Abstract
People with HIV (PWH) from racial/ethnic minority groups may be particularly vulnerable to the effects of the COVID-19 Pandemic. Exacerbated COVID-19-related stressors may lead to maladaptive coping mechanisms such as increased alcohol use. This study examined socioeconomic and psychosocial predictors of increased alcohol use during the first year of the COVID-19 Pandemic among PWH from racial/ethnic minority groups in South Florida. Data were collected from Ryan White Program clients during October 2020-January 2021 using a cross-sectional phone survey, and were analyzed using logistic regression modeling. Among 139 participants, 20% reported increased alcohol use. Findings showed that being unable to buy needed food (adjusted odds ratio [aOR]: 3.37; 95% confidence interval [CI]: 1.01–11.31) and spending more time caring for children (aOR: 5.22, 95% CI: 1.61–16.88) was associated with increased alcohol use during the Pandemic. Providing support to alleviate food insecurity and manage caregiving burden during public health crises like the COVID-19 Pandemic might help prevent increases in alcohol use among PWH.
Keywords: COVID-19 Pandemic, HIV, alcohol, stressors
Introduction
Similar to the HIV epidemic in the United States (U.S.), the COVID-19 Pandemic disproportionately affects racial/ethnic minorities and those who are socio-economically disadvantaged (CDC, 2019; Millett et al., 2020; Rodriguez-Diaz et al., 2020; Yancy, 2020). People with HIV (PWH) from racial/ethnic minority groups may be particularly vulnerable to the effects of the COVID-19 Pandemic. It is well-known that many racial/ethnic minorities with HIV already experience socioeconomic (e.g., food insecurity, housing instability, low income) and psychosocial stressors (e.g., stress, anxiety) (Pellowski, Kalichman, Matthews, & Adler, 2013). These stressors are being exacerbated by the COVID-19 Pandemic (Chenneville, Gabbidon, Hanson, & Holyfield, 2020; Winwood et al., 2021). For PWH, the COVID-19 Pandemic is additionally stressful due to the risk of severe COVID-19 associated with being immunocompromised and HIV care and treatment interruptions (Winwood et al., 2021).
COVID-19 related stressors may result in maladaptive coping mechanisms such as increased alcohol use (Schmidt et al., 2021). In fact, recent studies have reported increases in alcohol use during the COVID-19 Pandemic among PWH (Asiimwe et al., 2023; Schaaf et al., 2022; Weerasuria et al., 2021; Zabel et al., 2023). This is particularly of concern for this population because unhealthy alcohol use can weaken the immune system and its ability to fight HIV and COVID-19, decrease antiretroviral therapy (ART) adherence, accelerate HIV disease progression, impair decision making, and cause negative psychological effects (Marshall et al., 2017; Monnig, 2017; Williams et al., 2016; Wu, Metzger, Lynch, & Douglas, 2011). As such, this study aimed to examine whether alcohol use increased during the first year of the Pandemic (March 2020 to January 2021) among PWH from racial/ethnic minority groups, and to explore associated socioeconomic and psychosocial stressors.
Methods
Study population, design and procedures
A cross-sectional survey was conducted between October 2020 and January 2021 among 298 adults aged 18 or older with HIV who have received medical case management services from the Miami-Dade County Ryan White HIV/AIDS Program (RWP), and who self-identified as being African American, Hispanic/Latino, or Haitian. Participants were recruited from lists of RWP clients who had previously provided consent to be contacted for research (n=187), and from RWP adult clients who had participated in a client satisfaction survey that was being administered around the same time (n=111). Participants completed the survey by telephone in their preferred language (English, Spanish or Haitian Creole) and received a $25 electronic gift card for their time. This research study was approved by the Florida International University Institutional Review Board, and all participants provided documented verbal informed consent.
