A Contextualization of Transgender Women and Condom Use Using the HIV Syndemic Framework: Scoping Review.

Objective: To contextualize condom use in the transgender women population utilizing the HIV syndemic framework. Methods: Studies reporting condom use frequency and syndemic factors associated with HIV risk in transgender women were systematically searched. We followed the Scoping Reviews (PRISMA-ScR) checklist. Results: Social factors have a proven relationship with using condoms and HIV among transgender women. Syndemic factors, defined as co-occurring adverse factors that interact to contribute to risk behaviors, deserve a specific analysis to develop strategies to face HIV among transgender women. Conclusions: A syndemic perspective allows to generate specific health intervention and prevention policies to protect transgender women.

Exploring Psychosocial and Structural Syndemic Effects as Predictors of HIV Risk Behaviors Among Black Women (HPTN 064).

Background: Syndemic models have been used in previous studies exploring HIV-related outcomes; however, these models do not fully consider intersecting psychosocial (e.g., substance use, depressive symptoms) and structural factors (unstable housing, concentrated housing vacancy) that influence the lived experiences of women. Therefore, there is a need to explore the syndemic effects of psychosocial and structural factors on HIV risk behaviors to better explain the multilevel factors shaping HIV disparities among black women. Methods: This analysis uses baseline data (May 2009-August 2010) from non-Hispanic black women enrolled in the HIV Prevention Trials Network 064 Women's Seroincidence Study (HPTN 064) and the American Community Survey 5-year estimates from 2007 to 2011. Three parameterizations of syndemic factors were applied in this analysis a cumulative syndemic index, three syndemic groups reflecting the level of influence (psychosocial syndemic group, participant-level structural syndemic group, and a neighborhood-level structural syndemic group), and syndemic factor groups. Clustered mixed effects log-binomial analyses measured the relationship of each syndemic parameterization on HIV risk behaviors in 1,347 black women enrolled in HPTN 064. Results: A higher syndemic score was significantly associated with increased prevalence of unknown HIV status of the last male sex partner (adjusted prevalence ratio (aPR) = 1.07, 95% confidence interval or CI 1.04-1.10), involvement in exchange sex (aPR = 1.17, 95% CI: 1.14-1.20), and multiple sex partners (aPR = 1.07, 95% CI: 1.06-1.09) in the last 6 months. A dose-response relationship was observed between the number of syndemic groups and HIV risk behaviors, therefore, being in multiple syndemic groups was significantly associated with increased prevalence of reporting HIV risk behaviors compared with being in one syndemic group. In addition, being in all three syndemic groups was associated with increased prevalence of unknown HIV status of the last male sex partner (aPR = 1.67, 95% CI: 1.43-1.95) and multiple sex partners (aPR = 1.53, 95% CI: 1.36-1.72). Conclusions: Findings highlight syndemic factors influence the lived experiences of black women.

Critical perspective on infodemic and infodemic management in previous Ebola outbreaks in Uganda.

This research investigates the complex dynamics of Uganda's recent Ebola outbreaks, emphasizing the interplay between disease spread, misinformation, and existing societal vulnerabilities. Highlighting poverty as a core element, it delves into how socioeconomic factors exacerbate health crises. The study scrutinizes the role of political economy, medical pluralism, health systems, and informal networks in spreading misinformation, further complicating response efforts. Through a comprehensive analysis, this study aims to shed light on the multifaceted challenges faced in combating epidemics in resource-limited settings. It calls for integrated strategies that address not only the biological aspects of the disease but also the socioeconomic and informational ecosystems that influence public health outcomes. This perspective research contributes to a better understanding of how poverty, medical pluralism, political economy, misinformation, and health emergencies intersect, offering insights for future preparedness and response initiatives.

Understanding psychosis complexity through a syndemic framework: A systematic review.

