Perceived impact of the COVID-19 pandemic and government restrictions on the lives of young adults living with HIV in Kisumu, Kenya

Abstract

Young adults with HIV (YAHIV) may be particularly vulnerable to the impact of the COVID-19 pandemic. In this context, associated mitigation measures among YAHIV can adversely impact fragile social and economic systems. We examined the impact of the pandemic and related government-mandated restrictions among YAHIV in Kisumu, Kenya. Between April-May 2021, a cross-sectional survey was conducted among a convenience sample of YAHIV 18–25 years receiving HIV care in Kisumu, Kenya. The information collected included demographics, COVID-19 knowledge, protective measures, and the impact of the pandemic and related restrictions on their daily lives and well-being since the start of the pandemic (i.e., curfews, lockdowns, school/workplace closures). Responses were analyzed using descriptive statistics. Of 275 YAHIV: median age 22 years (IQR: 19–24 years); 178 (65%) female; 222 (81%) completed some secondary education or higher; 108 (39%) lived in an informal housing area. Awareness of COVID-19 was high (99%), mean knowledge score was 4.32 (SD: 0.93; range 1–5) and most reported taking protective measures. Overall, 193 (70%) reported they were affected by COVID-19 and associated restrictions. Almost half (49%) reported changes in a living situation; 24% living with different people, 11% had moved/relocated, and 5% were newly living on the street. Additionally, respondents reported increased verbal arguments (30%) and physical conflict (16%) at home with 8% reporting someone having used/threatened them with a weapon, 12% experiencing physical abuse, 7% being touched in a sexual way without permission, and 5% had forced sex. Impacts of the pandemic and related restrictions were felt across various aspects of YAHIV’s lives, including disrupted living situations and increased exposure to verbal and physical conflict, including sexual violence. Interventions are needed to address the impact and potential negative long-term effects of the pandemic on YAHIV health and well-being.

Introduction

Young people have been impacted by the global COVID-19 pandemic and associated government restrictions in many ways including increased mental health issues, social and education disruptions, and economic vulnerability [1–3]. Studies conducted globally, including in Africa, show increased experiences of stress, anxiety, and depression among young people due to COVID-19 including feelings of loneliness, fear, and hopelessness [4–9]. Food shortages and lack of access to basic needs are among the economic impacts experienced by young people [10,11]. Disruptions in education were widespread with high rates of full day school closures, an average of 101 days from March 2020 to February 2021 in countries in the Eastern and Southern Africa region [12]. Reaching students by digital or remote learning programs was a challenge and students also struggled adapting to the virtual learning environment [9,13,14]. Globally, data indicates that the impacts of COVID-19 have also been experienced differently between males and females, with young women often experiencing more negative effects [15–17].

People living with HIV were also specifically impacted by COVID-19 as this group faced a higher risk of experiencing severe outcomes from COVID-19 [18,19]. Young people living with HIV may be particularly vulnerable to the negative effects of COVID-19 and associated mitigation measures as many face challenges of poverty, stigma, and living with a chronic disease requiring adherence to daily antiretroviral therapy (ART) [20–23]. Furthermore, retaining adolescents and youth in chronic care is often challenging [24–27], and exacerbated by humanitarian emergencies, large-scale disasters, and infectious outbreaks [28–31].

In response to COVID-19, national governments implemented a variety of public health measures to mitigate impact among communities and the health system, including travel restrictions, nationwide lockdowns, and isolation and quarantine measures [32]. The first case of COVID-19 was confirmed in Kenya on 12 March 2020 [33]. The response to COVID-19 by the Kenyan Government was swift. By March 20th, it had established rigorous guidance restricting international and national travel, and implementing social distancing, and curfews for citizens and businesses [34]. Additionally, the government managed a national health education media campaign to educate Kenyans on prevention measures, including behavioral messaging that encouraged Kenyans to stay home and avoid public transportation. To maintain HIV service delivery efforts, the Ministry of Health (MOH) expanded policies to maintain comprehensive care for clients and protect the health care system by reducing facility visit frequency including expansion of multi-month dispensing (MMD) polices to provide 3-months of ART regardless of age and viral load status [35]. Subsequently, Kenya experienced three additional COVID-19 waves in July/August 2020 (7-day average of daily cases at peak: 660 cases), October/November 2020 (7-day average of daily cases at peak: 1,108 cases) and March/April 2021 (7-day average of daily cases at peak: 1,354 cases) [36,37]. During this timeframe, the government restrictions varied as some were lifted or reduced. In response to the third COVID-19 wave in March/April 2021, the cessation of movement into and out of disease-infected counties (Nairobi, Kajiado, Machakos, Kiambu, and Nakuru) was specifically implemented, then lifted on May 1, 2021. All forms of public gathering, especially political rallies, were banned on March 12, 2021. Kenya started administering COVID-19 vaccinations on March 5, 2021, to priority populations, including frontline healthcare workers, uniformed officers, teaching staff, religious leaders, and citizens above 58 years [38].

