Abstract
Little is known about the psychological implications of the coronavirus disease 2019 (COVID-19) pandemic on people with HIV. The purpose of this study was to assess the impact of COVID-19 among men and women with HIV in Miami, Florida. We hypothesized that the burden of the COVID-19 pandemic will be higher for women, and psychological factors will increase COVID-19 burden among them. People with (n = 231) and without HIV (n = 42) residing in Miami, Florida completed a survey assessing psychological outcomes such as loneliness, depression, and stress, as well as the burden of COVID-19, on their daily lives. t-Tests and chi-square analyses were used to assess sex differences in study variables. Logistic regression was used to compare the interaction effects predicting stress and loneliness by COVID-19 burden and sex. A total of 273 completed the survey; the outcomes of the study, loneliness, and stress did not differ by HIV status (p = .458 and p = .922). Overall, men and women reported similar prevalence of COVID-19 burden. However, a greater proportion of women reported losing childcare than men (18% vs. 9%, p = .029, respectively), as well as losing mental health care (15% vs. 7%, p = .049, respectively). There was a significant interaction between COVID-19 burden and sex for loneliness and stress such that the association between COVID-19 burden and loneliness was greater for women (p < .001) than for men (p = .353) and the association between COVID-19 burden and stress was greater for women (p = .013) than men (p = .628). Both men and women with HIV are impacted by the COVID-19 pandemic, but women may experience higher levels of stress and loneliness than men. Sex differences may require tailored interventions to more effectively mitigate the impact of the pandemic on mental health.
Keywords: HIV, COVID-19, COVID-19 burden, mental health
Introduction
Since its emergence in late 2019 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread quickly around the world. With over 50 million infections and 1.3 million deaths worldwide,1–3 the pandemic has forced governments to implement rigorous lifestyle changes to prevent the spread of the virus. However, such interventions have had detrimental outcomes on the population's mental health including outcomes such as loneliness, depression, anxiety, and stress.4–6
Almost 1 year after the first cases of coronavirus disease 2019 (COVID-19) were identified,7 the highest case incidence and deaths are primarily occurring in the Americas,1,8 and the Southern United States is highly impacted by both HIV and COVID-19.9 The effects of the pandemic among people with HIV (PWH) have not been evaluated, although PWH may be at an increased risk for poor health outcomes associated with SARS-CoV-2 infection.10,11 In addition, PWH are at greater risk for poor mental health outcomes associated with loss of resources and psychological distress.8,12,13
While anxiety and insomnia tend to be more prevalent in women,14 recent studies have noted that mental health disorders have been exacerbated for women during the COVID-19 pandemic.15,16 For instance, those experiencing greater levels of COVID-19 burden may exhibit greater levels of mental health difficulties. This association, however, may be moderated by sex given the potentially disproportionate childcare burden on women. That is, as increased responsibilities in the household for women have been aggravated due to school closures and lack of childcare,8 the burden of the COVID-19 pandemic for women may be greater compared with men.
This study examined sex differences associated with the impact of COVID-19 among men and women with HIV in the Southeastern United States, during the first COVID-19 surge in Miami, Florida, an HIV epicenter. Due to higher rates of mental health disorders and greater potential household stress among women, we hypothesized that the association between stress and COVID-19 burden, as well as loneliness and COVID-19 burden, would be greater in women. It was anticipated that study results would provide guidance on strategies to assist men and women during the pandemic.
Methods
Participants and procedures
This cross-sectional study recruited participants using an existing registry of adult PWH collected by the Miami Center for HIV Research in Mental Health (CHARM)/Center for AIDS Research (CFAR). In addition, participants in the community were recruited using medical referrals, word-of-mouth, and/or printed flyers. Registry participants were adults (≥18 years) living in Miami, Florida. Participants were conveniently sampled and were recruited and assessed from May to December 2020. The goal was to survey as many participants as possible during this period of time. For participants recruited from the community, n = 111 potential candidates contacted the study personnel, and n = 38 were not eligible. For registry participants, out of n = 1,036 participants, n = 203 did not have contact information, n = 13 lived outside of Miami, n = 131 were not interested, n = 447 could not be reached, and n = 42 could not be reached. The study was approved by the University of Miami (UM) IRB (number: 20200340). Verbal consent was obtained by all participants before the administration of study survey through telephone or online by study staff. The survey was conducted with participants through telephone. Participants were given the option to respond to the survey in English or Spanish; interviewers and recruiters were fluent in English and Spanish.
