HIV Medicine. 2021;00:1–10. wileyonlinelibrary.com/journal/hiv
© 2021 British HIV Association
Received: 17 June 2021
Accepted: 23 September 2021
A qualitative study of the impact of coronavirus disease
(COVID- 19) on psychological and financial wellbeing and
engagement in care among men who have sex with men
living with HIV in Thailand
1Adam’s Love Global Foundation for
MSM and Transgender Health (ALGO),
2Institute of HIV Research and
Innovation (IHRI), Bangkok, Thailand
3Department of Global Health,
Amsterdam University Medical
Centers, University of Amsterdam, and
Amsterdam Institute for Global Health
and Development, Amsterdam, The
4Center for Newborn Screening,
Ethics, and Disability Studies, RTI
International, Research Triangle Park,
Chattiya Nitpolprasert, Adam’s Love
Global Foundation for MSM and
Transgender Health (ALGO), 151/10
Moo 10, Bangkuwat, Meung, Pathum
Thani 12000, Thailand.
amfAR, The Foundation for AIDS
Research; ViiV Healthcare & The
Positive Action for Adolescents
programme; U.S. National Institute
of Health’s National Institute of
Allergy and Infectious Diseases,
Eunice Kennedy Shriver National
Institute of Child Health and Human
Development, the National Cancer
Institute, the National Institute of
Mental Health, and the National
Institute on Drug Abuse, the National
Heart, Lung, and Blood Institute, the
National Institute on Alcohol Abuse
and Alcoholism, the National Institute
Objectives: The coronavirus disease (COVID- 19) pandemic is an unprecedented
event with massive global health and socio- economic impacts on vulnerable pop-
ulations, especially people living with HIV. The epidemic has severely affected
Thailand’s economy and potentially impacted the financial and psychological
wellbeing of Thai HIV- positive men who have sex with men (MSM).
Methods: Between 15 June and 10 December 2020, we conducted qualitative in-
terviews with 26MSM living with HIV in Thailand who participate in an Adam’s
Love We Care Study. We intentionally recruited individuals who may have ex-
perienced a greater impact of COVID- 19. Interviews explored worry, stigma and
stress surrounding COVID- 19, and multiple domains of potential COVID- 19 im-
pact: financial/employment, HIV service delivery and antiretroviral (ART) ad-
herence during the first 10months of the COVID- 19 pandemic.
Results: Participants perceived themselves as immunocompromised and sus-
ceptible, and feared contracting COVID- 19. Participants worried that contracting
COVID- 19 would lead to HIV status disclosure and stigmatization. Participants
had considerable worry about job loss as a result of the economic downturn, and
some shared challenges associated with relocation and re- engaging with HIV
care. Financial stress and lack of basic necessities caused by job losses were com-
monly reported. Participants reported optimal ART adherence as a consequence
of local HIV service delivery responses, convenient ART refills and Adam’s Love
online support interventions.
Conclusions: Our study highlights that the COVID- 19 pandemic produced high
levels of anxiety and concerns about additional stigma among MSM living with
HIV. It had a significant negative effect on the daily lives of our participants.
These findings indicate a need for the provision of confidential COVID- 19 diag-
nosis and care, relief programmes, vaccination roll- out equity, and addressing
employment needs of vulnerable populations.
NITPOLPRASERT et al.
