Impact of the COVID-19 Pandemic on Health Care Is Negatively Associated With Psychosocial Well-Being in an Italian Cohort of People Living With HIV.

Abstract

To the Editors: We read with great interest the article by Siewe Fodjo et al,1 entitled “Impact of the COVID-19 Pandemic on the Medical Follow-up and Psychosocial Well-Being of People Living With HIV: A Cross-Sectional Survey.” The authors assessed the possible consequences of the COVID-19 pandemic on the psychosocial well-being, access to health care services, and antiretroviral treatment (ART) provision of people living with HIV (PLWH). To this aim, they surveyed 317 PLWH originating from 32 countries, half of which are classified as lower middle-income countries (LMICs), between April 9, 2020, and May 17, 2020. Anxiety and depressive disorders were found in about 23% of participants. Thirteen participants (4.2%) reported an interruption of ART during the COVID-19 lockdown period. Difficulties related to ART refill included ART stock out at the clinic/pharmacy in 6 participants (1.9%), inability to go collect ART due to mobility restrictions in 21 participants (6.6%), and financial constraints in 2 participants (0.6%). A total of 104 participants (32.8%) reported some form of adaptation of HIV care such as changes in the amount of ART refills, teleconsultation for HIV follow-up, or obtaining ART without seeing a doctor.1 Their results showed that COVID-19 and associated restrictive measures have adversely affected the well-being and follow-up of PLWH around the world, especially those residing in LMICs. They recommended innovative antiretroviral provision and psychosocial support for PLWH during this outbreak.1 We are grateful to Siewe Fodjo et al1 for having contributed to a field where empirical data are lacking, specifically the consequences of the COVID-19 pandemic on HIV care and well-being of PLWH. Indeed, PLWH seem to be a group at greater risk of suffering from psychological distress during the COVID-19 pandemic because of a syndemic framework with the pandemic, exposure to mental health issues, and to a chronic illness.2–6 The Centers for Disease Control and Prevention also highlighted that individuals with chronic health conditions, such as PLWH, may develop a stronger stress response than the rest of the population.7 Moreover, outpatients' visits and treatment have been interrupted or postponed as a consequence of lockdown, leading to decreased engagement with care of PLWH in several countries.2,8–12 In our previous study, we showed that almost half of an Italian cohort of PLWH experienced a mild-to-severe adverse psychological impact related to the first stage of the COVID-19 pandemic and that among female PLWH and the elderly, those with a recent HIV diagnosis and more possible COVID-19 physical symptoms might be at greater risk of distress from the COVID-19 pandemic and might require particular care.13 Recently, we evaluated the impact of the pandemic on the PLWH treatment path and on the mental health status of an Italian cohort of PLWH in a cross-sectional study. Our findings seemed to confirm the conclusions of Siewe Fodjo et al1 and expand their contribution about PLWH in Italy. Indeed, their study included only 3 Italian PLWH. We enrolled PLWH under treatment at the Infectious Diseases Institute of the Fondazione Policlinico Universitario A. Gemelli IRCCS in Rome. They responded to an online survey from December 7 to December 23, 2020. Patients were invited to participate by telephone, and we sent them the link for completing the survey through email. Participants' details were hidden before the responses were analyzed to keep the data anonymous. We chose this time frame to analyze participants' responses during the second wave of the virus spread in Italy. We administered the Impact of Event Scale-Revised (IES-R)14–16 to measure the psychological impact of the COVID-19 pandemic and the Depression, Anxiety, and Stress Scale-21 (DASS 21)17,18 to measure mental health status. We collected demographic and HIV-associated clinical variables and information concerning greater difficulty than usual in obtaining medication [using a Likert scale from 1 (no difficulty) to 10 (extreme difficulty)], being forced to stay without medication or to skip outpatient visits because of pandemic restrictions, and worsening of the quality of care received [using a Likert scale ranging from 1 (no worsening) to 10 (extreme worsening)]. Furthermore, we collected a self-report measure of antiretroviral therapy adherence [using a Likert scale from 1 (no accuracy) to 10 (extreme accuracy)]. We used binary logistic regression analyses to explore factors significantly associated with mild-to-severe psychological distress measured by IES-R (score >23) and mild-to-extremely severe levels of depression (score >9), anxiety (score >6), and stress (score >10) measured by DASS-21. A 2-tailed P value of less than 0.05 was considered statistically significant. Owing to high intercorrelations between the collected COVID-19–related variables, only univariate analyses were run for these factors. A total of 60 Italian PLWH on ART completed the survey (full demographic and clinical characteristics are summarized in Table 1). Most participants were male (80%; n = 48), with ages ranging between 51 and 60 years (42%; n = 25), high school degree (40%; n = 24), and employed (63%; n = 38). Most of the enrolled participants presented a time >10 years from HIV diagnosis (62%; n = 37) and from the first ART (53%; n = 32) and reported HIV-RNA <50 copies/mL (83%; n = 50). TABLE 1. - Demographic and Clinical Characteristics and Impact on Treatment Variables (N = 60) Variables N (%) or Median* (IQR) Male gender 48 (80) Age, yr 31–40 