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Gilmore E, Duncan K, Ades V. Homelessness in Pregnancy and Increased Risk of Adverse Outcomes: A Retrospective Cohort Study. J Urban Health 2024; 101:383-391. [PMID: 38478248 PMCID: PMC11052971 DOI: 10.1007/s11524-024-00839-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 04/28/2024]
Abstract
Limited data indicates that homelessness during pregnancy is linked to adverse outcomes for both mothers and newborns, but there is an information gap surrounding pregnant individuals struggling with homelessness. In a landscape of increasing healthcare disparities, housing shortages and maternal mortality, information on this vulnerable population is fundamental to the creation of targeted interventions and outreach. The current study investigates homelessness as a risk factor for adverse obstetrical, neonatal, and postpartum outcomes. We reviewed more than 1000 deliveries over 1 year at a large public hospital in New York City, comparing homeless subjects to a group of age-matched, stably housed controls. Multiple outcomes were assessed regarding obstetrical, neonatal, and postpartum outcomes along with social stressors. Homeless pregnant individuals were more likely to experience numerous adverse outcomes, including cesarean delivery and preterm delivery. Their neonates were more likely to undergo an extended stay in the intensive care unit and evaluation by the Administration for Children's Services, suggesting that they may be at an increased risk for family separation. After delivery, patients were less likely to exclusively breastfeed or return for their postpartum visit. Regarding personal history, they were more likely to endorse a history of violence or abuse, use illicit substances, and carry a psychiatric diagnosis. These findings indicate that homelessness is linked to numerous adverse obstetrical, neonatal, and postpartum outcomes that worsen health indices and exacerbate pre-existing disparities. Initiatives must focus on improved outreach and care delivery for homeless pregnant individuals.
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Affiliation(s)
- Emma Gilmore
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA.
- Department of Obstetrics and Gynecology, University of Pennsylvania, 3737 Market Street, Philadelphia, PA, 19104, USA.
| | - Karen Duncan
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
| | - Veronica Ades
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
- Department of Obstetrics, Gynecology and Women's Health, Albert Einstein College of Medicine, Jacobi Medical Center, 1400 Pelham Parkway South, Building 1, BS27, Bronx, NY, 10461, USA
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Mars SG, Spinelli MA, Ondocsin J, Koester KA, Rodriguez ES, Jain J, Arreguin M, Johnson MO, Gandhi M. Pandemic expertise: qualitative findings on the experiences of living with HIV during the COVID-19 pandemic. AIDS Care 2024; 36:382-389. [PMID: 37621106 PMCID: PMC10891295 DOI: 10.1080/09540121.2023.2248579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
This qualitative study explored the experiences of people living with HIV (PLWH) in the San Francisco Bay Area, United States, during the COVID-19 pandemic and subsequent public health restrictions at a safety net HIV clinic. Patients (N = 30) were recruited for Spanish/English language semi-structured interviews (n = 30), translated when necessary, and analyzed thematically. The recurring theme of "pandemic expertise" emerged from the data: skills and attitudes developed through living with HIV helped PLWH cope with the COVID-19 pandemic, including effective strategies for dealing with anxiety and depression; appreciation for life; and practical experience of changing behavior to protect their health. A subset did not consider living with HIV helped them adapt to the COVID-19 pandemic, with some describing their lives as chaotic due to housing issues and/or ongoing substance use. Overall, interviewees reported finding trustworthy health information that helped them follow COVID-19 prevention strategies. Although living with HIV is associated with a higher prevalence of mental health concerns, substance use, and stigma, these challenges can also contribute to increased self-efficacy, adaptation, and resilience. Addressing structural issues such as housing appears to be key to responding to both pandemics.
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Affiliation(s)
- Sarah G Mars
- Department of Family and Community Medicine, University of California, San Francisco, CA, USA
| | - Matthew A Spinelli
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Jeff Ondocsin
- Department of Family and Community Medicine, University of California, San Francisco, CA, USA
| | - Kim A Koester
- Department of Medicine, University of California, San Francisco, CA, USA
| | | | - Jennifer Jain
- Department of Psychiatry and Behavior Sciences, University of California, San Francisco, CA, USA
| | - Mireya Arreguin
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Mallory O Johnson
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Monica Gandhi
- Department of Medicine, University of California, San Francisco, CA, USA
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Sprague Martinez L, Scott JC, Rocco M, Rajabiun S, Flores Rodriguez C, Cummings R, McKinney-Prupis E, Minott M, Walker-Jones J, Downes A, Wangari Walter A. Policies enacted during COVID-19 came with unintended health benefits: why go back? BMC Health Serv Res 2023; 23:496. [PMID: 37194099 DOI: 10.1186/s12913-023-09448-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 04/25/2023] [Indexed: 05/18/2023] Open
Abstract
OBJECTIVES To explore the impact of COVID-19 on the implementation of bundled interventions to improve the engagement and retention of Black women in HIV care. METHODS Pre-implementation interviews conducted between January and April 202 L with 12 demonstration sites implementing bundled interventions for Black women with HIV. Directed content analysis was employed to examine the site interview transcripts. RESULTS The pandemic intensified barriers to care and harmful social conditions. However, COVID-19 also forced pivots in health care and social service delivery and some of these changes benefited Black women living with HIV. CONCLUSIONS The continuation of policies that support the material needs of Black women with HIV and ease access to care is critical. Racial capitalism impedes the enactment of these policies and thus threatens public health.
