Written By: Lauren Lloyd, MsGH Candidate ’27
In a recent Distinguished Lecture hosted by the Center for Global Mental Health (CGMH), in collaboration with the Duke Center for AIDS Research (CFAR) and the Department of Psychiatry and Behavioral Sciences, Dr. Jasper Lee explored how syndemic theory can help address persistent barriers to HIV treatment and prevention across global settings. Introduced by Dr. Eve Puffer, Director of CGMH, the lecture highlighted how co-occurring psychosocial and structural challenges can interact to worsen health outcomes—and how multilevel interventions can respond.
Dr. Lee, a clinical psychologist in the Department of Psychiatry at Massachusetts General Hospital, described his work developing behavioral medicine interventions in the United States, South Africa, and Zimbabwe. He noted that while HIV prevalence in the United States is more concentrated among specific populations, including men, Black communities, and people living in the South, countries such as South Africa and Zimbabwe face more generalized epidemics across populations. Across all three settings, however, common barriers continue to undermine treatment adherence, engagement in care, and prevention efforts.
Central to the lecture was the concept of syndemics: the idea that multiple health and social problems cluster together and interact synergistically. Depression, post-traumatic stress disorder (PTSD), substance use, and food insecurity, Dr. Lee explained, do not simply co-occur. Rather, they often reinforce one another in ways that create worse outcomes than any single challenge alone. His research uses interaction models and network analysis to better understand how these factors combine and which problems may be most influential within broader systems of risk.
Drawing on work among people living with HIV in South Africa, Dr. Lee described high levels of syndemic burden. Roughly one-third of participants experienced four or five co-occurring challenges, while another third experienced two or three. Food insecurity emerged as a particularly important structural barrier, associated with poorer survival, lower treatment adherence, reduced access to care, compromised immune functioning, and higher levels of depression.
Using network analysis, Dr. Lee’s team identified depression, substance use, food insecurity, and PTSD as especially central drivers within the broader syndemic network. He also shared findings showing that depression and food insecurity interacted to shape HIV medication adherence over time. Similar patterns were observed among people living with HIV in Zimbabwe, suggesting these dynamics may extend across settings.
Qualitative research further illustrated the lived experience behind the data. Participants described food insecurity as an overwhelming stressor that reduced their ability to work, forced them to borrow money, worsened mental health, and interfered with clinic attendance and antiretroviral therapy (ART) adherence. Many of these effects closely mirrored symptoms of depression, underscoring how structural hardship can manifest psychologically. PTSD was similarly linked to shame, loss of social support, and alcohol use as a coping strategy. Together, these overlapping burdens sometimes culminated in severe distress and suicidal ideation.
In response, Dr. Lee discussed Project Umbona, a multilevel intervention designed to address depression, trauma, food insecurity, and HIV adherence simultaneously. Participants receive monthly food parcels, while one intervention arm also receives cognitive behavioral therapy tailored to syndemic challenges and medication adherence. The program combines food support with problem solving, behavioral activation, relapse prevention, and linkage to care—recognizing that individuals may be better able to engage in treatment when immediate material needs are also addressed.
Dr. Lee also reflected on how lessons from global mental health research can inform domestic work in the United States, including mobile health tools for monitoring adherence and the use of syndemic frameworks to address issues such as gun violence and suicide prevention among veterans.
Across the lecture, a clear message emerged: improving HIV outcomes requires addressing not only the virus itself, but also the intersecting psychological and structural conditions that shape people’s lives.