Psychotic conditions pose significant challenges due to their complex aetiology and impact on individuals and communities. Syndemic theory offers a promising framework to understand the interconnectedness of various health and social problems in the context of psychosis. This systematic review aims to examine existing literature on testing whether psychosis is better understood as a component of a syndemic. We conducted a systematic search of 7 databases, resulting in the inclusion of five original articles. Findings from these studies indicate a syndemic characterized by the coexistence of various health and social conditions, are associated with a greater risk of psychosis, adverse health outcomes, and disparities, especially among ethnic minorities and deprived populations. This review underscores the compelling need for a new paradigm and datasets that can investigate how psychosis emerges in the context of a syndemic, ultimately guiding more effective preventive and care interventions as well as policies to improve the health of marginalised communities living in precarity.

Trauma and mental disorder: multi-perspective depictions in Top Boy.

Psychiatry has often had an uneasy relationship with popular culture as depictions of mental health may be stigmatising and inaccurate. A recent critically acclaimed series, Top Boy, set in a crime-filled fictional housing estate in the London Borough of Hackney offers an informed and fairly balanced insight into broad mental health-related themes including racial trauma embodied in social inequities, the syndemic of mental disorder, substance misuse and gang-based crime as well as the psychosocial ramifications of illustrated mental health conditions. From both idiographic and nomothetic perspectives, Top Boy touches on a rich variety of structural determinants of mental health, as well as individual and environmental predisposition to mental disorder and substance misuse. The show offers an opportunity for education for both the broader society and the groups which suffer these syndemics. An understanding of how structural factors epidemiologically affect what psychiatric conditions individuals are likely to suffer, how they can be better reached by psychiatric services, and what interventions can help improve the socioeconomic factors that lead to the behaviours/paths that individuals end up is vital for public mental health policy.

The Intersectionality of Food Insecurity, Job Insecurity, Healthcare Insecurity, and Mental Health Challenges in NYC Households During Covid-19.

Our intersectional research explored food insecurity and job insecurity as predictors of healthcare insecurity and mental health challenges among households living in economic instability since the COVID19 pandemic began. The New York City COVID19 Research Team adapted a validated, web based, anonymous survey questionnaire using a Social Determinants of Health Framework. The study oversampled underserved populations with a total of 2,099 participants. We report strong associations between food insecurity and job insecurity among healthcare insecure households, and significant mental health challenges among food insecure and healthcare insecure households. This underscores the need for integrated social policies to protect underserved urban populations.

Do syndemic conditions predict HIV medication adherence among urban African American men?

Much progress has been made in advancing antiretroviral (ART) adherence, yet disparities remain. To explore relationships of syndemic conditions - co-occurring health conditions caused by combinations of biological, social, and structural factors - to ART adherence among African American men, we used data from longitudinal assessments of 302 African American men enrolled in a study designed to increase physical activity and healthy eating. Syndemic conditions included alcohol dependency, drug dependency, depression, post-traumatic stress disorder, and unstable housing. A syndemic conditions variable was operationalized to indicate the presence of 0-5 conditions. About 55% of participants had 1 or more syndemic conditions. Age and marriage were positively associated with ART adherence, whereas number of syndemic conditions was negatively associated with adherence during the 12-month period. The interaction of being married and the syndemic conditions variable significantly predicted greater adherence. Similarly, the interaction of more education and the syndemic conditions variable predicted greater adherence. In multiple regression models, the syndemic conditions variable remained significant (-0.018) in predicting adherence; however, there was no significant interaction among the 5 conditions. This study lends evidence to syndemics literature indicating deleterious consequences of negative life experiences on health outcomes.

Evidence of syndemic effects influencing older transgender persons' likelihood of contemplating suicide: results from a large national study.