The 2019 coronavirus disease (COVID- 19) pandemic is
an unprecedented event with massive global health and
socio- economic impacts on vulnerable populations, es-
pecially people living with HIV (PLHIV) who are already
disadvantaged by comorbidity, stigma and marginaliza-
tion.1,2 Thailand was among the first countries to report a
confirmed COVID- 19 case outside of China.3,4 Thailand’s
proactive lockdowns succeeded in containing the virus
during the first wave of the outbreak, with a low fatality
rate of 1.46% by May 2020.5 However, the Thai economy
has been severely affected by the lockdowns because of its
dependence on exports and foreign tourism.6 The tourism
sector accounts for 20% of the country’s gross domestic
product (GDP) and employs a large number of Thais, in-
cluding men who have sex with men (MSM), transgender
women (TGW), sex workers and other communities living
with HIV.3,7 Of an estimated 8.3million workers affected
by employment loss caused by COVID- 19, around 2.5mil-
lion (30.1%) are in the tourism sector.6,8 Over 23000 enter-
tainment venues across the country were closed.9 A recent
Joint United Nations Programme on HIV/AIDS (UNAIDS)
rapid assessment reported 91% of sex worker respondents
becoming unemployed as a result of the pandemic.10
Since 2010, Adam’s Love web- based interventions
(www.adams love.org) have successfully engaged Thai
MSM and TGW in HIV prevention and treatment cascades
through their novel online- to- offline (O2O) models.11- 13
Data from the Adam’s Love We Care study14 reveal that
over one- third of its MSM participants with HIV are em-
ployed by the tourism sector, for example in hotels, shop-
ping malls, entertainment venues, airlines and airports.
The Adam’s Love intervention provides a practical means
of exploring the impact of COVID- 19 on a hard- to- reach
population. Instant messaging and online chat with MSM
participants in the Adam’s Love We Care study provided
anecdotal evidence of the high negative impact of the
Overall health outcomes of MSM with HIV could be
adversely affected by the potential interactions between
COVID- 19 and HIV, and the impact of the pandemic on
stigma, isolation, fear and anxiety.15 Understanding such
impacts on the HIV care and wellbeing of MSM living
with HIV could emphasize the need for appropriate or
even different HIV care services and online and offline
support interventions. This study assessed the impact of
COVID- 19 on psychological and financial wellbeing and
engagement in care among Thai HIV- positive MSM par-
ticipants, and explored how Adam’s Love We Care might
have influenced these outcomes.
Study settings and participants
This substudy is a part of the Adam’s Love We Care
study conducted by the Adam’s Love Global (ALGO)
Foundation for MSM and Transgender Health (www.
adams love.org). The objective of the Adam's Love We Care
study is to improve clinic visit retention and antiretroviral
therapy (ART) adherence outcomes through individual-
ized eCounselling, educational video sessions, facilitation
of early linkage to ART, daily timely personalized ART re-
minders and clinic visit retention reminders.14,16 The cur-
rent substudy assessed the perceived and actual impacts
of COVID- 19 among Thai MSM living with HIV who were
members of the Adam’s Love network. We specifically
recruited participants from the ongoing Adam’s Love We
Care study who were located across Thailand. Those re-
cruited to participate either (1) had regular interactions
with eCounsellors or (2) proactively responded to the
daily personalized ART reminders confirming medication
From 15 June to 10 December 2020, we approached 35
MSM participants in the study via the eCounselling plat-
form, of whom nine participants did not respond to the
message or declined the invitation. After receiving per-
mission from interested participants, study staff contacted
via telephone and scheduled to interview 26 MSM partic-
ipants. We intentionally enriched the sample with nine
participants (9 of 26) who had expressed to eCounsellors
that they had experienced COVID- 19- related challenges
and who were more likely to have negative COVID- 19 im-
pacts, to explore the range and perceived seriousness of
During the first wave of the COVID- 19 outbreak, the
public health and media agencies released some poten-
tially identifiable information on COVID- 19 cases such
as gender, age, location, occupation and workplace. In
some cases, for example for public personalities, names
and a detailed log of their movements before they tested
positive for COVID- 19 were announced. Furthermore, the
of Diabetes and Digestive and Kidney
Diseases, and the Fogarty International
coronavirus disease (COVID- 19), economic disparities, men who have sex with men, people
living with HIV, severe acute respiratory syndromecoronavirus 2(SARS- CoV- 2)
government’s proactive contact tracing programme col-
lected personal information (including phone numbers,
which are linked to national identity cards).17
HIV care providers at the provincial level adopted var-
ious safety measures and practices during the COVID- 19
outbreak,3,18 such as home ART delivery, use of drive-
through booths and fast- track services to ensure ART refill
among PLHIV. To support our study participants during
the COVID- 19 pandemic, Adam’s Love staff worked
closely with the HIV care providers in various provinces
in Thailand to develop resources for disseminating infor-
mation on evolving HIV service delivery changes,19 and
harnessed real- time support interventions, for example
eCounselling sessions, online linkage support, personal-
ized ART and clinic visit reminders, to address individual
challenges and ensure seamless ART linkage during the
COVID- 19 outbreak.
