The Impact of COVID-19 on Cardiovascular Health Behaviors in People Living with HIV

Abstract

The COVID-19 pandemic’s impact on cardiovascular health behaviors including diet, physical activity, medication adherence, and self-care among people living with HIV (PLWH) remains unknown. Using qualitative analyses, we examined the impact of the COVID-19 pandemic on cardiovascular health behaviors among PLWH. Twenty-four PLWH were enrolled in this multisite study from September to October 2020. Individuals participated in semi-structured telephone interviews that were recorded, transcribed, and coded by 4 independent coders. Codes were adjudicated and analyzed for common themes. Participants were, on average, 59.2 years old (+/− 9.4), 75% African American (n=18) and 71% male (n=17). The pandemic altered cardiovascular disease health behaviors. PLWH changed diet based on stay-at-home orders and food access. Alterations in physical activity included transitioning from gym and group class exercise to home-based exercise. Antiretroviral adherence was maintained, even when other health behaviors wavered, suggesting resilience in PLWH that may be harnessed to maintain other health behaviors.

Introduction

People living with HIV (PLWH) are approximately twice as likely to develop cardiovascular disease (CVD) compared to the general population (Alonso et al., 2019). As the risk of cardiovascular disease is high among PLWH, risk reduction behaviors are imperative in this aging population. Lifestyle factors are primary contributors to CVD and include modifiable health behaviors such as diet, physical activity, medication adherence, and self-care (Lee et al., 2018).

The impact of the COVID-19 pandemic has been far-reaching, influencing many cardiovascular health behaviors. Limited access to grocery stores can alter food consumption including less consumption of fresh fruits and vegetables and more consumption of convenience and junk foods which are often laden with increased salt, fat and sugar (Di Renzo et al., 2020). Maintenance of regular physical activity is a cornerstone of cardiovascular health yet stay-at-home orders due to the COVID-19 pandemic led to the closure of gyms and other venues for physical activity. The COVID-19 pandemic led to inconsistent attendance at HIV medical appointments for many PLWH (Kalichman et al., 2020) and increased the use of telemedicine; although the ability to access medications during the pandemic did not seem to waver for most PLWH (Kalichman et al., 2020; Sun et al., 2020). Self-care is a critical factor for positive health outcomes and includes masking and social distancing. The ability of PLWH to maintain self-care during the COVID-19 pandemic is unclear.

Data describing the COVID-19 pandemic’s impact on cardiovascular health behaviors including diet, physical activity, medication adherence, and self-care in PLWH are limited. To help us better understand the impact of COVID-19 on CVD health behaviors among PLWH, we conducted qualitative analyses exploring the relationships across three diverse sites.

Methods

We enrolled participants from the Nurse-led Intervention to Extend the HIV Treatment Cascade for Cardiovascular Disease Prevention (EXTRA-CVD) study. EXTRA-CVD is a multisite randomized clinical effectiveness trial examining the efficacy of a novel prevention nurse intervention to encompass the HIV/AIDS treatment cascade for the treatment of hyperlipidemia and hypertension among PWH on ART (Okeke et al., 2019). Findings are reported according to the consolidated criteria for reporting qualitative research (COREQ) (Tong et al., 2007). Study procedures were approved by the University Hospitals Cleveland Medical Center Institutional Review Board (#03-18-16) and by reliant review at Duke Health and MetroHealth System.

Sample and Setting

PLWH were invited through convenience sampling to participate in semi-structured telephone interviews to assess changes in mood, health behaviors, and chronic disease management during the COVID-19 pandemic. As a purposive, convenience sample all participants contacted at their study visit were available for participation and met eligibility criteria. Twenty-four participants across three study sites including Duke Health (Durham, North Carolina), University Hospitals (Cleveland, Ohio) and MetroHealth System (Cleveland, Ohio) completed the interviews. Participants were eligible if they were enrolled in the EXTRA-CVD study. Eligibility criteria for the EXTRA-CVD study included the following: 18 years of age or older; received care at an HIV clinic where the study was taking place; had a recent HIV viral load that was < 200 copies/ml; had hypertension; and had hypercholesterolemia.

