Of 323 participants scheduled to be contacted, 52% (n = 167) were contactable. Three attempts on two separate days were made to contact all participants. The most common reasons for participants not being contactable were: i) participants choosing not to receive phone calls (36%, n = 56); ii) participants being out of cellular coverage area (33%, n = 51); iii) the phone number provided no longer being in use (25%, n = 39). None of those contacted refused the GAD-7 assessment, and the scale had high internal consistency for the study population (Cronbach’s alpha 0.96)
Study population characteristics and findings from statistical analysis
Median age of the participants contacted was 44 years (IQR:40–50), most were cisgender women (60%, n = 100) and 81% (n = 135) had a monthly household income of < 200 USD. Prior to the lockdown, a majority (57%, n = 95) had been employed in the informal sector. Thirty-eight percent (n = 64) had history of tuberculosis and 27% (n = 45) were living with another comorbid illness. A significant proportion were not aware of their latest CD4 counts (40%, n = 66) or viral loads (43%, n = 71) (Table 1). Two participants reported exposure to symptomatic SARS-CoV-2 individuals though none of the participants reported positive symptomatology.
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.
|
Approximately 25% (n = 41) had GAD-7 scores ≥ 10. When dichotomized by GAD-7 scores, PLHIV with fewer median days of remaining ART appeared to have higher scores compared to those who had more days of ART (p = 0.05) (Table 1). This remained significant even when the GAD-7 cut-off was raised to 15 (p = 0.02). There were no significant differences observed for the other variables (Table 1). This remained true even when GAD-7 cut-offs were changed.
When stratified by gender, cisgender men living without a spouse appeared to have higher GAD-7 scores as compared to cisgender men living with a spouse (p = 0.02). GAD-7 scores were independent of living with a spouse for women (supplementary file). Similarly, we observed minimally significant higher GAD-7 scores among men whose monthly family income was < 130 USD compared to those who had higher monthly family income (p = 0.09). However, these findings were no longer significant when the GAD-7 cut-off was changed to 5, 8 or 15, indicating significance to be a function of the cut-off used and hence unreliable.
Findings from thematic analysis
The open-ended question was added after 38 participants had been contacted. A further 7 participants declined to answer the question, so thematic analysis was conducted on a subset of 122 participant responses.
Relative to cause(s) for concern, assessed through the open-ended question, four themes were identified. These were 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 that expressed each theme. However, themes a) and b) were expressed by approximately two-thirds; c) by roughly half and d) by a third of the participants.
a) Concerns associated with the immediate present
Health-related: These were articulated as perceptions of 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 HIV-resultant immunodeficiency.
“I have low CD4 counts and I am also taking medicines for tuberculosis. I am scared that I will get infected with coronavirus.” (age range: 40–50, 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.” (age range: 40–50 years, cisgender woman, GAD-7 score: 10)
Health unrelated: Financial insecurity resulting from unemployment and a lack of savings, 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.” (age range: 50–60, 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.” (age range: 40–50, 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.” (age range:50–60 years, cisgender woman, GAD-7 score: 10)
b) Concerns associated with the imminent future
Health-related: These were articulated as apprehensions about COVID-19 persistence continuing to endanger personal health, following reopening.
“I work as a care counsellor in the ART centre. There are no coronavirus patients at this time point, but I am worried what will happen if they visit the centre in the future?” (age range: 40–50 years, cisgender man, GAD-7 score: 1)
“I am scared to return to get my medicines at the ART centre after the lockdown, if coronavirus does not end. Coronavirus must end.” (age range: 20–30 years, cisgender woman, GAD-7 score: 5)
Health unrelated: Fears about shortages of opportunities for gainful employment or dismissal from current employment fed into anxieties about an uncertain future that such eventualities would ensue. Such fears also 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?” (age range: 30–40 years, 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?” (age range: 40–50 years, 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?” (age range: 30–40 years, cisgender woman, GAD-7 score: 12)
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.” (age range: 40–50 years, 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.” (age range: 40–50 years, 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.” (age range: 30–40 years, cisgender male, GAD-7 score: 21)
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.” (age range: 40–50 years, cisgender man, GAD-7 score: 0)
“Now, I have work on the sewing machine and I am not worried at all.” (age range 30–40 years, cisgender woman, GAD-7 score: 0)
“I do not get out of the house and I am not worried at all.” (age range: 40–50 years, cisgender woman, GAD-7 score: 0)