OBJECTIVES: Very little research has examined suicidal ideation or the factors associated with contemplating suicide among older transgender adults. This paper examines whether or not there is evidence of syndemic effects influencing suicidal ideation among transgender persons aged 50 or older. METHODS: Data from the 2015 U.S. National Transgender Survey were used to examine five domains of potentially-syndemic effects (workplace issues, interactions with professionals, using public services, personal safety, and socioeconomic disadvantages) in a sample of 3,724 transgender Americans aged 50 or older. A dichotomous measure of suicidal ideation during the past year was the main outcome measure. RESULTS: The odds of contemplating suicide increased anywhere from 96% to 121% among people experiencing any of the problems under study, and anywhere from 258% to 1,552% (depending upon the syndemic effect domain in question) when they were faced by all of the experiences included in any particular domain. When all items were combined, exposure to any of the domains' problems elevated the risk of contemplating suicide by 276% and exposure to all of the problems examined increased the risk by 861%. The syndemic effects measure remained significant in multivariate analysis controlling for the influence of other potentially-relevant factors. CONCLUSIONS: Considerable evidence for the presence of syndemic effects was found, demonstrating that the more different types of adverse conditions that older transgender person's face, the more likely they are to experience to contemplate suicide. There is evidence that these effects diminish with advancing age.

Profiles of a COVID-19 Syndemic: Anti-Asian Racism, Economic Challenges, and Mental and Physical Health.

BACKGROUND: During the COVID-19 pandemic, Asians/Asian Americans have experienced co-occurring threats of anti-Asian racism, economic challenges, and negative mental and physical health symptoms. OBJECTIVES: We examined the co-occurrence of COVID-19-related anti-Asian discrimination and collective racism, economic stressors, and mental and physical health challenges for Asians/Asian Americans during the COVID-19 pandemic. We also examined Asian/Asian American subgroups associated with these threats. METHODS: Nationally representative data from the 2021 Asian American and Native Hawaiian/Pacific Islander COVID-19 Needs Assessment Project (unweighted N = 3,508) were used to conduct a latent profile analysis to identify unique typologies of the co-occurrence of these threats. We also conducted chi-square analyses to investigate subgroup differences by latent profile. RESULTS: We identified five distinct latent profiles: multi-threat impact, low impact, collective racism, health challenges, and economic/health challenges. Forty percent of Asians/Asian Americans were in the multi-threat impact profile, indicating high levels across COVID-19-related threats. Subgroup analyses revealed significant differences in profile membership. East Asians, US-born Asians/Asian Americans, and those aged 25-44 seemed to be particularly affected by the proposed syndemic; results also differed by income. CONCLUSION: Asians/Asian Americans have experienced co-occurring and interrelated threats during COVID-19 that suggest the presence of a syndemic. Results from our study point to vulnerable Asian/Asian American subgroups and the need for targeted public health efforts to address racism, health challenges, and economic challenges in the context of COVID-19.

Piloting Safety and Stabilization: A Multi-component Trauma Intervention to Improve HIV Viral Suppression, Retention in Care, and Post-traumatic Stress Disorder in a Southern United States HIV Service Organization.

In this observational study, we assessed the extent to which a community-created pilot intervention, providing trauma-informed care for persons with HIV (PWH), affected HIV care retention and viral suppression among PWH attending an HIV Services Organization in the Southern US. PWH with trauma exposure and/or trauma symptoms (N = 166) were offered a screening and referral to treatment (SBIRT) session. Per self-selection, 30 opted-out, 29 received SBIRT-Only, 25 received SBIRT-only but reported receiving other behavioral health care elsewhere, and 82 participated in the Safety and Stabilization (S&S) Intervention. Estimates from multivariable logistic regression analyses indicated S&S Intervention participants had increased retention in HIV care (adjusted odds ratio [aOR] 5.46, 95% CI 1.70-17.50) and viral suppression (aOR 17.74, 95% CI 1.83-172), compared to opt-out participants. Some evidence suggested that PTSD symptoms decreased for intervention participants. A randomized controlled trial is needed to confirm findings.