Data Collection and Analysis

The purpose of this analysis was to understand the impact of the COVID-19 pandemic on cardiovascular health behaviors in PLWH. The Social Ecological Model served as the framework for this analysis and captures the fluid interrelations among numerous individual and environmental factors (McLaren & Hawe, 2005). The interview guide queried about participants thoughts and beliefs about how the COVID-19 pandemic impacted their cardiovascular health. Questions regarding medication adherence (HIV and cardiovascular), diet, physical activity and social interactions were solicited. Follow-up probes such as “can you tell me more about that or can you tell me more about how that affects you” were implemented after significant statements were made or clarification of a statement was needed.

Data collection took place from September 2020 to October 2020. Verbal informed consent was obtained from all participants prior to any research activities. One interviewer (CHD) performed all interviews by telephone in a private setting. One interviewer was used for consistency in delivery of the interview and the interviewer’s racial ethnicity and positionality were not disclosed to the participants. All interviews were recorded and then professionally transcribed verbatim. Transcripts were de-identified prior to analysis and managed using Dedoose Version 8.3.35. The quality of the transcripts was verified through review of 25% of the interviews for accuracy and completeness of transcription. The sample size, which was determined a priori to ensure equal sample size representation across the three enrollment sites, was deemed by the coding team to provide sufficient data to reach saturation (i.e., when further transcripts led to limited changes in the codebook) (Saunders et al., 2018). The number of interviews conducted were determined based on the team’s experience in conducting qualitative descriptive studies (Webel et al., 2020).

All transcripts were independently coded by four team members (AW, EB, MM and CHD). Codes were adjudicated and analyzed for common themes by all team members and assigned final codes. All disagreements were resolved through consensus.

Finally, all transcripts were re-reviewed to examine presence and suitability with each assigned theme. Themes that appeared two or more times in the transcripts and additional analysis produced no new information or alterations to the code book were deemed final themes (Guest et al., 2006). The strongest data associated with the final themes are presented. An audit trail of decisions was kept, and codebook and descriptions were finalized by consensus by four team members (AW, EB, MM and CHD) and clarified as a group on how each code should be applied.

Results

On average, participants were 59.2 years old (+/− 9.4), 75% African American (n=18), 71% male (n=17), and on average have been living with HIV for 23 years (Table 1). Several themes emerged from the question, “What impact has COVID-19 had on your ability to manage your cardiovascular disease and self-care?” The five following behaviors were the most dominant/observed; promotion of self-care, diet modifications during COVID-19, restructured physical activity, faithfully taking medication, and perseverance in time of difficulty (Table 2).

Table 1.

Demographic Characteristics by Site

	Duke	Metro	University Hospitals
	n= 8	n= 8	n= 8
Age (average years) (SD)	54.1 (+/− 7.0)	60.1 (+/− 11.5)	63.3 (+/− 7.7)
Sex at birth (%)
Male	7 (87.5)	4 (50.0)	6 (75.0)
Female	1 (12.5)	4 (50.0)	2 (25.0)
Race (%)
Black/AA	6 (7.1)	5 (62.5)	7 (87.5)
White/Caucasian	1 (12.5)	3 (37.5)	1 (12.5)
Not reported/unknown	1 (12.5)	0 (0.0)	0 (0.0)
Years diagnosed with HIV (average) (SD)	25.2 (+/− 6.9)	17.3 (+/− 8.5)	26.4 (+/− 5.3)
ART/HAART Duration (year) (SD)	23.1 (+/− 6.9)	16.2 (+/− 9.4)	25.8 (+/− 5.0)
Diabetes (%)	25	0	25
Myocardial Infarction (%)	25	0	25

Note. SD= standard deviation; AA= African American; ART= antiretroviral therapy; HAART= highly active antiretroviral therapy

Table 2.

