{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,16]],"date-time":"2025-10-16T14:11:48Z","timestamp":1760623908590,"version":"build-2065373602"},"reference-count":37,"publisher":"BMJ","issue":"11","funder":[{"DOI":"10.13039\/100010676","name":"H2020 Societal Challenges","doi-asserted-by":"publisher","award":["825823"],"award-info":[{"award-number":["825823"]}],"id":[{"id":"10.13039\/100010676","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["J Epidemiol Community Health"],"accepted":{"date-parts":[[2025,7,15]]},"published-print":{"date-parts":[[2025,11]]},"abstract":"<jats:sec>\n<jats:title>Background<\/jats:title>\n<jats:p>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.<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>Methods<\/jats:title>\n<jats:p>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.<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>Results<\/jats:title>\n<jats:p>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).<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>Conclusions<\/jats:title>\n<jats:p>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.<\/jats:p>\n<\/jats:sec>","DOI":"10.1136\/jech-2025-223753","type":"journal-article","created":{"date-parts":[[2025,7,28]],"date-time":"2025-07-28T17:20:18Z","timestamp":1753723218000},"page":"849-857","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Syndemic processes between non-communicable diseases and HIV within the Kingdom of Eswatini"],"prefix":"10.1136","volume":"79","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6449-8026","authenticated-orcid":false,"given":"Niels","family":"Bal","sequence":"first","affiliation":[{"name":"Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands"},{"name":"Amsterdam Public Health Research Institute, Amsterdam, The Netherlands"},{"name":"Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Christopher","family":"Pell","sequence":"additional","affiliation":[{"name":"Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michaela","family":"Theilmann","sequence":"additional","affiliation":[{"name":"Universit\u00e4tsklinikum Heidelberg Heidelberg Institute of Global Health, Heidelberg, Germany"},{"name":"Division of Infectious Diseases, Brigham and Women\u2019s Hospital, Boston, Massachusetts, USA"},{"name":"Harvard Medical School, Boston, Massachusetts, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Katja","family":"Polman","sequence":"additional","affiliation":[{"name":"Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands"},{"name":"Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Trynke","family":"Hoekstra","sequence":"additional","affiliation":[{"name":"Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands"},{"name":"Amsterdam Public Health Research Institute, Amsterdam, The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bongekile Thobekile","family":"Cindzi","sequence":"additional","affiliation":[{"name":"Clinton Health Access Initiative, Mbabane, Eswatini"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ntombikele","family":"Ginindza","sequence":"additional","affiliation":[{"name":"Eswatini Ministry of Health, Mbabane, Eswatini"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sijabulile","family":"Dlamini","sequence":"additional","affiliation":[{"name":"Eswatini Ministry of Health, Mbabane, Eswatini"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lisa","family":"Stehr","sequence":"additional","affiliation":[{"name":"Universit\u00e4tsklinikum Heidelberg Heidelberg Institute of Global Health, Heidelberg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Harsh Vivek","family":"Harkare","sequence":"additional","affiliation":[{"name":"Swiss Tropical and Public Health Institute, Allschwil, Switzerland"},{"name":"University of Basel, Basel, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ria","family":"Reis","sequence":"additional","affiliation":[{"name":"Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands"},{"name":"Leiden University Medical Center Public Health and Primary Care, Leiden, Netherlands"},{"name":"School of Child and Adoloscent Health, University of Cape Town, Rondebosch, South Africa"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5490-8968","authenticated-orcid":false,"given":"Frank","family":"van Leth","sequence":"additional","affiliation":[{"name":"Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands"},{"name":"Amsterdam Public Health Research Institute, Amsterdam, The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,7,28]]},"reference":[{"key":"2025100902150808000_79.11.849.1","unstructured":"Institute for Health Metrics and Evaluation (IHME) . GBD compare. 2015. Available: http:\/\/vizhub.healthdata.org\/gbd-compare [Accessed 09 Jun 2025]."