Several studies have documented the impact of the COVID-19 pandemic on the economic, social, and mental health of young people in Kenya [39,40]. In general, participants reported significant disruptions to their health, well-being, and economic security, including the inability to meet basic economic needs, decreased income, and a lack of access to sexual and reproductive health services. Despite the high burden of HIV among young people in Kenya, little is known about their experiences throughout the COVID-19 pandemic [41,42]. In 2021, an estimated 1.4 million adolescents and adults aged 15 years and older were living with HIV in Kenya [43]. In 2018, the Kenya Population-based HIV Impact Assessment (KENPHIA) reported a 1.4% HIV prevalence among individuals ages 15–24 years (females: 2.2%, males: 0.6%) [44]. Additionally, about 2 in every 5 adult new HIV infections occurred among youth 15–24 years (40%) in 2017 [45]. In Kenya, there are HIV clinics that provide youth-friendly services [46] and other programs focused on providing support to young people living with HIV [47]. Youth-friendly services offer a strategic approach to support ART adherence and viral suppression among young people living with HIV. These services include dedicated healthcare settings for youth, peer support groups, caregiver engagement, trained healthcare providers, and counseling tailored to young people, all aimed at improving their engagement and health outcomes [48,49].

We report findings from a survey of young adults living with HIV (YAHIV) aged 18–25 years enrolled in HIV care at a large hospital in Kisumu, Kenya. The study aimed to assess YAHIV experiences related to COVID-19 and government restrictions; perceived impact of COVID-19 on their health and well-being; knowledge of, attitudes towards, and practices regarding COVID-19. Our findings provide a more robust understanding of how this more vulnerable population experienced the pandemic and perceived related government-mandated restrictions to impact their lives.

Materials and methods

Participants and procedures

The study was conducted in April-May 2021 at the Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH) in Kisumu, Kenya. At the time, ICAP at Columbia University was the President’s Emergency Program for AIDS Relief (PEPFAR) implementing partner supporting HIV services at JOOTRH including the Adolescent Patient Support Center (APSC) where participants were recruited. All YAHIV 18–25 years of age who were currently engaged in HIV care at APSC were considered potentially eligible to participate.

Clinic staff provided existing peer educators working at the APSC, who were also YAHIV, with a list of current patients who fit the eligibility criteria. A total of 12 peer educators were trained on study-specific procedures and good clinical practice, emphasizing procedures to avoid coercion among the study population ensuring participants clearly understood their right to decline and received unbiased information about the study’s risks and benefits, allowing for a voluntary decision. The peer educators conducted phone-based recruitment using approved scripts and invited those who were interested to come to the APSC. Upon arrival at APSC, clinic staff confirmed YAHIV eligibility and referred them to the peer educators who provided additional information about study procedures. Study visits were staggered to avoid crowding and personal protective equipment (PPE) was provided to all staff and YAHIV participants. Study procedures were conducted outdoors with the use of privacy barriers.

Prior to initiation of the survey, interested YAHIV read through the informed consent form on the tablet and were asked to indicate their consent by clicking the “I agree” or “I decline” options on the screen. During the recruitment and consenting process, it was made clear to potential participants that their decision to participate in the study would have no impact on the care they received at the APSC. Once consent was obtained, peer educators invited participants to a private, socially distanced area and provided instructions for self-administration of the tablet-based survey. Peer educators were available to participants during survey administration to answer questions or troubleshoot any issues. For those participants who preferred not to self-administer the survey, peer educators administered the survey directly. All study procedures were conducted in English. After completion, participants were compensated with the equivalent of $10 USD for their time.

