AIDS and Behavior (2021) 25:3658–3668
https://doi.org/10.1007/s10461-021-03292-y
ORIGINAL PAPER
Resilience, Anxiety, Stress, and Substance Use Patterns During
COVID‑19 Pandemic in the Miami Adult Studies on HIV (MASH) Cohort
Janet Diaz‑Martinez1 · Javier A. Tamargo1 · Ivan Delgado‑Enciso2 · Qingyun Liu1 · Leonardo Acuña3 ·
Eduardo Laverde3 · Manuel A. Barbieri3 · Mary Jo Trepka1 · Adriana Campa1 · Suzanne Siminski4 ·
Pamina M. Gorbach5 · Marianna K. Baum1
Accepted: 25 April 2021 / Published online: 19 May 2021
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021
Abstract
We evaluated mental health and substance use during the COVID-19 pandemic in 196 participants from the Miami Adult
Studies on HIV (MASH) Cohort. A survey was administered between July–August of 2020, including validated measures
of resilience and anxiety, a scale to measure COVID-19-related worry, and self-reported substance use. Compared to HIVuninfected participants (n = 80), those living with HIV (n = 116) reported fewer anxiety symptoms, less COVID-19-related
worry, and higher resilience. Those with more anxiety symptoms and lower resilience engaged in more frequent alcohol
consumption, binge drinking, and cocaine use. Alcohol misuse was more common among HIV-uninfected participants.
Cocaine use was reported by 21% fewer participants during the pandemic compared with 7.3 ± 1.5 months earlier. Possibly
due to their experiences with HIV, PLWH responded with higher resilience and reduced worry and anxiety to the adversities
brought by the COVID-19 pandemic.
Keywords HIV · COVID-19 · Resilience · Mental health · Substance use
Introduction
The circumstances generated by the COVID-19 pandemic
and the response to mitigate the spread of the infection
have had immense psychological impacts on mental health
on a global scale [1, 2]. A recent systematic review and
meta-analysis concluded that the COVID-19 pandemic can
increase the prevalence of stress, anxiety, and depression in
the general population [2]. COVID-19 could impose greater
psychological effects on vulnerable communities affected
* Marianna K. Baum
baumm@fiu.edu
1
Robert Stempel College of Public Health, Florida
International University, Miami, FL, USA
2
School of Medicine, University of Colima, Colima, MX,
Mexico
3
College of Arts, Sciences & Education, Florida International
University, Miami, FL, USA
4
Frontier Science Foundation, Brookline, MA, USA
5
Fielding School of Public Health, University of California,
Los Angeles, CA, USA
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Vol:.(1234567890)
by health disparities [3, 4]. The pandemic may particularly
adversely affect people living with HIV (PLWH) who are
already disproportionately impacted by racial and psychosocial hardships, including stigma and isolation [5]. In addition, PLWH suffer from high rates of multiple comorbidities
including diabetes, hypertension, liver disease, and elevated
rates of alcohol and substance use disorders (SUDs) [6–9].
On the other hand, PLWH are considered a resilient population [10]. Resilience has been described as a dynamic process influenced by biological, social, and environmental factors [11]. In a systematic review of literature, Windle defined
resilience as “the process of effectively negotiating, adapting
to, or managing significant sources of stress or trauma” [12].
Resilience may ameliorate psychological distress after traumatic events [13]. For example, higher levels of resilience
were associated with lower anxiety and depression among
COVID‐19 patients in Wuhan, China [14]. Nonetheless, the
psychological status of PLWH and their ability to cope during the COVID‐19 pandemic has not yet been sufficiently
explored.
Limited scientific evidence is available on how the
COVID-19 pandemic could lead to changes in substance
use patterns [15], which could ultimately heighten the
AIDS and Behavior (2021) 25:3658–3668
risks for the infection and lead to adverse outcomes. The
National Institute on Drug Abuse (NIDA) has declared that
the COVID-19 pandemic presents unique challenges for people with SUDs, such as interfering with recovery. NIDA,
therefore, has urged the research community to collect and
share data on drug use trends and their relationship with
COVID-19 [16].
South Florida suffers from multiple epidemics. In addition to the current COVID-19 crisis, South Florida has one
of the highest HIV incidence rates in the nation [17], an
epidemic that has been strongly linked to drug use in Miami,
Florida [18–20]. The clinical impact of HIV infection on the
natural history of COVID-19 is uncertain, although limited
evidence suggests that PLWH are not at greater risk of infection, severe disease, or death than the general population, if
they are effectively treated with antiretroviral therapy (ART)
[21, 22]. Therefore, the impact of the COVID-19 epidemic
on vulnerable and marginalized communities, and the intricate relationship between mental health and drug use in the
context of HIV and the COVID-19 pandemic warrants examination. The objectives of this study were to evaluate resilience, mental health and substance use patterns during the
COVID-19 pandemic among people living with and without
HIV from the Miami Adult Studies on HIV (MASH) Cohort.