Variables/measures
The COVID-19 survey was adapted from the MACS/WIHS Combined Cohort Study (MWCCS),17 and data were collected using the University of Miami licensed software REDCap®. The COVID-19 survey was designed to assess the impact of the COVID-19 pandemic on PWH and has been previously described.8,18 The factors outlined below included: sociodemographic characteristics, comorbidities, COVID-19 risk factors, COVID-19 preventive measures, COVID diagnosis, disruption of resources, and psychosocial factors.19–25
COVID-19 burden
This variable was constructed with the total sum score of items related to COVID-19: positive test, symptoms, contact to a case, suspected infection, affected by the pandemic (broadly), loss of resources (income, childcare, or housing, asked in the context of “Have you lost childcare during the pandemic?”), and disrupted access (health care, medication, and/or substance-use and mental health treatment, asked in the context of “Have you experienced lost access to healthcare during the pandemic?”). All variables had dichotomous response options (yes/no). All responses were then summed, following a syndemic perspective of how COVID-19 burden accumulates among PWH.12
Psychological factors
Stress
For this measure, a total sum score was estimated from the Perceived Stress Scale (PSS)22 defined by a 5-point Likert-type scale ranging from 1 = Never to 5 = Very. The PSS was adapted to the timeframe of the pandemic (since the COVID-19 pandemic began). Three of the four items were reverse coded before estimating the total score. Internal consistency in this sample was adequate (α = 0.78).
Loneliness
To asses loneliness, the UCLA Loneliness Scale21 was utilized in a 3-point Likert-type scale that included 1 = Hardly Ever, 2 = Some of the time, and 3 = Often. Participants were asked to rate how often they felt lack of companionship, feelings of isolation, and feelings of being left out during the COVID-19 pandemic. The responses were added to calculate the score. Internal consistency in this sample was acceptable (α = 0.74).
Depressive symptoms
Adopting the Center for Epidemiologic Studies Depression Scale,23 participants were asked the frequency of which they had identified with a specific feeling/mood in the past 2 weeks. The responses, using the 4-point Likert-type ordinal scale, were summed to calculate this variable. The reliability coefficient for this scale was in the acceptable range (α = 0.88).
Statistical analyses
Descriptive analyses included mean and standard deviation (SD) for key study variables. Independent sample t-tests and chi-square tests were used to compare participants by sex; the outcomes of the study were also tested for differences by HIV status using these bivariate tests. Interaction effects predicting stress and loneliness by COVID-19 burden × sex were completed using Model 1 of PROCESS macro by Hayes for SPSS; procedures for the macro have been extensively described in previous research.26 Analyses were conducted, and figures were plotted in SPSS v26. A threshold of p < .05 was used to establish statistical significance.
Results
Demographic characteristics, comorbidities, COVID-19 preventive measures, and psychosocial factor response characteristics
A total of 273 participants were included in the study. Participants were on average 50.96 years old (SD = 12.37), and 55% of participants were female. One-third of participants (31%) were employed, 73% had their own place (e.g., own house or apartment), and 42% had a monthly household income USD$1,000. More than half (56%) were Black/African American, and 50% were non-Hispanic. In terms of COVID-19 risk exposure, 25% had traveled to places with a high number of COVID-19 cases, 43% had hypertension, and 19% diabetes. For COVID-19 preventive measures, participants were mostly staying home (96%) and practicing social distancing (96%). At the time of the survey, one-quarter (23%) were self-isolating due to symptoms, and fewer were self-isolating due to contact (15%) or potential infection (14%). More than a third of participants (40%) had been tested for COVID-19. Among those who were tested, 19% had tested positive for COVID-19. Participants included those with (n = 231) and without HIV (n = 42) but did not differ in the study outcomes of loneliness and stress (p = .458 and p = .922). As such, subsequent analyses were conducted among people with and without HIV.
Men and women had similar characteristics although men reported a higher monthly household income (51% vs. 34% with a monthly household income of $1,000; p = .005), and women were more likely to be non-Hispanic (p = .041) and Black (p = .029). In addition, there was a greater proportion of women self-isolating due to potential infection with SARS-CoV-2 (18% vs. 9%; p = .029). Women also reported higher levels of stress (p = .041) and loneliness (p = .024), but not depressive symptoms. Therefore, interactions between sex and COVID-19 burden were only tested for stress and loneliness, but not depressive symptoms. A summary of the sociodemographic and COVID-19 response characteristics is presented in Table 1.
