The Syndemics of HIV, Mental Health, and Human Rights Concerns During the COVID-19 Pandemic

Overview: The current study examines the perceived health outcomes and human rights concerns for youth living with HIV in Uganda during the COVID-19 pandemic, using a phenomenological methodology.Proposal text: Purpose/background

Currently, over 150,000 (5%) of youth ages 18-24 are living with the human immunodeficiency virus (HIV) in Uganda (McHugh et al., 2018). Stigma and discrimination associated with HIV present a persistent barrier to the prevention and treatment of the disease. Goffman (1963) defines stigma as the labeling and discrediting individuals or groups based on an actual or perceived attribute, behavior, or membership in that group. HIV stigma is complex and mainly occurs due to a lack of accurate HIV information, cultural beliefs, and misinformation. Stigma and discrimination are the dominant factors responsible for individuals' refusal to access HIV testing, treatment uptake, and treatment delays, (UNAIDS, 2017). Stigma can be multi-dimensional, from internalized and perceived stigma to secondary and structural (Wu et al., 2015). These can affect emotional well-being, increased depression, anxiety, suicidality, and lower quality of life (Ashaba et al., 2018). The COVID-19 pandemic increased this complexity and created syndemics of clusters that created poor health outcomes for youth living with HIV (YPLHIV) in Kampala, Uganda. It has added another layer of obstacles to access health resources and other vital needs. The current study aims to use phenomenology to understand the lived experiences of stigma and discrimination among YPLHIV in Uganda given their social vulnerability context of living with HIV during the COVID-19 pandemic.

Methods
The study was conducted in collaboration with Uganda’s National AIDS Control Program, Ministry of Health, the Most At-Risk Populations Initiative (MARPI) clinic, and its sister networks in Kampala. Approval from the institutional review board (IRB) for the protection of human subjects was attained from US and Uganda. Data were collected through six focus groups (Nf31) between December 2020 to May 2021. They were audio-recorded, transcribed verbatim, and coded using thematic analysis.

Results
Five themes were extracted from the study. These extracted themes centered around two major factors: 1) health-related and 2) human rights concerns, both leading to poor adherence to antiretroviral treatment (ART). When it came to direct health-related outcomes, two major subthemes were apparent: a) fear of being vulnerable to COVID-19 as an HIV-positive patient and b) healthcare service-related challenges during the pandemic. Human rights concerns were centered around a) food insecurities and b) gender and identity-related human rights challenges. All these challenges created mental stress and poor overall health outcomes on ART adherence and worsening perceived mental health-related stress.

Conclusion/Implications
The findings highlight the complex syndemic interactions of the COVID-19 pandemic context, mental health challenges, and the added burden of living with HIV among the participants. The syndemic context frames the perceived experiences of stigma and challenges that reflect on mental health concerns as well as physical health concerns related to medication and treatment adherence while addressing resources and rights necessary for other social determinants of health. Social work researchers, advocates and policymakers, and programs must support and advocate for those who have HIV in mitigating these challenges in Uganda. Addressing these intersecting challenges through the multi-level intervention approach can provide comprehensive support to YPLHIV.