Prevalence of Mental Health Conditions Among People Living With HIV During the COVID-19 Pandemic

A Rapid Systematic Review and Meta-Analysis

Kai Wei Lee; Chin Siang Ang; Sin How Lim; Ching Sin Siau; Lai Teik Derek Ong; Siew Mooi Ching; Pei Boon Ooi


HIV Medicine. 2022;23(9):990-1001. 

In This Article

Abstract and Introduction


Background: The COVID-19 pandemic has generated many mental health problems worldwide. People living with HIV (henceforth known as PLHIV) bear a higher mental health burden in comparison with the general population. Therefore, their risk of mental health problems may be elevated during the pandemic.

Methods: We conducted a systematic review and meta-analysis to assess the prevalence of depression, anxiety, psychological stress, insomnia and loneliness among PLHIV during the COVID-19 pandemic. Observational studies in four databases published from 1 January 2020 to 30 April 2021 investigating the prevalence of mental health conditions during the COVID-19 pandemic were searched, and 197 articles were retrieved. After the processes of duplication removal, eligibility screening and full-text assessment, 10 articles were included in the systematic review and six articles for meta-analyses. A random-effects model was applied to derive the pooled prevalence of mental health conditions. The risk of bias was assessed using the STROBE checklist.

Results: Overall, the pooled prevalence rates of (moderate-to-severe) depression and anxiety among PLHIV were 16.9% [95% confidence interval (CI): 3.8%–30.0%] and 23.0% (95% CI: 12.0%–34.0%), respectively.

Conclusions: More research is needed to investigate the mechanism by which the pandemic affects the mental health of PLHIV. Support and programmes are needed to ameliorate the mental health problems in this marginalized population.


An estimated 37.7 million people globally were living with the HIV (PLHIV) in 2020.[1] In spite of medical advances in the diagnosis, treatment and management of HIV, PLHIV continue to face various challenges. The intersectionality of the HIV condition with structural and environmental factors such as underdevelopment (i.e. reduced development and population inequity) and poverty, legal and policy environments, and societal stigma has negative consequences on PLHIV's physical and mental health, especially among identified key populations groups, i.e. men who have sex with men, people in prisons, people who inject drugs, sex workers and transgender people.[2]

Mental health refers to our cognitive, emotional, psychological, behavioural and social well-being.[3] Mental health conditions involve changes in how people think, feel and behave (or a combination of these changes). These conditions can have a devastating effect on the rate of other health conditions, which may gradually diminish the quality of one's life if proper care and concern are not given such that the person is left untreated.[4] Mental health conditions usually develop from other chronic diseases among those who fail to cope with their predicaments and grieve losses in a healthy way.[5] Depression and anxiety are the most common psychological sequelae of HIV diagnoses, as found in a meta-analysis reporting that HIV infection is associated with a greater risk for depressive disorders [adjusted odds ratio = 1.99, 95% confidence interval (CI): 1.32–3.0];[6] positive diagnosis of an HIV infection has a small to medium effect on anxiety with a mean R = 0.39 (95% CI: 0.26–0.52).[7]

The prevalence of mental health conditions among PLHIV is high. Prior to the novel coronavirus (COVID-19) pandemic, the pooled prevalence of depressive symptoms among PLHIV was 32% in sub-Saharan Africa,[8] 38% in East Africa and 50.8% in China,[9] whereas the global pooled prevalence of post-traumatic stress disorder among adult PLHIV was 28%.[10] In the US, the prevalence of generalized anxiety symptoms among PLHIV was estimated to be at 19%, higher than in the US general population.[11] The presence of mental health conditions among PLHIV is associated with poor quality of life,[12] additional comorbidities,[13] societal stigma[14] and unemployment.[15] Mental illness among PLHIV is also associated with polysubstance use, being admitted for in-patient care and having recurrent visits to the emergency department.[11,16]

The relationship between mental health and HIV infection can also be bidirectional; however, this association can be direct and indirect, where HIV infection can either be a consequence of risky behaviours associated with a preceding poor mental health (e.g. as a result of substance misuse or alcoholism which causes poor judgment or leads to impulsive behaviour),[17–21] or result from a prior established mental illness in which people with mental health problems, who may generally have poor cognitive function and an altered perceived importance and attitude towards sexuality are more prone to committing higher-risk sexual behaviour (i.e. inconsistent condom use, having multiple sexual partners, trading sex) and therefore increase the chances of acquiring HIV.[22–24]

As a result of the COVID-19 pandemic, PLHIV have experienced an unprecedented disruption in their daily lives. This includes increased barriers to accessing healthcare in a timely and confidential manner, such as delay or disruptions in routine testing for HIV, being unable or unwilling to continue antiretroviral therapy (ART), and allocations for HIV care being channelled appropriately due to COVID-19 control.[25] Apart from healthcare issues, more than half of PLHIV in a multinational study reported a worse social life outside of the family.[26] These disruptions have been associated with an increased incidence of mental health conditions, including anxiety, distress, loneliness and insomnia.[27–30] Poor mental health may subsequently influence medication adherence, as was found in a study where depressed PLHIV were at higher odds of being non-adherent to taking their medications compared with those who were mildly or not depressed.[31,32] It is important for PLHIV to achieve their treatment goals such as the continuation of treatment and viral suppression, which ultimately lead to better health outcomes. In order for governments and policymakers to allocate resources and provide the necessary interventions for PLHIV with mental health conditions, a rapid review of the research is recommended.

The aim of the current systematic review and meta-analysis is to rapidly review the prevalence of depression, anxiety, psychological stress, insomnia and loneliness among PLHIV during the COVID-19 pandemic.