HIV-POSITIVE MSM, NETWORKS, AND COVID-19 1
The Impact of the COVID-19 Pandemic on HIV-Positive Men Who Have Sex With Men:
(Dis)connection to Social, Sexual, and Health Networks
Cory J. Cascalheira1 Corey Morrison2 Alexa B. D’Angelo2,3
Oziel Garcia Villanueva1Christian Grov2,3
1 New Mexico State University
2 City University of New York (CUNY) Institute for Implementation Science in Population
3 CUNY Graduate School of Public Health and Health Policy
The Version of Record of this manuscript has been published and is available in Psychology &
Sexuality (2022): https://doi.org/10.1080/19419899.2022.2112745
Data Availability: Data available upon request.
This work was supported by the National Institutes for Health under Grant UH3 AI
133675—PI Grov—Together 5000. Other forms of support include the CUNY Institute for
Implementation Science in Population Health, the Einstein, Rockefeller, CUNY Center for AIDS
Research (ERC CFAR, P30 AI124414). Cory Cascalheira is supported as a RISE Fellow by the
National Institutes of Health under grant R25GM061222.
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 3
The COVID-19 pandemic has disproportionately affected HIV-positive cisgender men who have
sex with men (MSM). Between May and June in 2020, we conducted one-on-one semi-
structured qualitative interviews with 20 HIV-positive MSM aiming to describe their
(dis)connection to social, sexual, and health networks during the COVID-19 pandemic. All
participants relied on social support networks to manage pandemic-based distress, using
computer-mediated communication as well as physical proximity. To connect to sexual
networks, this sample described adaptations to their partner selection strategies, such as
enumerating harm reduction approaches. To connect to health networks, participants depended
on reassuring providers, resourceful case managers, telehealth, and streamlined access to their
antiretroviral therapy (ART) medications. Nonetheless, stay-at-home recommendations reduced
community connection, sexual activity, and healthcare access for many participants, and
perceptions of these losses were shaped by psychosocial burdens (e.g., loneliness), structural
burdens (e.g., environmental barriers, financial difficulties), and health-protective factors (e.g.,
hopeful outlook, adherence to a regular routine). The COVID-19 pandemic appears to have
exacerbated health-related issues for HIV-positive MSM. Given the ongoing COVID-19
mutations, community-based organizations, clinicians, and researchers might use these findings
to modify HIV prevention and intervention efforts.
Keywords: HIV; men who have sex with men; COVID-19; healthcare; syndemic theory
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 4
Reports suggest that COVID-19 disproportionately affects minority communities and
people with preexisting health conditions (1,2), including cisgender men who have sex with men
(MSM) living with the human immunodeficiency virus (HIV; 3). Given the health vulnerabilities
of sexual minority adults (4), the presence of a chronic, highly stigmatized disease such as HIV
may exacerbate these health disparities in the age of COVID-19 (5). HIV-positive MSM, a
population who experienced higher rates of isolation prior to the pandemic (6), may face unique
challenges in staying connected to their communities, healthcare systems, and sexual partners.
However, apart from three studies (5,7,8), the majority of research on HIV-positive MSM and
COVID-19 is quantitative. A qualitative approach may reveal important nuances in how this
population is coping with disconnection from social, sexual, and health networks.
HIV-positive MSM may be uniquely susceptible to negative, COVID-19-related
outcomes due to their experiences of syndemic conditions. The syndemic model of health
problems is a framework that considers health risk as a compound of public health epidemics and
biological, psychological, and sociocultural factors (9,10). The framework encourages
researchers and health officials to consider structural factors (as opposed to individual and
biological factors alone) in explaining health burdens among marginalized populations, such as
greater risk for HIV seropositivity among MSM (11). Shiau et al. (10) proposed a syndemic
model of HIV and COVID-19 coinfection in which bidirectional relationships are hypothesized
between structural (e.g., food insecurity) and psychosocial (e.g., social isolation) burdens and
existing health problems (e.g., immunodeficiency, mental health issues). Evident from this
perspective is the synergistic potential for negative health outcomes among HIV-positive MSM
in the age of COVID-19. Research suggests that a syndemic model is useful for understanding
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 5
the coronavirus pandemic because COVID-19 is associated with both structural (e.g., income
reduction, loss of access to HIV care providers) and psychosocial (e.g., higher psychological
distress) burdens (8,12,13). Hence, structural and psychosocial burdens may shape how HIV-
positive MSM make sense of staying connected, accessing healthcare, and engaging in sex
during the pandemic.
