‘Epidemic’ Is Insufficient: HIV/AIDS Is a Syndemic Issue

red ribbonI recently was part of a group that developed and ran a workshop in Washington, D.C. called “Ethics, HIV, and Mental Health.” The audience was primarily made up of social work students at Gallaudet University, a private school for the deaf and hard of hearing. Our objectives were to have social workers reflect on how much has changed since HIV/AIDS emerged, and to equip participants with knowledge of new technologies and resources for helping to stop the spread of HIV. The big lesson for me was to see how HIV is still approached as an epidemic when the reality is that the syndemic perspective gives the greatest opportunity to grasp the challenges.

In the past, I wrote in this space about how HIV is often part of a syndemic for the individual impacted by HIV, as evidenced by the high correlation of depression and HIV. There are many other conditions—homelessness and addiction, to name two—that create mutually reinforcing conditions.

While clinicians, counselors, and therapists usually can grasp the syndemic perspective psychologically, there is a societal conversation that also needs to take place, one that transforms policy, education, and funding. Based on my experience with how entrenched the HIV/AIDS bureaucracy is, it seems clear that if this is going to happen, the social sciences (psychology, sociology) are going to have to take the lead.

First, let’s look at the difference between epidemic and syndemic. The epidemic approach focuses on one condition at a time, leaving other problems to be addressed by parallel enterprises. It tends to create a series of demographic silos that does not easily lend itself to seeing connectivity. The epidemic approach to HIV/AIDS reports impact of HIV based on race, sexual orientation, and gender, but none of these accounts for factors such as economics, employment, education, and mental health. This approach simply does not adequately describe the public health crisis that is HIV/AIDS.

Herein lies the challenge: the epidemic approach that is the driving force of programs, policy, funding, and public discourse focuses on only one aspect of syndemic work—trying to control the identified affliction (in this case HIV). This does little to help prevent the continuing syndemic and, in fact, can handcuff prevention efforts.

The syndemic perspective (a term coined by Dr. Merrill Singer in the 1990s) is, to borrow from Medicinenet.com, “a set of linked health problems involving two or more afflictions, interacting synergistically, and contributing to excess burden of disease in a population. Syndemics occur when health-related problems cluster by person, place, or time.” This definition further states that to prevent a syndemic, one must “prevent or control not only for the affliction, but also for the forces that tie the afflictions together.”

Herein lies the challenge: the epidemic approach that is the driving force of programs, policy, funding, and public discourse focuses on only one aspect of syndemic work—trying to control the identified affliction (in this case HIV). This does little to help prevent the continuing syndemic and, in fact, can handcuff prevention efforts. For example, one of the driving forces of the HIV syndemic is stigma, and yet many programs “target” high-impact groups as reported from epidemiological data, which only serves to perpetuate the stigma.

For those of us in the counseling and mental health profession, there are things we can do to change this—not only in our clinical work with people, but in our professional networks, work settings, and personal lives. As John Muir said, “When one tugs at a single thing in nature, he finds it attached to the rest of the world.”

We know this to be true in our work. We can play a role in helping our communities better understand that this is also true with HIV/AIDS and other conditions, and in doing so, we can perhaps help prevent the continuation of the syndemic.

© Copyright 2015 GoodTherapy.org. All rights reserved. Permission to publish granted by Brad Ogilvie, MS, LPC, LMFT, HIV / AIDS Topic Expert Contributor

The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

  • Leave a Comment
  • Benji

    May 19th, 2015 at 10:14 AM

    This has almost had a snowball effect in certain communities. When you begin to see an increase in one thing then the chances are relatively high that other things will also be on the increase.

  • Brad Ogilvie

    May 19th, 2015 at 1:14 PM

    Benji – I look at it more like picking the fruit from a cherry tree. The easy ones are down low, but the more out of reach they are, the more innovative we have to be, relying on other technologies and factors (in the analogy, how stable and firm the ground is, how strong the ladder is, is there a place to put it). In many cases where HIV is part of a syndemic, it can draw our attention to other on-going issues and injustices (such as poverty, depression, isolation), but if not handled well – as is the case now – focusing on one can cloud the others.

