COVID-19 among LGBTQ+ individuals living with HIV/AIDS: psycho-social challenges and care options

The COVID-19 pandemic has led to a state of legally-enforced and self-imposed social distancing, resulting in persistent social isolation [1]. Prolonged social isolation has adversely impacted the mental, social, sexual, and physical wellbeing of the global populace [2]. Coping with mental and physical stressors amidst the global lockdown is especially strenuous for the Lesbian, Gay, Bisexual, Transgender, Queer and more (LGBTQ+) community, who are frequently subjected to social stigma and minority stress [3].

LGBTQ+ individuals face markedly elevated psycho-social stress, including systematic stigmatization, and have higher rates of HIV-risk behaviors (alcohol, substance abuse, unsafe sexual behaviors) [4],[5]. As a result, they bear a disproportionate burden of Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) and HIV/AIDS-related co-infections [6]. Particularly, Men-having-sex with men have a 22 times greater likelihood of becoming infected with HIV compared to their heterosexual counterparts [7]. In the same vein, transgender women have a 12-fold susceptibility to acquiring HIV infection, compared to the general population [7]. Collectively, the high prevalence of risky maladaptive practices, psychological stressors and HIV/AIDS-associated perpetual immunocompromised state (low CD4 count), may put LGBTQ+ Living with HIV/AIDS at a much higher risk of contracting COVID-19 [8].

The prolonged lockdown has led to an alarming rise in physical and psycho-social burdens among LGBTQ+ individuals Living with HIV/AIDS [9],[10]. A recent survey conducted in July 2020 by The Trevor Project reported that one in four LGBTQ+ youth, were unable to access mental health care, three-fourths LGBTQ+ participants indicated increased loneliness and depression, and over half (53%) indicated experiencing symptoms of depression during the worldwide, COVID-19 lockdown [11]. Another survey, conducted by the UNAIDS, the LGBTQ+ Foundation, Johns Hopkins Bloomberg School of Public Health and, other global institutions shows that close to a quarter (21%) global LGBTQ+ populace, living with HIV experienced “restricted access” to Antiretroviral therapy refills [12].

The COVID-19 economic crisis has caused massive truncation in workforce, around the globe [13]. The rampantly occurring layoffs and job loss during the COVID-19 crisis have exacerbated the pre-existing, sub-optimal socio-economic burden among this stigmatized group [12]. Furthermore, the dual-minority identity of LGBT+ individuals living HIV (as HIV+ and LGBT+), increases their likelihood of experiencing poverty, unemployment, homelessness, and food insecurity [14]. Ongoing challenges such as lower health insurance, income, and employment rates, which are inordinately prevalent among LGBTQ+ living with HIV/AIDS, have worsened during the lockdown [15],[16]. The UNAIDS survey results referenced previously, depict that as of May 2020, 13% LGBTQ+ survey respondents were unemployed, and close to a quarter (21%) were worried about losing jobs in the future [12].

In addition to social discrimination and stigmatization, LGBTQ+ individuals bear an unfortunate burden of higher intimate partner violence (IPV) rates, relative to their heterosexual, cisgender counterparts [17]. Reportedly, most abusers threaten to divulge the victim's sexual/gender identity to homophobic/transphobic friends, family, and/or employers, as a means to usurp power and control [18]. Threats related to identity disclosure situation may be far more serious among individuals wanting to conceal their dual HIV/AIDS-LGBTQ+ status. The repercussions of IPV may be life-threatening in situations where perpetrators resort to violence, and afflict physical injury to their partners [19]. Home confinement during the COVID-19 pandemic hinders victims from seeking medical and/or legal assistance from criminal justice authorities, support groups and/or supportive friends and family [9]. Apart from preventing HIV-positive LGBTQ+ from seeking adequate support for mental health, the current stay-at-home orders have hindered access to antiretroviral treatment and HIV medical attention [20].