In terms of staying connected, social support may be difficult to maintain during stay-at-
home-orders. From a syndemic perspective, the potential for loneliness is a psychosocial burden
that may increase the risk of HIV and COVID-19 coinfection (9). Research suggests that
perceived loneliness can increase mortality and morbidity rates through lower wellbeing (14).
Data from Spain identified COVID-19-related loneliness as a strong predictor of symptoms of
depression, anxiety, and posttraumatic stress (15).
MSM may be particularly vulnerable to social disconnection during social distancing
ordinances. Since the pandemic began, MSM have reported fewer social interactions with friends
and family (8,12). Furthermore, COVID-19 may exacerbate the social isolation already
experienced among people living with HIV (PLWH; 16,17), generating greater distress (18) that
may not be assuaged by increased social media use (8). However, findings are inconclusive. A
2021 study, for example, found that HIV-positive MSM believe in collective action (e.g.,
“remembering the strength of [the gay] community in overcoming hardship;” 7), indicating that
community connection may be a protective factor for this population during stay-at-home orders.
Conversely, in a qualitative study of HIV-positive MSM coping with COVID-19 in the Southern
U.S., a participant disclosed: “I do feel alone, and it kind of reminds me of when I learned that I
had HIV” (8). Although living with a partner may counter loneliness, COVID-19-related
stressors (e.g., no distinction between work and home) are associated with poorer relationship
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 6
quality and greater partner conflict (19). Collectively, these findings suggest that stay-at-home
orders may strain cohabitating relationships or generate feelings of disconnection unique to HIV-
The two qualitative studies identified during our literature review that featured themes
associated with relationship maintenance either sought a rapid, preliminary description of
COVID-19-related issues (8) or collected data through open-ended survey responses (7).
Although these contributions are useful, the literature would benefit from a richer description of
relational coping strategies and perceived consequences of social disconnection using interviews.
Public and personal health require care continuity for PLWH because access to care
increases adherence to antiretroviral therapy (ART), thereby decreasing HIV transmissibility
(20). Access to HIV care provides additional individual benefits to PLWH, such as reducing the
risk of developing acquired immunodeficiency syndrome (AIDS) and increasing referral to
support services (21). The coronavirus pandemic threatens access to HIV care in several ways.
First, evidence indicates that COVID-19 may impair ART adherence for some HIV-positive
MSM (8,13), but not others (12). Second, the pandemic required many PLWH to stay home,
encouraging the rapid adoption of telehealth (20). Research suggests that telehealth can be
effective for some PLWH (22), but technological barriers (e.g., poor Internet service) can
complicate access to telehealth (8,9,18,20). Third, even among PLWH who maintained
healthcare access, there are documented concerns about the perceived interaction between
COVID-19 and HIV (5,18,23), possibly limiting how HIV-positive MSM connect to healthcare.
Two studies found that HIV-positive MSM expressed anxiety about immunosuppression, co-
occurring health conditions, and increased COVID-19 susceptibility (5, 8), but given that the
studies “did not consider the specific challenges” (5) or “aimed to identify the breadth of
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 7
experiences” (8), we sought to extend this work with an in-depth qualitative exploration of
specific healthcare challenges. Additionally, since studies have yet to explore how HIV-positive
MSM make sense of pandemic-based service disruptions and the loss of non-medical HIV
programming (e.g., support groups), we sought to address these gaps.