O quilombo Mata Cavalo/Brasil e a sindemia da COVID-19: o racismo e o direito de (r)existir em questão / The Mata Cavalo/Brazil quilombo and the COVID-19 syndemic: racism and the right to (r)exist in question

Resumo Comunidades quilombolas têm sentido efeitos do racismo aprofundados com a COVID-19 cujas repercussões se amplificam em contextos de desigualdades raciais, caracterizando-se como sindemia. O termo remete à sinergia de elementos biológicos, econômicos, ambientais, políticos e sociais que potencializam condições e estados coexistentes, repercutindo na vida e afetando a saúde. Assim, analisamos as repercussões da sindemia da COVID-19 a partir das percepções de lideranças de comunidade quilombola em Mato Grosso. Em estudo qualitativo entrevistamos três lideranças em maio/2022, usando roteiro semiestruturado e tratamos os dados pela análise temática. A sindemia da COVID-19 visibilizou a precariedade estrutural quanto ao transporte, estradas, saneamento, acesso à água, alimentos e serviços de saúde. O isolamento, mortes, medos tiveram repercussões psicossociais, mas ausência de atenção à saúde mental. Propostas antirracistas clamam por: reparar precariedades reconhecendo a dívida do Estado com a população negra; valorizar experiências, modo de vida, cosmovisão, valores civilizatórios ancestrais afrocentrados. Enfim, fortalecer, reafirmar e efetivar ações antirracistas como o Estatuto da Igualdade Racial e a PNSIPN em todos possíveis espaços, políticas e instituições.

Abstract Quilombola communities have felt the effects of racism deepened by COVID-19, whose repercussions are amplified in contexts of racial inequalities, characterizing it as a syndemic. The term refers to the synergy of biological, economic, environmental, political, and social elements that enhance coexisting conditions and states, impacting life and affecting health. Thus, our study seeks to analyze the repercussions of the COVID-19 syndemic based on the perceptions of quilombola community leaders in Mato Grosso, Brazil. In a qualitative study, three leaders were interviewed in May 2022, using a semi-structured script and treating the data through thematic analysis. The COVID-19 syndemic highlighted the structural precariousness of transport, roads, sanitation, and access to water, food, and health services. Isolation, deaths, and fears had psychosocial repercussions, but little attention was paid to mental health. Anti-racist proposals call for: repairing precariousness by recognizing the State's debt to the black population; valuing experiences, way of life, cosmovision, and Afro-centered ancestral civilizational values. Finally, the aim is to strengthen, reaffirm, and implement anti-racist actions, such as the Statute of Racial Equality and the PNSIPN, in all possible spaces, policies, and institutions.

Synergistic Epidemic or Syndemic: An Emerging Pattern of Human Diseases.

Synergistic epidemics refer to the phenomenon where the occurrence and interaction of multiple diseases or health conditions exacerbate their individual impact, leading to complex health challenges and increased vulnerability in populations. Syndemics are a complex, multilevel phenomenon. In a population with biological interactions, a syndemic is the accumulation of two or more concurrent or sequential epidemics, which significantly worsens the situation. Disease concentration, disease interaction, and their underlying social forces, such as poverty and social inequality, are the fundamental concepts. Extensive political, economic, and cultural factors have contributed to cluster epidemics of several infectious diseases, particularly HIV and tuberculosis. Concerning the SAVA (substance abuse, violence, AIDS) syndemic, this narrative review article explores the complex interactions between substance abuse, violence, and HIV/AIDS. Further, it describes in-depth interactions between the COVID-19 syndemic's health conditions, societal factors, biological factors, and global dynamics. The review also emphasizes how infectious and non-communicable diseases interact, emphasizing how having one condition can make the severity and outcomes of another worse. It investigates the causes of synergistic epidemics and the impact of environmental factors. Syndemics acknowledge that the presence of one condition can worsen the severity and progression of others and take into account the intricate relationships between diseases. We can create more efficient plans to enhance health outcomes, lessen disparities, and promote healthier communities by understanding the connections between disorders and the underlying social determinants. This narrative review provides insights into the emerging patterns of human diseases within synergistic epidemics.