The Impact of COVID-19 on Cardiovascular Behaviors in PLWH

Theme	Description	Quote	Implication on CVD Health Behaviors
Promotion of Self-Care	This encompassed social interactions, hygiene habit changes, mask wearing, and social distance (all-encompassing theme).	“Since the onset of the coronavirus I have not been to any family gatherings, no parties. Of my church events I do that streaming from the internet. No one has visited. I's been a little bit quiet. I have a dog though that keeps me company and also have a roommate so I just haven't really done much of anything other than cardiac rehab and going to the grocery store. And tha's pretty much it. I did visit a friend once a few months ago, but tha's the only visitation that I have done or received since the virus was announced.”- Male PLWH	- Promote health behaviors recommended by medical professionals and the CDC including mask wearing, social distancing and following lockdown mandates in order to promote health during public health crises.
Diet Modifications During COVID-19	The pandemic directly impacted diet, in various ways. Some people of have consumed more food “depression eating” and gained weight, others have stopped eating out as much and lost weight.	“Once the pandemic’s open and say dining rooms are open for the restaurants, I really don’t think I’m gonna go back to them. I mean I’ve found I guess healthier alternatives to eat from home, for less money. You know, a hamburger versus I can buy a bag of hamburgers for $13.00 where it cost me $13.00 for three hamburgers at a restaurant and I can have meals for four days with the hamburgers I buy. So, I’m finding I don’t need the fast food any more. Now, I can make it semi-healthier. I can use the lighter bread; I don’t have to use a thick bun and all the condiments and the fries and the grease. So, I learned to keep better eating.”- Male PLWH “We try to go to the grocery store once a week unless I have something. The only thing we really would ever go for now would be like side dishes because we have hamburger, chickens, and all that stuff’s in our freezer, so if we run out of side dishes that’s the only time we would go out. We went out today and we hadn’t gone out for the past two weeks. So, it just depends on what we need.” – Male PLWH	Proposed long term sustainability for positive post-pandemic eating habits due to the positive health implications (i.e. weight loss) and savings of money associated with at home cooking. - Consider diet plans to assist individuals to consume healthy diets during time of limited grocery store access.
Restructured Physical Activity	The pandemic and related guidance prompted participants to engage in taking walks and other forms of exercise that are close to home in order to comply with CDC recommendations.	“attended a small group at the building, in a small room where I'd go and do the treadmill for my arthritis, and the heart failure thing, and that I had to discontinue because of the size of the room and I was not want to be clients who actually, I was not a priority. Yeah so that ended. So, basically I'm leading rather sedentary existence right now.”- Male PLWH	- Expand physical activity plans to incorporate activities that are home based such as walking outside and climbing stairs.
Faithfully Take Medication	Medication adherence remained a priority; even in the midst of a pandemic. Participants expressed control over taking their medications and some expressed how it helped their immune system to take their medication.	“I do not miss taking my medicine. I don't care what time it is but I didn't have this problem. I don't care what time it is. I'm always taking my medicine. I don't forget that I just started some vitamins. I went on and bought me some vitamins. I said maybe this will help me build some energies so. And I might forget and take that because I just started it. But my regular medicine, well see, I don't call it HIV medicine. I called my medicine lifetime.”- Female PLWH	- Continue to emphasize the importance of medication adherence (ART and CVD medications) on CVD health outcomes in PLWH.
Perseverance in Times of Difficulty	Ability to be resilient in order to maintain health (e.g. medication adherence, self-care and physical activity) due to their ongoing chronic condition of HIV.	“There really wasn’t one consistent before the pandemic. And since the pandemic, I became more consistent with three to five days of walking two to four miles. So, it actually increased or improved significantly since the pandemic.” – Male PLWH	- Harness healthy behaviors (i.e. healthy diet, physical activity, medication adherence and self-care) to promote CVD health outcomes.

