Breakthrough in HIV Prevention: Syndemic-Focused Intervention Drives Testing Uptake in Chandigarh

A groundbreaking quasi-experimental study conducted in Chandigarh, India, has demonstrated the power of addressing psychosocial syndemic conditions to enhance HIV testing among men who have sex with men (MSM). Led by researchers from prestigious institutions like the Postgraduate Institute of Medical Education and Research (PGIMER) and the National Institute of Advanced Studies (NIAS), the intervention targeted depression, internalized homonegativity, and problematic alcohol use—key syndemic factors that exacerbate HIV risk. This real-world implementation research marks a significant step forward in integrating mental health support into India's National AIDS Control Programme (NACP), offering a scalable model for high-risk populations.

The study, published in the Indian Journal of Public Health, underscores how peer-delivered motivational interviewing can bridge gaps in HIV care continuum, particularly in urban settings where stigma remains a barrier. By focusing on MSM—a group disproportionately affected by HIV in India—the findings highlight the need for holistic approaches beyond biomedical interventions.

HIV Landscape in India: Persistent Challenges Amid Progress

India grapples with one of the world's largest HIV epidemics, with an estimated 2.5 million people living with HIV (PLHIV) as per the latest NACO 2025 estimates. New infections have declined by 48% since 2010, yet key populations like MSM account for a significant share, with prevalence rates up to 10 times higher than the general adult population. Under NACP Phase-V (2021-2026), the goal is epidemic control by 2025, emphasizing the 95-95-95 targets: 95% diagnosed, 95% on treatment, and 95% virally suppressed.

Despite free antiretroviral therapy (ART) availability, psychosocial barriers hinder testing and adherence. In Chandigarh, baseline data revealed 57.1% recent HIV testing among MSM, underscoring the urgency for targeted strategies. This study aligns with NACO's push for community-led interventions through targeted interventions (TIs) by NGOs.

Understanding Psychosocial Syndemics in HIV Context

Syndemic theory posits that co-occurring psychosocial conditions—such as depression, substance use, and stigma—interact synergistically to amplify disease burden. For MSM in India, internalized homonegativity (self-stigma from same-sex attraction) compounds societal discrimination, leading to risky behaviors. Problematic alcohol use, prevalent at 30% in the study baseline, further impairs judgment and testing motivation.

Depression affected 9.5% at baseline, often linked to minority stress. These syndemics create a vicious cycle: untreated mental health issues deter HIV testing, increasing transmission risk. The intervention disrupted this by screening and counseling, proving syndemic-informed approaches' efficacy in resource-limited settings.

Study Design and Methodology: A Real-World Quasi-Experimental Approach

Employing a pre-post quasi-experimental design, the type-2 hybrid implementation study (October 2019–June 2020) involved MSM from three Chandigarh NGOs under TI programs. Baseline screening (n=2046) used a 12-item tool; those with syndemic conditions were referred for counseling (post n=1812).

• Screening: Depression (PHQ-2), internalized homonegativity, AUDIT-C for alcohol, recent HIV testing/condom use.
• Intervention: Peer counselors delivered ≥2 motivational interviewing (MI) sessions on mental health, HIV testing motivation, safer sex; referrals for severe cases.
• Analysis: Z-tests for proportions, logistic regression for predictors; process evaluation via interviews (n=13).

This pragmatic design mirrors NACO TI workflows, enhancing scalability.

Key Results: Significant Gains in Testing and Reduced Syndemics

The intervention yielded compelling outcomes: 3-month HIV testing rose from 57.1% to 68.5% (p<0.001). Problematic alcohol use dropped from 30.0% to 18.4% (p<0.001), internalized homonegativity from 13.7% to 1.4% (p<0.001). Among baseline inconsistent condom users, 66% tested post-intervention (AOR=2.23). No significant changes in depression or consistent condom use, possibly due to COVID-19 disruptions.

Process data showed high acceptability: participants credited counseling for behavior shifts; stakeholders noted no added workload, praising staff capacity building.Explore research roles advancing such studies.

Photo by Markus Winkler on Unsplash

Role of Indian Higher Education Institutions in the Research

PGIMER Chandigarh's Department of Community Medicine and School of Public Health led implementation, with Prof. Manmeet Kaur as principal investigator. Collaborators included NIAS Bengaluru (Venkatesan Chakrapani, adjunct professor) and Tata Institute of Social Sciences Mumbai (Deepalatha Shetty, PhD scholar). Funded by ICMR, this exemplifies inter-institutional synergy in public health research.

These premier institutes train future researchers and practitioners, integrating syndemic theory into curricula. PGIMER's involvement highlights medical education's pivot toward psychosocial HIV care, fostering peer counselor training programs.

Stakeholder Perspectives and Implementation Fidelity

In-depth interviews revealed enthusiasm: service users reported reduced stigma and increased self-efficacy; TI managers valued integration with Form-B data collection. No fidelity issues; peer counselors enhanced motivation without overburdening educators. Chandigarh State AIDS Control Society endorsed scaling, aligning with NACP-V.

This stakeholder buy-in ensures sustainability, with calls to train existing staff like ANMs and outreach workers.

Challenges in Scaling Psychosocial Interventions Nationwide

Despite successes, hurdles persist: COVID-19 masked some effects; rural-urban disparities; limited mental health infrastructure. Stigma deters MSM engagement; funding for peer roles needed. Study limitations include no control group, potential external influences.

• Resource constraints in TIs
• Need for cost-effectiveness analysis
• Diverse regional syndemic profiles

Solutions: NACO guideline integration, university-led training via academic career development.

Implications for HIV Care Continuum and Public Health Policy

The study advances the HIV cascade by boosting diagnosis—the first 95. Recommendations: routine syndemic screening in TIs, MI training for staff, dedicated peer budgets. This could accelerate India's 95-95-95 goals, reducing transmissions.

Broader impacts: models for other key populations (transgender, sex workers); university research informs policy, positioning PGIMER/NIAS/TISS as leaders. Explore research jobs in public health.

Future Directions: Expanding Research and Interventions

Next steps: randomized trials, cost analyses, multi-site scaling. Universities can lead: PGIMER's School of Public Health could develop MOOCs on syndemic interventions. Longitudinal tracking post-COVID; AI for screening integration.

Optimistic outlook: with NACP-V momentum, psychosocial focus could end AIDS as public health threat by 2030. Aspiring researchers, check postdoc opportunities.

Photo by Elisa Stone on Unsplash

Actionable Insights for Health Professionals and Educators

Implement MI training: step-by-step—assess readiness, evoke change talk, plan testing. Universities: embed in MPH curricula. For PLHIV support, prioritize syndemic screening.

• Train peers via short courses
• Integrate with ART clinics
• Monitor via NACO dashboards

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