On January 29, 2025, Secretary of State Marco Rubio approved an “Emergency Humanitarian Waiver” to allow the President’s Emergency Plan for AIDS Relief (PEPFAR) to continue funding for HIV treatment, impacting 30 million people around the world.1 While seen as a brief reprieve in a time of broad reorganization of United States federal spending, it is inevitable that federal government actions will eventually disrupt funding for programs addressing the HIV epidemic.2 It is now essential that clinics and organizations working in the global fight against HIV revisit the design of care delivery for vulnerable people. Syndemic thinking offers a powerful conceptual framework to streamline evidence-based practices – from medical care to behavioral health and HIV prevention services – for innovation and cost reduction. As political changes impact public funding, especially for the poor and underserved, HIV providers are uniquely positioned to design new strategies of care delivery to address interrelated modern epidemics, from HIV and substance use to COVID-19 and beyond.
The evolution of HIV and AIDS is a unique phenomenon in modern medicine. Unlike the biomedical approach informing care for most conditions, research from HIV recognizes that complex socioeconomic factors such as income, schooling, drug use, unsafe sex, and other risky behaviors impact HIV transmission and outcomes.3 Informed by decades without effective medications, efforts to address the epidemic arose from diverse fields beyond traditional medicine, from medical anthropology to psychology and sociology.
The interconnections between substance use, violence, and AIDS was first conceptualized in 1996 by professor Merrill Singer and the Hispanic Health Council, working in a Puerto Rican community in Hartford, Conn.4 Applying anthropological and epidemiological analysis, the crisis of inner-city violence was laid bare. A myriad of social forces, from overcrowded housing, unemployment, physical and psychological abuse, low self-esteem, depression, and substance use, emerged from the stories of their participants, humanizing a complex social milieu of medical need. Their research implicated the insidious impact of structural racism, underpinned by incarceration, trauma, and gang violence, in creating oppression illness, a nebulous but increasingly granular portent of complex disease. Syndemic thinking interconnected the complex social environment of the American inner city, supporting a more holistic approach to servicing the needs of the poor.
Contemporary to this academic work, the grassroots pragmatic harm reduction philosophy gained steady evidence to warrant value. Through qualitative research from sociology to clinical psychology, community organizations established evidence supporting HIV prevention and risk reduction efforts.5,6 From syringe exchanges for people injecting drugs, to infectious disease testing and education, an empiric foundation for community level action emerged.5 The application of the social ecological model to the transmission of HIV added further nuance to the context of risk, encompassing interactions from the individual to government policy, and identifying interpersonal dynamics which could be incorporated into HIV reduction efforts.7 Now, decades after it first emerged, syndemic thinking continues to identify the complex biosocial interconnections, social factors, and impacts of economic disparity, informing our understanding of modern public health crises.8,9
Syndemic thinking focuses on substance abuse, risky sexual behavior, depression, intimate partner violence, stigma, sexually-transmitted infections (STIs), trauma, non-communicable diseases, and more, which exacerbate and are exacerbated by existing socioeconomic inequalities.10 “Sustained by a broader set of political-economic and social factors, including high rates of unemployment, poverty, homelessness, residential overcrowding, substandard nutrition, infrastructural deterioration, loss of quality housing stock, forced geographic mobility, family breakup and disruption of social support networks, health care inequality, and youth gang activities,” a myriad of variables emerge from syndemic research to guide support for people in need.4 The related concept of structural violence draws connections between socioeconomic factors and experiences of violence “unequally forced on people made more vulnerable by age, gender, ethnicity, and economics.”11 Beyond these forces of poverty and interpersonal stress, the added stigma associated with substance use forms an additional barrier to supporting people in need.12 Developing care systems which can address this complex multimorbid landscape that includes mental illness, substance use, and chronic medical conditions remains a global humanitarian need, as COVID-19 moves along social fault lines previously exploited by HIV.13,14
Is it possible to remain optimistic, buttressed by accumulated knowledge, in the face of such uncertainty? Can these concepts and strategies inform a new generation of action, leveraging best clinical practices with evidence-based prevention strategies? Can these non-linear social science concepts, outside the realm of conventional medicine, impart the authority to think and act through the power of creativity, to develop innovative approaches to support those in need?