Table 1.
Comparison of Demographic, COVID-19 Risk, and COVID-19 Response Characteristics by Sex
| Variable | All (N = 273) | Men (n = 122) | Women (n = 151) | Test statistic, p |
|---|---|---|---|---|
| Demographic characteristics | ||||
| Age (years) | 50.96 (12.37) | 53.32 (11.51) | 49.07 (12/74) | 2.89, .004 |
| Employed | ||||
| No | 84 (69.4%) | 84 (69.4%) | 113 (74.3%) | .81, .368 |
| Yes | 37 (30.6%) | 37 (30.6%) | 39 (25.7%) | |
| Living situation | ||||
| Someone else's house | 75 (27.5%) | 37 (30.6%) | 38 (25.0%) | 1.05, .305 |
| Own apartment or house | 198 (72.5%) | 84 (69.4%) | 114 (75.0%) | |
| Monthly household income | ||||
| $1,000 or less | 159 (58.2%) | 59 (48.8%) | 100 (65.8%) | 8.03, .005 |
| More than $1,000 | 114 (41.8%) | 62 (51.2%) | 52 (34.2%) | |
| Race | ||||
| Black/African American | 154 (56.4%) | 56 (46.3%) | 98 (64.5%) | 10.76, .029 |
| White | 94 (34.4%) | 49 (40.5%) | 45 (29.6%) | |
| Asian | 1 (0.4%) | 1 (0.8%) | 0 (0.0%) | |
| Native American | 5 (1.8%) | 3 (2.5%) | 2 (1.3%) | |
| Other | 19 (7.0%) | 12 (9.9%) | 7 (4.6%) | |
| Ethnicity | ||||
| Hispanic | 114 (41.8%) | 62 (51.2%) | 52 (34.2%) | 8.26, .041 |
| Non-Hispanic | 137 (50.2%) | 50 (41.3%) | 87 (57.2%) | |
| Haitian | 9 (3.3%) | 4 (3.3%) | 5 (3.3%) | |
| Other | 13 (4.8%) | 5 (4.1%) | 8 (5.3%) | |
| Contact through travel | ||||
| No | 204 (74.7%) | 97 (80.2%) | 107 (70.4%) | 3.41, .065 |
| Yes | 69 (25.3%) | 24 (19.8%) | 45 (29.6%) | |
| Hypertension | ||||
| No | 156 (57.1%) | 63 (52.1%) | 93 (61.2%) | 2.29, .130 |
| Yes | 117 (42.9%) | 58 (47.9%) | 59 (38.8%) | |
| Diabetes | ||||
| No | 222 (81.3%) | 102 (84.3%) | 120 (78.9%) | 1.27, .260 |
| Yes | 51 (18.7%) | 19 (15.7%) | 32 (21.1%) | |
| Renal disease | ||||
| No | 265 (97.1%) | 118 (97.5%) | 147 (96.7%) | .16, .693 |
| Yes | 8 (2.9%) | 3 (2.5%) | 5 (3.3%) | |
| COVID-19 preventive measures | ||||
| Staying home | ||||
| No | 11 (4.0%) | 6 (5.0%) | 5 (3.3%) | .49, .486 |
| Yes | 262 (96.0%) | 115 (95.0%) | 147 (96.7%) | |
| Social distancing | ||||
| No | 11 (4.0%) | 4 (3.3%) | 7 (4.6%) | .29, .588 |
| Yes | 262 (96.0%) | 117 (96.7%) | 145 (95.4%) | |
| Self-quarantine due to symptoms | ||||
| No | 210 (76.9%) | 96 (79.3%) | 114 (75.0%) | .71, .398 |
| Yes | 63 (23.1%) | 25 (20.7%) | 38 (25.0%) | |
| Self-quarantine due to contact | ||||
| No | 233 (85.3%) | 105 (86.8%) | 128 (84.2%) | .36, .551 |
| Yes | 40 (14.7%) | 16 (13.2%) | 24 (15.8%) | |
| Self-quarantine due to potential infection | ||||
| No | 234 (85.7%) | 110 (90.9%) | 124 (84.6%) | 4.79, .029 |
| Yes | 39 (14.3%) | 11 (9.1%) | 28 (18.4%) | |
| Tested for COVID-19 | ||||
| No | 164 (60.1%) | 68 (56.2%) | 96 (63.2%) | 1.36, .243 |
| Yes | 109 (39.9%) | 53 (43.8%) | 56 (36.8%) | |
| Psychosocial factors | ||||
| Stress (score) | 5.46 (3.13) | 5.02 (2.93) | 5.80 (3.25) | 2.05, .041 |
| Loneliness (score) | 4.82 (1.91) | 4.53 (1.78) | 5.05 (1.98) | 2.27, .024 |
| Depression (score) | 6.25 (4.22) | 5.96 (4.00) | 6.49 (4.39) | 3.58, .305 |
COVID-19, coronavirus disease 2019.