Between 1 February and 31 December 2020, the
eCounselling platform addressed over 180 inquiries from
study participants on topics including referral advice and
assistance regarding health insurance and HIV clinic re-
location, and details about ART refill procedures and
the clinic visit schedule during the COVID- 19 outbreak.
The eCounsellors also provided psychosocial support and
promoted emotional wellbeing, which helped the MSM
overcome stress, and motivated them to stay healthy and
positive in the COVID- 19 lockdown period.
This substudy is a part of the Adam’s Love We Care
study protocol approved by the Institutional Review
Board (IRB) of the Faculty of Medicine, Chulalongkorn
University, Bangkok, Thailand (IRB No. 602/58). All par-
ticipants provided informed consent to participate in the
main study and gave permission for audio- recording be-
fore commencement of the interview. Each received a
USD $30 gift voucher as compensation.
In- depth semi- structured interviews were conducted either
via telephone or in person by team members (CN and TA).
Interviews lasted approximately 30– 45min and were audio-
recorded with participants’ permission. The interview guide
was utilized to structure all interviews with prompts to
elicit exploration of topics (Table1). Demographic data col-
lected included the subject’s age, location and educational
attainment. Level of fear of COVID- 19 was measured by a
verbally administered numeric rating scale (NRS) ranging
from 0 to 10. This self- report scale is commonly used for as-
sessment of pain intensity and was adopted to measure the
TABLE Summary of the interview guide assessing perceived and experienced impacts of coronavirus disease (COVID- 19)
Domain Descriptions and key interview questions
(1) Response to COVID- 19 and impact on daily
Perceived COVID- 19 impact, fear of COVID- 19, COVID- 19 prevention strategies,
and life changes resulting from COVID- 19.
Sample questions: What are your thoughts and feelings about the COVID- 19
pandemic? How has your daily life been impacted by the COVID- 19 pandemic
and the national lockdown? How do you prevent yourself getting COVID- 19?
(2) Impact on work and economic situation Changes in occupation and monthly income at the time of the interview compared
with the pre- COVID- 19 period, resulting financial impact and economic
challenges faced, and participants’ perspective on revival of their financial
conditions and Thailand’s projected economic recovery to the pre- COVID- 19
Sample questions: What are the challenges in your employment resulting from
COVID- 19? How do you cope with changes in your work and life? What are
other financial challenges faced by you as a result of COVID- 19?
(3) HIV service delivery Clinic visit retention and ART adherence impact.
Sample questions: What are the challenges of and barriers to timely ART refill, ART
adherence and making clinic visits during the COVID- 19 pandemic? How do you
communicate with your health care providers during the national lockdown?
(4) Impact of Adam’s Love online support
intervention during the COVID- 19 pandemic
Impact of Adam’s Love interventions, e.g. daily personalized ART reminders and
real- time eCounselling support, in reducing COVID- 19- related anxiety and
addressing ART and retention challenges.
Sample questions: How did Adam’s Love support help with maintaining ART
adherence, retention in care, and psychosocial wellbeing during the COVID- 19
Note: Broad domains and key interview questions are shown. Unstructured follow- up probes were used to further explore points as they arose during the
Abbreviation: ART, antiretroviral therapy.