Beyond continuity of care issues, there is limited evidence on how HIV-positive MSM
describe the perceived impact of COVID-19 on their health status. Rhodes and colleagues (8)
identified changes in sleep and increased worry. Quinn et al. (7) suggested that HIV-positive
MSM follow recommended CDC guidelines to protect their physical health and draw on their
experience living with HIV to cope with COVID-19-related fears. Evidence also indicates that
symptoms of depression and anxiety have increased (12,13). However, across these studies, it is
unclear which structural and psychosocial factors HIV-positive MSM would describe as
contributing to their health concerns.
Given recommendations for social distancing and staying at home, it is no surprise that
researchers have observed changes in sexual behavior as a result of COVID-19 (24–26). Sexual
behaviors, desires, and fantasies have changed during pandemic-based stay-at-home orders
(26,27), suggesting that people have maintained their sexual networks in novel ways. Among
MSM specifically, evidence is mixed. Some MSM reported fewer sexual partners (12,23) while
others reported more casual partners (12,28–30) and an increased use of dating applications (12).
Since less sex might amplify perceived loneliness and other adverse outcomes of COVID-19
(25,31), exploring how HIV-positive MSM cope with fewer sexual partners might inform public
health initiatives and clinical practice. Conversely, given that casual sex could increase the
spread of the coronavirus, it is important for public health stakeholders to know how HIV-
positive MSM describe their engagement in sex during COVID-19.
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 8
This study used thematic analysis to complement and to extend previous research with
HIV-positive MSM coping with COVID-19 by focusing on specific challenges, aiming for
descriptive depth, and using semi-structured interviews. We aimed to answer the research
question: what are the ways in which HIV-positive MSM described their (dis)connection to
social, sexual, and health networks during the COVID-19 pandemic?
Materials and Methods
Participants & Procedures
Participants were recruited from the Together 5,000 cohort study. The cohort and study
procedures have been fully described elsewhere (32). Briefly, the goal of Together 5,000 is to
identify modifiable individual and structural factors associated with HIV risk and PrEP uptake.
Together 5,000 eligibility criteria for enrollment specified that participants were aged 16 to 49,
had at least two male sex partners in the prior 3 months, were not currently participating in an
HIV vaccine or pre-exposure prophylaxis (PrEP) clinical trial, were not currently taking PrEP,
lived in the U.S. or its territories, were not known to be HIV-positive, had a gender identity other
than cisgender female, and reported one additional behavioral or clinical criteria that increased
one’s vulnerability to HIV (32). Inclusion criteria for this qualitative supplement consists of (a)
being a member of the Together 5,000 cohort and (b) reporting a positive HIV status since
enrollment. Between May and June of 2020, in response to the COVID-19 pandemic, we
conducted one-on-one qualitative interviews with 20 HIV-positive MSM (
= 36.9; SD = 8.3)
who were randomly selected from the larger study, contacted via email, and invited to participate
in the current study. Most identified as gay (n = 18) and two were bisexual (n = 2). The sample
was a majority people of color (n = 11). Participants had completed some college (n = 10), or
earned a bachelor’s degree (n = 5), or held a master’s degree (n = 1) at the time of enrollment.
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 9
They were employed full-time (n = 8), currently unemployed (n = 5), going to school but not
working (n = 3), collecting disability (n = 2), or employed part-time (n = 2). Two participants
reported incarceration within the last year. Finally, participants were regionally diverse, with
most participants residing in the West (n = 8), followed by the South (n = 7), the Northeast (n =
4) and the Midwest (n = 1).
Participants provided informed consent. Interviews lasted between 45 minutes to one
hour, were audio-recorded, and were conducted either via Zoom or telephone. The interview
guide followed a semi-structured format. A two-step transcription process was used. First, the
initial transcription of audio-recorded interviews occurred via a natural language processing
algorithm. Second, to address quality assurance (33), research staff listened to each audio file
while proofreading the initial transcription. Participants were compensated with a $40 Amazon
gift card. All procedures were approved by the IRB affiliated with the senior author’s home
Data Analysis and Trustworthiness
Several methodological assumptions guided our thematic analysis (34,35). First, this
project focused on the identification of semantic themes. That is, the researchers coded data at
the explicit level of meaning without searching for an underlying interpretation beyond the
theoretical framework. Second, this project sought a rich description of the data across
participants. Finally, the thematic analysis started with theoretical coding by organizing data
according to the structural and psychosocial burdens specified by syndemic theory (9), then
shifted to inductive coding to determine how participants described their experience.
