# Assessing a Syndemic of Discrimination, Material Insecurity, Depression, Substance Use, and Violence Among Sexual and Gender Minorities in Nigeria Using Mixed Methods

## TL;DR

This study explores how discrimination, poverty, and violence contribute to higher HIV rates among sexual and gender minorities in Nigeria.

## Contribution

The study provides new evidence of a syndemic affecting sexual and gender minorities in Nigeria and its link to HIV prevalence.

## Key findings

- Every quartile increase in the syndemic index was associated with an 18% increase in HIV prevalence.
- Qualitative findings emphasized the role of discrimination, material insecurity, and depression in the syndemic.
- Co-prevalence of syndemic components was significantly stronger than expected, supporting the syndemic model.

## Abstract

Sexual and gender minority people (SGM) in Nigeria experience disproportionate HIV burden, with an HIV prevalence four to ten times higher than the national average. Better understanding the factors that create HIV vulnerability in this population is important for designing effective interventions, particularly in a context largely hostile to SGM. We assessed a conceptual model describing a syndemic of discrimination, material insecurity, depression, substance use, intimate partner violence, and police and other violence among SGM in Abuja, Nigeria. As part of a larger, longitudinal study examining noncommunicable disease outcomes within this population, we conducted a mixed methods analysis using both quantitative intake data (n=515) as well as data from three focus groups (n=36), collected from July 2023 through May 2024. We tested for intercorrelations among syndemic components, and associations between a cumulative syndemic index and HIV status using modified Poisson regression. We also conducted a convergent qualitative assessment of the conceptual model in three focus group discussions. Finally, we examined co-prevalence of syndemic components highlighted in our qualitative findings. There were consistent intercorrelations among syndemic components, supporting the presence of a syndemic. After adjustment for sociodemographic factors, every quartile-unit increase in the syndemic index was associated with an 18% increase in prevalence of HIV (aPR=1.18, 95% CI 1.07, 1.29). Additionally, our qualitative findings highlighted relationships between discrimination, material insecurity, and depression as especially relevant among this population. When using our quantitative data to examine the co-prevalence of pairs of syndemic components identified as particularly salient in our qualitative analyses, nearly every relationship was significantly stronger than expected. We found strong evidence of a syndemic of discrimination, material insecurity, depression, substance use, intimate partner violence, and police and other violence among SGM in Abuja, Nigeria as salient to the health outcomes of SGM in Nigeria. Overall, our findings highlight the presence of a multilevel syndemic that informs multilevel intervention targets. Interventions must target not simply the individual level, but also incorporate larger scale social and structural change efforts.