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Affiliation(s)
| | | | - Melanie Rocco
- Boston University School of Social Work, Boston, MA, US
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Streuli S, Garfein RS, Gaines T, Fielding-Miller R. COVID-19 disproportionately impacts access to basic needs among households with disabled members. Disabil Health J 2023; 16:101443. [PMID: 36764843 PMCID: PMC9851949 DOI: 10.1016/j.dhjo.2023.101443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 12/19/2022] [Accepted: 01/13/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND The COVID-19 pandemic has disproportionately impacted disabled people, especially those who are members of marginalized communities that were already denied access to the resources and opportunities necessary to ensure health equity before the pandemic. OBJECTIVE Compare COVID-19 impact on basic needs access among households with and without disabled adults. METHODS An online survey was distributed to households with children enrolled in one of 30 socially vulnerable elementary or middle schools in San Diego County, California. We measured disability using the single-item Global Activities Limitations Indicator. We measured pandemic impacts on basic needs access using the RADx-UP common data elements toolkit. We then assessed number of impact items reported by household disability using multivariable linear regression, adjusting for household income, household size, education, parent gender, and child's ethnicity. RESULTS Of 304 participants, 41% had at least one disabled household member. Participants reporting a disabled household member were more likely to report challenges accessing basic needs, such as food, housing, healthcare, transportation, medication, and stable income during the pandemic (all p < 0.05). Difficulty accessing basic needs was significantly associated with household income and parent gender in the final regression model. CONCLUSIONS Households with a disabled member were significantly more likely to experience difficulty accessing basic needs during the COVID-19 pandemic. This has important implications for the disproportionate impact of COVID-19 on disabled people, especially those from low-income communities that already face barriers to accessing resources. To improve COVID-19 outcomes for disabled people, we must focus on meeting their basic needs.
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Affiliation(s)
- Samantha Streuli
- Herbert Wertheim School of Public Health & Human Longevity Science, University of California San Diego. 9500 Gilman Drive, La Jolla CA 92093, USA.
| | - Richard S Garfein
- Department of Medicine, Division of Global Public Health, University of California San Diego. 9500 Gilman Drive, La Jolla CA 92093, USA.
| | - Tommi Gaines
- Department of Medicine, Division of Global Public Health, University of California San Diego. 9500 Gilman Drive, La Jolla CA 92093, USA.
| | - Rebecca Fielding-Miller
- Herbert Wertheim School of Public Health & Human Longevity Science, University of California San Diego. 9500 Gilman Drive, La Jolla CA 92093, USA.
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Carrico AW, Cherenack EM, Rubin LH, McIntosh R, Ghanooni D, Chavez JV, Klatt NR, Paul RH. Through the Looking-Glass: Psychoneuroimmunology and the Microbiome-Gut-Brain Axis in the Modern Antiretroviral Therapy Era. Psychosom Med 2022; 84:984-994. [PMID: 36044613 PMCID: PMC9553251 DOI: 10.1097/psy.0000000000001133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/18/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Depression, substance use disorders, and other neuropsychiatric comorbidities are common in people with HIV (PWH), but the underlying mechanisms are not sufficiently understood. HIV-induced damage to the gastrointestinal tract potentiates residual immune dysregulation in PWH receiving effective antiretroviral therapy. However, few studies among PWH have examined the relevance of microbiome-gut-brain axis: bidirectional crosstalk between the gastrointestinal tract, immune system, and central nervous system. METHODS A narrative review was conducted to integrate findings from 159 articles relevant to psychoneuroimmunology (PNI) and microbiome-gut-brain axis research in PWH. RESULTS Early PNI studies demonstrated that neuroendocrine signaling via the hypothalamic-pituitary-adrenal axis and autonomic nervous system could partially account for the associations of psychological factors with clinical HIV progression. This review highlights the need for PNI studies examining the mechanistic relevance of the gut microbiota for residual immune dysregulation, tryptophan catabolism, and oxytocin release as key biological determinants of neuropsychiatric comorbidities in PWH (i.e., body-to-mind pathways). It also underscores the continued relevance of neuroendocrine signaling via the hypothalamic-pituitary-adrenal axis, autonomic nervous system, and oxytocin release in modifying microbiome-gut-brain axis functioning (i.e., mind-to-body pathways). CONCLUSIONS Advancing our understanding of PNI and microbiome-gut-brain axis pathways relevant to depression, substance use disorders, and other neuropsychiatric comorbidities in PWH can guide the development of novel biobehavioral interventions to optimize health outcomes. Recommendations are provided for biobehavioral and neurobehavioral research investigating bidirectional PNI and microbiome-gut-brain axis pathways among PWH in the modern antiretroviral therapy era.
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Fernandez SB, Lopez C, Ibarra C, Sheehan DM, Ladner RA, Trepka MJ. Examining Barriers to Medication Adherence and Retention in Care among Women Living with HIV in the Face of Homelessness and Unstable Housing. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11484. [PMID: 36141757 PMCID: PMC9517674 DOI: 10.3390/ijerph191811484] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/04/2022] [Accepted: 09/06/2022] [Indexed: 06/16/2023]
Abstract
Despite advances in biomedical treatments, women living with HIV (WLH) who experience homelessness and housing instability suffer suboptimal HIV outcomes, even when linked to treatment. The purpose of this study was to explore experiences of housing instability among WLH and to understand its role in their ability to adhere to antiretroviral medication and remain retained in care. Sixteen women who were linked to Ryan White Program HIV care in South Florida participated in in-depth interviews. The findings focus around four larger themes: difficulty storing medication, privacy- and stigma-related issues, inconsistent access to medication and health care disruptions, and competing and unmet physical and mental health needs. Findings underscore the importance of strategies that are responsive to the disruption of routines and are sensitive to privacy issues in shared dwelling spaces; the proactive inquiry of behavioral and environmental considerations when prescribing antiretroviral medication; and the identification and treatment of comorbid conditions. This study provides evidence for strategies to facilitate self-management and improve modifiable system realities to augment larger-level policy and funding shifts that are critically needed to end the epidemic among vulnerable populations living with HIV.