Themes were generated according to a six-phase process (35). First, the first and second
author read over the transcripts and noted their initial ideas using analytical memos. Second, the
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 10
first and second author generated initial codes for the same transcript. This initial list of codes
served as the foundation for the team-based codebook (36). The first and second authors met to
merge their coding scheme, to define the codes, and to agree on the boundary of the codes
(36,37). Next, they applied the codebook to the next two transcripts and met to compare their
coding list until consensus was reached. Third, the first and second author met to cluster the
codes into potential themes (35). Fourth, the first author reviewed the candidate themes against
the entire dataset to consider whether there were enough data to warrant the establishment of the
theme. Fifth, themes were defined with illustrative quotes followed by a brief interpretation.
Finally, illustrative data were extracted as examples. All analyses were conducted in Dedoose, a
secure and collaborative software program for qualitative coding and analysis.
Common methods of quality assurance, otherwise known as trustworthiness (37), were
used in the present study (33). Morrow (38) specified four criteria for trustworthy qualitative
research in the postpositivist tradition. Credibility was achieved through peer debriefing.
Specifically, the first and second author met weekly to discuss their reactions to the transcripts,
to audit each other’s coding decisions, and to arrive at consensus for each transcript.
Transferability, dependability, and confirmability were achieved through audit trails (38), which
were posted as meeting notes on the Open Science Framework. Themes were grounded in the
data adequately and reported only if they were consistent across the dataset. Moreover, the fourth
author, who was uninvolved with data collection and analysis, audited the thematic analysis and
codebook, evaluated the themes for consistency, and assisted with excerpt extraction.
Team-based thematic analysis generated six themes from the qualitative data: (a)
experiences of (dis)connection, (b) health status, (c) health-protective factors, (d) continuity of
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 11
care, (e) psychosocial burdens, and (f) structural burdens. Illustrative excerpts were edited
slightly for readability (e.g., removed repeated words).
Experiences of (Dis)connection
During COVID-19, all HIV-positive MSM in this sample either sought connection to
personal and sexual relationships, navigated partner selection in the context of stay-at-home
recommendations, and/or felt disconnected from community, personal relationships, and casual
partners. All participants described helpful social interactions with family, friends, or sexual
partners. In the domain of personal relationships, one participant gradually managed his COVID-
19-related distress by connecting to friends:
I'm getting really better about it […] I just let my friends […] know about my mental
state […] And that’s been through either just like texting, through social media platforms,
or it’s been also just a lot of FaceTime. I do find myself sometimes also lacking to make
an effort to communicate, and I wonder if that has anything to do with, again, me just
feeling depressed or fatigued. (31-year-old Latino gay man)
Participants (n = 16) also used technology to maintain relationships with family and sexual
partners, relying primarily on social media, text messaging, and video calls. However, for n = 12
participants, physical proximity to others tended to buffer against pandemic-related distress.
