Study population
Of 323 potential participants, 167 (52%) were able to be contacted, and all were included in the quantitative analysis. Among those not able to be contacted after three attempts on two separate days (n=156), 36% chose not to receive phone calls, 33% were out of cellular coverage area, and 25% had provided a phone number that was no longer in use. Overall (n=167), median age was 44 years (IQR 40 – 50), 60% were cisgender women (n=100), 81% had a monthly household income below 200 USD, and 57% had been employed in the informal sector prior to the lockdown. A significant proportion were not aware of their latest CD4 counts (40%) or viral loads (43%), 38% had a history of tuberculosis, 27% (n=45) were living with another comorbid illness, and two participants reported exposure to symptomatic SARS-CoV-2 individuals, but none of the participants reported positive symptomatology (Table 1).
Table 1
Distribution of GAD-7 scores of by sociodemographic and clinical characteristics among PLHIV contacted
|
Total
N (%)
|
GAD-7 ≥ 10
n (%)
|
GAD-7 < 10
n (%)
|
p-value
|
N (%)
|
167
|
41 (24.6)
|
126 (75.4)
|
-
|
Median age in years (IQR)
|
44 (40–50)
|
43 (40–49)
|
45 (40–50)
|
0.8
|
Gender
Cisgender men
Cisgender women
Transgender woman
|
66 (39.5)
100 (59.9)
1 (0.6)
|
17 (41.5)
23 (56.1)
1 (2.4)
|
49 (38.9)
77 (61.1)
0
|
0.3
|
Monthly household income (USD)
< 65
65–130
131–199
≥ 200
|
35 (20.9)
64 (38.3)
36 (21.6)
32 (19.2)
|
11 (26.8)
14 (34.1)
10 (24.4)
6 (14.6)
|
24 (19.0)
50 (39.6)
26 (20.6)
26 (20.6)
|
0.6
|
Education
No formal education
≤ 9 years
> 9 years
|
22 (13.2)
74 (44.3)
71 (42.5)
|
4 (9.8)
22 (53.7)
15 (36.6)
|
18 (14.3)
52 (41.3)
56 (44.4)
|
0.4
|
Employment prior to lockdown †
Unemployed
Informal sector
Salaried
|
33 (19.8)
95 (56.9)
39 (23.3)
|
9 (21.9)
25 (61.0)
7 (17.1)
|
24 (19.0)
70 (55.6)
32 (25.4)
|
0.5
|
Living with a spouse‡
Yes
No
|
83 (49.7)
84 (50.3)
|
19 (46.3)
22 (53.7)
|
64 (50.8)
62 (49.2)
|
0.7
|
Median duration on ART in years (IQR)
|
9.8 (6.5–12.9)
|
9.5 (6.7–11.8)
|
9.9 (6.4–13.1)
|
0.4
|
Latest CD4 counts (cells/mm3)
< 500
≥ 500
Do not know
|
44 (26.4)
57 (34.1)
66 (39.5)
|
10 (24.4)
13 (31.7)
18 (43.9)
|
34 (26.9)
44 (34.9)
48 (38.1)
|
0.8
|
Latest viral load
Undetectable (< 50 copies/mL)
≥ 50 copies/mL
Do not know
|
87 (52.1)
9 (5.4)
71 (42.5)
|
16 (39.0)
3 (7.3)
22 (53.7)
|
71 (56.3)
6 (4.8)
49 (38.9)
|
0.1
|
Prior history of tuberculosis
Yes
No
|
64 (38.3)
103 (61.7)
|
19 (46.3)
22 (53.7)
|
45 (35.7)
81 (64.3)
|
0.3
|
Living with another comorbidity §
Yes
No
|
45 (27.0)
122 (73.0)
|
12 (29.3)
29 (70.7)
|
33 (26.2)
93 (73.8)
|
0.7
|
Median days of remaining ART (IQR)
|
60 (28–76)
|
32 (17–60)
|
60 (30–79)
|
0.05
|
Discontinued HAART during the lockdown
|
5 (3.3)
|
-
|
-
|
-
|
ART – Antiretroviral Therapy
Median GAD-7 score for the study population was 3 (IQR: 0–9), range 0–21
† Informal sector employment for women mainly included working as house maids or domestic help (89%), for men this was mainly as daily wage laborers (92%)
‡ Living with a spouse: No includes PLHIV who are single, widowed, separated or divorced
§ Comorbidity includes having any of the following: COPD, asthma, CVD, hypertension, diabetes, renal disease, cancer.
|
Thematic analysis was conducted on a subset of 122 participant responses, after excluding the first 38 participants (for whom the open-ended question had not been asked) and an additional 7 participants who declined to answer the question.
