In India, which has the world's third largest HIV epidemic, loss from the HIV care continuum leads to excess morbidity and mortality among people living with HIV (PLHIV) and jeopardizes the promise of treatment as prevention.? Our understanding of the causes of loss to HIV care in India, however, is extremely limited. Common, co-morbid psychosocial and structural conditions?including depression, violence, poverty, and food insecurity?may be important factors contributing to loss to care in India. Because these conditions often co-occur and are driven by common structural and social forces, the term ?syndemics? has been applied to refer to the ways in which these conditions interact with each other and mutually reinforce their adverse impacts on HIV treatment and prevention. Syndemic theory has mainly been applied to explain HIV risk among men who have sex with men in high-income countries, but few studies have examined the effect of syndemic conditions on HIV-related health outcomes in low- and middle-income countries such as India. My long-term career goal is to understand the impact of syndemic conditions on HIV-related outcomes, including loss from the HIV care continuum, and to develop effective interventions targeting the barriers to care presented by these syndemic conditions. To achieve this goal, I will need additional mentorship and training in qualitative methods, complex modeling approaches, and intervention development for the Indian context. Drawing upon this training and my previous research in this field, I will conduct a study at the YR Gaitonde Centre for AIDS Research and Education in Chennai, India with the goal of achieving my scientific objective: an understanding of the impact of syndemic conditions on loss from the HIV care continuum and the development of a pilot intervention for syndemic-affected PLHIV at risk for loss to care. My central hypothesis is that syndemic conditions are associated with loss to care and lack of virologic suppression among PLHIV in India. I further hypothesize that a pilot intervention targeting syndemic-affected PLHIV will be feasible and acceptable to patients and providers. To test these hypotheses, I will pursue the following 3 specific research aims: 1) conduct qualitative interviews to refine a model of syndemic conditions contributing to loss to care among PLHIV in Chennai, India; 2) estimate the impact of syndemic conditions on loss to care and lack of virologic suppression among PLHIV in India; and 3) develop and pilot-test an intervention to prevent loss to care and lack of virologic suppression among syndemic-affected Indian PLHIV. I am well positioned to achieve these aims given my previous research experience with syndemic conditions in LMICs including in India as well as an internationally renowned mentorship team with expertise in qualitative methods, complex modeling approaches, syndemic theory, and behavioral interventions. The proposed research is innovative and significant as the results will help policymakers identify Indian PLHIV at risk for loss to care and design effective, multi-faceted interventions addressing syndemic conditions to keep Indian PLHIV in care and virologically suppressed.
In India, loss from the HIV care continuum leads to excess morbidity and mortality among people living with HIV (PLHIV) and jeopardizes the promise of 'treatment as prevention.? This project aims to improve our understanding of the impact of syndemic psychosocial and structural conditions on loss from the HIV care continuum to inform the development of a multi-faceted intervention to keep Indian PLHIV in care and virologically suppressed.