The predisposition to HIV-risk behaviors (particularly unprotected sex) among LGBT+ individuals has exacerbated during the ongoing pandemic. The UNAIDS survey shows that 13% LGBTI respondents reported reduced ability to negotiate for safer sex, 1% have turned to sex work, and 2% were continuing to sell sex; during the pandemic [21]. The continual engagement in unsafe sexual practices, despite orders of strict isolation put LGBTQ+ at a much higher risk for acquiring both HIV and coronavirus.

At this juncture, we must acknowledge the impact of the structural inequities in worsening the health and socio-economic burden among HIV-positive LGBT+ individuals within social minority communities. In the United Sates, structural inequities are known to widen intergroup disparities in healthcare access, and promote stigma, stress, and political marginalization of these communities [22]. As a result, racial/ethnic minority groups, especially Afro-Americans and Hispanics inordinately suffer from adverse health conditions. It must be noted that Black and Hispanic/Latino MSM are at particularly high risk for HIV, compared with MSM from other communities; and structural racism during the current pandemic increases their susceptibility to COVID-19 [22],[23].

The ongoing pandemic has grievously impacted both the mental and physical well-being of HIV-positive LGBTQ+ individuals [23]. Limited accessibility to support services amplifies risk to COVID-19, as well as other chronic illnesses [24]. To add, LGBTQ+ people living with HIV bear a high threat to discrimination in health care, and thereby refrain from adequately seeking medical support and mental health assistance [25]. At this point, it is critical that multidisciplinary LGBTQ+ service providers, including health professionals, employers, social services providers, educational institutions and community organizations, move toward online service delivery [24],[26]. Particularly, both mental health providers, and medical professionals need to utilize a tailored-approach, to suit the needs of LGBTQ+ individuals living with HIV/AIDS.

The effective utilization of telemedicine services in expanding HIV care across LGBTQ+ communities has been demonstrated previously [27]. LGBTQ+ clients seeking telemedicine-led HIV care appreciate the continuity in health care, especially during these unprecedented, “social distancing” times [28]. In addition, the benefits of tele-counselling in mitigating the mental health ramifications of COVID-19 have been widely discussed [29]. While delivering mental health services to LGBTQ+ individuals living with HIV/AIDS, adopting a non-judgmental, friendly responses are critical to fostering trust and confidence [30]. At the same time, introducing provider-friendly policies will ease service delivery and safeguard providers from incurring financial losses [31],[32]. For example, many insurance companies are allowing therapists to bill for online therapy during the pandemic. Additionally, some states in the U.S. have permitted leniency in licensure expiration dates and/or requesting therapists with expired licenses return to the field [33],[34].

Medical efforts targeted towards HIV-positive/at-risk LGBTQ+ individuals must aim towards improving accessibility to routine HIV care and testing, providing screening services for HIV co-infections and COVID-19, and alleviating discrimination against LGBTQ+/HIV-positive individuals in a cost-friendly healthcare setting. Community clinics catering to the HIV-positive and/or LGBTQ+ clients may consider precociously supplying essential amenities, such as Preexposure (PrEP)/postexposure prophylaxis (PEP), condoms, emergency contraception, sterile needles, and lubricants [35]–[38]. These clinics may also serve as hubs for connecting clients to peer support services and domestic violence shelters and refuges.

Since the World Health Organization's release of the HIV self-testing guidelines in 2016, HIV self-tests have gained global acceptability among a wide-range of at-risk communities [39]. At-home HIV testing effectuates early diagnosis, and is particularly relevant during the ongoing pandemic. It offers fast results within the ease and comfort of one's home; promotes social-distancing and restricts community exposure to COVID-19 [39]. Other recommendations include, implementing flexible health services such as mobile clinics in low socio-economic areas and supplying ART refills lasting at least six months [40]. Restrictive measures imposed during the ongoing pandemic have exacerbated the pre-existing health disparities among at-risk/HIV-positive LGBT+ individuals. Clinical and social efforts towards uplifting at-risk/HIV-positive LGBTQ+ individuals, should persevere even after the pandemic; with specialized attention directed towards high-risk minority groups.