Methods
Data was collected during July and August of 2020 from
participants in the Miami Adult Studies on HIV (MASH)
cohort, which follows over 1000 people living with and
without HIV. The MASH cohort is largely comprised of
Black and Hispanic, middle-aged individuals who live in a
poor urban sector of Miami, FL. Participants are recruited
from neighboring clinics, particularly the Borinquen Health
Care Center (https://www.borinquenhealth.org/), as well as
nearby food banks and shelters. Participation in the MASH
cohort is contingent on confirmation of HIV status (e.g.
rapid antigen/antibody test, nucleic acid test) confirmed
with name and date of birth or from medical records with
participants’ signed release of medical information. Participants are followed every 6 months for a range of data,
including morbidity, healthcare access and utilization, medication adherence, socioeconomic factors, and use of alcohol,
tobacco, and illicit substances.
All MASH cohort participants were eligible to participate in the survey. A convenience sample of 200 MASH
cohort participants were randomly contacted by telephone
and invited to participate in a supplemental study of the
impact of the COVID-19 epidemic on their lives. In total,
232 participants were called, 200 were reached, and all of
those that were reached agreed to participate. Four participants were excluded from the analyses due to missing data.
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The study protocol was approved by the Institutional Review
Board at Florida International University. Verbal consent
was obtained, witnessed, and documented by two members
of our research staff. A survey was administered by phone
and participants were given an incentive of $20 for their
participation. The survey was designed by the Collaborating Consortium of Cohorts Producing NIDA Opportunities
(C3PNO), which coordinates U01 cohort studies funded by
the National Institutes for Drug Abuse (NIDA). The C3PNO
COVID-19 Survey includes original and validated questionnaires; survey and sources available at https://www.c3pno.
org.
Data from the COVID‑19 Survey
The General Anxiety Disorder-7 (GAD-7) is a 7-item
screening tool used to assess symptoms of anxiety [23, 24].
The total score ranges from 0 to 21; scores of 10 or more are
indicative of the presence of anxiety symptoms.
COVID-19-related worry was assessed by asking participants “On a scale of 1 to 10, how worried are you about the
COVID-19 pandemic? 1 being not worried at all and 10
being extremely worried.” Scores of ≥ 6 were considered
high levels of worry.
The Brief Resilience Scale (BRS) was used to assess
resilience [25, 26]. Scores range from 0 to 6. High resilience
was defined as scores above the median value for our study
sample (> 3.4).
The Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) questionnaire was used to assess alcohol
consumption [27]. Scores of ≥ 4 for men and ≥ 3 for women
are indicative of alcohol misuse. Binge drinking was determined with the third item of the AUDIT-C and defined as
“monthly or more” consumption of ≥ 5 or ≥ 4 drinks on one
occasion for males and females, respectively.
Data Collected Pre‑pandemic
Data from participants’ last cohort visit was used to supplement this analysis, with a mean range of 7.3 ± 1.5 months
between the two assessments. Sociodemographic characteristics (age, gender, race/ethnicity, income), AUDIT-C,
and substance use (30-day frequency) were self-reported.
Anthropometric and blood pressure measurements and fasting blood draws were performed by trained research staff
and used to determine body mass index (BMI), hypertension
(systolic ≥ 130 or diastolic ≥ 85 mm Hg), and hyperglycemia
(fasting glucose ≥ 100 mg/dL).
Statistical Analysis
Descriptive statistics are reported as mean ± standard deviation (SD) or as No. (%). The primary independent variable
13
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was HIV status, and the primary outcomes were anxiety
symptoms, COVID-19-related worry, resilience, and drug
use. T-tests and Chi square tests were performed to test for
group differences in continuous and categorical outcomes,
respectively. Within group differences in frequencies were
tested with McNemar’s test. Correlation analyses included
Pearson product-moment correlations for two continuous
variables and Spearman’s rank correlations when at least one
variable was ordinal. Logistic regressions were performed
to calculate odds ratios (OR) and 95% confidence intervals
(CI) for anxiety symptoms, high levels of COVID-19-related
worry, and high resilience for PLWH compared to HIVuninfected participants. Adjusted odds ratios (AOR) were
calculated by adjusting for sociodemographic characteristics
(age, sex, race/ethnicity, income, education, housing, and
employment). Results were considered statistically significant at two-tailed P < 0.05. The data analysis for this paper
was generated using SAS software, version 9.4. Copyright
© 2002-2012 SAS Institute Inc.