COVID-19 burden
One-fifth (19%) of participants reported testing positive for COVID-19. Approximately one-fifth (21%) reported having COVID-19 symptoms, having contact with someone with COVID-19 (21%), or perceiving themselves to be infected by COVID-19 (21%). About two-thirds (60%) of participants reported being affected by COVID-19 in some way, 48% due to losing their job or working fewer hours, 14% lost childcare, 9% lost other financial resources, and 7% lost housing. Regarding health care, 8% reported being unable to take their medications, 15% being unable to afford medical care, mental health care (12%), or substance abuse treatment (2%).
Men and women had similar prevalence of the items included in the burden score except for loss of childcare and mental health care. A greater proportion of women reported losing childcare than men (18% vs. 9%, p = .029), as well as mental health care (15% vs. 7%, p = .049) during COVID-19. Table 2 summarizes burden by sex.
Table 2.
Incidence of Experiences Related to COVID-19 Burden by Sex
| Variable | All | Men | Women | Test statistic, p |
|---|---|---|---|---|
| Tested positive for COVID-19 | ||||
| No | 220 (80.6%) | 93 (76.9%) | 127 (83.6%) | 1.93, .165 |
| Yes | 53 (19.4%) | 28 (23.1%) | 25 (16.4%) | |
| COVID-19 symptoms | ||||
| No | 217 (79.5%) | 94 (77.7%) | 123 (80.9%) | .43, .511 |
| Yes | 56 (20.5%) | 27 (22.3%) | 29 (19.1%) | |
| Contact with someone with COVID-19 | ||||
| No | 215 (78.8%) | 89 (73.6%) | 126 (82.9%) | 3.51, .061 |
| Yes | 58 (21.2%) | 32 (26.4%) | 26 (17.1%) | |
| Perceived COVID-19 infection | ||||
| No | 215 (78.8%) | 91 (75.2%) | 124 (81.6%) | 1.64, .201 |
| Yes | 58 (21.2%) | 30 (24.8%) | 28 (18.4%) | |
| Affected by COVID-19 | ||||
| No | 110 (40.3%) | 52 (43.0%) | 58 (38.2%) | .65, .420 |
| Yes | 163 (59.7%) | 69 (57.0%) | 94 (61.8%) | |
| Lost job or worked fewer hours | ||||
| No | 141 (51.6%) | 59 (48.8%) | 82 (53.9%) | .73, .394 |
| Yes | 132 (48.4%) | 62 (51.2%) | 70 (46.1%) | |
| Lost childcare | ||||
| No | 234 (85.7%) | 110 (90.9%) | 124 (81.6%) | 4.79, .029 |
| Yes | 39 (14.3%) | 11 (9.1%) | 28 (18.4%) | |
| Lost other financial resources | ||||
| No | 248 (90.8%) | 107 (88.4%) | 141 (92.8%) | 1.52, .218 |
| Yes | 25 (9.2%) | 14 (11.6%) | 11 (7.2%) | |
| Loss of housing | ||||
| No | 253 (92.7%) | 112 (92.6%) | 141 (92.8%) | .01, .949 |
| Yes | 20 (7.3%) | 9 (7.4%) | 11 (7.2%) | |
| Unable to take medications | ||||
| No | 250 (91.6%) | 110 (90.9%) | 140 (92.1%) | .13, .724 |
| Yes | 23 (8.4%) | 11 (9.1%) | 12 (7.9%) | |
| Unable to afford medical care | ||||
| No | 232 (85.3%) | 101 (84.2%) | 131 (86.2%) | .22, .641 |
| Yes | 40 (14.7%) | 19 (15.8%) | 21 (13.8%) | |
| Loss of mental health care | ||||
| No | 241 (88.3%) | 112 (92.6%) | 129 (84.9%) | 3.85, .049 |
| Yes | 32 (11.7%) | 9 (7.4%) | 23 (15.1%) | |
| Loss of substance use care | ||||
| No | 268 (98.2%) | 119 (98.3%) | 149 (98.0%) | .04, .844 |
| Yes | 5 (1.8%) | 2 (1.7%) | 3 (2.0%) | |
Model 1: Sex differences in the association between stress and COVID-19 burden
Table 3 shows a summary of the linear regression model predicting stress by COVID-19 burden, sex, as well as the interaction between COVID-19 burden and sex; no other variables were included in the models. The interaction between COVID-19 burden and sex was significant (p = .025). Specifically, the association between stress and COVID-19 for men was not significant (B = 0.10, p = .353), but it was significant among women (B = 0.45, p < .001). The interaction between COVID-19 burden and sex is plotted in Figure 1.