Impactos da covid-19: desafios da pandemia na perspectiva da comunicação e saúde / Impacts of covid-19: challenges of the pandemic in perspective of communication and health / Impactos del covid-19: desafíos de la pandemia en perspectiva de la comunicación y la salud

O ano de 2020 ficou marcado pelo surgimento da maior pandemia deste século, a covid-19. Somando-se às dificuldades impostas por uma emergência sanitária dessa amplitude, fomos desafiados também por fenômenos comunicacionais complexos, como a desinformação, a infodemia, a sindemia e as fake news, o que gerou a necessidade de a doença ser vista por perspectivas antes negligenciadas. O livro Desinformação e covid-19: desafios contemporâneos na comunicação e saúde oferece uma diversidade de análises e iniciativas para o enfrentamento das dificuldades fomentadas pela covid-19, a partir de diferentes concepções teóricas que buscam compreender as interfaces complexas que conectam a comunicação e a saúde. Como resultado, temos a expectativa de que se amplie a capacidade de garantirmos os direitos de cidadania, com uma saúde realmente equânime, universal e integral, oferecendo respostas melhores às crises que, porventura, estejam em nosso futuro

The year 2020 was marked by the emergence of the biggest pandemic of this century, covid-19. In addition to the difficulties imposed by a health emergency of this magnitude, we were also challenged by complex communicational phenomena, such as disinformation, infodemic, syndemic, and fake news, which generated the need for the disease to be seen from previously neglected perspectives. The book Disinformation and Covid-19: Contemporary Challenges in Communication and Health offers a diversity of analyses and initiatives to face the difficulties fostered by covid-19 from different theoretical conceptions that seek to understand the complex interfaces that connect communication and health. As a result, we expect that the capacity to guarantee citizenship rights will be expanded, with truly equitable, universal and comprehensive health, offering better responses to the crises that may be in our future

El año 2020 ha estado marcado por la aparición de la mayor pandemia de este siglo, el covid-19. Además de las dificultades que impone una emergencia sanitaria de esta envergadura, también nos hemos visto desafiados por complejos fenómenos de comunicación como la desinformación, la infodemia, la sindemia y las fake news, lo que ha llevado a la necesidad de contemplar la enfermedad desde perspectivas que hasta ahora se habían descuidado. El libro Desinformación y covid-19: desafíos contemporáneos en comunicación y salud ofrece una variedad de análisis e iniciativas para abordar las dificultades causadas por el covid-19 desde diferentes concepciones teóricas que buscan comprender las complejas interfaces que conectan la comunicación y la salud. Como resultado, tenemos la expectativa de que podemos ampliar nuestra capacidad para garantizar los derechos de la ciudadanía, con una salud verdaderamente equitativa, universal e integral, ofreciendo mejores respuestas a las crisis que pueden acechar nuestro futuro

Children of a syndemic: co-occurring and mutually reinforcing adverse child health exposures in a prospective cohort of HIV-affected mother-infant dyads in Cape Town, South Africa.

