A qualitative study of the social and structural vulnerabilities of HIV and chronic disease syndemics in low-resource urban health facilities in South Africa.

Low- and middle-income countries are experiencing multiple epidemics, including HIV and chronic non-communicable diseases. These epidemics present a serious public health concern as they increase the demand for health services, negatively impact quality of life, and increase mortality. While efforts have been made to integrate care approaches within primary care, people living with HIV (PLWH) experiencing chronic comorbidities often face intersecting social and structural vulnerabilities that are not fully recognized. Given the robust evidence of converging epidemics of HIV and other chronic conditions, through the lens of syndemic theory, this study aimed to identify and examine the social and structural vulnerabilities driving syndemic disease within an urban population of PLWH in South Africa. This study applied a qualitative research design involving in-depth interviews with 13 PLWH and 14 healthcare providers in Johannesburg, South Africa collected between August and September 2024. Structural vulnerabilities (disrupted access to care, unemployment, migration) and social vulnerabilities (income, social support, violence, stigma) influence disease clusters through multiple pathways including chronic stress-induced physiological changes, reduced agency, and providers who lacked structural competency in recognizing how vulnerabilities impact disease pathogenesis and management. Direct consideration of these vulnerabilities with structural reform will meet the unique health needs and challenges of HIV and chronic disease syndemics. This will involve providers considering the social structures that undermine the capacities of patients and direct attention to social vulnerabilities through increased availability of resources both within and beyond healthcare facilities.