Depression, HIV, and COVID-19: A Deadly Trifecta

Even before the isolation of SARS-CoV-2, the virus that causes COVID-19, depression had become a disorder of international public health concern and an immense socioeconomic burden on individuals and communities worldwide. For example, from 1990 to 2017, the number of incident cases of depression globally increased by nearly 50%. ¹ Despite this statistic, most of those afflicted with depression still receive inadequate or no treatment. ² The spread of COVID-19 appears to have exacerbated problems related to mental health and illness: in the second quarter of 2020, the prevalence of depression had increased 4-fold from the same time in 2019. ³ Moreover, certain populations, such as people living with HIV (PLWH), are at elevated risk of severe illness or death because of COVID-19.^4,5 Of note, PLWH have experienced more severe depression than their HIV-negative counterparts during the COVID-19–precipitated health crisis. ⁶ To this end, COVID-19 has been described not as a pandemic but as a syndemic, which refers to a cluster of multiple diseases whose interaction can produce more adverse outcomes in the socioeconomic environment and among people who have one or more of the diseases themselves.^7,8 Thus, for the threat of the COVID-19 syndemic to be contained, the devastation of other diseases that COVID-19 can exacerbate, such as depression and AIDS, must be addressed within communities and societies worldwide.^8-10

Socioeconomic Upheaval and Mental Illness

In addition to its effects on health and mental health, the COVID-19 syndemic has facilitated an economic downturn associated with high unemployment rates, newfound or worsening poverty and food insecurity, school closures, social isolation, and suicidality. First, the COVID-19–associated economic downturn resulted in an unemployment rate estimated to be as high as 16%—comparable to that seen during the Great Depression. ¹¹ Second, economic downturns and pandemics have been associated with upticks in suicide rates: the severe acute respiratory syndrome (SARS) outbreak in 2003 was associated with an elevation in completed suicides in select populations of older adults in China. ¹² Moreover, the Great Recession of 2008 was found to have accelerated the already increasing suicide rate in the United States. ¹³ Some preliminary research has indicated that, in certain parts of the world, the COVID-19 syndemic is associated with an increase in suicides. ¹⁴ In a similar vein, elevated levels of suicidal ideation were observed in the United States subsequent to March 2020; this represented a 2-fold elevation compared with 2018. ³

Loneliness and social isolation have both altered individual behavior and emotion and further predisposed people toward more severe physical illness. To be more specific, COVID-19–related quarantines have worsened anxiety and facilitated depression in individuals, whose resultant anger and frustration were demonstrated to be associated with domestic violence and have fueled defiance of lockdown measures. ¹⁵ Furthermore, restrictions on movement and closures of markets because of these lockdown measures could be associated with limitations on food production and transportation as well as loss of income—both of which could affect individuals’ and families’ obtainment of food. ¹⁶ Resultant malnutrition could hamper immune defenses and worsen health outcomes in these populations. When the aforementioned phenomena are combined with prior persistence of poverty and discrimination and copresence of other infectious diseases such as tuberculosis, the likelihood of severe illness or death from COVID-19 is greatly increased.^16,17

Disproportionate Effects of Illness in Communities

COVID-19 has further uncovered the prior existence of health disparities in race, economic stratification, and HIV-positive status. These disparities affect, for example, onset and maintenance of illness, enhanced risk of adverse outcomes from COVID-19, and acquisition of treatment for or prevention against COVID-19 and other illnesses. To be more specific, Black people are hospitalized because of complications related to COVID-19 at almost 3 times the rate of White people and die because of complications related to COVID-19 at almost twice the rate of White people. ¹⁸ Of note, these disparities exist despite a near-equal risk for COVID-19 infection among Black and White people. Furthermore, communities of ethnic minority groups in the United Kingdom were found to have diminished access to and consumption of HIV tests, which undermined equalization of access to SARS-CoV-2 tests, ¹⁹ as well as lower COVID-19 vaccine uptake in 2021. ²⁰ This same trend of differential vaccine uptake on the basis of ethnic or racial status also persisted in the United States within the same time frame. ²¹