NITPOLPRASERT et al.
degree of fear in this study. The participants were asked to
rate their fear of COVID- 19 infection on a scale categorized
as follows: 0 for no fear, 1– 3 for mild fear, 4– 6 for moderate
fear, 7– 9 for severe fear and 10 for extreme fear.20,21
All interviews were conducted in Thai, recorded and
transcribed in Thai and then translated into English.
Descriptive statistics were used to describe the demo-
graphics of the participants. We used an inductive the-
matic analysis approach given the lack of literature on the
impact of COVID- 19 on MSM living with HIV. Transcripts
were independently reviewed by two investigators (CN
and TA). At the 23rd interview, we found repetition in the
interview suggesting saturation. Interviews were contin-
ued with three additional participants to assure that no
new themes were emerging from the data.
A coding frame was developed after data immersion.
Transcripts were coded by CN and TA, using a matrix in
Microsoft (v. 2019) to identify patterns and cate-
gories. All data were double- coded and any discrepan-
cies identified during this process were resolved through
discussion. After the discussion and consensus, the two
investigators interpreted the data through conceptualiza-
tion into themes and subthemes based on the relationship
between codes and frequencies of theme endorsement by
the participants. All authors discussed and confirmed the
implications of the findings.
A total of 26 MSM participants living with HIV were inter-
viewed. The median age was 29 [interquartile range (IQR)
27– 30] years and most (21 of 26) reported having a suppressed
HIV viral load. Half of the participants (13 of 26) worked in
the tourism industry, with 12 of 13 living in tourism- reliant
Thai provinces (defined as provinces with the highest-
ranking income earned from foreign tourism). Among the
26 participants, nine participants had recently relocated as
a consequence of job losses. Of these nine participants who
relocated, six migrated their HIV clinics to a new province
and changed their health care insurance coverage from a
compulsory health insurance for private sector employees
under the Social Security Scheme to the Universal Coverage
Scheme (the government’s 30- Baht Scheme). The number
of participants with <$300 monthly income increased from
four participants prior to the COVID- 19 outbreak to 13 at
the time of the interview (Table2).
The interview data revealed three primary themes, in-
cluding: (1) anxiety related to COVID- 19, including fear
of contracting COVID- 19 and concern about HIV status
disclosure, (2) anticipated and experienced impact of
COVID- 19 on employment, financial health and reloca-
tion, and (3) impact of COVID- 19 on HIV service delivery
and ART refill and clinic visit retention.
Worry and anxiety about the
COVID- 19 pandemic
MSM participants living with HIV expressed high levels
of fear and anxiety about the COVID- 19 pandemic, with
a median score of 8 out of a maximum score of 10 (IQR
5– 9) on a verbally administered NRS. Interview data re-
vealed two subthemes pertaining to different dimensions
of anxiety: (1) fear and worry about their own health and
their weakened immune status, and fear of contracting
COVID- 19, and (2) fear of HIV status disclosure and the
stigma surrounding this.
Fear of COVID- 19 and having an impaired
immune response and self- perceived
likelihood of contracting COVID- 19
More than half of the participating MSM living with
HIV (15 of 26) perceived themselves to be immunocom-
promised and vulnerable to the COVID- 19 epidemic
and feared being exposed to and contracting COVID- 19.
Participants adopted stringent personal hygiene and
precautionary measures to help overcome their fears of
COVID- 19 and concerns about their health.
For example, one participant described how his fear in-
creased based on having a known COVID- 19 case at work.
I experienced extreme anxiety and fear
during COVID- 19 mostly due to personal
health reasons and since I have low immu-
nity. A colleague at my office got infected
with COVID- 19, which made me even more
(30- year- old MSM working in downtown
Participants were especially concerned that their body’s im-
mune response to the novel coronavirus might be compro-
mised. One participant shared the following.
I felt paranoid and fearful mostly because I’m
not a healthy person and have HIV virus in my
body. My work involves meeting foreigners so
I’m even more at risk.