Results
Sample Characteristics
Table 1 displays the socioeconomic and clinical characteristics of the participants. The study sample included a total
of 196 participants, including 116 (59.2%) PLWH and 80
(40.8%) HIV-uninfected participants. A total of 69 (35.2%)
participants reported having been tested for COVID-19 by
nasopharyngeal swabs and only 4 (2.0%) had tested positive. Participants had a mean age of 56.6 ± 6.7, 51.0% were
female, 75.5% Black non-Hispanic, and 16.8% Hispanic. The
vast majority earned below $15,000 annually per household
(76.3%), were unemployed (including disability, 90.3%), and
had a high-school education or less (72.4%). Prior to the
pandemic, most participants reported having health insurance (87.2%), Medicare or Medicaid coverage (80.5%), and
had received primary care in the past 12 months (93.3%),
but less than half (47.7%) reported having received mental
health care. Only 13 (6.6%) participants reported having
health insurance without Medicare or Medicaid coverage.
The majority of PLWH were receiving ART (99.1%),
86.2% were virally suppressed (< 200 HIV RNA copies/mL)
and had a mean CD4 lymphocyte count of 652.7 ± 333.9
cells/µL at their last clinic visit. Compared to PLWH, HIVuninfected participants were slightly older (55.7 ± 6.5 vs.
57.8 ± 6.8, respectively; t = 2.16, P = 0.032) and were
more likely to be homeless (2.6% vs. 10.0%, respectively;
χ2 = 4.91, P = 0.026). Additionally, prior to the pandemic,
a greater proportion of PLWH reported having health insurance (92.1% vs. 80.3%; χ2 = 5.96, P = 0.015), Medicare or
Medicaid coverage (85.1% vs. 74.1%; χ2 = 3.66, P = 0.056),
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AIDS and Behavior (2021) 25:3658–3668
and receiving primary (97.4% vs. 87.7%; χ 2 = 7.18,
P = 0.007) and mental health care (51.8% vs. 42.0%;
χ2 = 1.82, P = 0.178) in the past 12 months, although the
difference was only statistically significant for insurance and
primary care. No other sociodemographic or clinical characteristic significantly differed between PLWH and HIVuninfected participants.
The characteristics of the participants in this study were
representative of the overall characteristics of the MASH
cohort, with the exception that, compared to the overall
cohort, Hispanics were under-sampled (16.8% vs. 29.0%,
respectively) and Black non-Hispanics were over-sampled
(75.5% vs. 61.7%, respectively).
Mental Health and Substance Use
We performed correlation analyses between GAD-7,
COVID-19-related worry, BRS, and substance use (Table 2).
Anxiety symptoms were directly correlated with COVID19-related worry (r = 0.33, P < 0.0001), and these were
both inversely correlated with resilience (r = − 0.40 and
r = − 0.14, respectively; P < 0.0001 for both). Additionally,
anxiety symptoms correlated with alcohol misuse, binge
drinking, and cocaine use. Resilience was inversely correlated with binge drinking.
Stratifying the sample by HIV status showed several differences related to substance use patterns. Among PLWH,
anxiety symptoms directly correlated with binge drinking
and cocaine use. On the other hand, among HIV-uninfected
participants, COVID-19-related worry correlated with alcohol misuse.
Resilience, Anxiety, and Stress
Anxiety symptoms, COVID-19-related worry, and high
resilience were reported by 18.9%, 71.4% and 49% of participants, respectively. PLWH, compared to HIV-uninfected
participants, had lower mean GAD-7 (measure for anxiety)
(3.6 ± 5.1 vs 6.8 ± 6.2; t = 3.92, P < 0.001) and COVID19-related worry (6.8 ± 3.2 vs 7.9 ± 3.0; t = 2.30, P = 0.023),
and higher BRS (measure for resilience) (3.5 ± 0.6 vs
3.3 ± 0.7; t = 2.17, P = 0.031), respectively (Table 3). Similar results were obtained when comparing the risk for anxiety symptoms, high levels of COVID-19-related worry, and
high resilience (Table 3). Compared to HIV-uninfected participants, PLWH had lower odds of having anxiety symptoms (OR = 0.39, 95% CI 0.18–0.81; χ2 = 6.31, P = 0.012)
and lower odds of high levels of COVID-19-related worry
(OR = 0.42, 95% CI 0.21–0.83; χ2 = 6.21, P = 0.013), as
well as twofold higher odds of high resilience (OR = 2.01
95% CI 1.13–3.60; χ2 = 5.59, P = 0.018). These relationships remained largely unchanged after adjusting for
AIDS and Behavior (2021) 25:3658–3668
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Table 1 Socioeconomic and
clinical characteristics of
MASH cohort participants
during the COVID-19 pandemic
Age, years
Sex, male
Race/ethnicity
Black non-Hispanic