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Affiliation(s)
- Sofia B. Fernandez
- School of Social Work, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL 33199, USA
- Research Center in Minority Institutions (RCMI), Florida International University, Miami, FL 33199, USA
| | - Cindy Lopez
- Research Center in Minority Institutions (RCMI), Florida International University, Miami, FL 33199, USA
| | - Cynthia Ibarra
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL 33199, USA
| | - Diana M. Sheehan
- Research Center in Minority Institutions (RCMI), Florida International University, Miami, FL 33199, USA
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL 33199, USA
- Center for Substance Use and HIV/AIDS Research on Latinos in the United States (C-SALUD), Florida International University, Miami, FL 33199, USA
| | | | - Mary Jo Trepka
- Research Center in Minority Institutions (RCMI), Florida International University, Miami, FL 33199, USA
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL 33199, USA
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Rodriguez NM, Martinez RG, Ziolkowski R, Tolliver C, Young H, Ruiz Y. "COVID knocked me straight into the dirt": perspectives from people experiencing homelessness on the impacts of the COVID-19 pandemic. BMC Public Health 2022; 22:1327. [PMID: 35820879 PMCID: PMC9275174 DOI: 10.1186/s12889-022-13748-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/06/2022] [Indexed: 11/18/2022] Open
Abstract
Background People experiencing homelessness are uniquely susceptible and disproportionately affected by the impacts of the COVID-19 pandemic. Understanding context-specific challenges, responses, and perspectives of people experiencing homelessness is essential to improving pandemic response and mitigating the long-term consequences of the pandemic on this vulnerable population. Methods As part of an ongoing community-based participatory research study in partnership with a homeless service organization in Indiana, semi-structured interviews were conducted with a total of 34 individuals experiencing homelessness between January and July 2021. Guided by the NIMHD Health Disparities Research Framework, which builds on the socio-ecological model, data was thematically coded using Nvivo12 qualitative coding software and themes were organized by levels of influence (individual, interpersonal, community, societal) and domains of influence (biological, behavioral, physical/built environment, sociocultural environment, health care system). Results Narratives revealed numerous and compounding factors affecting COVID-19 risks and health outcomes among people experiencing homelessness across all levels and domains of influence. At the individual level, people experiencing homelessness face unique challenges that heightened their susceptibility to COVID-19, including pre-existing physical and mental health conditions, substance use and behavioral health risks, socioeconomic precarity, and low health literacy and COVID-related knowledge. At the interpersonal level, poor communication between people experiencing homelessness and service providers led to limited understanding of and poor compliance with COVID safety measures. At the community level, closures and service disruptions restricted access to usual spaces and resources to meet basic needs. At a policy level, people experiencing homelessness were disregarded in ways that made pandemic relief resources largely inaccessible to them. Conclusions Our findings reveal important and mitigable issues with ongoing pandemic response efforts in homeless populations through direct, first-hand accounts of their experiences during COVID-19. These insights offer opportunities for multilevel interventions to improve outreach, communication, and impact mitigation strategies for people experiencing homelessness. This study highlights the importance of centering the voices of vulnerable communities to inform future pandemic response for homeless and other underserved and marginalized populations.
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Affiliation(s)
- Natalia M Rodriguez
- Department of Public Health, College of Health and Human Sciences, Purdue University, West Lafayette, IN, USA. .,Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, IN, USA.
| | - Rebecca G Martinez
- Department of Anthropology, College of Liberal Arts, Purdue University, West Lafayette, Indiana, USA
| | - Rebecca Ziolkowski
- Department of Public Health, College of Health and Human Sciences, Purdue University, West Lafayette, IN, USA
| | - Cealia Tolliver
- Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, Indiana, USA
| | - Hope Young
- Department of Public Health, College of Health and Human Sciences, Purdue University, West Lafayette, IN, USA
| | - Yumary Ruiz
- Department of Public Health, College of Health and Human Sciences, Purdue University, West Lafayette, IN, USA
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From crisis to crisis: impacts of the COVID-19 pandemic on people living with HIV and HIV/AIDS service organizations in Indiana. BMC Health Serv Res 2022; 22:622. [PMID: 35534824 PMCID: PMC9081957 DOI: 10.1186/s12913-022-07998-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 04/26/2022] [Indexed: 11/17/2022] Open
Abstract
Background The COVID-19 pandemic thrust people living with HIV (PLWH) and HIV/AIDS service organizations into an environment ripe with uncertainty. This study examined Indiana HIV/AIDS service provider perceptions of how COVID-19 affected the overall health and access to care of their clients, and how the organizations prepared for, adapted, and responded to the needs of PLWH during the pandemic. Methods Guided by the socioecological model, fifteen semi-structured interviews were conducted with ten different HIV/AIDS service organizations across the state of Indiana. Results Despite the profound disruptions experienced by HIV programs, HIV/AIDS service organizations responded quickly to the challenges posed by the COVID-19 pandemic through myriad innovative strategies, largely informed by prior experiences with the HIV epidemic. Conclusions The lessons provided by HIV/AIDS service organizations are invaluable to informing future pandemic response for PLWH. Service delivery innovations in response to the COVID-19 crisis may provide insights to improve HIV care continuity strategies for vulnerable populations far beyond the pandemic. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07998-0.