Promotion of Self-Care

In order to follow CDC guidelines and adjust to life during the COVID-19 pandemic, participants described modifications to their daily lives. At the individual level of the Social Ecological Model, while some participants expressed skepticism about certain behaviors (e.g. mask wearing), on the whole individuals adopted current recommendations by the CDC including mask wearing, social distancing and following lockdown mandates in order to promote self-care and maintain their health. A majority of participants cited individual level reasons for following CDC recommendations (e.g. desire not to contract COVID-19). Additionally, a few participants also cited organization and community level reasons for following recommendations by the CDC, including having trust in their medical professional’s advice regarding CDC recommendations and not being a vector of COVID-19 for the community.

• “I really don’t trust the face mask. I really don’t think, you know, that’s my own personal issue over it, but I do wear it. If they’re saying that it’s going to prevent it, then I have no other choice but to believe it, but if you can smell gases or smell things or cologne or perfume through a face mask, what’s to say you can’t get the virus.” – Male PLWH

• “Well, I don’t have too many social interactions right now, because like I said, I have to protect myself. ”- Male PLWH

• “But I mean, I listen to the science. That's why we go to doctors.”- Male PLWH

Participants also described forming new self-care habits to promote wellness during the COVID-19 pandemic including reading, meditation, spiritual involvement and journaling. Self-care habits were highly tailored to the individual.

• “Well, my positive is just trying to keep myself safe and it just making me want to get even more closer to God, getting more into my reading because I wasn't reading as much, but it makes me want to just be more close to Him.”- Female PLWH

At the individual level of the Social Ecological Model participants described adopting behaviors to support their immune health including the use of home remedies. At the interpersonal level many PLWH applied information from the news and family remedies to stay healthy and mitigate illness during the pandemic.

• “Now, on the news they keep talking about how to help your immune system with vitamin C, D, B-12, or zinc and stuff like that. So, that has increased. Now I take enough pills in the morning, well throughout the day. I really don’t like taking added stuff, but I make sure that I take something like zinc or vitamin C.”- Male PLWH

• “Me, myself, I always when I get sick, I always drink raw honey with lemon tea, peppermint tea, or lemon tea with cinnamon in it.”- Female PLWH

Diet modifications during COVID-19

The COVID-19 pandemic influenced the dietary intake of PLWH, but in divergent ways for different people. Dietary habits became healthier for some but unhealthier for others. At the individual level of the Social Ecological Model some PLWH reported an increased consumption of food, “depression eating,” that led to weight gain. In contrast, others stopped eating out as much and subsequently lost weight. At the public policy level, grocery shopping behaviors were altered by many PLWH to abide by social distancing and lockdown recommendations. In contrast to the wider public, food delivery services were not utilized in this patient population prior to or during the pandemic

• “Well, you know when I’m at home I get bored. I cook. I eat more than I used to eat. And that’s a good thing, I think, but my diabetes doesn’t think so.”- Male PLWH

• “Losing weight. You now, without obviously, not buying as much fast food and all the stuff that I used to eat it’s helping.”- Male PLWH

Restructured Physical Activity

The pandemic’s impact on physical activity in PLWH included shifting exercise from gym and in person group exercise classes to home-based exercise (e.g. walking, climbing stairs). The weather had a mediating effect on exercise in this patient population

• “Well, before, I went to the gym, and I do some swimming and actually I was a part of the group for Zumba. So, Zumba, I did every other day. But right now, I cannot join that, so what I do is I walk around my neighborhood, and I walk like for 45 minutes every day.”– Male PLWH

• “Recently when I found out that this is getting worse, it’s getting worse and now in the wintertime it’s gonna be like isolation for me. Not taking walks because it’s too cold for me.” – Female PLWH

Faithfully take medication

PLWH reported that medication adherence, to both HIV and CVD medications, remained a priority even in the midst of the pandemic. PLWH expressed feeling empowered to take their medication and a few participants expressed that taking their ART helped them to maintain their strong immune system and fight COVID-19. At the individual level of the Social Ecological Model, the risk of further immunological decline was an underlying motivation for PLWH to maintain their medication adherence. At the organization level of the Social Ecological Model participants felt an obligation to take their medications as prescribed by their medical provider to maintain their health. Mail order medication programs were utilized by many PLWH prior to and during the pandemic without disruption.