Survey measure

The quantitative survey consisted of 107 close-ended questions adapted from multiple survey tools including the KENPHIA household questionnaire [44], World Health Organization (WHO) tool for behavioral insights on COVID-19 [50], and the 2020 Household Pulse Survey [51]. Survey questions focused on individual-level factors including demographic characteristics, household information, educational status, as well as inter-personal factors including relationship status. COVID-19 knowledge, attitudes, perceptions, adherence to precautions, and the perceived impact of COVID-19 and related government restrictions were assessed in the survey. More specifically, questions on the domains of housing, education, employment, finances, food access, access to HIV care, safety/violence, HIV stigma, and mental health during COVID-19 were presented in the survey. Mental health screening questions included validated standards from the generalized anxiety disorder 2-item (GAD-2) [52] and the patient health questionnaire 2-item (PHQ-2) [53]. The survey tool was pilot tested at APSC among the study population and updated based on feedback.

Data analysis

We present descriptive data on the characteristics of YAHIV 18–25 years of age. We also examined participant characteristics and their COVID-19 knowledge, attitudes, and practices. Descriptive analyses were conducted using SAS (Version 9.4, SAS Institute Inc., Cary, NC, USA). P-values estimating the extent to which random variability can explain observed differences by sex were estimated using Chi-square or Fisher’s Exact statistics for categorical variables, and t-statistics for continuous variables. We also examined characteristics according to sex; p-values <0.05 are noted in the tables and footnotes for categorical variables.

We measured knowledge about COVID-19 using ‘true’/’false’/‘prefer not to answer’ responses to statements about COVID-19 transmission and prevention using questions adapted from previous COVID-19 surveys [40]. For the analysis, we dichotomized responses into incorrect/‘prefer not to answer’ and correct for each question. For mental health screening, GAD-2 and PHQ-2 scores were totaled and analyzed using a total score of 3 or greater as showing signs of possible generalized anxiety disorder (GAD-2) [52] and possible depressive disorder (PHQ-2) [53] to be further evaluated.

Ethical approvals

The study protocol was approved by the Institutional Review Boards/Ethics Committees at the Columbia University Irving Medical Center (AAAT2632) and the Maseno University Ethics and Research Committee (MUERC/00886/20).

Results

Characteristics of study participants

An estimated 407 YAHIV aged 18–25 active on ART were registered at the health facility where the survey was implemented. A total of 364 YAHIV were contacted by peer educators and 43 did not have current contact information. Of those contacted, 292 were eligible for the study and 275 enrolled. A total of 275 YAHIV completed the survey from April-May 2021. Median age was 22 years (interquartile range [IQR] = 19–24 years) and 178 (65%) were female. Most (82%) had completed secondary education or higher. At the time of the survey, 40% were living in an informal settlement (slum) in Kisumu, of which nearly half (48%) lived in the Manyatta slum. An additional 22% lived in uptown Kisumu in permanent housing while 38% reported living in villages outside of Kisumu City. Two-thirds (66%) had a boyfriend or girlfriend and over one-third (39%) of YAHIV had children with 14% having more than one child. Female participants were significantly more likely to report having a boyfriend/girlfriend as well as having at least one living child (Table 1).

Table 1. Demographic characteristics of young adults with HIV (18–25 years) completing the cross-sectional survey in Kisumu, Kenya, April-May 2021 (N = 275).

	Total		Male		Female
	N	%	N	%	N	%
	275	100%	97	35%	178	65%
Age, median (IQR)	22 (19–24)		20 (19–23)		22.5 (20–24)
Highest level of education (N = 270)	270	98%	95	98%	175	98%
Nursery/Preschool—Primary Class 4	3	1%	0	0%	3	2%
Primary Class 5–8	45	17%	10	11%	35	20%
Secondary Form 1–4	135	50%	53	56%	82	47%
Technical School	16	6%	5	5%	11	6%
University	33	12%	14	15%	19	11%
College	38	14%	13	14%	25	14%
Residential area (currently living) (N = 272)	272	99%	96	99%	173	97%
Village outside Kisumu city	104	38%	38	40%	66	38%
Up Town (permanent housing)	60	22%	27	28%	33	19%
Informal settlement (slum)	108	40%	31	32%	77	44%
Has boyfriend / girlfriend* (N = 259)	259	94%	90	93%	169	95%
Yes	170	66%	51	57%	119	70%
No	89	34%	39	43%	50	30%
Number of living children*
0	168	61%	87	90%	81	46%
1	70	25%	6	6%	64	36%
2	29	11%	4	4%	25	14%
3	5	2%	0	0%	5	3%
4 or more	3	1%	0	0%	3	2%
Total number of people in household (including self) (N = 274)	274	99%	96	99%	178	100%
1 to 3	68	25%	26	27%	42	24%
4 to 6	128	47%	49	51%	79	44%
7 or more	78	28%	21	22%	57	32%
Number of rooms in household* (N = 260)	260	95%	91	94%	169	95%
1	124	48%	34	37%	90	54%
2	84	32%	31	34%	53	31%
3	36	14%	17	19%	19	11%
4 or more	16	68%	9	10%	7	4%

* = p-value < 0.05.