Table 3.
Sex Differences in the Association Between Stress and COVID-19 Burden
| Variables | B | SE | t | p |
|---|---|---|---|---|
| Constant | 5.50 | 1.41 | 3.89 | .001 |
| Sex | −1.01 | 0.87 | −1.16 | .246 |
| COVID-19 burden | −0.24 | 0.25 | −0.97 | .332 |
| Sex × COVID-19 burden | 0.35 | 0.15 | 2.26 | .025 |
There was a significant interaction between COVID-19 burden and sex (p = .025), such that the association between COVID-19 burden predicting stress differed between male (1) and female (2) participants.
SE, standard error.
FIG. 1.
Stress by COVID-19 burden and sex. Interaction between COVID-19 burden and sex predicting stress. At high levels of COVID-19 burden, female participants experienced greater stress. Men's level of loneliness remained relatively unchanged regardless of COVID-19 burden (p = .025). COVID-19, coronavirus disease 2019.
Model 2: Sex differences in the association between loneliness and COVID-19 burden
Table 4 shows a summary of the linear regression model predicting loneliness by COVID-19 burden, sex, as well as the interaction between COVID-19 burden and sex; no other variables were included in the models. The interaction between COVID-19 burden and sex was significant (p = .041). Specifically, the association between COVID-19 burden and loneliness was significant for women (B = 0.45, p < .001) but not for men (B = 0.10, p = .353). Similarly, the association between stress and COVID-19 was significant for women (B = 0.16, p = .013), but it was not found for men (B = −0.03, p = .628). The interaction between COVID-19 burden and sex is plotted in Figure 2.
Table 4.
Sex Differences in the Association Between Loneliness and COVID-19 Burden
| Variables | B | SE | t | P |
|---|---|---|---|---|
| Constant | 5.15 | 0.88 | 5.89 | .001 |
| Sex | −0.46 | 0.54 | −0.85 | .396 |
| COVID-19 burden | −0.23 | 0.15 | −1.49 | .137 |
| Sex × COVID-19 burden | 0.20 | 0.10 | 2.06 | .041 |
There was a significant interaction between COVID-19 burden and sex (p = .041), such that the association between COVID-19 burden predicting loneliness differed between male (1) and female (2) participants.
FIG. 2.
Loneliness by COVID-19 burden and sex. Interaction between COVID-19 burden and sex predicting loneliness. At high levels of COVID-19 burden, female participants experienced greater loneliness. Men's level of loneliness remained relatively unchanged regardless of COVID-19 burden (p = .041).