INTRODUCTION: Several HIV-related syndemics have been described among adults. We investigated syndemic vulnerability to hazardous drinking (HD), intimate partner violence (IPV) and household food insecurity (HFIS) in breastfed children born without HIV in urban South Africa. We compared those who were perinatally HIV exposed (CHEU) to those who were not (CHU), under conditions of universal maternal antiretroviral therapy (ART) and breastfeeding. METHODS: A prospective cohort of pregnant women living with HIV (WLHIV), and without HIV, were enrolled and followed with their infants for 12 months postpartum (2013-2017). All WLHIV initiated antenatal efavirenz-based ART. Measurements of growth (∼3 monthly), infectious cause hospitalisation, ambulatory childhood illness (2-week recall) and neurodevelopment (BSID-III, measured at ∼12 months' age) were compared across bio-social strata using generalised linear regression models, with interaction terms; maternal data included interview-based measures for HD (AUDIT-C), IPV (WHO VAW) and HFIS. RESULTS: Among 872 breastfeeding mother-infant pairs (n = 461 CHEU, n = 411 CHU), WLHIV (vs. HIV negative) reported more unemployment (279/461, 60% vs. 217/411, 53%; p = 0.02), incomplete secondary education (347/461, 75% vs. 227/411, 55%; p < 0.0001), HD (25%, 117/459 vs. 7%, 30/411; p < 0.0001) and IPV (22%, 101/457 vs. 8%, 32/411; p < 0.0001) at enrolment; and HFIS at 12 months (45%, 172/386 vs. 30%, 105/352; p > 0.0001). There were positive interactions between maternal HIV and other characteristics. Compared to food secure CHU, the mean difference (95% CI) in weight-for-age Z-score (WAZ) was 0.06 (-0.14; 0.25) for food insecure CHU; -0.26 (-0.42; -0.10) for food secure CHEU; and -0.43 (-0.61; -0.25), for food insecure CHEU. Results were similar for underweight (WAZ < -2), infectious-cause hospitalisation, cognitive and motor delay. HIV-IPV interactions were evident for ambulatory diarrhoea and motor delay. There were HIV-HD interactions for odds of underweight, stunting, cognitive and motor delay. Compared to HD-unexposed CHU, the odds ratios (95% CI) of underweight were 2.31 (1.11; 4.82) for HD-exposed CHU; 3.57 (0.84; 15.13) for HD-unexposed CHEU and 6.01 (2.22; 16.22) for HD-exposed CHEU. CONCLUSIONS: These data suggest that maternal HIV-related syndemics may partly drive excess CHEU health risks, highlighting an urgent need for holistic maternal and family care and support alongside ART to optimise the health of CHEU.

The "triple whammy": Serious psychological distress, suicidal ideation, and substance misuse among transgender persons.

PURPOSE: This paper examines the conjoint effects of serious psychological distress, suicidal ideation, and substance abuse among transgender adults. The principal aims are to determine the prevalence of this "triple whammy," identify the factors underlying the co-occurrence of all three problems, and to determine if there is evidence of syndemic effects underlying the "triple whammy." METHODS: Data from the 2015 U.S. National Transgender Survey were used to examine the "triple whammy" relationship in a sample of 27,715 transgender Americans aged 18 or older. Odds ratios and multivariate logistic regression were performed to examine the data. RESULTS: 13.3 % of the study participants reported experiencing serious psychological distress, suicidal ideation, and substance abuse. The most potent predictors of the "triple whammy" were younger age, a greater number of anti-transgender experiences, and not reaching various transition milestones. Strong evidence emerged to indicate the presence of syndemic effects in operation. CONCLUSIONS: Experiencing the combination of adverse mental health and substance abuse was not uncommon in this population of transgender adults. Being young, experiencing a larger variety of types of anti-transgender discrimination, harassment, and violence, and not reaching specific transition milestones all had a significant impact on the odds that people would experience the "triple whammy." This was particularly true when these measures were examined in conjunction with one another, because of strong syndemic effects.

Childhood Adversity Determines the Syndemic Effects of Violence, Substance Misuse, and Sexual Behavior on Psychotic Spectrum Disorder Among Men.