    Ultimately, for me, what we need is a structural transformation that is “bottom-up” rather than “top-down”, but unfortunately all the money and power resides largely in the reverse, so creative grassroots ideas and innoventions have a difficult time getting the support to try new things.

  • carlton

    May 20th, 2015 at 9:39 AM

    But if you don’t target the high risk groups then how do you slow down the primary cause of much of this which is actually HIV spread and transmission?

  • Stephen B.

    May 20th, 2015 at 12:51 PM

    Thanks Brad for your insightful post on HIV/AIDS. The lack of knowledge is the most limiting component of the HIV/AIDS Syndemic. There is an urgent need to teach and make the healthcare community, the politicians, the funding agencies, the governments/leaders of the nations affected by HIV/AIDS and ALL of us, aware that our current approach to HIV/AIDS is like putting a bandage on a cut that needs sutures. The knowledge base on HIV/AIDS treatment/management has to be revised and improve.

  • Brad Ogilvie

    May 20th, 2015 at 12:52 PM

    Carlton – there are already many groups that target the high-risk groups and they have reached a plateau. The highest-risk don’t generally respond to and in fact might flee from targeted campaigns (i.e. closeted gay men – how do you target them?); likewise, lower risk groups are left out and they too can get HIV, just at lower transmission rates. Prevention needs a comprehensive approach, and in our profession we have an opportunity to change the paradigm with our understanding of human psychology that epidemiological approaches sometimes miss.

  • Petros K

    May 20th, 2015 at 3:03 PM

    Well put

  • Clint

    May 21st, 2015 at 3:37 AM

    It saddens me that it has taken this long for people to begin making these connections… my concern is that it could be too little too late in changing the way that most people think about this issue? And I also wonder how this new approach is going to work in more third world settings where HIV is also a big problem but the situations and living conditions are so very different than what we experience here in the US or Canada.

  • Brad Ogilvie

    May 21st, 2015 at 2:13 PM

    Clint – I have actually been writing about and making these connections for well-over a decade, quite vocal at a wide-range of committee and advisory meetings (as co-chair, rep, etc.) There has often been strong agreement from people, but a sense of powerlessness to change things. Social networking and our own voices with clients give us opportunities to change things from the bottom-up, not top-down. For me, after a decade, it’s actually a bit of relief to see others agreeing.

  • Veronica

    May 21st, 2015 at 2:29 PM

    I would say that poverty and lack of education play a huge role in the syndemic that we see with HIV spread and depression. I would also suggest that there is also a strong correlation between these things as well as unemployment.

    Look, most of the time we are dealing with a population of people who have been left behind for whatever reason for a very long time. There are going to be a lot of different things that are wrong in those communities. It is up to us to figure out now the things that are right and see what we can do to advocate for more of that rather than only stating the obvious and continuing to highlight that that is wrong.

  • Roland M

    May 21st, 2015 at 11:20 PM

    I work since decennia on the Tuberculosis problem and find all what is said here quite usual: an entrenched bureaucracy (the WHO) applies consistently a herd médicine, without ever any qualitative change in diagnosis, prognosis and treatment, to a problem that needs a comprehensive appoach.
    As far as HIV is concerned, may I draw your attention on the following publication:


    The product it describes may be of help

  • jerry

    May 22nd, 2015 at 10:39 AM

    Are we seeing any real progress worldwide with new HIV cases going down?

  • Clay

    May 23rd, 2015 at 1:00 PM

    A great way to start that societal conversation that we need to have is to start with the politicians in Washington. They are the ones who make all of the big decisions about funding so they are the ones whose voices speak loud and clear when ours sometimes become muffled.

  • Tara

    May 25th, 2015 at 6:53 AM

    I am sure that from a world health point of view there has typically been only one way to look at this and that is as an epidemic with only health and academical ramifications. And while that has been somewhat true for the beginning of the disease, I can easily see how this has now developed into more than that, something that has caused a crisis in many other life aspects. I don’t think that there are a lot of people who would naturally see this, but it is important to point it out and show how HIV has become so much more than just a healthcare crisis.

  • Theo

    May 26th, 2015 at 1:46 PM

    “When one tugs at a single thing in nature, he finds it attached to the rest of the world.”

    This is the perfect quote to sum it all up!

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