COVID-19 information, knowledge and prevention practices

Almost all (99%) participants had heard of COVID-19 with most getting COVID-19-related information across multiple sources, including television, radio, social media, and/or conversations with family/friends and health workers. Despite high levels of awareness and multiple information sources, about one-third (31%) of participants reported not currently having enough COVID-19 information and an additional 6% reported being unsure if they had sufficient information. Over half (56%) of the YAHIV (N = 263) trusted the COVID-19 information from the MOH “fully” (32%) or “a lot” (24%). Of the remaining participants (N = 117), 20% were neutral and 19% trusted the information “a little” and 6% did not trust the information. The overall mean COVID-19 knowledge score was 4.32 (SD: 0.93; range 1–5), suggesting an overall 86% correct rate on this knowledge test. More than half (56%) of the participants answered all five questions correctly. Most participants reported frequent handwashing and/or use of hand sanitizer (91%) and wearing face masks (85%) as COVID-19 prevention practices. In general, YAHIV participants reported avoiding large groups/gatherings (77%). However, over half (55%) also reported being in a crowded place within the last 30 days before the survey. Females were more likely than males to express concern about contracting COVID-19 and more likely to implement certain prevention practices.

Overall perceived impacts of COVID-19 and government restrictions

When asked how COVID-19 and the government restrictions affected them, 30% of YAHIV stated the restrictions did not affect them. However, 70% felt that the restrictions had multiple impacts, mainly on their daily routine (38%) and views on travel and immigration (22%), and relationships (14%), including general positive effects (13%). Perceived impacts on specific aspects of YAHIV lives are described below.

Perceived impact on education, work, finances, and food

Of the 167 (61%) YAHIV who reported being in school before COVID-19, 29% stopped attending school entirely, 45% switched to remote learning, and 26% reported no change. In addition, YAHIV reported that they, themselves, as well as individuals who support them financially were working less (63%) and earning less income (73%) than before COVID-19. Changes in finances resulted in YAHIV and their households reducing spending, mostly on transportation (44%) and food (42%). Females were more likely than males to report reductions in spending on food. Almost one-third of participants reported that they often (7%) or sometimes (29%) did not have enough food to eat before the pandemic whereas, almost half of the YAHIV reported not having enough to eat often (8%) or sometimes (35%) in the last seven days. When comparing the change in food eaten at the household level from before and during COVID-19, over half (64%) reported no change while the remaining saw a negative (27%) or positive (10%) change. Furthermore, since the start of COVID-19 and associated restrictions, 7% of surveyed YAHIV reported that someone in their household had sex for money, good, gifts, rent, or other items and 9% reported that they had sex in exchange for money and goods. Young women were more likely to report having sex in exchange for money, food, gifts, rent, or other items since COVID-19 and the MOH restrictions began (Table 2).

Table 2. Perceived educational and economic impacts of COVID-19 on YAHIV in Kisumu, Kenya, April-May 2021 (N = 275).

