COVID-19, You’re Driving Me Crazy!

A popular song from the 1930s about love gone wrong could well sum up how people living with HIV feel about the COVID-19 pandemic—it’s driving us crazy! People with HIV were already subject to a range of medical, mental health, and psychosocial challenges before the pandemic. The pandemic itself has exacerbated many of these challenges, making life more complicated and more stressful for those living with HIV. In addition, the HIV-affected population includes a number of groups already impacted by disparities in health care, including women, people of color, gay men, and transgender people. These are the same health care disparities that the COVID-19 pandemic has exploited. So this pandemic is hitting people with HIV every which way, including in the mental health arena.

A useful way to look at the convergent impacts of HIV, COVID-19, and health care disparities among vulnerable populations is through the lens of syndemics, a recent conceptual framework that explores the way health conditions are embedded in social, economic, environmental, and political frameworks that intensify their effects. It comes from the words “synergistic” and “pandemic,” and it helps explain why HIV and COVID-19 together are more dangerous than either of them alone. Stephanie Shiau, Ph.D., M.P.H., an epidemiologist who teaches at the Rutgers School of Public Health and specializes in HIV, and her colleagues offer a syndemic perspective on HIV and COVID-19. In their view, many other health challenges amp up the impact of COVID-19 among those living with HIV. These, in turn, are fueled by a wide range of biological, behavioral, psychosocial, and structural factors.

According to the syndemic model, the health problems that converge on people with HIV during the COVID-19 pandemic include other infectious disease (e.g., tuberculosis), non-infectious chronic conditions (e.g., hypertension, diabetes, cancer), sexually transmitted infections, malnutrition, substance use, and mental health conditions (e.g., depression, anxiety, insomnia). These health problems interact with a long list of social, political, environmental, and systemic burdens that undermine the reality or subjective perception of safety, security, and wellbeing. These burdens can include poverty, housing insecurity and homelessness, food insecurity and hunger, racism, homophobia, transphobia, misogyny, violence, and lack of access to many basic services and amenities, among other factors. These health problems and environmental concerns are all happening at the same time, and they create a synergistic feedback loop, meaning the environmental issues make the health issues worse, and vice versa. “Such synergies are even greater in older people living with HIV, who also are at higher risk for COVID-19–related mortality,” write Shiau and colleagues in a recent article in the psychology journal AIDS and Behavior.

Any research about COVID-19 and mental health among Black, queer, and transgender people is relevant to people living with HIV, since HIV so disproportionately affects these communities. Lisa Fortuna, M.D., M.P.H., an associate professor of psychiatry at the University of California San Francisco (UCSF), along with her colleagues, has written about the disproportionate physical and mental health impacts of COVID-19 on communities of color in the United States, and the need for a trauma-informed social justice response. Fortuna and colleagues state that rates of toxic stress among communities of color—arising from racial injustice and social disparities—have increased during the pandemic, leading to worse physical health, mental health, and socioeconomic outcomes for these most vulnerable populations. “Traumatic loss,” they write in a recent article in the journal Psychological Trauma, “combined with inequities in resources, is a risk factor for posttraumatic stress disorder (PTSD) and long-term mental and physical health consequences.”

Glenn-Milo Santos, Ph.D., M.P.H., an associate professor of community health systems at UCSF, along with his colleagues, has studied the impacts of COVID-19 among gay men and other men who have sex with men (MSM), including impacts on mental health, HIV treatment, and HIV prevention. They surveyed a worldwide sample of men through a social networking app. Many of those who participated in the survey reported mental health consequences, as well as interruptions to HIV prevention and testing and HIV care and treatment. These consequences, as well as economic impacts of the pandemic, were significantly greater among people with HIV, nonwhite people, immigrants, sex workers, and underserved and under-resourced groups. About a third screened positive for anxiety, depression, or both.

Research led by Megan Marziali, a public health student at Columbia University, suggests that the mental health consequences of the COVID-19 pandemic may lead to worse physical health outcomes for people with HIV. Before COVID-19, Marziali and colleagues conducted a survey to explore the link between social isolation, loneliness, and physical health among gay, bisexual, and other men who have sex with men in Vancouver, Canada, among those both living with and without HIV. Among HIV-positive participants who said they were in poor physical health, 87% said they experienced loneliness. By contrast, among HIV-positive participants who said they were in good physical health, only 59% reported loneliness. “So even before COVID, we were seeing associations between loneliness and poor self-rated physical health, which is partly mediated by depression,” Marziali said, responding to questions via email. “We also found, in a separate study conducted pre-COVID, that social isolation is associated with mortality,” Marziali added. “This is all to say that, even prior to COVID, we were observing an association between isolation, loneliness, and negative health outcomes,” Marziali explained.

Marziali and colleagues point out that the current quarantine measures have never been implemented on this scale before, and that many people, including those living with HIV, may be experiencing difficulty in coping with the resulting isolation. In addition, they note, members of vulnerable populations may face new challenges in accessing social support during the COVID-19 pandemic, leading to increased rates of social isolation and loneliness. As Marziali and colleagues point out, other research has shown that social isolation is comparable to known risk factors for death, including smoking and high blood pressure.

“In terms of the pandemic, we need to be looking forward and acknowledging that we are in this for the long haul,” Marziali said. “Given the circumstances, there needs to be increased funding specifically for community-based organizations that service people living with HIV to tailor services for the current situation. I believe that investments in online services that bolster social connections are needed now and would also pay off in the future to address social isolation and loneliness post-COVID,” Marziali added.