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Spinelli MA, Le Tourneau N, Glidden DV, Hsu L, Hickey MD, Imbert E, Arreguin M, Jain JP, Oskarsson JJ, Buchbinder SP, Johnson MO, Havlir D, Christopoulos KA, Gandhi M. Impact of Multicomponent Support Strategies on Human Immunodeficiency Virus Virologic Suppression Rates During Coronavirus Disease 2019: An Interrupted Time Series Analysis. Clin Infect Dis 2022; 75:e947-e954. [PMID: 35245934 PMCID: PMC9129130 DOI: 10.1093/cid/ciac179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND After coronavirus disease 2019 (COVID-19) shelter-in-place (SIP) orders, viral suppression (VS) rates initially decreased within a safety-net human immunodeficiency virus (HIV) clinic in San Francisco, particularly among people living with HIV (PLWH) who are experiencing homelessness. We sought to determine if proactive outreach to provide social services, scaling up of in-person visits, and expansion of housing programs could reverse this decline. METHODS We assessed VS 24 months before and 13 months after SIP using mixed-effects logistic regression followed by interrupted time series (ITS) analysis to examine changes in the rate of VS per month. Loss to follow-up (LTFU) was assessed via active clinic tracing. RESULTS Data from 1816 patients were included; the median age was 51 years, 12% were female, and 14% were experiencing unstable housing/homelessness. The adjusted odds of VS increased 1.34 fold following institution of the multicomponent strategies (95% confidence interval [CI], 1.21-1.46). In the ITS analysis, the odds of VS continuously increased 1.05 fold per month over the post-intervention period (95% CI, 1.01-1.08). Among PLWH who previously experienced homelessness and successfully received housing support, the odds of VS were 1.94-fold higher (95% CI, 1.05-3.59). The 1-year LTFU rate was 2.8 per 100 person-years (95% CI, 2.2-3.5). CONCLUSIONS The VS rate increased following institution of the multicomponent strategies, with a lower LFTU rate compared with prior years. Maintaining in-person care for underserved patients, with flexible telemedicine options, along with provision of social services and permanent expansion of housing programs, will be needed to support VS among underserved populations during the COVID-19 pandemic.
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Affiliation(s)
- Matthew A Spinelli
- Department of Medicine, Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, California, USA
| | - Noelle Le Tourneau
- Department of Medicine, Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, California, USA
| | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Ling Hsu
- San Francisco Department of Public Health, San Francisco, California, USA
| | - Matthew D Hickey
- Department of Medicine, Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, California, USA
| | - Elizabeth Imbert
- Department of Medicine, Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, California, USA
| | - Mireya Arreguin
- Correspondence: M. A. Spinelli, 995 Potrero Avenue, Ward 84, San Francisco, CA 94110 ()
| | - Jennifer P Jain
- Department of Psychiatry, University of California, San Francisco, California, USA
| | - Jon J Oskarsson
- Department of Medicine, Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, California, USA
| | - Susan P Buchbinder
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA,San Francisco Department of Public Health, San Francisco, California, USA,Department of Medicine, Division of Prevention Science, University of California, San Francisco, California, USA
| | - Mallory O Johnson
- Department of Medicine, Division of Prevention Science, University of California, San Francisco, California, USA
| | - Diane Havlir
- Department of Medicine, Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, California, USA
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Chilot D, Woldeamanuel Y, Manyazewal T. COVID-19 Burden on HIV Patients Attending Antiretroviral Therapy in Addis Ababa, Ethiopia: A Multicenter Cross-Sectional Study. Front Med (Lausanne) 2022; 9:741862. [PMID: 35308528 PMCID: PMC8924523 DOI: 10.3389/fmed.2022.741862] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 01/07/2022] [Indexed: 12/18/2022] Open
Abstract
Background There has been promising progress toward screening, testing, and retaining patients with HIV in care in Ethiopia. Concern exists that possible disruptions in HIV programs due to coronavirus disease 2019 (COVID-19) could result in a more HIV-related mortality and new HIV infections. This study aimed to investigate the real-time burden of COVID-19 on patients with HIV attending antiretroviral therapy. Methods We conducted a facility-based, multicenter, and cross-sectional study among patients with HIV attending antiretroviral therapy in 10 healthcare facilities in Addis Ababa, Ethiopia, in the COVID-19 pandemic period. Data were collected using adapted, interviewer-based questionnaires, and entered into EpiInfo version 7 and exported to SPSS version 26 for analysis. Result A total of 212 patients with HIV were included. The participants who missed visits for refill were 58 (27.4%). When the effects of other independent variables on appointments/visits for refill were controlled, the following characteristics were found to be the most important predictors of missed appointments (p< 0.05): age ≥ 55 [adjusted odds ratio (AOR) = 6.73, 95% CI (1.495-30.310)], fear of COVID-19 [AOR = 24.93, 95% CI (2.798-222.279)], transport disruption [AOR = 4.90, 95% CI (1.031-23.174)], reduced income for traveling to a health facility [AOR = 5.64, 95% CI (1.234-25.812)], limited