	Total		Male		Female
	N	%	N	%	N			%
	275	100%	97	35%	178			65%
Education
Changes in schooling (N = 167)	167	61%	68	70%		99	56%
Stopped attending school entirely	49	29%	17	25%		32	32%
Switched to remote learning	75	45%	34	50%		41	41%
No change	43	26%	17	25%		26	26%
Economic
Items YAHIV or family had to cut back spending on
Transportation	121	44%	42	43%		79	44%
Food*	115	42%	32	33%		83	47%
Hair dressing salon*	71	26%	10	10%		61	34%
Airtime	64	23%	19	20%		45	25%
Hygienic products or toiletries	45	16%	14	14%		31	17%
Feminine care products*	41	15%	6	6%		35	20%
Alcohol	9	3%	2	2%		7	4%
Cigarettes	6	2%	3	3%		3	2%
One statement that best describes the food eaten in your household before the COVID-19 pandemic
Enough of the kinds of food (I/we) wanted to eat	97	35%	40	41%		57	32%
Enough, but not always the kinds of food (I/we) wanted to eat	81	29%	32	33%		49	28%
Sometimes not enough to eat	79	29%	20	21%		59	33%
Often not enough to eat	18	7%	5	5%		13	7%
One statement that best describes the food eaten in your household in last 7 days
Enough of the kinds of food (I/we) wanted to eat	54	20%	26	27%		28	16%
Enough, but not always the kinds of food (I/we) wanted to eat	102	37%	36	37%		66	37%
Sometimes not enough to eat	96	35%	26	27%		70	39%
Often not enough to eat	23	8%	9	9%		14	8%
Change in food eaten in your household (before COVID-19 pandemic vs. in last 7 day)
Positive change	27	10%	7	7%		20	11%
Negative change	73	27%	25	26%		48	27%
No change	175	64%	65	67%		110	62%
Confidence that your household will be able to afford the kinds of food you need
Not at all confident	115	42%	32	33%		83	47%
Somewhat confident	42	15%	15	15%		27	15%
Moderately confident	81	29%	34	35%		47	26%
Very confident	37	13%	16	16%		21	12%
Anyone in household (not including the YAHIV) exchanged sex for money, food, gifts, rent or other items since COVID-19 and the Government restrictions began (N = 252)	20	7%	4	4%		16	9%
YAHIV self-reported having sex for money, food, gifts, rent or other items since COVID-19 and the MOH restrictions began* (N = 271)	25	9%	4	4%		21	12%

* = p-value < 0.05.

Perceived impact on healthcare access and outcomes

In the past month, one quarter (25%) of YAHIV experienced a delay in receiving healthcare and 24% did not receive the medical care they needed for something other than COVID-19. Most (81%) YAHIV reported that they had not missed any scheduled HIV appointments since the start of the restrictions. Of the 15% who missed an appointment, the most common reasons included: lack of money or insurance (44%), inconvenience- location/hours (37%), canceled due to COVID-19 (17%), or they forgot (10%). For 26% of YAHIV, COVID-19 and government restrictions made it more difficult to access ART medications and 10% reported missing a dose since the government restrictions started.

Almost one-fourth (23%) of the YAHIV screened positive on GAD-2 for signs of possible generalized anxiety disorder (score ≥3). Similarly, 25% of YAHIV scored between 3–6 on PHQ-2, suggesting evidence of possible depressive disorder to be further evaluated. There were no statistically significant gender differences found among healthcare and mental health impact variables (Table 3).

Table 3. Perceived healthcare and mental health impacts of COVID-19 on YAHIV in Kisumu, Kenya, April-May 2021 (N = 275).

	Total		Male		Female
	N	%	N	%	N	%
	275	100%	97	35%	178	65%
Healthcare
At any time in the past month, experienced delay in getting medical care because of COVID-19	68	25%	22	23%	46	26%
At any time in the past month, need medical care for something other than COVID-19, but did not get it because of COVID-19	66	24%	20	21%	46	26%
Missed any scheduled appointments with at the HIV clinic since the lockdown
Yes, missed a visit	41	15%	14	14%	27	15%
No, did not miss a visit	224	81%	78	80%	146	82%
Did not have a visit scheduled to miss	5	2%	2	2%	3	2%
Do not know if visit missed	5	2%	3	3%	2	1%
COVID-19 and restrictions make it more difficult to get ARVs/ART (N = 256)	72	28%	26	27%	46	26%
COVID-19 and restrictions cause to miss taking doses of ARVs/ART at any time, or stop all together (N = 258)
I have missed doses	26	10%	14	15%	12	7%
I stopped taking my ARVs	3	1%	1	1%	2	1%
I have not missed any doses	229	89%	78	84%	151	92%
Mental Health
GAD-2 Scores (N = 262)
0–2	200	76%	74	80%	126	73%
3–6	62	24%	18	20%	47	27%
PHQ-2 Scores (N = 263)
0–2	195	74%	71	77%	124	73%
3–6	68	26%	21	23%	47	27%

