala G, Neith KL. Safer sex stories told by young gay men: building on resiliency through gay-boy talk. J Gay Lesb Issues Educ. 2005;2:37–50.CrossRefGoogle Scholar
  53. 53.
    Vongchak T, Kawichai S, Sherman S, Celentano DD, Sirisanthana T, Latkin C, Wiboonnatakul K, Srirak N, Jittiwutikarn J, Aramrattana A. The influence of Thailand’s 2003 ‘war on drugs’ policy on self-reported drug use among injection drug users in Chiang Mai. Thailand Int J Drug Policy. 2005;16:115–21.CrossRefGoogle Scholar
  54. 54.
    van Griensven F, Naorat S, Kilmarx PH, Jeeyapant S, Manopaiboon C, Chaikummao S, Jenkins RA, Uthaivoravit W, Wasinrapee P, Mock PA, Tappero JW. Palmtop-assisted self-interviewing for the collection of sensitive behavioral data: randomized trial with drug use urine testing. Am J Epidemiol. 2006;163:271–8.PubMedCrossRefGoogle Scholar
  55. 55.
    Coates TJ, Richter L, Caceres C. Behavioural strategies to reduce HIV transmission: how to make them work better. Lancet. 2008;372:669–84.PubMedCrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • T. E. Guadamuz
    • 1
    • 2
  • K. McCarthy
    • 3
  • W. Wimonsate
    • 3
  • W. Thienkrua
    • 3
  • A. Varangrat
    • 3
  • S. Chaikummao
    • 3
  • A. Sangiamkittikul
    • 3
  • R. D. Stall
    • 2
  • F. van Griensven
    • 4
    • 5
  1. 1.Department of Society and Health, Faculty of Social Sciences and HumanitiesMahidol UniversityNakorn PathomThailand
  2. 2.Department of Behavioral and Community Health SciencesUniversity of Pittsburgh Graduate School of Public HealthPittsburghUSA
  3. 3.Thailand Ministry of Public Health—U.S. Centers for Disease Control and Prevention CollaborationNonthaburiThailand
  4. 4.Thai Red Cross AIDS Research Center and HIV Netherlands Australia Thailand Research CollaborationBangkokThailand
  5. 5.Division of Preventive Medicine and Public HealthUniversity of California at San FranciscoSan FranciscoUSA

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