Discussion
The rapid spread of the SARS-CoV-2 has disrupted most social and economic structures worldwide, posing important challenges for the physical and mental well-being, and may disproportionately affect PWH and women. This study evaluated the burden of the SARS-CoV-2 pandemic among PWH in Miami, Florida, a city severely affected by both HIV and COVID-19 and examined the relationship between stress and loneliness among both men and women. Study results indicate that overall most men and women reported being impacted by the pandemic, and study outcomes (loneliness and stress) did not differ by HIV status. However, women reported higher levels of stress, loneliness, and COVID-19 burden compared with men, and COVID-19 burden predicted the level of stress and loneliness among women. These results are in line with previous outbreaks that found communicable diseases to impact mental health. During the SARS outbreak, about 54% of the population rated the psychological impact of the outbreak as moderate or severe.27 More recently, studies have also found that although self-isolating and social isolation are vital to contain the spread of the virus, adverse psychological issues such as depression, loneliness, anxiety, and stress are increasingly reported.27–30
Sex-differences in COVID-19-related morbidity and mortality have been extensively documented indicating that women are less likely to die.31 This advantage may arise from differences in immunological and coping mechanisms between sexes.32 Conversely, socially prescribed caregiving roles exclusively allocated to women may also contribute to a greater psychological burden in this group. In the present sample, women were more likely to lose childcare and mental health care than their male counterparts. Previous research has illustrated that the shift in household demands following closures in school and day care negatively impacted working mothers more so than fathers, highlighting the existing gender gap in work related benefits.8,33 In this study, women demonstrated stronger associations between the burden of COVID-19, stress, and loneliness than found in men, an association that may have been influenced by differing coping mechanisms among women compared to men.8,18 Such differences suggest the need for an individualized gender-based intervention approach building mitigating the pressures associated with women's roles within the family and household. Similarly, the combination of the loss of childcare that may temporarily relieve women from household requirements, disruption in regular work hours, and reduced access to mental health support diminishes physical and emotional well-being.34 Recent studies examining the mental health impact of COVID-19 confinement illustrate that depressive symptoms, anxiety, and post-traumatic stress disorder are more severe in women who have lower levels of well-being.35 In this study, men and women had similar levels of depression, but women reported greater loss of mental health care, which over time may result in worse mental health outcomes, disruptions in family routines, and may impact children. In addition, if women are serving as primary caregivers, their mental health and well-being have important implications for the family unit and, in PWH, may result in poor HIV medication adherence and HIV outcomes. Along with other negatively impacted groups such as the unemployed, low-income, and minorities, women are at greater vulnerability to stressors due to depletion of resources, and women may require dedicated interventions to address resource disruptions during the pandemic.36
This study used a composite sum score to assess the burden of COVID-19 that included the loss of income, childcare, housing, health care, COVID-19 positivity, related symptoms, and suspect infection. The assessment of the psychological burden of COVID-19 in the present sample does concur with sex differences in previous studies.16,37 In this sample, women were more likely to suspect COVID-19 infection than their male counterparts, which may have led women to experience greater levels of stress compared to men. Similar studies found the suspicion of COVID-19 infection alone to lead to depression and lower quality of life.38 This sex-specific influence of the COVID-19 burden on risk factors leading to stress and loneliness has implications for treatment and prevention of other health related effects. As noted above, the associations between sex-specific differences and psychological impact and their possible protective effects against negative outcomes in clinical characteristics and prognosis of COVID-19 are possible future routes to study.39,40
There are several limitations to be noted. Due to the cross-sectional nature of the study, a causal inference cannot be established, thus larger longitudinal studies are needed. Our convenience sample was recruited from Miami and is not representative of the general population or of Miami.41 Furthermore, random sampling instead of convenience sampling might have brought about more representative results to enhance the generalizability of the results. Specifically, different levels of depression, stress, and loneliness may have influenced participants' decision to participate in the study. Participant responses are subject to recall bias. Participant self-assessment of psychological issues such as loneliness, depression, and stress may not concur with an assessment by a mental health professional. Finally, participants were only given the option to complete the survey in English or Spanish. Therefore, it is possible that participants not fluent in English or Spanish may have been excluded.
Conclusion
Results from this study suggest that both men and women with HIV are impacted by the COVID-19 pandemic, but women may experience higher levels of stress and loneliness. Understanding the association between the COVID-19 pandemic burden, stress, and loneliness can shed light on appropriate strategies to preserve the mental health of PWH in the face of the COVID-19 pandemic. Therefore, there is an urgent need for timely psychological assessment and appropriate intervention to prevent the development of psychological distress.
Acknowledgments
The authors thank the ACTION 1 and 2 team members who conducted the surveys and the participants who contributed information without whom this study would not have been possible.
Authors' Contributions
All authors were responsible for data acquisition and interpretation of results. All authors had full access to all the data in the study and take responsibility for the accuracy and the integrity of the data analysis. C.U.S. and V.J.R. contributed with the data analyses. M.L.A. and D.L.J. were responsible for study concept and design. All authors were responsible for drafting and critical revision of the article for important intellectual content.
Author Disclosure Statement
Funding from the National Institutes of Health (NIH) supported this article; the authors have no other disclosures.
Funding Information
This work was supported by National Institutes of Health grants to the University of Miami Center for AIDS Research grant (P30A1073961) and the Center for HIV and Research in Mental Health (P30MH116867). V.J.R.'s work on this article was partially supported by a Ford Foundation Fellowship, administered by the National Academies of Sciences, Engineering, and Medicine.
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