Dependent Variable
Increased alcohol use during the COVID-19 Pandemic was the outcome of interest. This variable was measured with the statement “Compared to before the COVID-19 Pandemic, I am drinking more alcohol.” Responses ranged from 1=strongly agree to 5=strongly disagree and 6=doesn’t drink. A total of 139 respondents reported alcohol use (47% of the total sample). Those participants who responded ‘strongly agree’ or ‘agree’ were classified as ‘yes, alcohol use increased’ and those who responded ‘neither agree nor disagree’, ‘disagree’, or ‘strongly disagree’ as ‘no, alcohol use did not increase’.
Independent Variables
Sociodemographic variables included age, gender, sexual orientation, race/ethnicity, highest level of education, employment prior to the Pandemic, and income as a percent of federal poverty level as of March 2020. Socioeconomic stressors included job loss due to the Pandemic, and compared to before the Pandemic, decreased household income, increased inability to buy needed food, more difficulty paying for housing, and at risk of losing current housing. The psychosocial stressors included worry about getting COVID-19, worry about family or friends getting COVID-19, and compared to before the Pandemic, more anxiety, stress, time spent caring for children, and time spent caring for family members or other adults. Stressor variables were measured using yes/no or 5-point Likert scale responses.
Data Analysis
All data analyses were performed in SAS version 9.4. Chi-square tests (or Fisher exact tests when applicable) were used to compare increased alcohol use by sociodemographic characteristics and COVID-19-related socioeconomic and psychosocial stressors. Using increased alcohol use as the dependent variable, unadjusted and adjusted odds ratios (OR) and 95% confidence intervals (CI) for independent variables were estimated with logistic regression modeling. Only those variables with a p-value <0.20 in the bivariate analyses were included in the full model. Given the small numbers in some categories for the logistic regression model, variables rated on a 5-point Likert scale were categorized into 1) an ‘agree or strongly agree’ group and 2) a ‘neither agree nor disagree, disagree, or strongly disagree’ group, and bivariate analyses were re-run for consideration for inclusion in the logistic regression model. Similarly, given the small number of transgender or non-binary participants (3 transgender women, 1 transgender man, 3 non-binary) for the logistic regression, we removed these seven participants. In addition, listwise deletion removed participants with missing values on any variable included in the adjusted logistic regression model. This reduced our sample size in the full model from 139 to 135.
Results
Of the 139 participants, 85 (61.2%) identified as non-Hispanic (non-Haitian) Black/African Americans (hereafter African Americans), 39 (28.1%) as Hispanic and 15 (10.8%) as Haitian (Table 1). The largest proportion was aged 50 years or older (51.1%, 71, followed by those aged 35–49 years (28.1%, 39). Just over half were cis-males (51.1%, 71), 43.9% (61) cis-females and 5.0% (7) transgender or non-binary. Over a third (37.5%, 51) of participants identified as lesbian, gay, or bisexual. Fifty-three percent (74) had less than or a high school diploma or GED, and 38.9% (54) lived in households with income below 100% of the Federal Poverty Line as of March 2020. Just over half (75) were employed full-time and 16.7% (23) part-time or occasionally prior to the Pandemic.
Table 1.