Living with a partner was the only form of consistent social contact for six participants:
I'm very grateful to have my partner here [… because] I have cried things out, you know,
I'm constantly talking to my partner about how I feel. (28-year-old Multiracial gay man)
Intimate partnerships emerged as an important form of sexual connection during COVID-
19. Indeed, half of the sample reported monogamous relationships as a source of social support
and sexual fulfillment. Most single HIV-positive MSM (n = 9) used sexual webcamming,
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 12
pornography, sexting, and dating apps to feel connected to their sexual networks; three continued
to have sex during the pandemic with casual partners whom they had known prior to stay-at-
Overall, seven HIV-positive MSM acquired new partners during COVID-19-related
restrictions. However, both partnered and single HIV-positive MSM (n = 15) described
adaptations to their partner selection behaviors during stay-at-home recommendations. Some
strategies prioritized physical health over sexual connection (i.e., no sex at all). Other strategies
aimed to reduce harm while pursuing sexual connection, such as (a) vetting new partners
according to their adherence to “social distancing” and “using face masks” (30-year-old Black
gay man), (b) asking whether potential partners “played with a lot of guys” or “if they travel
everywhere” (39-year-old Asian bisexual man), (c) inquiring about “showing all signs of
COVID” prior to meeting (51-year-old White gay man), (d) limiting partners to men with whom
they had sex “with in the past” (34-year-old Latino gay man), (e) limiting sex to erotic “chit
chat” (31-year-old Latino gay man), or (f) otherwise assessing risk to determine “like any STD
[…] if I want to take the chance” (51-year-old White gay man). However, four participants
emphasized that these new strategies would likely not change their partner selection behaviors
Despite the many strategies of connection employed by this sample of HIV-positive
MSM, most participants experienced disconnection (n = 19). For participants without the
privilege of physical proximity to family and friends, isolation was more salient. Participants
began to call their family “a lot more” just to have “somebody to talk to” (39-year-old Asian
bisexual man). For participants for whom connection to the local “gay” community mattered, the
pandemic resulted in a significant loss:
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 13
As far as connecting with the community at large? No, I think it’s been […] difficult. We
understand that we’re all in it together. And there’s been, you know, outreach things from
the community to the gay community—whatever—to connect us all over. But instead of
knowing how individuals are doing throughout the community, you just—you don’t see
them […] it’s not like you get to be together […] So, that’s a tough one. (46-year-old
White gay man)
Disconnection from the wider “gay” community also manifested in disrupted access to
sexual networks. Despite desiring sexual connection, half of the participants reported less sex,
fewer partners, or no sex at all (n = 10):
I even thought about breaking up with this guy just because I was like: “someone I just
met versus me potentially dying,” you what I mean? (31-year-old Latino gay man)
Nine participants identified dating apps (e.g., Grindr, Scruff) as beneficial for fulfilling their
sexual needs, either via erotic chat (n = 9) or finding new sexual partners while implementing
harm reduction strategies (n = 7). However, 11 participants reported no use of these apps either
due to being monogamous (n = 9) or due to other COVID-19-related concerns (n = 3).
A minority of HIV-positive MSM (n = 4) reported positive changes to their health status,
such as eating well. Another set of participants (n = 3) reported no changes to their physical or
mental health status. Overall, however, stay-at-home recommendations resulted in perceived
increases in physical and mental health symptoms (n = 14), even among two participants who
experienced some positive changes. Twelve HIV-positive MSM reported greater physical health
problems, such as hyper/insomnia. For one participant, structural burdens in his local
environment, compounded with stay-at-home recommendations, impaired his ability to eat well:
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 14
I stay around all these fast-food restaurants. If I like a salad, I eat it at work […] Healthy
foods, you have to go to the grocery store and get it yourself because you can't get it from
[where I live …] I feel like I’ve gained weight […] while being in the house. (41-year-old
Black bisexual man)
Other participants (n = 9) described mental health concerns, such as feeling “on edge”
(33-year-old White gay man), “self-destructive” (29-year-old Latino gay man), and
“overwhelmed” (31-year-old Latino gay man). Mental health problems were most salient for
participants facing coexisting psychosocial and structural burdens:
I’m so scared to even go out in my own living room […] My anxiety and depression has
kind of went off the charts […] I’ve been dealing with major depression and stuff
because of me not being able to work and […] I want to work but I have so many medical
issues [… plus] finding that disability [was] denied. (45-year-old White gay man)
Feelings of disconnection also contributed to greater mental health problems:
I feel a little bit disconnected […] I’m not taking care of myself […] when everything
started, I had a lot of anxiety. I remember like the first week that I woke up at 3 AM and I
—my body kind of, like, forgot how to breathe or something. (31-year-old Latino gay
A smaller set of HIV-positive MSM (n = 5) reported struggling with substance use during
stay-at-home recommendations. One participant identified the loss of his faith-based support
groups as the reason COVID-19 threatened his eight months of sobriety:
Just the temptation has been really, really strong […] with COVID and I’m stranded here,
and I just think of you know, “gosh, I wish I could just get high.” But I’m trying to hold
on to my sobriety, but I also have this other side pulling at me. Like, if I’m going to be in
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 15
my room by myself, at least, you know: […] “You’re not going out and hurting anybody
—you’re in your room, [so] just get high.” (45-year-old White gay man)
At least one health-protective factor was evident at the intrapersonal, behavioral, or
systemic level for all participants. At the intrapersonal level, participants reported awareness of
COVID-19 risk behaviors, positive affect, and hopeful attitudes towards the future. When
participants were informed about and remembered the science of COVID-19 (n = 17), they
described “being really extra careful” (31-year-old Latino gay man) while resisting unpleasant
predictions and despair:
So, I should be worried simply for the fact that I have a compromised immune system.