BACKGROUND AND HYPOTHESIS: Childhood adversity (CA) increases the risk for several adult psychiatric conditions. It is unclear why some exposed individuals experience psychotic symptoms and others do not. We investigated whether a syndemic explained a psychotic outcome determined by CA. STUDY DESIGN: We used self-reported cross-sectional data from 7461 British men surveyed in different population subgroups. Latent class analysis (LCA) identified categorical psychopathological outcomes. LCs were tested by interaction analysis between syndemic factors derived from confirmatory factor analysis according to CA experiences. Pathway analysis using partial least squares path modeling. RESULTS: A 4-class model with excellent fit identified an LC characterized by both psychotic and anxiety symptoms (class 4). A syndemic model of joint effects, adducing a 3-component latent variable of substance misuse (SM), high-risk sexual behavior (SH), violence and criminality (VC) showed synergy between components and explained the psychotic outcome (class 4). We found significant interactions between factor scores on the multiplicative scale, specific only to class 4 (psychosis), including SM × SH, SH × VC, and SM × VC (OR > 1, P < .05); and on the additive scale SM × SH (relative excess risk due to interaction >0, P < .05), but only for men who experienced CA. CONCLUSION: Multiplicative synergistic interactions between SM, SH, and VC constituted a mechanism determining a psychotic outcome, but not for anxiety disorder, mixed anxiety disorder/depression, or depressive disorder. This was specific to men who had experienced CA along direct and syndemic pathways. Population interventions should target SM and VC in adulthood but prioritize primary prevention strategies for CA.

Salud pública en Ecuador:vacunación obligatoria contra la COVID-19 y certificado de vacunación / Salut pública a l'Equador: vacunació obligatòria contra la COVID-19 i certificat de vacunació / Public health in Ecuador: Mandatory vaccination against COVID-19 and vaccine certificate

La vacuna obligatoria de la COVID-19 y la exigencia del certificado en Ecuador constituyen políticas que dependen de la gobernabilidad y gobernanza del poder central, que arrastra crisis políticas, socioeconómicas, jurídicas, ambientales, de salud y salubridad, de gestiones anteriores y propias. Políticas enmarcadas en un modelo paternalista de salud, que es justificado en el caso de la vacuna obligatoria, por el riesgo y daño del SARS-Cov2, que forzó la autonomía al orden social, y que han generado debate. Existe un 7.8% de la población disidente a la vacuna por razones epistémicas de falta de conocimiento de su funcionamiento, y ético-políticas basadas en la libertad individual, pensamiento, y el alcance de poder del Estado. Las estadísticas demuestran que la mayoría de las personas vacilantes a la inmunización son sujetos colectivos históricamente discriminados como los indígenas Afroecuatorianos y Montubios, que muchos pertenecen a la clase social baja, y habitan en la periferia, que previamente a la pandemia, carecía de infraestructura en salud. Demostrando como las determinantes de la salud influyen, y se conjugan en un complejo biosocial diverso, creando vulnerabilidades y privilegios. La pandemia expone las desigualdades y los problemas del modelo del Sistema Nacional de Salud. Por lo tanto, a través del método dialéctico, el artículo analiza las posiciones opuestas a la inmunización imperativa, y propone una tercera basada en un modelo sindémico de salud, que considera al complejo biosocial, cuyo mínimo normativo son los derechoshumanos, libertad, dignidad y principios bioéticos, principalmente de vulnerabilidad, interdependencia, diversidad cultural, pluralismo y justicia social.(AU)