(42- year- old MSM)
Another participant noted:
When I read that over 100 000 people have
died from COVID- 19 in the US, I felt scared
and avoided crowded places because I have a
(29- year- old MSM)
Fear of HIV status disclosure and stigma
surrounding it if diagnosed with COVID- 19
Thai public health measures and practices were de-
scribed as creating anxiety, as MSM participants were
afraid of disclosing their HIV status if they contracted
COVID- 19 and were worried that the information would
be released to colleagues, employers or the public, and
therefore limited their movements. One participant
I felt extremely scared, and paranoid. I
didn't dare to go anywhere. If I contracted
COVID- 19, the local authorities would
make public announcement and my details
would appear in headlines, and people will
know my HIV status. I often consulted with
Adam's Love for support during this time.
(30- year- old MSM)
TABLE Demographic characteristics of a qualitative sample of 26Thai men who have sex with men (MSM) living with HIV (n = 26)
Age (years) [median (IQR)] 29 ([27– 30)
Location [n (%)]
Bangkok 5 (19.2)
Tourism- reliant provinces other than Bangkoka12 (46.2)
Other provinces (in the central, northeast and west of Thailand) 9 (34.6)
City relocation [n (%)]
Yes 9 (34.6)
No 17 (65.4)
Change of health insurance coverage and HIV clinic relocation as a result of COVID- 19 impact [n (%)]
Yes 6 (23.1)
No 20 (76.9)
Education [n (%)]
High school or lower 4 (15.4)
Bachelor’s degree or higher 22 (84.6)
Occupation (prior to the COVID- 19 pandemic) [n (%)]
Tourism and service sector (e.g. hotels, airlines, airports, tours, malls, cinemas and entertainment venues) 13 (50)
Other employment (e.g. private and government sector) 11 (42.3)
Student 2 (7.7)
Monthly income (in 2019, prior to the COVID- 19 pandemic) [n (%)]
<$300 4 (15.4)
$300– 1000 14 (53.8)
> $1000 8 (30.8)
Monthly income (during the COVID- 19 pandemic at the time of the interview) [n (%)]
<$300 13 (50)
$300– 1000 9 (34.6)
>$1000 4 (15.4)
Suppressed viral load (<50copies/mL) [n (%)] 21 (80.8)
Abbreviation: IQR, interquartile range.
aTourism- reliant provinces in Thailand were defined as those that ranked highest in terms of income earned from foreign tourism and included Bangkok,
Phuket, Krabi, Surat Thani, Chonburi, Chiang Mai, Phang Nga, Prachuap Khiri Khan, Trat and Rayong.
Source: Tourism Statistics (classify by region and province, 2020), Ministry of Tourism and Sports, Thailand.
NITPOLPRASERT et al.
The impact of COVID- 19 on the
economy, employment and relocation
because of work
Financial stress and lack of basic necessities as a conse-
quence of job losses or reductions in salaries were high-
lighted in interviews by 19 of the 26 participants. As one
I haven't worked for 5 months, and skipped
meals to pay for my rent and utilities. The
stress from COVID- 19 has impacted me
personally on a daily level so I avoid eating
during daytime. Every day I get up and check
on which hotels and restaurants are open and
knock on each hotel door asking for a job in
the area. I haven't been successful yet.
(21- year- old MSM based in a major tourist
The virus itself is not stressful, but no income
is the real stress. Hotels are closed and staff
(24- year- old MSM working in a major tourist
Almost half of participants (12 of 26) shared their expecta-
tion of a grim long- term outlook with regard to personal life
and economic recovery to pre- COVID- 19 levels and high-
lighted their hopes of a vaccine as a key factor for the coun-
try’s economic revival. One participant noted:
If there is no vaccine, people will not be confi-
dent in tourism. We need foreign tourists back;
they are main income source for [tourist area],
only then can we survive. I think revival will
take around 2– 3years.
