Syndemic processes between non-communicable diseases and HIV within the Kingdom of Eswatini

Background
Sub-Saharan Africa faces a double burden of disease due to the continued high prevalence of infectious diseases such as HIV and tuberculosis, and a concurrent increase in non-communicable diseases. The co-occurrence and clustering of multiple diseases can cause a syndemic, synergistically interacting epidemics, driven by context.

Methods
This cross-sectional study investigated potential syndemics in Eswatini, by determining geospatial disease concentration and estimating interaction between four diseases and the impact of context on these interactions. Using data from the WHOPEN@Scale household survey, we estimated generalised linear models with a quasi-Poisson link, incorporating three-way interaction terms. Joint effect estimates and the relative excess risk due to interaction (RERI) between diseases and contextual factors were estimated.

Results
Conditions with comorbid depression were concentrated in the middle of the country near the capital, and the combinations without depression mostly in the north. Additive interaction was found between HIV and diabetes across all three contextual factors, in particular for people who are the sole household member aged 30 or above RERI: 0.46 (95% CI 0.12 to 0.80) and those who had lost their partner RERI: 0.44 (95% CI 0.02 to 0.86).

Conclusions
We show that HIV and diabetes exhibit syndemic properties, indicated by geospatial variation, additive interaction as well as interaction with context. The lifelong chronicity and stigmatising nature of both diseases emphasise the importance of the social and financial context surrounding affected individuals. While the other disease pairs did not exhibit syndemic properties, the worst health outcomes among the double-exposed stipulate that comorbidity remains important within treatment guidelines.