Characteristics of sample by reported increased alcohol use compared to before the COVID-19 Pandemic
| Increased Alcohol Use during COVID-19 Pandemica | ||||
|---|---|---|---|---|
|
| ||||
| Total n (%) |
Yes n (%) |
No n (%) |
p-value | |
| 139 | 28 (20.1) | 111 (79.9) | ||
| Sociodemographic Characteristics | ||||
|
| ||||
| Age (years) | 0.1376 | |||
| 22–34 | 29 (20.9) | 9 (31.0) | 20 (69.0) | |
| 35–49 | 39 (28.1) | 9 (23.1) | 30 (76.9) | |
| 50+ | 71 (51.1) | 10 (14.1) | 61 (85.9) | |
| Gender b | 0.1654 | |||
| Cis-female | 61 (43.9) | 9 (14.8) | 52 (85.3) | |
| Cis-male | 71 (51.1) | 16 (22.5) | 55 (77.5) | |
| Transgender or non-binary | 7 (5.0) | 3 (42.9) | 4 (57.1) | |
| Sexual orientation | 0.0180 | |||
| Lesbian, gay, or bisexual | 51 (37.5) | 15 (29.4) | 36 (70.6) | |
| Heterosexual | 85 (62.5) | 11 (12.9) | 74 (87.1) | |
| Missing | 3 | 2 | 1 | |
| Race/ethnicity | 0.9170 | |||
| African American | 85 (61.2) | 18 (21.2) | 67 (78.8) | |
| Haitian | 15 (10.8) | 3 (20.0) | 12 (80.0) | |
| Hispanic | 39 (28.1) | 7 (18.0) | 32 (82.1) | |
| Highest level of education | 0.0978 | |||
| Less than or high school diploma or GED | 74 (53.2) | 11 (14.9) | 63 (85.1) | |
| Some college or college graduate | 65 (46.8) | 17 (26.2) | 48 (73.9) | |
| Employment (prior to COVID-19 Pandemic) | 0.5222 | |||
| Full-time | 75 (54.4) | 15 (20.0) | 60 (80.0) | |
| Part-time or occasionally | 23 (16.7) | 3 (13.0) | 20 (87.0) | |
| Unemployed | 40 (29.0) | 10 (25.0) | 30 (75.0) | |
| Missing | 1 | 1 | ||
| Federal Poverty Level | 0.9577 | |||
| <100% | 54 (38.9) | 11 (20.4) | 43 (79.6) | |
| ≥100% | 85 (61.2) | 17 (20.0) | 68 (80.0) | |
|
| ||||
| COVID-19 Socioeconomic Stressors | ||||
|
| ||||
| Lost job due to the COVID-19 Pandemic | 0.0599 | |||
| Yes | 31 (22.5) | 10 (32.3) | 21 (67.7) | |
| No or unemployed before the Pandemic | 107 (77.5) | 18 (16.8) | 89 (83.2) | |
| Missing | 1 | 1 | ||
|
Compared to before the COVID-19 Pandemic,…
I have decreased household income |
0.0198 | |||
| Yes | 67 (48.2) | 19 (28.4) | 48 (71.6) | |
| No or don’t know | 72 (51.8) | 9 (12.5) | 63 (87.5) | |
| I am now unable to buy the food I need c | 0.0174 | |||
| Agree or strongly agree | 40 (28.8) | 14 (35.0) | 26 (65.0) | |
| Neither agree nor disagree | 21 (15.1) | 4 (19.1) | 17 (81.0) | |
| Disagree or strongly disagree | 78 (56.1) | 10 (12.8) | 68 (87.2) | |
| I am having more difficulty paying for housing | 0.0250 | |||
| Agree or strongly agree | 58 (41.7) | 18 (31.0) | 40 (69.0) | |
| Neither agree nor disagree | 14 (10.1) | 2 (14.3) | 12 (85.7) | |
| Disagree or strongly disagree | 67 (48.2) | 8 (11.9) | 59 (88.1) | |
| I am now at risk of losing my current housing | 0.0356 | |||
| Agree or strongly agree | 30 (21.6) | 10 (33.3) | 20 (66.7) | |
| Neither agree nor disagree | 16 (11.5) | 5 (31.3) | 11 (68.8) | |
| Disagree or strongly disagree | 93 (66.9) | 13 (14.0) | 80 (86.0) | |
|
| ||||
| COVID-19 Psychosocial Stressors | ||||
|
| ||||
| I worry about getting COVID-19 | 0.7163 | |||
| Agree or strongly agree | 84 (60.4) | 16 (19.1) | 68 (81.0) | |
| Neither agree nor disagree | 10 (7.2) | 3 (30.0) | 7 (70.0) | |
| Disagree or strongly disagree | 45 (32.4) | 9 (20.0) | 36 (80.0) | |
| I worry about my family or friends getting COVID-19 | 0.4226d | |||
| Agree or strongly agree | 113 (81.3) | 21 (18.6) | 92 (81.4) | |
| Neither agree nor disagree | 6 (4.3) | 2 (33.3) | 4 (66.7) | |
| Disagree or strongly disagree | 20 (14.4) | 5 (25.0) | 15 (75.0) | |
| Compared to before the COVID-19 Pandemic,… | ||||
| I am more anxious | 0.5497 | |||
| Agree or strongly agree | 77 (55.4) | 18 (23.4) | 59 (76.6) | |
| Neither agree nor disagree | 8 (5.8) | 1 (12.5) | 7 (87.5) | |