access to masks [AOR = 7.67, 95% CI (1.303-45.174)], sanitizer [AOR = 0.07, 95% CI (0.007-0.729)], and non-medical support [AOR = 2.32, 95% CI (1.547-12.596)]. The participants were well aware of the COVID-19 preventive measures. The most costly COVID-19 preventive measures that cause financial burden to the patients were the costs for buying face masks (63.7%), disinfectants (55.2%), and soap for handwashing (22.2%). The participants who missed follow-up diagnostic tests were 56 (26.4%). Variables, which were found to be statistically significant, include the following: age ≥ 55 [AOR = 0.22, 95% CI (0.076-0.621)], partial lockdown [AOR = 0.10, 95% CI (0.011-0.833)], limited access to health services [AOR = 0.15, 95% CI (0.045-0.475)], reduced income for traveling to health facility [AOR = 0.18, 95% CI (0.039-0.784)], and unable to get masks [AOR = 0.12, 95% CI (0.026-0.543)]. The participants who missed counseling services were 55 (25.9%). In multivariate logistic regression, the following were statistically significant: age ≥ 55 [AOR = 0.21, 95% CI (0.078-0.570)], fear of COVID-19 [AOR = 0.11, 95% CI (0.013-0.912)], reduced income [AOR = 0.17, 95% CI (0.041-0.699)], unable to get face masks [AOR = 0.19, 95% CI (0.039-0.959)], and partial lockdown [AOR = 0.08, 95% CI (0.008-0.790)]. Conclusions The COVID-19 had a significant burden on patients with HIV to attend their routine clinical care and treatment, which may lead to treatment failure and drug resistance. The impact was on their appointments for medication refills and clinical and laboratory follow-ups. Targeted initiatives are needed to sustain HIV clinical care and treatment services and improve the well-being of people living with HIV.
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Affiliation(s)
- Dagmawi Chilot
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Yimtubezinash Woldeamanuel
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tsegahun Manyazewal
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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11
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MacNeill JJ, Linnes JC, Rodriguez NM. From Crisis To Crisis: Impacts Of The COVID-19 Pandemic On People Living With HIV And AIDS Service Organizations In Indiana. RESEARCH SQUARE 2022:rs.3.rs-1003567. [PMID: 35194595 PMCID: PMC8863148 DOI: 10.21203/rs.3.rs-1003567/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Background: The COVID-19 pandemic thrust people living with HIV (PLWH) and HIV/AIDS service organizations into an environment ripe with uncertainty. This study examined Indiana AIDS services provider perceptions of how COVID-19 affected the overall health and access to care of their clients, and how the organizations prepared for, adapted, and responded to the needs of PLWH during the pandemic. Methods: Guided by the socioecological model, fifteen semi-structured interviews were conducted with ten different HIV/AIDS service organizations across the state of Indiana. Results: Despite the profound disruptions experienced by HIV programs, HIV/AIDS service organizations responded quickly to the challenges posed by the COVID-19 pandemic through myriad innovative strategies, largely informed by prior experiences with the HIV epidemic. Conclusions: The lessons provided by HIV/AIDS service organizations are invaluable to informing future pandemic response for PLWH. Service delivery innovations in response to the COVID-19 crisis may provide insights to improve HIV care continuity strategies for vulnerable populations far beyond the pandemic.
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12
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Beltran RM, Holloway IW, Hong C, Miyashita A, Cordero L, Wu E, Burris K, Frew PM. Social Determinants of Disease: HIV and COVID-19 Experiences. Curr HIV/AIDS Rep 2022; 19:101-112. [PMID: 35107810 PMCID: PMC8808274 DOI: 10.1007/s11904-021-00595-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The differential impact of the COVID-19 and HIV pandemics on marginalized communities has renewed calls for more robust and deeper investigation into structural and social causes of health inequities contributing to these infections, including underlying factors related to systematic racism. Using the Social Determinants of Health (SDOH) framework, we analyzed parallel and divergent factors associated with COVID-19 and HIV/AIDS and the prevalence of disparate disease in diverse communities. We utilized PRISMA guidelines to identify relevant literature (N = 210 articles) that resulted in a review of 125 articles included in our synthesis. RECENT FINDINGS With racial health inequities as a core contributor to disease vulnerability, we also identified other factors such as economic stability, social and community support, the neighborhood and built environment, healthcare access and quality, and education access and quality as important socioecological considerations toward achieving health equity. Our review identifies structural and systematic factors that drive HIV and COVID-19 transmission. Our review highlights the importance of not solely focusing on biomedical interventions as solutions to ending HIV and COVID-19, but rather call for building a more just public health and social service safety net that meets the needs of people at the intersection of multiple vulnerabilities.
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Affiliation(s)
- Raiza M Beltran
- David Geffen School of Medicine, Department of Infectious Diseases, UCLA Global HIV Prevention Research Program, 10833 Le Conte Avenue, Los Angeles, CA, 90095, USA.