Over the last year, our organization, a Federally Qualified Health Center (FQHC), has been developing a synergistic coordinated support strategy, focusing on person-centered engagement, while leveraging public health expertise and clinical experience in infectious diseases and substance use care. We aim to actively reduce barriers to support, from harm reduction to clinical care, ultimately providing linkages to behavioral health, primary care, and social support services. Growing from organizational roots as an AIDS service organization (ASO), we integrated walk-in infectious disease testing and harm reduction services – including a large volume syringe service program (SSP) – with focused clinical services, reflecting public health priorities.
We identified several key areas of priority, hoping to reach people unable to engage with our more traditional outpatient clinic model. Beginning with comprehensive STI testing and treatment, we focused on process improvement and integration with existing free testing programs. With funding from city and state public health initiatives, we developed an enhanced linkage strategy focused on hepatitis C (HCV) treatment, inspired by peer support programs used in HIV around the world.15 Community needs assessments of people using our syringe service program called for enhanced wound care and lower barrier to access medication assisted treatment (MAT) for opiate use disorder. We prioritized walk-in appointments and developed streamlined registration and clinical flow processes, using a collaborative and iterative approach rooted in respect for all team members.16 Driven largely by word-of-mouth advertising, we steadily reached more people and developed protocols for rapid access to HIV pre- and post-exposure prophylaxis (PrEP, PEP), MAT, and targeted behavioral health case management services.
Essential to the development of this model of care delivery were several important organizational features. As an FQHC, we are co-located with a pharmacy as well as in-house laboratory services. Design of the prevention department considered the high volume of participants during times of syringe exchange and distribution, and intentional art and messaging create a welcoming space while advertising available services. A collaborative, multidisciplinary, and empathic team, including people with lived experience, work with individuals to overcome structural barriers into care, enhancing information exchange to improve clinical outcomes. The connection between the larger clinic and collaborating pharmacy can anticipate medication demands, ensuring buprenorphine products (MAT), direct acting antivirals (DAA), antiretrovirals (for HCV, HIV, and PrEP) and other important medications are readily available.
Funding for this work mirrors public health priorities at federal, state, and local levels. Early in the history of our organization, Ryan White funding provided for expansions in services, which has continued with trends in community health, later becoming a FQHC, and incorporating various HIV prevention programs into the mission. More recently, as the accidental drug overdose epidemic reached our community, we established as a Certified Community Behavioral Health Center (CCBHC), further enhancing our ability to provide comprehensive mental health support. Through all of this, an approach based on evidence and a social ecological conception of risk informs the design of our services, from the individual to community levels, with awareness of the political changes influencing policy and funding support.
Over the last year, the development of our low barrier, prevention access clinic has been an incredible opportunity to connect with and impact the lives of many people caught in the complex social spaces of concentrated poverty. I have discovered creative approaches in my medical practice, with outcomes far superior to my initial expectations. As interconnections between substance use, mental illness, and infectious diseases becomes clearer, strategies to address this complexity, and the associated economic and social impact, must evolve.17 Thankfully, tools to create novel methods of care delivery are emerging from the world of human-centered design thinking. Design thinking relies on intuition and pattern recognition, while recognizing that emotional impact and ultimate functionality drive any human-centered process, including health service delivery. From User-Experience design (UX) in technology, to “patient journey” maps used by large health care systems, design thinking provides a methodology to uncover new solutions through iterative action.18 Although people, communities, resources, and organizational structures differ, multiple toolkits are available and have been applied to complex human problems across the globe.19,20 Rooted in an empathic consideration for the complexity of people, and centering the power of personal stories, design thinking dovetails with medical and humanitarian ethics in offering a path towards person-centered health care of the future.
Through its evolution, syndemic thinking and other sociologically informed research work has exposed the complex social milieu informing health risks in vulnerable populations. While inspiring innovation as a heuristic for advocacy in HIV care, the empirical validity of syndemic theory has been called into question.21 A recent study using respondent driven sampling of men who have sex with men across 12 cities in India found additive but not synergistic association with adverse outcomes from individual level sexual risk, prompting calls for more empiric research into the complex dynamics of syndemic theory.22 With this in mind, I wonder if the power of syndemic thinking is better leveraged to drive innovative design in health care service delivery, instead of a reductive focus on individual outcomes. Syndemic thinking offers a robust body of evidence which can embolden strategies to co-locate high value services in communities of need, recognizing that syndemic factors cluster at community levels, mediated by interpersonal relations, and not always within individuals. In a time of rising uncertainty, high cost, and growing needs, I hope the insights gained from syndemic thinking can inform the development of community centered health care, supported by efficient and impactful services our communities deserve.