| Disagree or strongly disagree | 54 (38.9) | 9 (16.7) | 45 (83.3) | |
| I am more stressed | 0.1289 | |||
| Agree or strongly agree | 74 (53.2) | 19 (25.7) | 55 (74.3) | |
| Neither agree nor disagree | 8 (5.8) | 0 | 8 (100) | |
| Disagree or strongly disagree | 57 (41.0) | 9 (15.8) | 48 (84.2) | |
| I spend more time caring for children | 0.2246 | |||
| Agree or strongly agree | 33 (23.7) | 10 (30.3) | 23 (69.7) | |
| Neither agree nor disagree | 9 (6.5) | 1 (11.1) | 8 (88.9) | |
| Disagree or strongly disagree | 97 (69.8) | 17 (17.5) | 80 (82.5) | |
| I spend more time caring for family members or other adults who need me | 0.2919 | |||
| Agree or strongly agree | 67 (48.2) | 14 (20.9) | 53 (79.1) | |
| Neither agree nor disagree | 9 (6.5) | 0 | 9 (100) | |
| Disagree or strongly disagree | 63 (45.3) | 14 (22.2) | 49 (77.8) | |
Notes:
Increased alcohol use during the COVID-19 Pandemic was categorized as ‘yes’ for those who reported agreeing or strongly agreeing to increased alcohol use vs. ‘no’ for all others.
The gender variable was recoded by removing the seven transgender or non-binary participants and the bivariate analysis was re-run for consideration for inclusion in the logistic regression model.
Variables rated on a 5-point Likert scale were categorized into 1) an ‘agree or strongly agree’ group and 2) a ‘neither agree nor disagree, disagree, or strongly disagree’ group, and bivariate analyses were re-run for consideration for inclusion in the logistic regression model.
Fisher’s exact test p-value
Percentages may not add up to 100% due to rounding.
Twenty percent (28) of participants reported increased alcohol use during the Pandemic. With respect to socioeconomic stressors, 22.5% (31) reported having lost their job due to the Pandemic, and 48.2% (67) reported decreased household income compared to before the Pandemic. Twenty-eight percent (40) agreed or strongly agreed that they were now unable to buy needed food, 41.7% (58) were having difficulty paying for housing, and 21.6% (30) reported being at risk of losing their current housing compared to before the Pandemic. Moreover, in terms of psychosocial stressors, 60.4% (84) agreed or strongly agreed that they were worried about getting COVID-19, and 81.3% (113) were worried about family or friends getting COVID-19. Moreover, 55.4% (77) agreed or strongly agreed that they were more anxious, 53.2% (74) were more stressed, 23.7% (33) spent more time caring for children, and 48.2% (67) spent more time caring for family members or other adults who needed them compared to before the Pandemic.
Factors Associated with Increased Alcohol Use During the Pandemic
In the bivariate analyses, lesbian, gay, or bisexual participants (29.4%) were more likely to report increased alcohol use than heterosexual participants (12.9%; p=0.0180; Table 1), as were participants who reported decreased household income compared to before the COVID-19 Pandemic (28.4%) compared to those who didn’t report decreased household income (12.5%; p=0.0198). Moreover, those participants who agreed or strongly agreed that they were now unable to buy needed food compared to before the COVID-19 Pandemic (35.0%) were more likely to report increased alcohol use than those who neither agreed nor disagreed (19.1%) or disagreed or strongly disagreed (12.8%; p=0.0174). Those participants who agreed or strongly agreed that they had more difficulty paying for housing (31.0%) and were now at risk of losing their current housing (33.3%) compared to before the COVID-19 Pandemic were more likely to report increased alcohol use than those who neither agreed nor disagreed (14.3%, 31.3%) or disagreed or strongly disagreed (11.9%, 14.0%; p=0.0250, p=0.0356 respectively).