White non-Hispanic
Hispanic
Household income
$15,000 or less
$15,000–$30,000
$30,000 or more
Education
Less than high-school
High-school or GED
More than high-school
Housing
House/apartment
Homeless
Employment
Unemployed
Employed
Healthcare
Insured
Medicare or medicaid
Received primary carea
Received mental careb
Metabolic
Obesity
Hypertension (SBP ≥ 130 OR DBP ≥ 85)
Hyperglycemia (Fasting glucose ≥ 100)
Total
(N = 196)
% or
Mean ± SD
HIV+
(N = 116)
% or
Mean ± SD
HIV−
(N = 80)
% or
Mean ± SD
Test
P
56.6 ± 6.7
49.0%
55.7 ± 6.5
50.0%
57.8 ± 6.8
47.5%
t = 2.16
χ2 = 0.118
0.032
0.730
75.5%
7.7%
16.8%
77.6%
8.6%
13.8%
72.5%
6.2%
21.2%
χ2 = 2.07
0.358
76.3%
20.4%
3.2%
74.1%
24.1%
1.8%
79.7%
14.9%
5.4%
χ2 = 3.86
0.143
45.9%
26.5%
27.6%
46.6%
26.7%
26.7%
45.0%
26.3%
28.7%
χ2 = 0.099
0.951
94.4%
5.6%
97.4%
2.6%
90.0%
10.0%
χ2 = 4.91
0.026
90.3%
9.7%
93.1%
6.9%
86.3%
13.7%
χ2 = 2.54
0.111
87.2%
80.5%
93.3%
47.7%
92.1%
85.1%
97.4%
51.8%
80.3%
74.1%
87.7%
42.0%
χ2 = 5.96
χ2 = 3.66
χ2 = 7.18
χ2 = 1.82
0.015
0.056
0.007
0.178
45.9%
44.9%
19.9%
46.6%
44.9%
16.5%
45.0%
45.0%
25.0%
χ2 = 0.046
χ2 = 0.001
χ2 = 2.12
0.830
0.981
0.145
Data are presented as the mean ± standard deviation (using t test for comparison) and percentages (using
Pearson Chi square test for comparison). Bolded values denote statistical significance (P < 0.05).
a
During the past 12 months, have you seen or talked to any of the following health care providers about
your own health? A primary care physician or general physician (M.D. or D.O.)
b
During the past 12 months, have you seen or talked to any of the following health care providers about
your own health? A mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or
clinical social worker
sociodemographic factors (age, gender, education, employment, income, housing status) and metabolic parameters
(Table 3).
Additionally, we performed linear regressions to examine whether resilience confounded the relationship between
HIV and anxiety symptoms and COVID-19-related worry
(Table 4). In univariate regressions (Model 1), both HIV
and resilience were independently associated with lower
anxiety symptoms and COVID-19-related worry. When the
model included both HIV and resilience, the effect of HIV
on anxiety symptoms was attenuated, with a tendency to
attenuate the effect of HIV on COVID-19-related worry as
well (Model 2). On the other hand, we found no evidence of
a significant interaction effect between HIV and resilience
(Model 3).
Substance Use Patterns
Table 5 compares substance use between PLWH and HIVuninfected participants before and during COVID-19 pandemic. Before the COVID-19 pandemic, HIV-uninfected
participants were more likely to use cocaine than PLWH
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AIDS and Behavior (2021) 25:3658–3668
Table 2 Correlation coefficient values among mental health scores and substance use during the COVID-19 pandemic in the Miami Adult HIV
Studies (MASH) cohort
Total (N = 196)
GAD-7a
COVID-19 worrya
Tobaccoa
Alcohol misuseb
Binge drinkingb
Cannabisb
Cocaineb
PLWH (N = 116)
HIV-uninfected (N = 80)
GAD-7
Worry
BRS
GAD-7
Worry
BRS
GAD-7
Worry
BRS
–
–
0.09
0.16*
0.43****
0.12
0.19**
0.33****
–
0.06
− 0.03
0.09
− 0.05
− 0.06
− 0.40****
− 0.14****
0.01
0.06
− 0.35**
− 0.08
0.05
–
–
0.14
0.09
0.32**
0.11
0.24**
0.31***
–
0.05
0.09
0.20
0.01
− 0.10
− 0.31****
− 0.02
0.02
0.03
− 0.27^
− 0.11
0.03
–
–
− 0.03
0.13
0.54***
0.03
− 0.13
0.30**
–
0.02
0.30**
0.01
− 0.21
0.03
− 0.46****
− 0.26****
0.04
0.19
− 0.41**
− 0.001
0.04
BRS Brief Resilience Scale, GAD-7 General Anxiety Disorder-7, PLWH people living with HIV
Bolded values denote statistical significance (P < 0.05)
a
Pearson correlation test
b
Spearman correlation test
*P value < 0.05; **P value < 0.01; ***P value < 0.001; ****P value < 0.0001
^Tendency to statistical significance, P value < 0.10 for a two-sided test
(41.2% vs. 26.7%; χ2 = 4.54, P = 0.033) and showed a trend
towards higher alcohol misuse as well (43.7% vs. 30.4%;
χ 2 = 3.64, P = 0.056). During the pandemic, there was
a higher proportion of HIV-uninfected participants who
reported alcohol misuse compared to PLWH (50.0% vs
29.3%; χ2 = 8.62, P = 0.003), but there was no difference in
rates of cocaine use (15.0% vs. 13.8%; χ2 = 0.06, P = 0.8). In
fact, the frequencies of cocaine use significantly dropped by
12.9% and 26.5% among PLWH and HIV-uninfected participants, respectively. No between- or within-group differences
were seen for cigarette smoking and use of cannabis.