},{"key":"2025100902150808000_79.11.849.2","doi-asserted-by":"crossref","first-page":"e1375","DOI":"10.1016\/S2214-109X(19)30374-2","article-title":"Burden of non-communicable diseases in sub-Saharan Africa, 1990\u20132017: results from the Global Burden of Disease Study 2017","volume":"7","author":"Gouda","year":"2019","journal-title":"Lancet Glob Health"},{"key":"2025100902150808000_79.11.849.3","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(17)30003-X"},{"key":"2025100902150808000_79.11.849.4","first-page":"99","article-title":"A dose of drugs, a touch of violence, a case of AIDS: Conceptualizing the Sava Syndemic","volume":"24","author":"Singer","year":"1996","journal-title":"Free Inq"},{"key":"2025100902150808000_79.11.849.5","doi-asserted-by":"crossref","first-page":"114656","DOI":"10.1016\/j.socscimed.2021.114656","article-title":"Syndemic theory, methods, and data","volume":"295","author":"Mendenhall","year":"2022","journal-title":"Soc Sci Med"},{"key":"2025100902150808000_79.11.849.6","doi-asserted-by":"crossref","first-page":"943","DOI":"10.1080\/17441692.2020.1724317","article-title":"Whither syndemics?: Trends in syndemics research, a review 2015\u20132019","volume":"15","author":"Singer","year":"2020","journal-title":"Glob Public Health"},{"key":"2025100902150808000_79.11.849.7","doi-asserted-by":"publisher","DOI":"10.1016\/j.socscimed.2015.06.024"},{"key":"2025100902150808000_79.11.849.8","doi-asserted-by":"crossref","DOI":"10.1080\/16549716.2021.1927332","article-title":"Syndemic contexts: findings from a review of research on non-communicable diseases and interviews with experts","volume":"14","author":"Pirrone","year":"2021","journal-title":"Glob Health Action"},{"key":"2025100902150808000_79.11.849.9","first-page":"33","article-title":"A Tutorial on Interaction","volume":"3","author":"VanderWeele","year":"2014","journal-title":"Epidemiol Methods"},{"key":"2025100902150808000_79.11.849.10","doi-asserted-by":"crossref","first-page":"258","DOI":"10.5172\/hesr.2012.21.3.258","article-title":"At special risk: Biopolitical vulnerability and HIV\/STI syndemics among women","volume":"21","author":"Ostrach","year":"2012","journal-title":"Health Sociol Rev"},{"key":"2025100902150808000_79.11.849.11","doi-asserted-by":"publisher","DOI":"10.3945\/ajcn.111.012070"},{"key":"2025100902150808000_79.11.849.12","doi-asserted-by":"crossref","DOI":"10.3390\/ijerph19031101","article-title":"HIV, Tuberculosis, and Food Insecurity in Africa-A Syndemics-Based Scoping Review","volume":"19","author":"Ojo","year":"2022","journal-title":"Int J Environ Res Public Health"},{"key":"2025100902150808000_79.11.849.13","unstructured":"UNAIDS . Eswatini. 2022. Available: https:\/\/www.unaids.org\/en\/regionscountries\/countries\/swaziland [Accessed 02 Apr 2024]."},{"key":"2025100902150808000_79.11.849.14","doi-asserted-by":"crossref","DOI":"10.3390\/healthcare9070835","article-title":"The Rising Burden of Diabetes-Related Blindness: A Case for Integration of Primary Eye Care into Primary Health Care in Eswatini","volume":"9","author":"Maseko","year":"2021","journal-title":"Healthcare (Basel)"},{"key":"2025100902150808000_79.11.849.15","doi-asserted-by":"crossref","DOI":"10.1186\/s13063-023-07096-4","article-title":"Strengthening primary care for diabetes and hypertension in Eswatini: study protocol for a nationwide cluster-randomized controlled trial","volume":"24","author":"Theilmann","year":"2023","journal-title":"Trials"},{"key":"2025100902150808000_79.11.849.16","unstructured":"The P4H network . Eswatini. 2024. Available: https:\/\/p4h.world\/en\/countries\/eswatini\/ [Accessed 20 Jun 2025]."},{"key":"2025100902150808000_79.11.849.17","unstructured":"The Global Fund . Eswatini meets global 95-95-95 hiv target. 2020. Available: https:\/\/www.theglobalfund.org\/en\/stories\/2020\/2020-09-14-eswatini-meets-global-95-95-95-hiv-target\/ [Accessed 02 Apr 2024]."},{"key":"2025100902150808000_79.11.849.18","unstructured":"World Health Organization . Hypertension. 2023. Available: https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/hypertension [Accessed 16 Jun 2025]."},{"key":"2025100902150808000_79.11.849.19","unstructured":"World Health Organization . Use of glycated haemoglobin (\u200eHbA1c) in diagnosis of diabetes mellitus. Geneva, 2011."