(24- year- old MSM)
Stress and trauma of unemployment and
related challenges faced by MSM living
Participants constantly worried about losing their jobs
during the epidemic. MSM participants highlighted their
experiences of becoming unemployed.
In the beginning I didn't think it would be
me. If you received a call from the hotel em-
ployer to meet them, it meant you are proba-
bly going to be fired. Every time someone was
asked to leave, the hotel security guard would
accompany them. I felt awful.
(30- year- old MSM)
One participant accepted reduced pay and decided not to re-
locate in search of work, fearing that mandatory HIV testing
may be required by a new employer. He noted:
The hotel that I work for doesn't require man-
datory HIV testing. If I go back home, and
restart, it is very difficult, as they all require
mandatory HIV testing and I am afraid of HIV
status disclosure and not getting a job.
(35- year- old MSM based in a major tourist
Relocation as a result of the COVID- 19
pandemic in search of job opportunities or
moving back to live with parents
One- third of participants (nine of 26) located in provinces
outside Bangkok relocated to a new province in search of
job opportunities or moved back to live with their parents.
After being fired, I decided to leave [major
tourist area] and return home, mostly because
I have a chronic disease (HIV). I quarantined
at my house. The nurse, chief of the village,
and staff (total three people) visited my house,
and asked me to stay in a separate room in the
house with a separate toilet (to comply with
the government’s restrictions on interprovin-
cial travel amid COVID- 19 controls). They
would come to give me food and drinks.
(42- year- old MSM)
My workplace was closed due to COVID- 19,
so I decided to come back to my childhood
home in another province and live with my
family as an unemployed person. I still don’t
know what to do next, so I have to rely on my
parents for now.
(29- year- old MSM)
Impact of COVID- 19 on HIV service
delivery, ART adherence, ART refill and
clinic visit retention
Participants universally appreciated local- and provincial-
level HIV service delivery changes during the COVID- 19
epidemic, especially extended help and home delivery and
mailing options offered by health care providers for ART re-
fill and fast- track services to avoid overcrowding at clinics.
I had less than a month’s pills left with me and
my HIV clinic contacted me offering to send
the medicine via the postal service. I immedi-
ately agreed and waited for the package to ar-
rive. When I opened it, the medicine package
was camouflaged and well wrapped.
(30- year- old MSM based in central Thailand)
Conversely, some participants felt reluctant to choose the
home delivery and mailing options because of fear of HIV
status disclosure, and opted for a fast- track service for ART
refill at the clinic.
I felt scared of the idea of receiving HIV medi-
cation via post. I remember an incident in the
news when the postman opened someone’s
package, and I thought if they opened my pack-
age and found out my HIV status, they would
be disgusted with me and my family.
(29- year- old MSM based in Bangkok)
Six participants who received fast- track ART services (six of
26) shared their positive attitudes and experiences with effi-
cient clinic visit procedures. As one participant noted:
The clinic scheduled limited numbers of peo-
ple, so the place was not crowded, and they
maintained social distancing and all pre-
ventive measures. The procedure was very
smooth and fast. I could finish all procedures
and received my medication within an hour.
(30- year- old MSM based in Bangkok)
Two participants living in remote provinces (two of 26) ex-
pressed concern that there would be inadequate supplies of
HIV medicines and possibly disrupted supply chains as a con-
sequence of the intensive response focusing on COVID- 19,
national lockdowns, and transportation restrictions.
What concerned me most was regarding HIV
medication stock in Thailand. I was afraid
Thailand would run out of medication doses.
What if they close the country and borders, in-
cluding shipping, would that deplete the ART
stock? With HIV virus in my body, I cannot live
without medicine. I fear we would be forced to
miss the dose.