When participants were asked “What have you noticed
about the price of (cocaine) in the past month?” 19 (9.7%)
reported that prices of cocaine had gone up. When asked
“What changes, if any, have you noticed regarding your ability to get (cocaine) in the past month?” 14 (7.14%) reported
that cocaine was harder to obtain.
Discussion
The COVID-19 pandemic generated a global crisis and a
rapid implementation of extraordinary changes that have disproportionally impacted marginalized populations [28]. The
aim of this study was to examine resilience, mental health
and substance use patterns during the COVID-19 pandemic
among people living with and without HIV from the MASH
cohort. The data used in this analysis was collected between
July and August of 2020, in the midst of rising COVID19 cases and deaths in Florida after easing of restrictions
that were placed to mitigate the spread of the disease. Our
findings revealed that PLWH reported higher resilience and
less anxiety symptoms and COVID-19-related worry than
13
HIV-uninfected peers. Our findings also suggest that higher
resilience partially explains why PLWH displayed lower
anxiety and worry. Significant relationships were found
between mental health, particularly anxiety, and substance
use. Our results indicate that, compared to their peers, many
PLWH may be protected from psychosocial stressors during
the COVID-19 pandemic via psychological resilience, which
they have built over time through the management of the
HIV infection [10]. Our study emphasizes that public health
efforts to promote resilience in vulnerable populations may
enable such groups to cope with and overcome the adversities generated by the COVID-19 pandemic.
Resilience can be considered a positive adaptation to
challenges and is comprised of both internal (e.g. self-efficacy, coping skills) and external factors (e.g. social support).
Our findings suggest that PLWH have higher resilience than
HIV-uninfected peers. People living with HIV, due to their
effort to manage a chronic and potentially fatal disease, have
developed resilient characteristics [10]. This, in turn, might
have equipped PLWH with coping mechanisms that allow
them to adapt and manage their anxiety and worry about
the COVID-19 pandemic to a greater degree than individuals with the same race/ethnicity and similar socioeconomic
status who are uninfected with HIV. PLWH have been living with HIV for an average of 16 ± 9 years and are highly
engaged in HIV care and are adherent to treatment, as evidenced by the great majority of them (86.2%) having suppressed HIV viral load. As such, the resilience observed
among PLWH in this study may be a result of their many
years living with and managing HIV disease, as well as their
unfettered access to medical care and support services.
