In this Tanzanian study exploring COVID-related and generalized anxiety and its association with health outcomes among ALWH in care, we observed overall low proportions of moderate-severe generalized and COVID-19 specific anxiety. Importantly, there was no association between COVID-19 anxiety and either visit adherence or VLS. However, higher GAD was associated with lower odds of VLS, after adjusting for multiple factors. Maintaining VLS is critical to reducing transmission and HIV-related morbidity and mortality in this vulnerable population.
The low rates of both COVID- related and generalized anxiety among ALWH during COVID-19 in this study were surprising given the multiple challenges and widespread disruptions caused by the pandemic globally [41]. Several countries in SSA as well as globally have reported adverse effects of the COVID-19 pandemic on health care services, the environment and social support networks in adolescents with and without HIV [42, 43]. In a study conducted by the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) in 2021, teams from multiple countries in SSA reported interruptions to prevention programs, diagnostic testing, and access to ART during COVID-19. Individual-level impacts included feelings of social isolation, loneliness, loss to follow-up, food insecurity, poverty, and increases in adolescent pregnancies and sexually transmitted infections [10]. Many studies have also reported an increased risk of anxiety, depression, feeling lonely, and a reduction in the quality of life among adolescents during the COVID-19 lockdown because of these stressors [44–46].
There are several possible explanations of the lower rates of COVID-19 related anxiety in our study including low perceived risk of COVID-19, high levels of social support and short periods of lockdown in Tanzania which could have prevented isolation and anxiety as a result. It is notable that the highest COVID-19 anxiety score in our study was in the individual domain ‘The likelihood of a country running short of ARVs due disruption of production’ suggesting adolescents are more concerned about care interruptions than the risk of COVID-19 to themselves. In contrast, the ratings for self-perceived risk from COVID-19 infection were low. This concern has been reflected in other studies from Tanzania and other settings and is being explored in ongoing qualitative work by our team. In a survey of COVID knowledge and risk perception conducted among Tanzanians > 18 during the COVID pandemic, the proportion of persons who perceived themselves as low risk for COVID-19 was significantly higher than those who perceived themselves as high risk. Also, 44% believed the hot climate prevented COVID-19 spread [47]. In a study in Lebanon during COVID-19, among the 18% of adolescents who were found to have severe social anxiety, no correlation was found between having anxiety and acknowledging or fearing COVID-19 morbidity [48].
The high rates of perceived social support, parental support and other socio-environmental factors reported among study participants, all of which are strongly associated with positive mental health in AWHIV, could have also contributed to low rates of both COVID-19 related anxiety and GAD [49, 50]. In a recent systematic review of mental health conditions among AWHIV by Too et al., higher social support, family cohesion and positive parenting were all associated with lower rates of anxiety and depression [49]. This high level of social support could have also contributed to the low rates of depression observed in our cohort, a mental health condition highly correlated with anxiety in this population [51, 52].
Lockdowns introduced by COVID-19 severely restricted social interactions and several studies have reported the negative impacts of lockdown on adolescent mental health including feelings of isolation and separation from family and friends [53, 54]. In Tanzania, stringent nationwide lock downs introduced during COVID-19 were significantly shorter than in other countries (2–3 months) [22, 55 56]. Disruptions to social support systems and levels of anxiety among AWHIV as a result, could have been minimized and support from the family or other non-healthcare related support may have also remained constant or even increased. This high level of support and continuity of care could have also contributed to the low rates of HIV stigma observed in this study population.
Although we did not observe any association between COVID-19 related anxiety or GAD and visit adherence in this study, it is notable that visit adherence overall was < 75% in almost half of the study population. This is likely due to the impact of the COVID-19 pandemic on routine HIV services which even in the absence of long lockdowns were severely disrupted [57].
Despite suboptimal visit adherence, over 80% of participants were virologically suppressed. Both low GAD and high physical health scores were associated with VLS in this study. In Tanzania, during COVID-19, the government allowed the dispensing of extra ART to minimize physical contact which likely protected against significant interruptions to treatment and declining rates virologic suppression as a result. Our findings are similar to those from the Congo and other SSA countries which also showed stable or improved VLS during COVID-19 for many of the same reasons [58–60]. High ratings in social support, and self-management also likely contributed to the high proportion with VLS, although associations between these factors and VLS were not significant after adjusting for other potential confounders. High levels of social support and high self-management among AWHIV have also been shown to be associated with improved outcomes in HIV in several other studies [61, 62].
Finally, female gender was also marginally associated with improved visit adherence (p = .055) and associated with VLS (p = .049), which has also been reported before the COVID-19 pandemic [60]. It is an important finding to note considering the disproportionate effect COVID-19 had on adolescent girls mental health and well-being generally, and increased exposure to gender-based violence, school exclusion and economic hardships [63, 64].
To our knowledge this is one of the largest studies examining COVID-19 related anxiety and its association with health outcomes in AWHIV in Tanzania. However, our study had some limitations. The COVID related anxiety questionnaire adopted was one of the few published scales at the time of the study, and had not been validated in Tanzania or other LMIC settings during the early phases of the pandemic. Questions mostly focused on perceived risk of COVID-19 and concerns about COVID-19 transmission. The survey did not include questions on impacts on health and memory; financial wellbeing and lifestyle; social support; general health; coping strategies; and self-care. However, many of these areas were assessed in other validated questionnaires that were administered as part of this study which provided important insight into these areas in times of stress even if the questions were not COVID-19 specific. This study was also performed after COVID-19 surveillance and mitigation measures in Tanzania were halted in June 2020, only 3 months after the onset of the pandemic. Thus, these findings may not necessarily be generalizable to other settings, where mitigation measures were more stringent and general awareness of COVID-19 perhaps higher. Given the dynamic situation of COVID-19, prompting a range of different responses from individual to policy levels, the results may not be reflective of other times during the pandemic.