(27- year- old MSM based in northeast
A positive impact of the Adam’s Love online support
intervention was expressed by the participants. The ma-
jority of participants (18 of 26) took advantage of the
real- time eCounselling support regarding health care in-
surance and HIV clinic relocation assistance, ART refill
and clinic scheduling, COVID- 19 prevention advice, and
psychosocial support during the COVID- 19 pandemic,
and six (of 18) proactively shared how having access to
Adam’s Love online support and regular interactions
with eCounsellors during the lockdown period helped
reduce their stress and lessened the negative impact of
The study explored the perceived and experienced im-
pacts of COVID- 19 among Thai MSM living with HIV par-
ticipating in the Adam’s Love We Care study. Our findings
are summarized under three themes: (1) anxiety related to
COVID- 19, (2) the impact of COVID- 19 on employment
and financial wellbeing, and (3) the impact of COVID- 19
on HIV service delivery.
Our study results show that anxiety among partici-
pants was related to perceptions about the personal risk
of contracting COVID- 19. Participants considered them-
selves to be immunocompromised and less healthy, and
had high levels of fear of being exposed to and contracting
COVID- 19. These results are similar to the high levels of
fear, anxiety and stress about COVID- 19 infection found
among PLHIV in Spain and Turkey.22,23
Stigma in the COVID- 19 context requires consider-
ation as it may lead to poorer mental health outcomes.24,25
Government requirements on sharing of personal infor-
mation through a contact- tracing app and local public
announcements sharing the details of people contract-
ing COVID- 1926,27led to a perceived fear of the stigma of
HIV status disclosure among our study participants, who
worried about being identified as a PLHIV if they con-
tracted COVID- 19. This finding suggests a critical need
for changes in Thailand’s COVID- 19 crisis management
to ensure confidentiality and anonymity of persons diag-
nosed with COVID- 19.
The most common and most serious impact of
COVID- 19 was adverse socio- economic consequences.
These consequences increased stress, affected food security,
and negatively impacted participants’ quality of life. A re-
lated finding is that PLHIV experienced job insecurity and
unemployment. These results are consistent with emerging
perspectives from Malaysia and the European Union labour
markets, for which the impact of COVID- 19 will probably be
concentrated among the most vulnerable populations.28,29
NITPOLPRASERT et al.
Fear of mandatory HIV testing by potential employers
limited some participants’ job opportunities and added
to their anxiety. In Thailand, mandatory HIV testing
during the application process is particularly prevalent
in hospitality and food services and some government
jobs. The Thai Labour Ministry report confirms our find-
ings that up to 30% of PLHIV have reported experiencing
discrimination by employers on the basis of their HIV
The Bank of Thailand foresees that the tourism industry
will recover towards the first quarter of 2023.31 This slow
pace of recovery will challenge our participants’ hopes for
a return to their normal lives after a successful global vac-
cination programme. By April 2021, only 0.2% of the Thai
population had received at least one dose of a COVID- 19
vaccine.32,33 Given the lack of a clear COVID- 19 vaccine
procurement and roll- out plan, the current situation of
economic disparities and challenges faced by vulnerable
groups could persist for years.
MSM living with HIV who participated in our study
reported adequate access to ART and stated that they
were able to maintain optimal ART adherence during the
COVID- 19 epidemic. ART adherence was also facilitated
by their desire to maintain healthy and strong immunity.
HIV service delivery measures by the Thai health care sys-
tem, including home ART delivery, use of drive- through
booths, and fast- track ART pick- up services, helped our
participants to maintain their HIV care. Our data suggest
no withdrawal of care as a consequence of the impact of
COVID- 19. This is in contrast to recent studies where the
fear of contracting COVID- 19 was found to have led to
decreased engagement with care among PLHIV in several
countries in Europe and Africa.22,34- 37 Two participants’
perceived concerns regarding a possible shortage of ART
medications as a result of national lockdowns and trans-
portation restrictions and the ability to continue ART pro-
curement in the country were similar to the findings of a
study in Central and Eastern Europe.35
Having access to real- time support was an important
aspect of support for the Adam’s Love study participants
to help them cope with anxiety and worry and acquire
reliable, adequate details about ART refill and relocation
during the pandemic. The ongoing relationship and trust
built between Adam’s Love and the study participants shed
light on the impact of disruptive events like COVID- 19 on
this particular population. Evidence of the impact of such
online interventions in scaling up HIV testing, treatment
and pre- exposure prophylaxis (PrEP) uptake11,12,38,39 and
reducing HIV risk behaviours40 has previously been ob-
tained. These ongoing networks and the data obtained
through them are informative for Adam’s Love and for
stakeholders in terms of understanding the emerging
needs of PLHIV and emphasize the need for appropriate
and innovative online and offline HIV care support inter-
ventions during the COVID- 19 crisis.