},{"key":"2025100902150808000_79.11.849.20","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1016\/j.socscimed.2015.10.015","article-title":"Stress, diabetes, and infection: Syndemic suffering at an urban Kenyan hospital","volume":"146","author":"Mendenhall","year":"2015","journal-title":"Soc Sci Med"},{"key":"2025100902150808000_79.11.849.21","doi-asserted-by":"publisher","DOI":"10.1046\/j.1525-1497.2001.016009606.x"},{"key":"2025100902150808000_79.11.849.22","doi-asserted-by":"crossref","DOI":"10.1186\/s12906-023-04184-5","article-title":"Reasons for using traditional and complementary care by people living with HIV on antiretroviral therapy and association with interrupted care: a mixed methods study in Eswatini","volume":"23","author":"Molemans","year":"2023","journal-title":"BMC Complement Med Ther"},{"key":"2025100902150808000_79.11.849.23","doi-asserted-by":"crossref","first-page":"113122","DOI":"10.1016\/j.socscimed.2020.113122","article-title":"Exploring syndemic vulnerability across generations: A case study of a former fishing village in the Netherlands","volume":"295","author":"Slagboom","year":"2022","journal-title":"Soc Sci Med"},{"key":"2025100902150808000_79.11.849.24","doi-asserted-by":"crossref","first-page":"282","DOI":"10.1080\/24709360.2020.1850171","article-title":"Moving from two- to multi-way interactions among binary risk factors on the additive scale","volume":"4","author":"Katsoulis","year":"2020","journal-title":"Biostat Epidemiol"},{"key":"2025100902150808000_79.11.849.25","doi-asserted-by":"publisher","DOI":"10.1007\/s10654-011-9554-9"},{"key":"2025100902150808000_79.11.849.26","doi-asserted-by":"publisher","DOI":"10.1093\/ije\/dyr218"},{"key":"2025100902150808000_79.11.849.27","doi-asserted-by":"publisher","DOI":"10.1093\/cid\/cix998"},{"key":"2025100902150808000_79.11.849.28","doi-asserted-by":"publisher","DOI":"10.1097\/QAI.0b013e318158c0a6"},{"key":"2025100902150808000_79.11.849.29","doi-asserted-by":"crossref","first-page":"201","DOI":"10.2989\/16085906.2023.2266406","article-title":"\u201cWe will tell when we are ready\u201d: perinatally HIV-infected adolescents and self-disclosure of their status in Eswatini","volume":"22","author":"Dlamini","year":"2023","journal-title":"Afr J AIDS Res"},{"key":"2025100902150808000_79.11.849.30","doi-asserted-by":"crossref","first-page":"449","DOI":"10.1080\/17441692.2014.998698","article-title":"When HIV is ordinary and diabetes new: remaking suffering in a South African township","volume":"10","author":"Mendenhall","year":"2015","journal-title":"Glob Public Health"},{"key":"2025100902150808000_79.11.849.31","doi-asserted-by":"publisher","DOI":"10.1038\/mp.2013.20"},{"key":"2025100902150808000_79.11.849.32","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2020-038199","article-title":"Depressive symptoms and cardiovascular disease: a population-based study of older adults in rural Burkina Faso","volume":"10","author":"Brinkmann","year":"2020","journal-title":"BMJ Open"},{"key":"2025100902150808000_79.11.849.33","doi-asserted-by":"crossref","DOI":"10.1186\/s12960-024-00913-0","article-title":"Human and financial resource needs for universal access to WHO-PEN interventions for diabetes and hypertension care in Eswatini: results from a time-and-motion and bottom-up costing study","volume":"22","author":"Harkare","year":"2024","journal-title":"Hum Resour Health"},{"key":"2025100902150808000_79.11.849.34","doi-asserted-by":"crossref","DOI":"10.3389\/ijph.2023.1605551","article-title":"Diabetes-Tuberculosis Care in Eswatini: A Qualitative Study of Opportunities and Recommendations for Effective Services Integration","volume":"68","author":"Williams","year":"2023","journal-title":"Int J Public Health"},{"key":"2025100902150808000_79.11.849.35","doi-asserted-by":"crossref","first-page":"287","DOI":"10.1080\/01459740.2022.2043306","article-title":"HIV Support Groups and the Chronicities of Everyday Life in eSwatini","volume":"41","author":"Vernooij","year":"2022","journal-title":"Med Anthropol"},{"key":"2025100902150808000_79.11.849.36","doi-asserted-by":"crossref","first-page":"129","DOI":"10.1016\/j.socscimed.2015.07.016","article-title":"Commentary on \u201cSyndemics of psychosocial problems and HIV risk: A systematic review of empirical tests of the disease interaction concept\u201d by A. Tsai and B. Burns","volume":"145","author":"Stall","year":"2015","journal-title":"Soc Sci Med"},{"key":"2025100902150808000_79.11.849.37","doi-asserted-by":"crossref","DOI":"10.7448\/IAS.20.1.21691","article-title":"Performance of self-reported HIV status in determining true HIV status among older adults in rural South Africa: a validation study","volume":"20","author":"Rohr","year":"2017","journal-title":"J Int AIDS Soc"}],"container-title":["Journal of Epidemiology and Community Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/jech-2025-223753","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,16]],"date-time":"2025-10-16T13:47:09Z","timestamp":1760622429000},"score":1,"resource":{"primary":{"URL":"https:\/\/jech.bmj.com\/lookup\/doi\/10.1136\/jech-2025-223753"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,7,28]]},"references-count":37,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2025,10,9]]},"published-print":{"date-parts":[[2025,11]]}},"alternative-id":["10.1136\/jech-2025-223753"],"URL":"https:\/\/doi.org\/10.1136\/jech-2025-223753","relation":{},"ISSN":["0143-005X","1470-2738"],"issn-type":[{"type":"print","value":"0143-005X"},{"type":"electronic","value":"1470-2738"}],"subject":[],"published":{"date-parts":[[2025,7,28]]}}}