NCHHSTP Syndemic Approach

Syndemic approach

Our vision at NCHHSTP is a future free of HIV, viral hepatitis, sexually transmitted infections (STIs), and tuberculosis (TB). We work each day to protect and promote health for all people in all communities, yet our work is often segmented by disease or condition. Many of the diseases and conditions addressed by NCHHSTP share similar affected populations, geographic locations, and social and structural determinants. Because of these overlaps, some groups of people are affected by these infections more than others. NCHHSTP is moving toward an approach that recognizes these commonalities, while also acknowledging the unique aspects of disease prevention.

Most commonly, a syndemic is defined as a "population-level clustering of social and health problems. The criteria of a syndemic are:

1. Two (or more) diseases or health conditions cluster within a specific population;
2. Contextual and social factors create the conditions in which two (or more) diseases or health conditions cluster; and
3. The clustering of diseases results in adverse disease interaction, either biologic or social or behavioral, increasing the health burden of affected populations.

At NCHHSTP, we also think of the potential positive opportunities that a syndemic approach provides, including a more holistic approach to individual and population health and improved efficiency in providing services.

NCHHSTP priority syndemics

HIV, viral hepatitis, STIs, and TB infections are often endpoints of similar upstream drivers that can lead to or interact with disease and exacerbate negative health outcomes. The NCHHSTP syndemics are driven by societal, structural, and intermediary outcomes that lead to clustering of HIV, viral hepatitis, STIs, and TB. The inter-connected syndemics that NCHHSTP has identified and prioritized include:

• HIV, viral hepatitis, STIs, overdose, and substance use
• HIV, STIs and hepatitis B
• HIV and TB
• TB and hepatitis B

NCHHSTP's syndemic approach

NCHHSTP's Syndemic Approach recognizes the interrelated health and social challenges affecting the diseases and health outcomes we work to address. We can leverage the strong foundation of the Program Collaboration and Service Integration (PCSI) initiative from 2009 to build NCHHSTP's Syndemic Approach and address the NCHHSTP-related syndemics through priority strategies and foundational pillars that work toward more holistic service delivery for populations affected by multiple diseases and conditions with the goal of improving health and quality of life for people with and at risk for HIV, viral hepatitis, STIs, or TB.

NCHHSTP has identified five high-impact, priority strategies to begin to advance our Syndemic Approach and to embed this approach in how NCHHSTP operates.

1. Provide multi-disease services in venues by staff who are able to address more than one infection and link to care, prevention, and social and structural services, as needed.
2. Multi-pathogen diagnostic testing strategies that develop and expand diagnostic and other technological solutions to conduct tests for multiple infections at the same encounter.
3. Case investigation and outbreak response activities that address multiple infections through an integrated response strategy.
4. Health communications that use integrated disease and prevention communication messages, products and campaigns.
5. Integrated and aligned data systems that provide the structure and processes to collect, report and monitor multiple health outcomes using consistent variables.

Foundational pillars

To implement NCHHSTP's Syndemic Approach successfully and achieve a more holistic public health delivery model, it is important to not only identify priority strategies, but also to address and incorporate critical foundational pillars:

1. People: Reach priority populations,
2. Places: Implement approach in the right geographic locations and venue types,
3. Policy: Support effective policy interventions that address social and structural factors, and
4. Science: Conduct research to advance syndemic approaches

People: reach priority populations

The NCHHSTP syndemics are compounded by intersecting disparities that drive poor health outcomes and increase burden of disease. Health disparities may occur by gender, race or ethnicity, education, income, disability, geographic location, and sexual orientation, and are directly related to social determinants of health like poverty, unequal access to health care, stigma, and racism.

The priority populations for the NCHHSTP Syndemic Approach, identified below, vary depending on the infection concerned due to the different epidemiological, biological, social and structural determinants that affect each infection. For example, persons born outside the United States are priority populations for hepatitis B and TB, but not chlamydia; the racial and ethnic populations experiencing disparities varies greatly by infection, and adolescents are not a priority population for TB.

• Gay, bisexual, and other men who have sex with men
• Transgender women
• Persons who inject or use drugs
• Racial and ethnic populations experiencing disparities within these syndemics
• Adolescents
• Persons born outside of the United States
• Persons who spent time in jails, youth correctional facilities, or prisons
• Persons experiencing homelessness
• Persons who exchange sex for money or drugs
• Persons who are pregnant

Places: implement approach in the right locations and venue types

Implementing the syndemic strategies in the right places—particularly where geographic burden intersects with venues that serve priority populations—is essential for implementing a successful syndemic approach.

• Specific venue types that the NCHHSTP Syndemic Approach should prioritize include HIV/STI/sexual health clinics, community health centers, syringe services programs, substance use disorder treatment centers, correctional facilities, homeless shelters, emergency departments, and schools.
• Expanding the use of virtual and other alternative spaces may reduce barriers (stigma, transportation, or work/childcare schedules, etc.) that keep people away from more traditional venues that require in-person visits. Telemedicine, virtual counseling, self-collection of specimens, and home-based testing can allow for opportunities to provide interventions for multiple diseases and conditions.

Policy: support effective policy interventions that address social and structural factors

This NCHHSTP Syndemic Approach also supports creating policies, structures, and processes to address the underlying social and structural factors affecting priority populations. Factors, such as systemic racism, discrimination, homophobia, transphobia, misogyny, poverty, xenophobia, and other systemic biases reinforce existing disparities, contribute to development of syndemics and need to be identified and addressed for each priority population and place. For policies to be effective they will need to create multiple opportunities for individuals to receive culturally and linguistically responsive prevention, care, and treatment. This will require thoughtful partnerships both within and outside public health.

Science: conduct research to advance syndemic approaches

New diagnostics, therapeutics, and prevention modalities have revolutionized public health. NCHHSTP has a key role in moving science from the bench to the field and ensuring the most impactful research is supported and equitably delivered to prevent infection and improve equity. Advances in areas such as multi-infection diagnostics are needed to increase our understanding of NCHHSTP syndemics and improve how we work to address them.

Guiding principles and enabling operational processes

The NCHHSTP Strategic Plan's guiding principles of high impact prevention, cross-sector collaboration, and equity, along with the corresponding operational processes, provide the basis of NCHHSTP's priority strategies and foundational pillars.

We work to identify and modify or develop operational structures, processes, and policies that enable and support the NCHHSTP Syndemic Approach. These structures and processes should address key challenges including unclear allowable uses of funds, guidance, prioritization, and internal capacity.

Through our NCHHSTP Syndemic Approach, we are supporting our public health partners by implementing a more holistic public health syndemic strategy that includes:

• Implementing priority interventions,
• Putting people first,
• Investing in the places most affected and most able to reach those in need,
• Supporting effective policy interventions and conducting research to advance syndemic approaches, and
• Guiding our work in high impact prevention, cross-sector collaboration, equity and enabling operational principles and processes

Working together with partners, NCHHSTP's Syndemic Approach can help achieve the goals of improving the health of persons living with or potentially at risk for HIV, viral hepatitis, STIs, and TB; preventing new infections; reducing disparities; and improving health equity.