The impact of the COVID-19 pandemic on mental health and mental health care of people living with HIV (PLHIV) in California.

People living with HIV (PLHIV) in the United States often face multiple psychosocial and structural burdens that increase their vulnerability to mental health conditions. Access to mental health care is particularly important considering the strong link between good mental health and ongoing HIV treatment adherence.¹ However there are also multiple personal and structural barriers to accessing quality mental health services for PLHIV, including limited provider networks.² What is not currently known is how the COVID-19 pandemic has impacted the mental health of PLHIV and their access to mental health services, particularly in light of the rapid transition to telehealth-based care.

Semi-structured qualitative interviews were conducted between May and July 2021 with 12 PLHIV who used mental health services in California and 10 provider informants. Inclusion criteria for clients were PLHIV aged 18+ who accessed services in California for mild-to-moderate mental health conditions during the COVID-19 pandemic. Provider informants were clinical and non-clinical staff working in mental health services for PLHIV in California. Informants were purposively recruited and offered an incentive for taking part. Framework analysis was used to explore convergences and divergences in informant perspectives to identify thematic findings.³

1. The impact of the COVID-19 pandemic on the mental health of PLHIV

Most clients reported that their mental health had been negatively impacted by the COVID-19 pandemic. All providers also reported increased mental health deterioration, crises, and substance use among their clients. There was particular stress and anxiety reported around the unknowns of HIV and COVID-19 co-infection. Providers also reported increases in Post-Traumatic Stress Disorder (PTSD) among some older men who have sex with men (MSM) and survivors of the HIV/AIDS epidemic in the 1980s and 1990s, as well as increased depression and loneliness attributed to isolation from stayat-home orders. Some clients and providers also shared stories of mental health resilience during the pandemic, notably coming from other older MSM who had gained resilience from experiences with the HIV/AIDS epidemic.

“I’ve had some clients say, “Now, the wider population can appreciate what we went through,”, “Oh, yeah. This isn’t my first pandemic.” So, they are expressing some resiliency, too….I think some of them felt more understood or maybe people could have more empathy for what they’ve been through before.”

‘S’- Director & Outreach Worker, Female

2. The impact of the COVID-19 pandemic on mental health service delivery

All providers spoke about the negative impact of the pandemic on service delivery, especially compounding pre-existing resource challenges. All clients reported interruptions to, or loss of their usual mental health care, which negatively impacted their mental health. Most providers reported increased service demand from the onset and throughout the COVID-19 pandemic from clients experiencing mental health deterioration and crises, including from new and returning clients. Providers attributed increased outreach to pandemic related stress, anxiety and fear of HIV and COVID-19 co-infection. Some providers whose routine service scope included treating mild-to-moderate mental health conditions spoke instead of having to care for clients in the midst of severe mental health crises. Most providers reported particular difficulties engaging vulnerable clients facing mental health crisis and substance use relapse.

“[The Substance addiction therapy group] stopped for a couple of months. And those couple of months, I started going through it because I have nothing to do, I’ll stay home. All I’ll do is eat and go to sleep … I was getting depressed. I didn’t want to do anything, especially anything physical, anything productive, anything – like just stay home. And then my addiction got a little bit stronger too. So, I started using a little bit more…and then when the Zoom came in, I still was feeling like that. So, it was just pointless to go because I was going to be there just like a zombie. And I stopped [attending zoom therapy].”

‘H’- Gay Latinx Male, Aged 43

3. Telehealth during the COVID-19 pandemic and beyond

Although clients often recognized the positive and convenient aspects of using telehealth, the majority reported negative experiences around transitioning to its use. These experiences often presented a barrier to receiving and delivering ongoing mental health care, and in some cases led to client disengagement and drop-off in care provision. The impact of this was particularly significant on more vulnerable clients such as older, isolated MSM, people experiencing houselessness, and racial and ethnic minorities, who were less able to engage in telehealth due to the digital
divide. Most providers reported challenges during the rapid transition to telehealth including lack of clear implementation guidance, delays and difficulty gaining telehealth platform approval in their institutions. Despite initial challenges, providers and clients both felt that a hybrid model of inperson and telehealth care would be adopted for future care delivery, given time and resource to implement this in a client centered manner.

“Our folks who experience homelessness, folks with substance use and mental health issues. So, in our population, those folks are often the ones who COVID hit the hardest and also who have the most barriers to technology. So, if they’re experiencing homelessness, they might lose their phone. They might not have – I don’t know how to say it – technology literacy of how to use a Zoom or things like that.”

‘ G’- Program Supervisor, Female

“I don’t think we’re going to go back to pre-COVID times in any way. I think we have changed fundamentally as a society and that the new normal will look a little bit different than what was normal before COVID. One of the things that I think won’t change is telehealth. I think the genie’s been let out of the bottle and it’s not going back.”

‘Dr I’- Service Manager, Female

The COVID-19 pandemic brought challenges and barriers unique to PLHIV who use mental health services, which need to be taken into account if mental health interventions are to be accessible and high quality in the new era of care delivery, and further long-term harm is to be prevented. Specific attention needs to be paid to more vulnerable sub-groups with more individualized interventions to ensure services are accessible. Lessons should be learned from the pandemic to ensure that services are more resilient, especially in the face of future pandemics. PLHIV are both a vulnerable group and a resilient one, with many using their strength and resources to face the pandemic head on, therefore lessons should also be learned from this group.

Resources and support should be made available to PLHIV with mental health conditions to ensure that their needs continue to be met in the midst of public health crises, like the COVID-19 pandemic. At an individual level, such resources should address the digital divide that leaves some unable to take full advantage of telehealth options. Additionally, strategies are needed to maintain the personalized feel of in-person therapy during public health emergencies.