Impact on housing, neighborhood safety and violence

Almost half of YAHIV (49%) reported changes in living situation (self or someone in their home), including 24% living with different people, 24% moved, and 10% newly living on the street since the start of COVID-19. Additionally, YAHIV reported increased experiences of verbal arguments in their household toward themselves (14%) and others (17%) as well as an increase in physical conflict toward themselves (6%) and others (10%). Over half of YAHIV reported that their neighborhood was safer (27%) or as safe (33%) since the start of COVID while 40% reported decreased neighborhood safety. Many reported experiences of verbal abuse or threats (23% total: 24% of all females, 20% of all males), or having been punched, kicked, whipped, beaten with an object or choked/smothered (12% total: 15% of all females, 7% of all males), or threatened with a knife, gun or other weapon (8% total: 8% of all females, 6% of all males) (Fig 1). Additionally, some YAHIV reported sexual violence including: someone touched them in a sexual way without permission, but did not try to force sex (7% total: 8% of all females, 5% of all males), someone tried to make them have sex against their will but did not succeed (4% total: 5% of all females, 3% of all males) or someone forced them to have sex (5% total: 7% of all females, 2% of all males). Higher rates of violence were observed among females across all categories; however, none of the gender differences were statistically significant.

Fig 1. Self-reported experiences of violence since the start of COVID-19 among YAHIV in Kisumu, Kenya, April-May 2021 (N = 275).

Discussion

The COVID-19 pandemic has been well documented to have broadly disrupted the social fabric, as well as economic, health, and healthcare infrastructure globally [54–57]. Furthermore, adverse consequences of the pandemic and the related mitigation efforts are likely to be most pronounced in low-income countries where the population is already disadvantaged and at risk for poor outcomes. The findings reported here contribute to the emerging body of knowledge around the perceived impacts of COVID-19 in a particularly vulnerable group residing in a low-income country [41,42], namely YAHIV in Kenya. This group is at heightened risk as they are on the cusp of independent adulthood with a chronic, stigmatized disease and a host of existing social and economic vulnerabilities. Overall, we found that YAHIV in Kenya had high rates of COVID-19 knowledge, were aware of the risk of getting COVID-19, and understood practices to minimize this risk but did not always adhere to these practices. YAHIV reported that COVID-19 impacted their economic, mental, and physical well-being and caused specific disruptions in their home lives with reported increases in verbal and physical conflict. While our data did not indicate many significant differences between male and female young adults on perceived impacts of COVID-19, the differences we did see align with other reports [15–17]. By investigating the impact of the pandemic on YAHIV in Kenya, results from this survey can inform adaptations to existing young adult-focused programs or the development of novel interventions to address the increasingly urgent needs of this population.

For individuals and families who are already struggling with high rates of poverty, even small economic changes can have a significant impact on their daily lives and wellbeing. In our study, economic vulnerability appeared to increase during the pandemic with YAHIV reporting lost work and reduced spending on basic needs, mainly on transportation and food. It has been reported that COVID-19 impacted transportation [58] and shopping [59] behaviors as going to markets and shops were associated with a higher risk of contracting COVID-19. In our study, females were more likely to cut down spending on food which may be due to females tending to use more prevention practices [60,61] and/or females often overseeing food shopping for the household [62]. Consequently, there was only a small increase in the number of YAHIV reporting food deprivation since the start of COVID-19. This may be because more than a third of participants had already been experiencing food insecurity prior to COVID-19. Greater increases in food insecurity in the context of COVID-19 were also observed in a study conducted in Kenya and Uganda [63].

Despite broad disruptions to health service delivery globally and in Kenya [64], we found that essential HIV services, particularly access to treatment, were relatively well maintained at the time of the survey. This is likely due to the fact that young adults enrolled in this study were receiving HIV care within a specialized healthcare setting that offered high-quality, personalized services tailored to their age group. In response to the COVID-19 pandemic, healthcare providers implemented exceptional measures to facilitate uninterrupted access to ART, including home delivery, and minimize medication interruptions among these young individuals. Overall, YAHIV in our survey were still able to access their ART medications, though some reported delays in receiving healthcare and stated that COVID-19 and government restrictions made it more difficult to get their medications leading to some missing a dose since the start of COVID-19. Our survey did not explore the exact reasons ART medication was more difficult to obtain, but it may be due to lack of access (transport, money, etc.) and less about the supply of ART medications. This experience stands in contrast to other settings in which clinical care, including HIV services, were negatively impacted thus threatening the progress that has been made to strengthen health systems, most notably HIV care services [65]. Our findings underscore the potential of high-quality medical care tailored to specific groups and the ability of this personalized care system to overcome the challenges of disruptive events like COVID-19.