La vacuna obligatòria de la COVID-19 i l'exigència del certificat a l'Equador constitueixen polítiques que depenen de la governabilitat i governança del poder central, que arrossega crisis polítiques, socioeconòmiques, jurídiques, ambientals, de salut i salubritat, de gestions anteriors i pròpies. Polítiques emmarcades en un model paternalista de salut, que és justificat en el cas de la vacuna obligatòria, pel risc i mal del SARS-Cov2, que va forçar l'autonomia a l'ordre social, i que han generat debat. Existeix un 7.8% de la població dissident a la vacuna per raons epistèmiques de falta de coneixement del seu funcionament, i ètic-polítiques basades en la llibertat individual, pensament, i l'abast de poder de l'Estat. Les estadístiques demostren que la majoria de les persones vacil·lants a la immunització són subjectes col·lectius històricament discriminats com els indígenes Afroequatorians i Montubios, que molts pertanyen a la classe social baixa, i habiten en la perifèria, que prèviament a la pandèmia, mancava d'infraestructura en salut. Demostrant com les determinants de la salut influeixen, i es conjuguen en un complex biosocial divers, creant vulnerabilitats i privilegis. La pandèmia exposa les desigualtats i els problemes del model del Sistema Nacional de Salut. Per tant, a través del mètode dialèctic, l'article analitza les posicions oposades a la immunització imperativa, i proposa una tercera basada en un model sindèmic de salut, que considera al complex biosocial, que el seu mínim normatiu són els drets humans, llibertat, dignitat i principis bioètics, principalment de vulnerabilitat, interdependència, diversitat cultural, pluralisme i justícia social.(AU)

The compulsory COVID-19 vaccine and the requirement of the certificate in Ecuador constitute policies that depend on the governability and governance of the central power, which drags political, socioeconomic, legal, environmental, health, and sanitation crises from previous administrations and its own. Policies framed in a paternalistic health model, which is justified in the case of themandatory vaccine, by the risk and damage of SARS-Cov2, which forced autonomy into the social order, and which have generated debate. There is a 7.8% of the population dissenting to the vaccine for epistemic reasons of lack of knowledge of its functioning, and ethical-political reasons such as individual freedom, religion, thought, and the scope of State`s power. Statistics show that most of the people hesitant to immunization are historically discriminated collective subjects such as Afro-Ecuadorians, andMontubio indigenous people. Most of them belong to the lower social class, and live in the periphery, which prior to the pandemic, lacked health infrastructure. Demonstrating how the determinants of health influence and combine in a diverse biosocial complex, creating vulnerabilities and privileges. The pandemic exposes the inequalities and problems of the paternalistic model of the National Health System. Therefore, through the dialectic method, the article analyzes the positions opposed to imperative immunization, and proposes a third one based on a syndemic model of health, which considers the biosocial complex, whose normative minimum are human rights, freedom, dignity, and bioethical principles, mainly vulnerability, interdependence, cultural diversity, pluralism, and social justice.(AU)

Site assessment survey to assess the impact of the COVID-19 pandemic on HIV clinic site services and strategies for mitigation in Washington, DC.

INTRODUCTION: The COVID-19 pandemic has created substantial interruptions in healthcare presenting challenges for people with chronic illnesses to access care and treatment services. We aimed to assess the impact of the pandemic on HIV care delivery by characterizing the pandemic-related impact on HIV clinic-level services and the mitigation strategies that were developed to address them. METHODS: The data comes from a site assessment survey conducted in the DC Cohort, an observational clinical cohort of PWH receiving care at 14 HIV outpatient clinics in Washington, D.C. Frequency counts and prevalence estimates of clinic-level survey responses about the impact of care delivery, COVID-19 testing, and vaccinations and mitigation strategies are presented. RESULTS: Clinics reported an increase in temporary clinic closures (n = 2), reduction in clinic hours (n = 5), telehealth utilization (n = 10), adoption of multi-month dispensation of antiretroviral (ARV) medication (n = 11) and alternative drug delivery via postal/courier service, home/community delivery or pick-up (n = 11). Clinics utilized strategies for PWH who were lost to follow-up during the pandemic including offering care to persons with any income level and insurance status (n = 9), utilizing e-prescribing for auto refills even if the patient missed visits (n = 8), and utilization of the regional health information exchange to check for hospitalizations of PWH lost to follow-up (n = 8). Most social services offered before the pandemic remained available during the pandemic; however, some support services were modified. CONCLUSIONS: Our findings demonstrate the extent of pandemic-era disruptions and the use of clinic-level mitigation strategies among urban HIV clinics. These results may help prepare for future pandemic or public health emergencies that disrupt healthcare delivery and access.