- UCLA Hub for Health Intervention, Policy and Practice (HHIPP), CA, Los Angeles, USA.
| | - Ian W Holloway
- UCLA Hub for Health Intervention, Policy and Practice (HHIPP), CA, Los Angeles, USA
- Department of Social Welfare, School of Public Affairs, UCLA Luskin, Los Angeles, CA, USA
- California HIV/AIDS Research Program, Los Angeles, CA, USA
| | - Chenglin Hong
- UCLA Hub for Health Intervention, Policy and Practice (HHIPP), CA, Los Angeles, USA
- Department of Social Welfare, School of Public Affairs, UCLA Luskin, Los Angeles, CA, USA
- California HIV/AIDS Research Program, Los Angeles, CA, USA
| | - Ayako Miyashita
- UCLA Hub for Health Intervention, Policy and Practice (HHIPP), CA, Los Angeles, USA
- Department of Social Welfare, School of Public Affairs, UCLA Luskin, Los Angeles, CA, USA
| | - Luisita Cordero
- UCLA Hub for Health Intervention, Policy and Practice (HHIPP), CA, Los Angeles, USA
| | - Elizabeth Wu
- UCLA Hub for Health Intervention, Policy and Practice (HHIPP), CA, Los Angeles, USA
- Department of Social Welfare, School of Public Affairs, UCLA Luskin, Los Angeles, CA, USA
- California HIV/AIDS Research Program, Los Angeles, CA, USA
| | - Katherine Burris
- UNLV School of Public Health, UNLV Population Health & Health Equity Initiative, University of Nevada, Las Vegas, NV, USA
| | - Paula M Frew
- UNLV School of Public Health, UNLV Population Health & Health Equity Initiative, University of Nevada, Las Vegas, NV, USA
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Martino RJ, Krause KD, Griffin M, LoSchiavo C, Comer-Carruthers C, Halkitis PN. Employment Loss as a Result of COVID-19: a Nationwide Survey at the Onset of COVID-19 in US LGBTQ+ Populations. SEXUALITY RESEARCH & SOCIAL POLICY : JOURNAL OF NSRC : SR & SP 2022; 19:1855-1866. [PMID: 34804251 PMCID: PMC8590522 DOI: 10.1007/s13178-021-00665-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/28/2021] [Indexed: 05/15/2023]
Abstract
INTRODUCTION The unemployment rate in the US reached record highs during the COVID-19 pandemic, but little is known about the job loss experiences of lesbian, gay, bisexual, transgender, and queer (LGBTQ+) individuals, who are already economically disadvantaged due to structural and social inequities. METHODS Cross-sectional data on unemployment due to COVID-19 were collected between May and July 2020 among 1090 individuals across the US through an online survey. RESULTS Respondents who had been employed prior to COVID-19 formed the analytic sample (n = 990). Of these, 298 (27.3%) reported job loss or being furloughed due to COVID-19. When controlling for all other factors, we found statistically significant higher rates of unemployment among younger participants, HIV-positive individuals, men, Black and White non-Hispanic participants, those with less educational attainment, and those in multi-person homes. CONCLUSIONS The employment of LGBTQ+ people has been undermined by COVID-19, but as with all populations, those with multiple minority identities, such as Black or HIV+ and LGBTQ+, have been most severely affected. POLICY IMPLICATIONS LGBTQ+ populations in the US have experienced high levels of unemployment due to COVID-19. This study highlights the need for national data collection on sexual orientation and gender identity for unemployment as well as the need for substantive policies, such as expanding unemployment to assist in the economic recovery for populations most affected by COVID-19 and the Equality Act to offer further workplace protections.
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Affiliation(s)
- Richard J. Martino
- Center for Health, Identity, Behavior, and Prevention Studies (CHIBPS), Rutgers School of Public Health, Rutgers University, Newark, NJ USA
| | - Kristen D. Krause
- Center for Health, Identity, Behavior, and Prevention Studies (CHIBPS), Rutgers School of Public Health, Rutgers University, Newark, NJ USA
- Department of Urban-Global Health, Rutgers School of Public Health, Rutgers University, Newark, NJ USA
| | - Marybec Griffin
- Center for Health, Identity, Behavior, and Prevention Studies (CHIBPS), Rutgers School of Public Health, Rutgers University, Newark, NJ USA
| | - Caleb LoSchiavo
- Center for Health, Identity, Behavior, and Prevention Studies (CHIBPS), Rutgers School of Public Health, Rutgers University, Newark, NJ USA
| | - Camilla Comer-Carruthers
- Center for Health, Identity, Behavior, and Prevention Studies (CHIBPS), Rutgers School of Public Health, Rutgers University, Newark, NJ USA
| | - Perry N. Halkitis
- Center for Health, Identity, Behavior, and Prevention Studies (CHIBPS), Rutgers School of Public Health, Rutgers University, Newark, NJ USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Rutgers University, Piscataway, NJ USA
- Department of Urban-Global Health, Rutgers School of Public Health, Rutgers University, Newark, NJ USA
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Economic impact of COVID-19 pandemic on healthcare facilities and systems: International perspectives. Best Pract Res Clin Anaesthesiol 2021; 35:293-306. [PMID: 34511220 PMCID: PMC7670225 DOI: 10.1016/j.bpa.2020.11.009] [Citation(s) in RCA: 146] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/07/2020] [Accepted: 11/10/2020] [Indexed: 12/24/2022]
Abstract
International hospitals and healthcare facilities are facing catastrophic financial challenges related to the COVID-19 pandemic. The American Hospital Association estimates a financial impact of $202.6 billion in lost revenue for America's hospitals and healthcare systems, or an average of $50.7 billion per month. Furthermore, it could cost low- and middle-income countries ~ US$52 billion (equivalent to US$8.60 per person) each four weeks to provide an effective healthcare response to COVID-19. In the setting of the largest daily COVID-19 new cases in the US, this burden will influence patient care, surgeries, and surgical outcomes. From a global economic standpoint, The World Bank projects that global growth is projected to shrink by almost 8% with poorer countries feeling most of the impact, and the United Nations projects that it will cost the global economy around 2 trillion dollars this year. Overall, a lack of preparedness was a major contributor to the struggles experienced by healthcare facilities around the world. Items such as personal protective equipment (PPE) for healthcare workers, hospital equipment, sanitizing supplies, toilet paper, and water were in short supply. These deficiencies were exposed by COVID-19 and have prompted healthcare organizations around the world to invent new essential plans for pandemic preparedness. In this paper, we will discuss the economic impact of COVID-19 on US and international hospitals, healthcare facilities, surgery, and surgical outcomes. In the future, the US and countries around the world will benefit from preparing a plan of action to use as a guide in the event of a disaster or pandemic.