Prior to the COVID-19 pandemic, adolescent and young adult mental health had emerged as a pressing global concern, with a notable increase in reports of depression and anxiety among young people in both low- and high-income countries [66–69]. Further, YAHIV experience higher rates of mental health disorders compared to uninfected young adults [70–73]. Our survey results indicate that almost a quarter of YAHIV screened positive for potential anxiety and/or depressive disorder warranting further evaluation and follow-up. These rates are similar to those reported by Dyer et al among 20–24-year-olds living with HIV reporting mild-severe depression [41]. While we cannot make any direct associations between these mental health screening results and COVID-19 pandemic, other research indicates that the COVID-19 pandemic and its associated mitigation measures further exacerbated the growing mental health challenges in this population [74–76]. These findings underscore the urgent need to provide mental health services and evaluations for the growing populations of YAHIV [77–79].

One of the major impacts of COVID-19 and the associated restrictions reported in the survey was related to the disruptions and changes in YAHIV living situations. Since the start of COVID-19, a quarter of YAHIV reported living with different people. Concomitantly, there was an increase in verbal arguments or conflicts in their household towards themselves (14%) and others (17%) as well as an increase in physical conflict toward themselves (6%) and others (10%). In Latin American and the Caribbean, 21% of adolescents reported more arguments at home during COVID-19 lockdown [80]. A global systematic review found increases in domestic violence cases during COVID-19 with multiple studies in Africa reporting increases in gender-based violence specifically [81]. Overall, our study showed high rates of violence among both females and males, with higher rates observed among females. In Kenya, high rates of violence among YAHIV, including gender-based violence, have been reported before [82] and during COVID-19 [83]. A study conducted in Kenya, Uganda, Nigeria, and South Africa found that gender-based violence prevention and response services were negatively impacted by COVID-19 and services decreased due to government restrictions [84]. The increases in violence and unsafe settings observed in our study may have negatively impacted the mental health, well-being, and ART adherence [22] of YAHIV who experienced disruptions to their social support networks and services during the COVID-19 restrictions. In our survey, the higher rates of violence reported among females, though not statistically significant, is a notable finding that should be taken into consideration by programs engaging females, including family planning and antenatal care health facilities.

There are limitations to this study. First, the study was conducted at a single healthcare facility in Kisumu, Kenya with a limited sample size, and may not be generalizable to other locations. Furthermore, it was based on a convenience sample of YAHIV actively engaged in care which limits our findings to those who are currently in HIV services. Surveys were self-administered to allow privacy and encourage truthfulness among adolescent respondents. However, YAHIV may have chosen to select socially acceptable answers. Although peer educators were present during the survey administration to provide technology support and answer questions, YAHIV may not have fully understood all of the questions. Additionally, due to funding constraints, this study was limited to only a quantitative survey. While the quantitative analysis provided valuable insights, incorporating a qualitative component would have allowed for a richer understanding of the findings by providing context and depth to the observed results. Future research should consider including qualitative methods, such as interviews or focus groups, to explore YAHIV experiences and perceptions, thereby enriching the findings and supporting a more holistic interpretation.

Conclusion

Our analysis expands upon the literature exploring the knowledge, attitudes, and practices as well as the impact of COVID-19 among YAHIV in Western Kenya [41,42]. Specifically, our study explored the perceived impact of COVID-19 on young adults who were established in HIV care and recruited directly from an HIV health center. YAHIV in Kenya were knowledgeable about COVID-19 and prevention practices despite inconsistent adherence. Impacts of the pandemic and government restrictions were felt across various aspects of YAHIV’s lives, including disrupted living situations and increased exposure to verbal and physical conflict, including sexual violence. This study provides new insights into the lived experiences of this YAHIV population residing in a low-income setting. Understanding the perceived economic, social and health impacts among this population is essential to recognize what support is needed now and can be offered in the future, especially during other crisis situations. These data can provide insight that can not only inform programming and services for YAHIV including HIV care and treatment, family planning, support group and antenatal services, but also be used as a guide for future pandemic preparedness efforts.

Supporting information

S1 Checklist

(DOCX)

Data Availability

The deidentified dataset analyzed during the study is available at figshare here: https://figshare.com/articles/dataset/Perceived_Impact_of_the_COVID-19_Pandemic_and_Government_Restrictions_on_the_Lives_of_Young_Adults_Living_with_HIV_in_Kisumu_Kenya/25620783.

Funding Statement

The authors received no specific funding for this work.