Resilience was inversely correlated with anxiety and
worry. Furthermore, only 13% of PLWH reported anxiety
T-test were performed to compare distribution of GAD-7, worry (1 to 10), and BRS scores
Logistic regressions were performed with HIV-uninfected individuals set as reference group
Estimates are adjusted for sociodemographic characteristics (age, sex, race/ethnicity, income, education, housing, and employment)
b
c
d
Bolded values denote statistical significance (P < 0.05)
AOR adjusted odds ratio, BRS Brief Resilience Scale, GAD-7 General Anxiety Disorder-7, PLWH people living with HIV
Anxiety symptoms were measured by the GAD-7, with scores ≥ 10 considered the presence of anxiety symptoms. COVID-19-related worry was measured with a scale of 1 to 10, with scores
of ≥ 6 considered high levels of worry. Resilience was measured with the BRS, with scores of ≥ 3.4 considered as high resilience
–
0.38, 0.17–0.85
–
0.37, 0.18–0.80
–
1.97, 1.05–3.73
–
0.012
–
0.013
–
0.018
–
6.31
–
6.21
–
5.59
–
0.39, 0.18–0.81
–
0.42, 0.21–0.83
–
2.01, 1.13–3.60
< 0.0001
–
0.023
–
0.031
–
3.92
–
2.30
–
2.17
–
6.8 ± 6.2
27.5%
7.9 ± 3.0
81.3%
3.3 ± 0.7
38.8%
Negative (N = 80)
Positive (N = 116)
3.6 ± 5.1
12.9%
6.8 ± 3.2
64.7%
3.5 ± 0.6
56.0%
4.9 ± 5.8
18.9%
7.2 ± 3.2
71.4%
3.4 ± 0.6
49.0%
GAD-7
Anxiety symptoms
COVID-19 worry
High levels of worry
BRS
High Resilience
a
–
5.51
–
6.42
–
4.41
P
χ2
AOR, 95% CIc,d
P
χ2
OR, 95% CIc
P
t
HIV statusb
Total (N = 196)
Table 3 Comparison of anxiety symptoms, worry, and resilience between PLWH and HIV-uninfected participants during the COVID-19 pandemica
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–
0.018
–
0.011
–
0.035
AIDS and Behavior (2021) 25:3658–3668
symptoms as compared to 28% of the HIV-uninfected participants. In comparison, a population-based study of
PLWH reported a 19% prevalence of anxiety symptoms
during 2015-2016, also using the GAD-7 [29]. Among
the general U.S. population, the rate of anxiety reported
in 2019 was 8.2% and rose to approximately 30% during
the COVID-19 pandemic [30], similar to the rate observed
among HIV-uninfected participants in the MASH cohort.
Likewise, the proportion of participants who reported high
levels of COVID-19-related worry was significantly lower
among PLWH (64.7%) than among the HIV-uninfected
participants (81.3%). Higher resilience among PLWH may
in part explain the lower prevalence of anxiety symptoms
and COVID-19 related worry when compared to HIV-uninfected participants. Indeed, resilience attenuated the effect
of HIV status on mental health, particularly anxiety symptoms. These findings are consistent with prior reports. A
large multicenter study of PLWH in the United Kingdom
found that resilience was inversely related to the prevalence
of depression and anxiety [31]. Resilience has been found
to be a protective factor for the mental health of HIV + men
who have sex with men [32, 33].
Additionally, our study shows that the COVID-19 pandemic has impacted substance use in the MASH cohort.
Cocaine use is a major cause of drug-related deaths in South
Florida [34]; yet, we found a significant decline in its use
during the COVID-19 pandemic as compared to 7.3 ± 1.5
months earlier, prior to lockdowns. While cocaine use was
higher among HIV-uninfected participants than PLWH prior
to the pandemic, the frequency of use during the pandemic
did not differ between the two groups. We did not observe
significant changes in alcohol consumption, but alcohol
misuse was more prevalent among the HIV-uninfected participants during the pandemic. Interestingly, the prevalence
of alcohol misuse during the pandemic among PLWH was
29%, similar to what has been reported for PLWH in the U.S.
before the pandemic (27%) [35].
The reduction of cocaine use follows a reduction in the
supply chain of the drug, imposed by the measures to contain the pandemic, rather than individual decisions or circumstances [36, 37]. In fact, the participants reported that
the drug had become more expensive and harder to obtain.
During the pandemic, cocaine prices have sharply increased
in Miami [36], and 76.3% of our study population earned
$15,000 or less annually, which made the existing illicit market too expensive to sustain with their income. A report prepared by the United Nations Office on Drug Crime Global
Research Network showed that new patterns of drug use
have emerged during the pandemic [37]. While there has
been an overall decrease in consumption of drugs, there are
concerns about increased use of more easily obtained substances (e.g. alcohol) and more harmful patterns of drug use
among people with SUDs [15, 37].
