Impact of syndemic heavy drinking, smoking, and depression on mortality among MSM with and without HIV: A longitudinal study

Abstract

Background: Heavy drinking, smoking, and depression are common among men who have sex with men (MSM). The association of co-occurring longitudinal patterns of these conditions and mortality among MSM were tested, applying a syndemic framework - the interaction of two or more conditions that contribute to poor health outcomes.

Methods: Longitudinal data from 1999 to 2018 from the Multicenter AIDS Cohort Study of 3046 MSM were analyzed. Group-based trajectories models (GBTM) of alcohol use, smoking, and depressive symptoms were developed. Syndemic phenotypes were defined based on overlapping high-risk group membership in the GBTM for each condition (i.e., heavy drinking, current smoking, severe depressive symptoms). Cox proportional hazards models estimated confounder-adjusted associations of syndemic phenotypes with mortality (National Death Index, n = 395; median follow-up 16.0 years). An interaction between HIV and syndemic phenotypes on mortality was tested.

Results: Syndemic phenotypes included no high-risk conditions (63 %), heavy drinking only (3 %), smoking only (16 %), depressive symptoms only (10 %), and two or more high-risk trajectories (9 %, sustained syndemic). Among MSM, the syndemic was associated with greater mortality risk compared to no conditions (hazard ratio [HR] 4.48, 95 % confidence interval [CI] 3.21, 6.26) or any single condition (heavy drinking HR 1.84, CI 0.90, 3.75; smoking HR 2.70, CI 2.03, 3.59; depression HR 2.31, CI 1.69, 3.14). The interaction between syndemic phenotype and HIV on mortality risk was significant.

Conclusions: The long-term clustering of high-risk drinking, smoking, and depressive symptoms occurred in nearly 10 % of MSM and was associated with increased mortality risk, especially among MSM living with HIV.

Keywords: Alcohol; Depression; HIV; MSM; Mortality; Smoking; Syndemic; Trajectory.

Fig. 1.

Group Based Trajectories of Alcohol Use, Depressive Symptoms, and Smoking among MSM with and without HIV in the United States, 1999–2018 (N = 3046). Graph A. features trajectories of alcohol use; B. features trajectories of depressive symptoms; C. features trajectories of smoking. Solid lines represent empirical averages. Solid circles represent actual averages of each timepoint. Dashed lines represent 95 % confidence intervals of the trajectory average. Time points are based on the average time since baseline across all waves of recruitment. High-risk trajectories are noted in red.

Fig. 2.

Kaplan-Meier Survival Curves for All-cause Mortality by Syndemic Trajectory Phenotypes among MSM with and without HIV in the United States, 1999–2018. Lifetable Shown by Follow-up Period. Log-rank Test P < 0.001.

Fig. 3.

Interaction of Syndemic Trajectory Phenotypes and HIV on Mortality among MSM in the United States, 1999–2018. Abbreviations: HCV, Hepatitis C Virus; HIV, Human Immunodeficiency Virus; MWH, Men with HIV; MWOH, Men without HIV. Model controlled for age, race, education enrollment wave, HCV status, and illicit drug use. Red vertical line indicates a Hazard Ratio of 1.0 for the reference group of No Condition/MWOH; Black solid circle indicates hazard ratio, horizonal lines indicate 95 % CI; Wald test P < .001.