In the adjusted logistic regression model, inability to buy needed food and more time spent caring for children were significantly associated with increased alcohol use during the Pandemic (Table 2). Specifically, those who agreed or strongly agreed that they were now unable to buy needed food (adjusted odds ratio [aOR]: 3.37; 95% confidence interval [CI]: 1.01–11.31) or were spending more time caring for children (aOR: 5.22, 95% CI: 1.61–16.88) compared to before the COVID-19 Pandemic were more likely to report increased alcohol use.
Table 2.
Unadjusted and adjusted odds ratios and 95% confidence intervals for reporting increased alcohol use compared to before the COVID-19 pandemic and selected characteristics (n=135)a
| Increased Alcohol Use during the COVID-19 Pandemic |
|||
|---|---|---|---|
| Total number | OR (95% CI) | aOR (95% CI)b | |
| Sociodemographic Characteristics | |||
|
| |||
| Age (years) | |||
| 22–34 | 29 | 2.75 (0.98–7.71) | 0.96 (0.27–3.44) |
| 35–49 | 39 | 1.83 (0.67–4.98) | 0.94 (0.28–3.15) |
| 50+ | 71 | Ref | Ref |
| Sexual orientation a | |||
| Lesbian, gay, or bisexual | 51 | 2.80 (1.17–6.72) | 2.87 (0.93–8.86) |
| Heterosexual | 85 | Ref | Ref |
| Highest level of education | |||
| Less than or high school diploma or GED |
74 | 0.49 (0.21–1.15) | 0.46 (0.15–1.38) |
| Some college or college graduate | 65 | Ref | Ref |
|
| |||
| COVID-19 Socioeconomic Stressors | |||
|
| |||
| Lost job due to the COVID-19 Pandemic a | |||
| Yes | 31 | 2.35 (0.95–5.84) | 1.54 (0.47–5.00) |
| No or unemployed before the Pandemic |
107 | Ref | Ref |
| Compared to before the COVID-19 Pandemic,… | |||
| I have decreased household income | 2.77 (1.15–6.66) | 2.01 (0.58–6.94) | |
| Yes | 67 | ||
| No or don’t know | 72 | Ref | Ref |
| I am now unable to buy the food I need b | |||
| Agree or strongly agree | 40 | 3.27 (1.38–7.74) | 3.37 (1.01–11.31) |
| Neither agree nor disagree, disagree, or strongly disagree | 99 | Ref | Ref |
| I am having more difficulty paying for housing | |||
| Agree or strongly agree | 58 | 3.20 (1.35–7.59) | 0.81 (0.20–3.27) |
| Neither agree nor disagree, disagree, or strongly disagree | 81 | Ref | Ref |
| I am now at risk of losing my current housing | |||
| Agree or strongly agree | 30 | 2.53 (1.02–6.29) | 1.47 (0.41–5.33) |
| Neither agree nor disagree, disagree, or strongly disagree | 109 | Ref | Ref |
|
| |||
| COVID-19 Psychosocial Stressors | |||
|
| |||
| I am more stressed | |||
| Agree or strongly agree | 74 | 2.15 (0.90–5.16) | 1.25 (0.43–3.66) |
| Neither agree nor disagree, disagree, or strongly disagree | 65 | Ref | Ref |
| I spend more time caring for children | |||
| Agree or strongly agree | 33 | 2.13 (0.87–5.22) | 5.22 (1.61–16.88) |
| Neither agree nor disagree, disagree, or strongly disagree | 106 | Ref | Ref |
Notes:
Four participants were not included in the adjusted logistic regression model due to missing values on the ‘sexual orientation’ and ‘lost job due to the COVID-19 Pandemic’ variables. Listwise deletion was used reducing sample from 139 to 135.
aOR=adjusted odds ratio; CI=confidence interval; unadjusted and adjusted ORs for variables with a p-value of <.20 in bivariate analyses; aORs come from a model that simultaneously adjusted for all variables in the model.