There are a number of possible causes of these phenomena. First, elevated medical mistrust—often attributed to racial discrimination associated with, for example, the Tuskegee Syphilis Study—in Black people in the United States could hinder acquisition of treatment for COVID-19 and COVID-19 vaccination. ²² Such racial discrimination can also perpetuate the risk behaviors, such as unprotected sex, that sustain the spread of HIV. ²² Moreover, health care disruptions can have more pronounced effects within contexts of comorbidities, such as HIV-positive status. For example, lockdowns were found to have interrupted continua of care that promote medication adherence in PLWH, which was suboptimal even before March 2020, with only a small minority of PLWH achieving viral suppression.^23-25 These disruptions, combined with observed increases in HIV-1 viral load in cases of coinfection with SARS-CoV-2, increase the likelihood of severe illness or death from COVID-19 among PLWH.^5,24 This likelihood is of particular concern to Black populations, as Black men account for the most sizable number of new HIV-positive classifications. ²⁶ Certain comorbidities, such as cardiovascular disease, obesity, and various cancers, which raise the risk of severe illness or death from COVID-19, are more prevalent among non-Hispanic Black and Hispanic people in the United States, PLWH, and/or those who have depression.^27-30 Lastly, access to care varies based on race, economic status, HIV-positive status, and presence of mental illness. As stated previously, most people with depression still receive inadequate or no treatment. ² As it pertains to HIV-positive status, the presence of mental illness and lack of food or transportation can further undermine access to and retention in care for PLWH; as a result, these factors can contribute to an overall rise in hospital costs.^31,32 As it relates to race, non-White victims of racial discrimination are less likely to have health insurance and, thus, more likely to postpone or fail to seek care compared with White people who have not experienced racial discrimination. ³³ As it pertains to economic status, wealthier people in the United States consume a more disproportionate share of health care resources over time than people with less personal wealth. ³⁴ All these factors provide evidence that health and socioeconomic burdens within the context of COVID-19 are unequally distributed across certain communities and populations.

Disinformation, Discrimination, and Distrust

Within the sphere of public health, disinformation further complicates civic discernment of whom to trust and where and from whom to seek medical care. Concomitant discrimination toward those who are ill or are perceived to be ill can further perpetuate disparities and deepen medical mistrust. As it relates to HIV/AIDS, self-reported discrimination based on HIV-positive status is elevated among homosexual men compared with heterosexual men, and internalization of institutional discrimination among PLWH who use substances is common.^35,36 This discrimination eroded social support for those based on HIV-positive status, which hinders acquisition of care, antiretroviral therapy (ART) adherence, and attainment of viral suppression as well as worsens the mental health of homosexual men and people who inject drugs.^35-38

COVID-19 is not without examples of disinformation and concomitant discrimination based on perception of presence or absence of illness or ethnic or racial status. To start, health care workers and those believed to be ill with COVID-19 in Central America, Africa, and India have been attacked or barred from public transportation in their communities. ³⁹ Furthermore, harsh media presentations and quotations that linked Asian people directly to the international spread of COVID-19 (ie, “the Chinese virus” or “the Wuhan virus”) reflected misconceptions about and pernicious attitudes toward those believed to be responsible for COVID-19. ⁴⁰ As a result, self-reported anti-Chinese xenophobia and overall discrimination toward Asian American people in 2020 were widespread.^41,42 As with PLWH, these phenomena threaten mental health and further inhibit health care access among victims of this discrimination. In turn, disinformation and discrimination sustain health disparities among victims of discrimination.^40-43

Public Health Implications

Whether it be somatic or mental disease, access to health care resources and positive health outcomes within the context of both HIV/AIDS and COVID-19 appear to be uneven across communities and populations based on race, economic status, and actual or perceived presence of somatic or mental illness. As such, this syndemic of depression, HIV/AIDS, and COVID-19 threatens to further deepen societal health disparities that predate COVID-19. To put it simply, no epidemic occurs within a vacuum.

Thus, far more attention must be paid to the effect this syndemic will have on mental health outcomes, risk behaviors, medical distrust, and discrimination. To minimize undesirable health outcomes and maximize desirable ones, continued use of and investment in telemedicine and its infrastructure can lower health care costs and equalize access.^43,44 These virtual approaches hold promise for the promotion of broader population health and mental health and should be disseminated further within the medical sphere.^42,45-48 To address the structural racism that sustains health disparities and resultant medical distrust, problems such as mass incarceration and opioid abuse should be more wholly addressed within the political sphere through comprehensive legislation and reform. ⁴⁹ To further address distrust, attenuate risk behavior, and combat misconception-based discrimination, health education curricula should be modified and funded to better empower people to acquire evidence-based information and make health-based decisions that facilitate positive health practices, behaviors, and outcomes. ⁵⁰

Governments can facilitate efforts meant to combat structural racism in health care, invest in telemedical infrastructure, and restructure health education curricula in public schools. These ventures can be accomplished via compassionate outreach to victims of discrimination, conscientious allocation of necessitated funds or reparations, enhanced educational and mental health initiatives via professional and paraprofessional dispatch, and public–private partnerships. ⁵¹ To be more specific, to maximize compliance, promote uptake of preventive tools and treatment modalities, and undercut discriminative behavior, public servants and health experts alike should communicate with the broader population via accessible media. These communications should account for people’s anxieties, biases, and fears; consider the intersectionalities of a multitude of audiences; and consist of clear and concise behavioral recommendations in the development of consumable educational material. ⁵² Failure to address all of these facets related to care, dissemination, and education could hamper adherence to containment efforts and sustain health disparities. In this scenario, COVID-19 would not be the last crisis that exposes societal fault lines; stokes distrust and fear among those most vulnerable to socioeconomic debilitation, illness, or death; and costs societies trillions of dollars and millions of lives.