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Table 4 Resilience as a
potential confounder between
HIV and mental healtha
AIDS and Behavior (2021) 25:3658–3668
Model
Parameter
1a (univariate)
1b (univariate)
2 (multiple)
HIV
Resilience
HIV
Resilience
3 (with interaction) HIV
Resilience
HIV*Resilience
Anxiety symptoms
COVID-19 worry
β
SE
t
− 3.17
− 3.39
− 2.50
− 3.11
− 8.29
− 0.67
− 1.70
0.81
0.55
0.76
0.54
3.81
1.66
1.09
− 3.92
0.0001
− 6.14 < 0.0001
− 3.30
0.001
− 5.72 < 0.0001
− 2.18
0.031
− 0.40
0.687
− 1.55
0.123
P
β
SE
t
P
− 1.05
− 0.66
− 0.93
− 0.56
− 4.37
− 0.89
− 1.01
0.46
0.33
0.46
0.33
2.31
1.01
0.66
− 2.30
− 2.01
− 2.02
− 1.69
− 1.89
− 0.88
− 1.52
0.023
0.046
0.045
0.093
0.060
0.378
0.131
a
Resilience was measured with the Brief Resilience Scale (BRS); anxiety symptoms were measured with
the Generalized Anxiety Disorder-7 (GAD-7); COVID-19-related worry was measured with a scale of 1 to
10
Bolded values denote statistical significance (P < 0.05)
Table 5 Comparison of
substance use by HIV status
and time of assessment (before
and during the COVID-19
pandemic)
Substances
Alcohol misusec
Binge drinkingd
Smoker (tobacco)
Cannabis
Cocaine
Total
N = 196
Before
During
COVID-19
χ2
Pb
Before
During
COVID-19
χ2
Pb
Before
During
COVID-19
χ2
Pb
Before
During
COVID-19
χ2
Pb
Before
During
COVID-19
χ2
Pb
PLWH
N = 116
HIV-uninfected
N = 80
χ2
Pa
35.9%
37.8%
30.4%
29.3%
43.7%
50.0%
3.64
8.62
0.056
0.003
0.24
0.622
17.3%
15.8%
0.22
0.637
14.8%
12.9%
1.32
0.251
21.3%
20.0%
1.37
1.78
0.242
0.183
0.31
0.578
51.0%
48.0%
0.33
0.564
47.4%
43.1%
0.06
0.808
56.2%
55.0%
1.48
2.68
0.223
0.101
1.64
0.201
26.0%
25.5%
2.78
0.096
23.3%
21.5%
0.08
0.782
30.0%
31.2%
1.11
2.34
0.291
0.125
0.07
0.796
32.65%
14.3%
0.40
0.5271
26.7%
13.8%
0.20
0.6547
41.2%
15.0%
4.54
0.06
0.033
0.812
36.00
< 0.001
15.00
0.0001
21.00
< 0.001
AUDIT-C Alcohol Use Disorders Identification Test-Consumption, PLWH people living with HIV
Bolded values denote statistical significance (P < 0.05)
a
Chi square tests were performed for between groups comparisons of PLWH vs. HIV-uninfected
b
McNemar’s tests were performed for within group comparisons of before vs. during COVID-19 pandemic
c
Alcohol misuse was determined by AUDIT-C ≥ 4 in men, ≥ 3 in women
d
Binge drinking was determined by self-reported monthly or higher consumption of ≥ 5 or ≥ 4 drinks on
one occasion for males and females, respectively, on the AUDIT-3
13
AIDS and Behavior (2021) 25:3658–3668
When we examined the relationship between resilience,
mental health, and substance use during the pandemic, we
found that anxiety symptoms correlated with alcohol misuse,
binge drinking, and cocaine use. Resilience was inversely
correlated with binge drinking. COVID-19-related worry
was correlated with alcohol misuse only among HIV-uninfected participants. Mental health disorders, such as mood
and anxiety disorders, often co-occur with SUDs [38–40]. In
the general U.S. adult population, almost 20% of all persons
with a diagnosis of SUD had at least one co-occurring anxiety disorder [38]. These connections underscore the crucial
role of mental health in the successful treatment of SUDs
and in preparing and supporting populations for dealing with
crises, such as pandemics and natural and man-made disasters. Some have called for a larger emphasis on resilience in
the treatment of SUDs, as it may have behavioral and biological benefits [41]. Because psychological resilience may
offer a level of protection against mental health disorders
[42, 43], strategies to promote resilience at the individual
and community levels may offer substantial benefits during
and after the COVID-19 pandemic.
Chandra et al. described psychological (and physical) health as one of the core components of community
resilience [44] and how health promotion is a key lever to
enhance community resilience [45]. Not surprisingly, PLWH
in the MASH cohort report healthcare access and utilization in greater proportions than HIV-uninfected participants.
Federally-funded programs like the Ryan White HIV/AIDS
Program support PLWH with insufficient financial resources
with medical and support services including mental health
and treatment for SUDs. This type of support may contribute to resilience among PLWH and may partially explain
the results of this study. Consequently, increased access to
mental health and substance use services could play a role
in increasing resilience, mitigating anxiety and stress, and
addressing social needs that may arise during the COVID-19
pandemic among HIV-uninfected people who may not have
access to medical care and other support services. While the
COVID-19 pandemic has presented with significant challenges to public mental health, it is also an opportunity for
improvements in mental health services [46]. To mitigate
the impact of the pandemic, health systems should facilitate
the continuation of mental health services for those with
pre-existing conditions, as well as increase access to those
who develop mental health problems during the pandemic
whether they are HIV-infected or not [46]. Community outreach, through partnerships between healthcare providers
and other social services, can help promote mental health
literacy, identify stressors in the community, and encourage
vulnerable individuals to seek care [46].