Discussion
Amidst the life and health stressors of the COVID-19 Pandemic for PWH from racial/ethnic minority groups, 20% of PWH with alcohol use in our study reported increases in use during the Pandemic. Two stressors were associated with increases in alcohol use during the Pandemic: inability to buy food needed and more time spent caring for children.
Our finding of the association between inability to buy needed food and increased alcohol use during the Pandemic is consistent with previous studies linking food insecurity with problematic patterns of alcohol use in the general population (Bergmans, Coughlin, Wilson, & Malecki, 2019; Nagata et al., 2021). A possible explanation for this association could be that PWH may have increased their alcohol consumption to cope with the physical and psychological distress of not being able to buy needed food during the Pandemic. However, since we cannot rule out a bidirectional association, it could also be that increased alcohol use may have predisposed PWH to food insecurity by depleting limited financial resources away from obtaining needed food. This may have been exacerbated by easier access to alcohol during the Pandemic through delivery apps and online vendors. Although future research is needed to confirm the direction of this association, this finding suggests that mitigating food insecurity during times of crisis like the COVID-19 Pandemic might help prevent increases in alcohol use among PWH by reducing the psychological distress of inadequate access to food. This is particularly important due to the potential negative effects of food insecurity and alcohol use on adherence to HIV treatment and suppressed viral load (McLinden, Stover, & Hogg, 2020; Williams et al., 2016).
Moreover, consistent with previous research in the general population (Schmidt et al., 2021), our study found that more time spent caring for children during the Pandemic was associated with increases in alcohol use. This finding suggests that PWH who are caregivers in our sample possibly increased their alcohol consumption as a way to cope with the added demands and burden (e.g., remote schooling) of caring for children given that schools and childcare centers were closed during our study period due to the Pandemic. PWH with children might need to receive psychological support and resources to better manage increased caregiving responsibilities and stressors during public health crises like the COVID-19 Pandemic. It would be important for future studies to fully explore this association and examine whether it differs by gender as women tend to carry a disproportionate caregiver burden (Power, 2020); our small sample size didn’t allow us to explore this.
Limitations
One limitation of this study is that we did not use a validated measure to assess alcohol use because we were interested in relative alcohol use compared to before the Pandemic. Second, our data may have been prone to recall and desirability bias, and thus underreporting of increased alcohol use (Northcote & Livingston, 2011). To minimize these issues, interviewers were trained to remind participants of the specific recall period, provide enough time to think and respond, as well as emphasize data confidentiality. Third, selection bias may be present in our study as our sample was drawn entirely from PWH who were receiving regular medical case management and HIV care services from the RWP program, and were interested and responsive to participating in research studies. It is possible that participants may have experienced fewer disruptions, adverse situations, and issues with alcohol and substance use during the Pandemic. Fourth, our convenience sample and geographic location may limit the generalizability of our findings. Lastly, the cross-sectional design of our survey limits inferences about the direction and causality of the associations found.
Conclusion
Our study showed changes in alcohol use among some PWH during the COVID-19 Pandemic, with those experiencing food insecurity and higher caregiving responsibilities being more likely to report increases in alcohol use. Existing programs for PWH such as the RWP program might need to consider providing additional food assistance, expanding ways to access food assistance (e.g., home delivery), as well as promoting utilization of remote mental health services to be able to manage exacerbated stressors and alcohol use during times of crisis like the COVID-19 Pandemic. In addition, health care providers should screen for problematic alcohol use and provide treatment referrals when needed as increased alcohol use may persist even after the Pandemic.
Acknowledgments
The authors would like to acknowledge the staff of Behavioral Science Research as well as the Miami-Dade County Ryan White Program for assisting in the implementation of this study.
This work was supported by awards R01MD012421 and U54MD012393 from the National Institute on Minority Health and Health Disparities. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
Disclosure of Interest
All authors declare that they have no conflicts of interest and do not have any financial disclosures to report.
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