{
  "abstract": "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.",
  "authors": [
    {
      "affiliations": [
        "Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands",
        "Amsterdam Public Health Research Institute, Amsterdam, The Netherlands",
        "Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands"
      ],
      "name": "Niels Bal"
    },
    {
      "affiliations": [
        "Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands"
      ],
      "name": "Christopher Pell"
    },
    {
      "affiliations": [
        "Universitätsklinikum Heidelberg Heidelberg Institute of Global Health, Heidelberg, Germany",
        "Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts, USA",
        "Harvard Medical School, Boston, Massachusetts, USA"
      ],
      "name": "Michaela Theilmann"
    },
    {
      "affiliations": [
        "Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands",
        "Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium"
      ],
      "name": "Katja Polman"
    },
    {
      "affiliations": [
        "Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands",
        "Amsterdam Public Health Research Institute, Amsterdam, The Netherlands"
      ],
      "name": "Trynke Hoekstra"
    },
    {
      "affiliations": [
        "Clinton Health Access Initiative, Mbabane, Eswatini"
      ],
      "name": "Bongekile Thobekile Cindzi"
    },
    {
      "affiliations": [
        "Eswatini Ministry of Health, Mbabane, Eswatini"
      ],
      "name": "Ntombikele Ginindza"
    },
    {
      "affiliations": [
        "Eswatini Ministry of Health, Mbabane, Eswatini"
      ],
      "name": "Sijabulile Dlamini"
    },
    {
      "affiliations": [
        "Universitätsklinikum Heidelberg Heidelberg Institute of Global Health, Heidelberg, Germany"
      ],
      "name": "Lisa Stehr"
    },
    {
      "affiliations": [
        "Swiss Tropical and Public Health Institute, Allschwil, Switzerland",
        "University of Basel, Basel, Switzerland"
      ],
      "name": "Harsh Vivek Harkare"
    },
    {
      "affiliations": [
        "Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands",
        "Leiden University Medical Center Public Health and Primary Care, Leiden, Netherlands",
        "School of Child and Adoloscent Health, University of Cape Town, Rondebosch, South Africa"
      ],
      "name": "Ria Reis"
    },
    {
      "affiliations": [
        "Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands",
        "Amsterdam Public Health Research Institute, Amsterdam, The Netherlands"
      ],
      "name": "Frank van Leth"
    }
  ],
  "title": "Syndemic processes between non-communicable diseases and HIV within the Kingdom of Eswatini",
  "uid": "ee1ce895-319a-5c76-8e83-5d0f1ffc7d94"
}