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Riley ED, Raven MC, Dilworth SE, Braun C, Imbert E, Doran KM. Using a "Big Events" framework to understand emergency department use among women experiencing homelessness or housing instability in San Francisco during the COVID-19 pandemic. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 97:103405. [PMID: 34403865 PMCID: PMC8581479 DOI: 10.1016/j.drugpo.2021.103405] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/27/2021] [Accepted: 07/29/2021] [Indexed: 11/19/2022]
Abstract
Background The COVID-19 pandemic created a major public health crisis that disrupted economic systems, social networks and individual behaviors, which led to changes in patterns of health care use. Factors associated with emergency department (ED) visits during the pandemic among especially high-risk individuals are unknown. We used a “Big Events” approach, which considers major disruptions that create social instability, to investigate ED use in people experiencing homelessness or housing instability, many of whom use drugs. Methods Between July and December 2020, we conducted a community-based San Francisco study to compare homeless and unstably housed (HUH) women who did and did not use an ED during the first 10 months of the pandemic. Results Among 128 study participants, 34% had ≥1 ED visit during the pandemic. In adjusted analysis, factors significantly associated with ED use included experiencing homelessness, cocaine use and increased difficulties receiving drug use treatment during the pandemic. Conclusion These findings build on the “Big Events” approach to considering risk pathways among people who use drugs. They suggest the importance of ensuring access to housing and low-barrier non-COVID health services, including drug treatment, alongside crisis management activities, to reduce the health impacts of public health crises.
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Affiliation(s)
- Elise D Riley
- University of California, San Francisco, Department of Medicine, Division of HIV, Infectious Diseases and Global Medicine, San Francisco, CA, USA.
| | - Maria C Raven
- University of California, San Francisco, Department of Emergency Medicine and UCSF Philip R. Lee Institute for Health Policy Studies, San Francisco, CA, USA
| | - Samantha E Dilworth
- University of California, San Francisco, Department of Medicine, Center for AIDS Prevention Studies, San Francisco, CA, USA
| | - Carl Braun
- University of California, San Francisco, Department of Medicine, Division of HIV, Infectious Diseases and Global Medicine, San Francisco, CA, USA
| | - Elizabeth Imbert
- University of California, San Francisco, Department of Medicine, Division of HIV, Infectious Diseases and Global Medicine, San Francisco, CA, USA
| | - Kelly M Doran
- New York University School of Medicine, Ronald O. Perelman Department of Emergency Medicine and Department of Population Health, New York, NY, USA
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Chilot D, Woldeamanuel Y, Manyazewal T. COVID-19 Burden on HIV Patients Attending Antiretroviral Therapy in Addis Ababa, Ethiopia: A Multicenter Cross-Sectional Study. RESEARCH SQUARE 2021. [PMID: 34341785 PMCID: PMC8328071 DOI: 10.21203/rs.3.rs-699963/v1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background There has been promising progress towards screening, testing, and retaining HIV patients in care in Ethiopia. Concern exists that possible disruptions in HIV programs due to COVID-19 could result in more HIV-related mortality and new HIV infections. This study aimed to investigate the real-time burden of COVID-19 on HIV patients attending antiretroviral therapy. Methods We conducted a facility-based, multicentre, cross-sectional study among HIV patients attending antiretroviral therapy in 10 healthcare facilities in Addis Ababa, Ethiopia, in the COVID-19 pandemic period. Data was collected using adapted, interviewer-based questionnaires, and entered into Epi Info version 7 and exported to SPSS version 26 for analysis. Result A total of 212 patients with HIV were included. Participants who missed visits for refill were 58 (27.4%). When the effects of other independent variables on appointments/visits for refill were controlled, the following characteristics were found to be the most important pridictors of missed appointments (P < 0.05): age ≥ 55 [AOR = 6.73, 95% CI (1.495–30.310)], fear of COVID-19 [AOR = 24.93, 95% CI (2.798-222.279)], transport disruption [AOR = 4.90, 95% CI (1.031–23.174)], reduced income for traveling to health facility [AOR = 5.64, 95% CI (1.234–25.812)], and limited access to mask [AOR = 7.67, 95% CI (1.303–45.174)], sanitizer [AOR = 0.07, 95% CI (0.007–0.729)] and non-medical support [AOR = 2.32, 95% CI (1.547–12.596)]. The participants were well aware of the COVID-19 preventive measures. The most costly COVID-19 preventive measures that cause financial burden to the patients were costs for buying facemasks (63.7%), disinfectants (55.2) and sops for handwashing (22.2). Participants who missed follow-up diagnostic tests were 56 (26.4%). Variables which were found to be statistically significant include the following: age ≥ 55 [AOR = 0.22, 95% CI (0.076–0.621)], partial lockdown [AOR = 0.10, 95% CI (0.011–0.833)], limited access to health services [AOR = 0.15, 95% CI (0.045–0.475)], reduced income for traveling to health facility [AOR = 0.18, 95% CI (0.039–0.784)], and unable to get mask [AOR = 0.12, 95% CI (0.026–0.543)]. Participants who missed counseling services were 55 (25.9%). In multivariate logistic regression the following were statisticaly significant: age ≥ 55 [AOR = 0.21, 95% CI (0.078–0.570)], fear of COVID-19 [AOR = 0.11, 95% CI (0.013–0.912)], reduced income [AOR = 0.17, 95% CI (0.041–0.699)], unable to get face mask [AOR = 0.19, 95%CI (0.039–0.959)], and partial lockdown [AOR = 0.08, 95% CI (0.008–0.790)]. Conclusions COVID-19 had a significant burden on HIV patients to attend their routine clinical care and treatment, which may lead to treatment failure and drug resistance. The impact was on their appointments for medication refills and clinical and laboratory follow-ups. Targeted initiatives are needed to sustain HIV clinical care and treatment services and improve the wellbeing of people living with HIV.