12 (20) 41–50 10 (16.7) 51–60 25 (41.7) >60 13 (21.7) Education Lower secondary school 13 (21.7) Upper secondary school 24 (40) Bachelor's degree 23 (38.3) Sexual orientation Heterosexual 23 (38.3) Homosexual 37 (61.7) Employment status Unemployed 9 (15) Retired 13 (21.7) Employed 38 (63.3) Years from HIV diagnosis <5 yrs 9 (15) 5–10 yrs 14 (23) >10 yrs 37 (61.7) Time from starting the first ART regimen <5 yrs 11 (18.3) 5–10 yrs 17 (28.3) >10 yrs 32 (53.3) Own viremia knowledge 50 (83.3) HIV-RNA <50 copies/mL 50 (83.3) Adherence,* on a 0–10 scale 9.45 (0.81) Difficulty in obtaining medication* on a 0–10 scale 1 (1–6) Worsening of the received care's quality* 1.50 (1–6) Skip outpatient visits 23 (38.3) Stay without medication 10 (16.7) *Median (IQR).IQR, interquartile range; N, number. Overall, 33% (n = 20) of the PLWH showed a mild-to-severe psychological impact of COVID-19 on their life according to the IES-R. Regarding the DASS-21, 10% (n = 6) of PLWH obtained a score that suggested the presence of mild-to-severe levels of depression and anxiety and 6.7% (n= 4) of stress. A time between 5 and 10 years from HIV diagnosis was correlated with a trend toward significance to mild-to-severe levels of depression (DASS-21) [odds ratio (OR) 9.8; 95% confidence interval (CI): 0.92 to 104.1; P = 0.058] compared with a time >10 years. Demographic variables and other factors related to the severity of HIV infection (time from the first ART, HIV-1 plasma viral load, and adherence to ART in the past month) were not found to be associated with the psychological impact and mental health evaluation. We investigated the impact of the pandemic on PLWH health care (Table 1). The mean perceived worsening of the received care was 3.27 (SD 1.50), whereas the mean difficulty in obtaining medication was 3.27 (SD 1.50). Furthermore, 38.3% (n = 23) of respondents were forced to skip outpatient visits and 16.7% (n = 10) to stay without medication. In addition, worsened quality of care was not associated with any available sociodemographic variables. For the sake of brevity, only significant associations on logistic univariate analyses were reported. Skipping outpatient visits because of pandemic restrictions was a factor for mild-to-severe levels of psychological distress measured by IES-R (OR 3.95; 95% CI: 1.27 to 12.26; P = 0.017) and for mild-to-severe levels of depression (OR 10.00; 95% CI: 1.08 to 92.10; P = 0.042) measured by DASS-21. Moreover, a higher perceived worsening of health care was significantly associated with mild-to-severe levels of anxiety (OR 1.30; 95% CI: 1.00 to 1.69; P = 0.050) and with a trend toward significance with stress (OR 1.36; 95% CI: 0.98 to 1.88; P = 0.059) according to DASS-21. In addition, greater difficulty in obtaining medication was significantly correlated with mild-to-severe levels of stress (OR 1.48; 95% CI 1.04 to 2.11; P = 0.029) measured by DASS-21. Taken together, our findings suggest that among PLWH those forced to skip outpatient visits, with difficulty in obtaining medication and with a higher perception of the worsening of health care because of pandemic restrictions, might be at greater risk of mental health issues. Thus, we confirmed the existence of an adverse impact of the COVID-19 pandemic on the access to health care services and on the psychosocial well-being identified by Siewe Fodjo et al also in a non-LMIC such as Italy and beyond the initial stage of the pandemic. Comparing our findings with those of the West European group (n = 143) in Siewe Fodjo et al's study, they reported lower rates of adaptation of HIV care and of ART interruption (24.5%, n = 35 and 3.6, n = 5, respectively) and higher percentages of anxiety and depressive disorders (17.5%, n = 25 and 18.9, n = 27, respectively). However, we identified a psychological distress rate measured by IES-R that was similar to the percentage of PLWH suffering from at least one psychosocial disorder in the overall population indicated by Siewe Fodjo et al (almost one-quarter). The differences between the 2 studies might be due to the use of different screening tools, which makes it difficult to compare the rate of psychosocial disorders, but also because of different timings of the 2 surveys. Moreover, the population of Siewe Fodjo's study is similar to ours for age (47.6, SD 12.4) and gender (71.6%, n = 227 were male), but it included a higher proportion of patients with a high level of education (36.9%, n = 117 were postgraduates) and with an undetectable viral load (94.5%, n = 288). Furthermore, we added evidence of a significant correlation between damage due to the pandemic on medical follow-up and reduced psychosocial well-being of PLWH (eg, higher risk of mild-to-severe levels of stress, anxiety, and depression). By contrast, Siewe Fodjo et al focused their analyses on the factors that could be associated with the development of flu-like symptoms among PLWH. Our conclusions are limited by the small sample size of the study, the use of an online survey that left unexplored the population that does not use network devices, and the cross-sectional nature of the observation; thus, future longitudinal studies are necessary to confirm and check the progress of our findings. In any case, these preliminary data add support to Siewe Fodjo et al's findings and highlight the importance of putting in place alternatives to in-person visits and providing support for patients' access to therapy according to their needs. Finally, our data indicate the importance of ensuring the continuity of HIV care during the pandemic and tailoring specific psychological interventions to improve the psychological well-being of PLWH, especially during a crisis such as the current COVID-19 pandemic.