• “I took my medication faithfully; I take it faithfully because I want to live. I have my medication personally delivered here, which is good, from a dispatcher, from a pharmaceutical company.” – Male PLWH

• “Me taking the HIV medication is also helping because it’s helping the immune system.”- Male PLWH

Perseverance in times of difficulty

PLWH displayed an increased resiliency, perhaps due to their ongoing chronic condition of HIV, in terms of medication adherence, self-care and physical activity. PLWH were adherent to their medication regime regardless of the world around them. Some PLWH used the extra time they had due to stay-at-home mandates to increase their physical activity. Many PLWH drew strength from their religion, home remedies, journaling, reading and meditation in very personal ways to promote self-care.

• “Well, I'm definitely staying at home more, and after I had the heart attack, I decided that I was going to drop some weight. So, I've been able to lose 40 pounds. And of course, diet and exercise are required to do that. So that sort of attributed to during the COVID-19 timing and the heart attack shortly after. Everything together sort of put me in a position to want to exercise and try to live a healthier life.” – Male PLWH

Discussion

To our knowledge, this is the first study to examine the impact of the COVID-19 pandemic on CVD health behaviors in PLWH. Our main themes recognized modified CVD health behaviors in PLWH as a result of the COVID-19 pandemic. We summarized our findings into five themes: promotion of self-care, diet modifications during COVID-19, restructured physical activity, faithfully taking medication, and perseverance in time of difficulty. No significant differences by site or sex at birth emerged regarding the five themes.

During the COVID-19 pandemic, self-care can be viewed as the process of making decisions aimed at prevention of COVID-19 illness and maintenance of wellbeing (De Maria et al., 2020). PLWH have had a high adherence to social distancing guidelines which is moderately influenced by their HIV status (Wion & Miller, 2021) . Our findings demonstrate modifications in daily behaviors such as social distancing and mask wearing were employed by PLWH to protect their health. Our data demonstrate some PLWH expressed initial reservation regarding COVID-19 mandates such as mask wearing but were ultimately persuaded to follow the CDC recommendations due to medical professional and social influences. This trust in their HIV medical professionals’ recommendations is consistent with the literature (Dang et al., 2012). This trusting provider-patient relationship should be leveraged during future public health crises to promote patient health outcomes.

The COVID-19 pandemic is associated with increased depression and anxiety and lower psychological well-being in the general population (Vindegaard & Benros, 2020). Our data demonstrate PLWH formed new self-care habits to cope with the CVOID-19 pandemic. These self-care habits including reading, meditation, spiritual involvement, and journaling brought individuals peace of mind during times of uncertainty related to the pandemic. The relationship between formation of self-care habits for coping during a global pandemic and mental health should be evaluated further.

We recognize that changes in diet and physical activity due to the COVID-19 pandemic are not unique to PLWH (Belén Ruiz-Roso et al., 2020; Mattioli et al., 2020). Regardless of the pandemic, PLWH have more food insecurity (Decker & Flynn, 2018) and worse dietary habits (Muhammad et al., 2019) and engage in less physical activity (Vancampfort et al., 2018). However, PLWH may require greater levels of physical activity to maintain physical health and functioning compared to the general population (Samaras et al., 2007; Willig et al., 2020). Therefore, the predisposition for PLWH to consume a poor diet and engage in less physical activity compounded in some cases by the COVID-19 pandemic necessitates attention and intervention.

Grocery shopping behaviors were altered by many PLWH to abide by social distancing and lockdown recommendations. PLWH decreased the frequency of grocery store visits in turn impacting the types of foods purchased. Limited visits to grocery stores led to decreased consumption of fresh fruits and vegetables. It is important to also note that food delivery services were not utilized in this patient population; however, it was not clearly defined as to why this patient population did not use these services. Overall, the long-term impacts of the pandemic on diet habits in PLWH will need to be examined in relation to CVD health behavior outcomes.