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Benfer EA, Vlahov D, Long MY, Walker-Wells E, Pottenger JL, Gonsalves G, Keene DE. Eviction, Health Inequity, and the Spread of COVID-19: Housing Policy as a Primary Pandemic Mitigation Strategy. J Urban Health 2021; 98:1-12. [PMID: 33415697 PMCID: PMC7790520 DOI: 10.1007/s11524-020-00502-1] [Citation(s) in RCA: 96] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/25/2020] [Indexed: 12/18/2022]
Abstract
The COVID-19 pandemic precipitated catastrophic job loss, unprecedented unemployment rates, and severe economic hardship in renter households. As a result, housing precarity and the risk of eviction increased and worsened during the pandemic, especially among people of color and low-income populations. This paper considers the implications of this eviction crisis for health and health inequity, and the need for eviction prevention policies during the pandemic. Eviction and housing displacement are particularly threatening to individual and public health during a pandemic. Eviction is likely to increase COVID-19 infection rates because it results in overcrowded living environments, doubling up, transiency, limited access to healthcare, and a decreased ability to comply with pandemic mitigation strategies (e.g., social distancing, self-quarantine, and hygiene practices). Indeed, recent studies suggest that eviction may increase the spread of COVID-19 and that the absence or lifting of eviction moratoria may be associated with an increased rate of COVID-19 infection and death. Eviction is also a driver of health inequity as historic trends, and recent data demonstrate that people of color are more likely to face eviction and associated comorbidities. Black people have had less confidence in their ability to pay rent and are dying at 2.1 times the rate of non-Hispanic Whites. Indigenous Americans and Hispanic/Latinx people face an infection rate almost 3 times the rate of non-Hispanic whites. Disproportionate rates of both COVID-19 and eviction in communities of color compound negative health effects make eviction prevention a critical intervention to address racial health inequity. In light of the undisputed connection between eviction and health outcomes, eviction prevention, through moratoria and other supportive measures, is a key component of pandemic control strategies to mitigate COVID-19 spread and death.
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Affiliation(s)
- Emily A Benfer
- Wake Forest University School of Law, 1834 Wake Forest Road, Winston Salem, NC, 27109, USA.
| | | | - Marissa Y Long
- Columbia University Mailman School of Public Health, New York, NY, USA
| | | | | | - Gregg Gonsalves
- Yale School of Public Health, Yale Law School, New Haven, CT, USA
| | - Danya E Keene
- Yale School of Medicine, Yale School of Public Health, New Haven, CT, USA
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Brown LB, Spinelli MA, Gandhi M. The interplay between HIV and COVID-19: summary of the data and responses to date. Curr Opin HIV AIDS 2021; 16:63-73. [PMID: 33186229 PMCID: PMC7735216 DOI: 10.1097/coh.0000000000000659] [Citation(s) in RCA: 112] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW We examine the interplay between the HIV and COVID-19 epidemics, including the impact of HIV on COVID-19 susceptibility and severe disease, the effect of the COVID-19 epidemic on HIV prevention and treatment, and the influence of the HIV epidemic on responses to COVID-19. RECENT FINDINGS Evidence to date does not suggest that people living with HIV (PLWH) have a markedly higher susceptibility to SARS-CoV-2 infection, with disparities in the social determinants of health and comorbidities likely having a greater influence. The majority of literature has not supported a higher risk for severe disease among PLWH in Europe and the United States, although a large, population-based study in South Africa reported a higher rate of death due to COVID-19. Higher rates of comorbidities associated with COVID-19 disease severity among PLWH is an urgent concern. COVID-19 is leading to decreased access to HIV prevention services and HIV testing, and worsening HIV treatment access and virologic suppression, which could lead to worsening HIV epidemic control. CONCLUSION COVID-19 is threatening gains against the HIV epidemic, including the U.S. Ending the HIV Epidemic goals. The ongoing collision of these two global pandemics will continue to need both study and interventions to mitigate the effects of COVID-19 on HIV efforts worldwide.
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Affiliation(s)
- Lillian B. Brown
- Division of HIV, ID, and Global Medicine, University of California, San Francisco
| | - Matthew A. Spinelli
- Division of HIV, ID, and Global Medicine, University of California, San Francisco
| | - Monica Gandhi
- Division of HIV, ID, and Global Medicine, University of California, San Francisco
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