Community resilience is considered fundamental to the
preparedness, response, and recovery to major traumatic
events [47]. In order to achieve community resilience,
3665
social, economic, structural, and health inequities must be
addressed. Targeted strategies to enhance and strengthen
individual and community resilience may help vulnerable
populations to adapt to the challenges of the COVID-19
pandemic and aid in their post-pandemic recovery. In addition to health promotion, Chandra et al. delineate education
as a way to improve risk communication [44, 45]. Tailored
educational materials can raise awareness, encourage protective behaviors, and relieve stress and anxiety by informing
and empowering the community. The integration and collaboration of governmental and non-governmental entities
are essential to building and strengthening community resilience [44] and build trust with minorities that often mistrust
government and medical systems [48–50]. Moreover, the
relationships between organizations and individuals can play
a significant role in building social connectedness, further
contributing to the resilience of a community [44].
Several strengths and limitations of our study must be
acknowledged. Our study was conducted in a well-characterized cohort of an underserved and vulnerable population
living in South Florida, largely comprised of low-income
minorities living with and without HIV and high rates of
comorbidities. As mentioned earlier, PLWH in the MASH
cohort have been living with HIV for nearly two decades
on average and are highly engaged with HIV care. Subsequently, our findings may not be generalizable to some
groups of PLWH within the U.S., such as those recently
diagnosed and those that may not be receiving treatment.
On the other hand, the MASH cohort resembles a large portion of the U.S. population of PLWH in that they are on
average middle-aged, Black non-Hispanic, and receiving
HIV care [17, 51]. The HIV-uninfected participants from
the MASH cohort were recruited from the same community
as their HIV + peers, therefore representing middle-aged,
low-income minorities with several social and economic
disadvantages. Validated and frequently used measures of
resilience and anxiety symptoms were used, allowing for
comparisons to other communities and populations. However, the data was self-reported, thus subject to bias and
under-reporting of substance use. Nonetheless, surveys were
administered by trained research staff working with these
participants every 6 months, which limits potential misunderstanding of the questions from the respondents. Lastly,
the cross-sectional study design does not allow for causation
to be inferred. Thus, longitudinal follow-up of the MASH
cohort based on this study’s findings may help us identify
the unique social disparities and mental health challenges
of a highly vulnerable community and inform public health
practices to improve mental health relief during times of
crises. The dissemination of our results can increase the
public visibility and awareness of the mental health vulnerabilities faced by marginalized communities amid the
13
3666
COVID-19 pandemic and unify efforts to eliminate mental
health inequities.
Conclusions
The COVID-19 pandemic generated a global crisis, which
has disproportionally impacted marginalized communities.
Our findings support the assertion that PLWH, by chronically dealing with a potentially deadly disease (i.e. HIV
infection), have acquired tools to build resilience, worry
less about COVID-19, and experience fewer anxiety symptoms than their HIV-uninfected peers. Nonetheless, the high
prevalence of anxiety and worry during the COVID-19 pandemic warrants improved public health efforts for mental
health relief. A decline in cocaine use was observed; however, the decline is likely due to reduced availability and
higher cost of the drug rather than personal choices. There
is much to be learned from exploring how vulnerable communities are affected by the COVID-19 pandemic and the
emerging changes on their mental health and substance use
patterns. Research is needed to identify psychosocial factors
that can improve the ability of marginalized communities
to cope with the pandemic by providing strategies to build
resilience to better prepare populations before, during, and
after broadly impacting crises.
Acknowledgements We thank the MASH Cohort participants, the
MASH research team, and C3PNO investigators for their contributions to this work.
Author Contributions Conceptualization: JDM, JAT, SS, PMB, and
MKB; Data curation: JAT, IDE, and QL; Formal analysis: IDE and
QL; Funding acquisition: SS, PMB, and MKB: Investigation: JDM and
JAT; Methodology: JDT, JAT, IDE, MJT, SS, PMB, and MKB; Project administration and supervision: AC and MKB; Writing—original
draft: JDM and JAT; Writing—review and editing: all authors critically
revised earlier versions of the manuscript. All authors have read and
approved the final version of the manuscript.
Funding The research reported in this publication was supported by the
National Institute on Drug Abuse of the National Institutes of Health
under Award No. U01-DA040381 and U24-DA044554-04S1. The content is solely the responsibility of the authors and does not necessarily
represent the official views of the National Institutes of Health.
Availability of Data Data described in the manuscript, code book, and
analytic code will be made available upon request pending application
and approval by the principal investigator (baumm@fiu.edu).
Declarations
Conflict of interest The authors have no conflicts of interest to report.
Consent to Participate All participants provided written informed
consent.
Ethics Approval FIU Institutional Review Board.
13
AIDS and Behavior (2021) 25:3658–3668
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