This study reports the impact of COVID- 19 on vulner-
able populations during the first 10- month wave of the
COVID- 19 outbreak in Thailand. Additional research is
needed to explore COVID- 19 impacts on MSM individu-
als over time. Although the national reach of the Adam’s
Love programme facilitated enrolment of participants
from different provinces of Thailand, this study was not
designed to obtain generalizable data. Furthermore, be-
cause the study recruited participants receiving an on-
going online intervention, the participants were likely
to be more engaged in care and more likely to be ART
adherent. We intentionally enriched the sample for par-
ticipants who experienced some problems associated
with COVID- 19 (nine of the 26 participants) to allow
characterization of the type and severity of impacts of
COVID- 19. Future studies are needed to assess the fre-
quency of specific COVID- 19 impacts among PLHIV in
Thailand. However, this is an important study given the
lack of data on the impact of COVID- 19 on MSM living
Our study highlights that the COVID- 19 pandemic re-
sulted in high levels of anxiety and concern about addi-
tional stigma among MSM living with HIV. A positive
finding in our participants is that COVID- 19 did not sig-
nificantly impact ART adherence in the short term. The
pandemic is causing considerable economic worry and
negative economic impact. These findings suggest that
there is a need for provision of confidential and stigma-
free COVID- 19 diagnosis and care, immediate economic
relief programmes and government policies aimed at vac-
cination roll- out equity, and for addressing employment
needs of vulnerable populations.
The authors gratefully acknowledge the participation of
the MSM participants in the Adam’s Love We Care study.
This study is an initiative of the Adam’s Love Global
Foundation for MSM and Transgender Health with support
from ViiV Healthcare, The Positive Action for Adolescents
programme, and amfAR and through a grant from the
US National Institute of Health’s National Institute
of Allergy and Infectious Diseases, Eunice Kennedy
Shriver National Institute of Child Health and Human
Development, the National Cancer Institute, the National
Institute of Mental Health, the National Institute on Drug
Abuse, the National Heart, Lung, and Blood Institute, the
National Institute on Alcohol Abuse and Alcoholism, the
National Institute of Diabetes and Digestive and Kidney
Diseases, and the Fogarty International Center as part of
the International Epidemiology Databases to Evaluate
AIDS (IeDEA; U01AI069907). The content is solely the
responsibility of the authors and does not necessarily rep-
resent the official views of the above institutions.
CONFLICTS OF INTEREST
The authors have no conflicts of interest to declare.
CN and TA conducted data collection and analysis. CN
assumed primary responsibility for writing and revising
the manuscript. All authors contributed to conceptual-
ization, interpretation of the findings and drafting of the
manuscript. All authors edited and reviewed the manu-
script and gave their final approval for submission to the
The content and views in this work are solely the respon-
sibility of the authors and do not necessarily represent the
views or policies of the US Army and the US Department
Tarandeep Anand https://orcid.
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How to cite this article: Nitpolprasert C, Anand
T, Phanuphak N, Reiss P, Ananworanich J, Peay
HL. A qualitative study of the impact of coronavirus
disease (COVID- 19) on psychological and financial
wellbeing and engagement in care among men who
have sex with men living with HIV in Thailand.
HIV Med. 2021;00:1– 10. doi:10.1111/hiv.13190