Early research demonstrates the COVID-19 pandemic is exacerbating the lack of adherence to daily physical activity recommendations in the general population (Dunton et al., 2020; Knell et al., 2020). Decreased physical activity can be attributed to previous lockdown mandates, restricted access to gyms and other venues for physical activity and change in daily routines (Knell et al., 2020). Our data suggest that PLWH had varied responses in terms of their ability to maintain their pre-pandemic level of activity. Some participants demonstrated an ability to be versatile and transition their gym-based exercise to home-based activities such as walking, climbing stairs, and jumping jacks. Other participants were discouraged by their inability to participate in group exercise and gym based physical activity and decided to opt out of maintaining a physical activity routine. Weather exacerbated challenges in achieving physical activity goals. In order to promote cardiovascular health behaviors, including physical activity, it is imperative to help PLWH identify alternative methods to promote physical activity during times of restriction to traditional gyms and other venues for physical activity.

The COVID-19 pandemic did not negatively impact ART adherence (Algarin et al., 2020; Kalichman et al., 2020; Sun et al., 2020). In fact, there are some reports that ART adherence has increased in response to the COVID-19 pandemic related to concerns about one’s health or increased time at home (Kalichman et al., 2020). Our data demonstrate ART adherence was maintained, even when other health behaviors wavered (i.e., diet and physical activity). Some PLWH expressed an urgency to adhere to their ART in order to maintain their immune system and mitigate the potential of acquiring the coronavirus.

Some research demonstrates that individuals were more likely to have issues with ART adherence during the CVOID-19 pandemic if they needed to travel to a different location to receive HIV care (Sun et al., 2020). Our data reveal many PLWH participated in mail order medication programs prior to and during the pandemic which provided them with minimal disruption in medication supply. These individuals expressed satisfaction and confidence in these mail order services. Our findings suggest the crucial need for strategies such as medication mail delivery services to maintain medication adherence during public health crises.

Resilience is the individual trait of emotional stability after experiencing a very stressful and or traumatic event such as the COVID-19 pandemic (Block & Kremen, 1996; Bonanno, 2004). PLWH have shown resilience during the COVID-19 pandemic through use of existing skillsets developed as long-term survivors of HIV (Gwadz et al., 2021). Our findings support that PLWH demonstrated resilience during the COVID-19 pandemic. The ability to maintain adherence to medication regimens, flexibility in physical activity, alteration in diet patterns and development of coping mechanism in the face of the pandemic demonstrates resiliency suggesting resilience in PLWH may be harnessed to maintain other health behaviors as well.

We used the Social Ecological Model as the framework to capture several interrelations among individual and environmental factors; though it should be noted that participants tended to focus on themselves (individual level) in their responses to COVID-19. This may be attributed to an individual’s perception of self-crisis with the inability to reflect on the greater population (i.e., the interpersonal and community levels of the SEM).

Our study had a number of limitations and strengths. Limitations of this study include: (1) the purposive sampling methods, enrolling individuals from the EXTRA-CVD study, which could lead to increased risk of bias; and (2) conducting interviews by telephone, which prevented observation of non-verbal expressions, limiting our understanding of the patient experience. Strengths of this study include: (1) a diverse study sample across three distinct locations; and (2) implementation of rigorous qualitative methods including sufficient data to reach saturation.

Conclusions

The COVID-19 pandemic dramatically altered CVD health behaviors among PLWH implying a need for engaged education focusing on the importance of CVD health behaviors (i.e., diet, physical activity, medication adherence and self-care), outlets to share experiences, and resources for people living and aging with HIV. During future public health crises, early interventions to promote positive cardiovascular health behaviors (e.g., diet, physical activity, medication adherence and self-care) may improve health outcomes for PLWH.