Prevalence of anxiety
The GAD-7 scale had high internal consistency among our study population (Cronbach’s alpha 0.96). Overall, approximately 25% of participants (n=41/167) reported anxiety symptoms consistent with generalized anxiety disorder. Participants with GAD-7 scores ≥10 were more likely to have fewer remaining days of ART medications (p=0.05) compared to those with scores below 10, and this difference remained significant when the GAD-7 cutoff was raised to 15 (p=0.02). Other variables did not differ significantly by GAD-7 score, even when alternative cutoffs were applied. When stratified by gender, cisgender men with GAD-7 scores ≥10 were more likely to be living without a spouse and marginally more likely to have a monthly family income below 130 USD (p=0.09) than those with scores below 10; among cisgender women, GAD-7 scores were independent of living with a spouse (supplementary file). These gender-specific findings were no longer significant when the GAD-7 cut-off was changed to 5, 8 or 15, indicating that significance was a function of the cut-off used and hence unreliable.
Causes of anxiety
The following four themes were identified in thematic analysis: a) concerns related to the immediate present; b) concerns related to the imminent future; c) lack of social and financial support; and d) indifference to circumstances secondary to COVID-19; themes a) and b) were further classified as health-related or health-unrelated. Cognizant of the qualitative framework of thematic analysis, we do not quantify the exact number of participants who expressed each theme. However, two-thirds expressed themes A and B, roughly one half expressed theme C, and one third expressed theme D.
Theme A: Concerns associated with the immediate present
Immediate health-related concerns were articulated as perceived increased susceptibility to COVID-19 or beliefs of being infected with COVID-19 in the absence of symptoms. These appeared to directly stem from participants’ self-awareness of immunodeficiency due to HIV.
“I have low CD4 counts and I am also taking medicines for tuberculosis. I am scared that I will get infected with coronavirus.” (cisgender man, GAD-7 score: 2)
“I have low immunity because of HIV, I am worried of getting COVID-19 infection. I feel that even a common cold could be coronavirus.” (cisgender woman, GAD-7 score: 10)
Immediate non health-related concerns centered around financial insecurity resulting from unemployment and a lack of savings and predominantly drove apprehensions about food security, eviction, and the ability to provide for the family.
“I am a construction worker. I am at home with my two children. My wife is dead. Currently I am worried about how the house will run as there is no money and no work.” (cisgender man, GAD-7 score:12)
“As the only earning member of my family, I am worried. My children are young. We are doing whatever it takes to get by, but because of the lockdown I am unemployed now. The house is rented. I cannot return to my village either.” (cisgender man, GAD-7 score: 6)
“There is no food at home currently and I cannot feed my children. I am a housewife and I have no income or savings. The children used to earn by washing cars.” (cisgender woman, GAD-7 score: 10)
Theme B: Concerns associated with the imminent future
Imminent health-related concerns were articulated as apprehension about COVID-19 persistence continuing to endanger personal health following a reopening.
“I work as a care counsellor in the ART center. There are no coronavirus patients at this time point, but I am worried what will happen if they visit the center in the future?” (cisgender man, GAD-7 score: 1)
“I am scared to return to get my medicines at the ART center after the lockdown, if coronavirus does not end. Coronavirus must end.” (cisgender woman, GAD-7 score: 5)
Imminent non health-related concerns included fears about shortages of opportunities for gainful employment or dismissal from current employment and fed into anxieties about an uncertain future that such eventualities would ensue. Such fears often co-existed with an anticipation for “normality”.
“I am a sex worker. My business is closed and I have no clients because of the lockdown. I will die of hunger if the virus continues. I am worried all the time. If coronavirus doesn't end, then what?” (cisgender woman, GAD-7 score: 5)
“I am going to lose my job because of this lockdown. I am eager to know when will COVID-19 end, when will we go back to normal life?” (cisgender woman, GAD-7 score: 9)
“I stay with my mother and sold fruits for a living. Now that has closed, and I don’t know when I will be able to start again. When will COVID-19 end? When can we start normal life?” (cisgender woman, GAD-7 score: 12)
Theme C: Lack of social and financial support
Isolation from family members and friends accompanied feelings of loneliness and helplessness, and the lack of financial buffers perpetuated these feelings.
“I stay alone. I used to run a beauty salon that I rented, which is now closed. I have no money to pay the owner who is asking for rent. I have no savings and no one to talk to. I have a lot of tension and I feel lonely.” (cisgender woman, GAD-7 score: 21)
“I stay alone. My daughter is recently married. I worked in a company, but it has closed. I have no salary and I stay in a rented house. I receive no help from my in-laws who stay in the same neighborhood.” (cisgender woman, GAD-7 score: 10)
This theme was also common among migrant workers from outside or within the state.
“My family is in Bihar (a state 900 miles to the east). I want to go home, but I can't. There is a lot of tension and I worry a lot. I have no work and no money now.” (cisgender male, GAD-7 score: 21)
Theme D: Indifference to circumstances secondary to COVID-19
Some remained unperturbed by the pandemic and its control measures. However, this indifference appeared to be closely linked to a sense of security by virtue of a profession, continuing employment or location.
“I work in the fields. There is no coronavirus there. Everything is fine.” (cisgender man, GAD-7 score: 0)
“Now, I have work on the sewing machine, and I am not worried at all.” (cisgender woman, GAD-7 score: 0)
“I do not get out of the house and I am not worried at all.” (cisgender woman, GAD-7 score: 0)