But at the same time, I’m not going to let something like this completely shut my life
down. (48-year-old Latino gay man)
Even when there were threats to one’s continuity of care, there was evidence of optimism and
I had my whole [HIV] appointment cancelled and pushed back. And I guess in a way that
it affected me, but it’s not really that bad. (28-year-old Multiracial gay man)
For HIV-positive MSM in monogamous relationships, translating awareness of COVID-
19 infection risk into behavioral health-protective factors was facilitated by intimate
Well, [my boyfriend and I] talk pretty much everywhere. We talk every day. So, he’s
always like, “put your mask on,” and I’m like, “yeah, put your mask on.” (31-year-old
Latino gay man)
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 16
Other harm reduction strategies were used at the behavioral level to protect health (n = 10),
including adherence to CDC guidelines (e.g., use of hand sanitizer). Participants also described
engaging in self-care to cope with disconnection from social, sexual, and health networks (n = 8).
Additionally, they emphasized the importance of establishing and adhering to a regular routine to
enhance their health status (n = 13):
I’m doing a lot better. I feel like the worst is past me, because you know, just giving up
my routine—my daily schedule […] But now I feel a lot better about it. I’m just creating
a new home routine here, and doing things I love, to keep my mind occupied and just to
keep myself healthy. (31-year-old Latino gay man)
Finally, at the systemic level, participants described having steady employment (n = 11),
a secure living environment (n = 14), and health insurance (n = 18) as factors that kept them
connected to their health networks and engaged in health-enhancing behaviors.
Continuity of Care
Participants (n = 19) described features that facilitated connection to health networks,
including HIV-specific care. In terms of general healthcare, most HIV-positive MSM (n = 13)
remained connected to their primary care physician via video calls, telephone appointments, and
the occasional in-person visit. Supportive, reassuring providers were especially important for this
sample during stay-at-home recommendations:
[The] appointment over the phone with one of my case managers helped […] they called
me just to make sure everything was good. How was my insurance working out during
this time? [They helped me to] make an arrangement for the change of pharmacy, and so
I didn’t have to be exposed going outside […They] followed up on all my appointments,
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 17
[they said] that everything was gonna stay the same. So, it was pretty good. (29-year-old
Latino gay man)
Three participants also perceived an increase in healthcare efficiency and “convenience” (26-
year-old White gay man) due to COVID-19, especially in terms of managing their HIV. One 36-
year-old White gay men noted how his engagement with his health network seemed “a little
Positive experiences with HIV care were described by most participants (n = 19). This
sample of HIV-positive MSM continued to receive their prescriptions by mail or in-person (n =
14) and adhered to their ART regimen (n = 18). Nearly half of the sample (n = 8) indicated
positive experiences with telehealth:
It was really nice not having to sit around in the waiting room. […] It was really fast. We
kind of skipped over all the, you know—they weigh you, they take your temperature,
they do your pulse, or whatever. Which, I'm sure I wouldn't want to [skip vitals] every
time but, you know, it doesn't really matter for one visit probably. (29-year-old White gay
Participants also reported that their case managers intervened to counter the structural burdens in
their lives (n = 8). For example, case managers assisted with accessing “rent assistance” (31-
year-old Latino gay man), sending “packages [of…] food” (28-year-old Multiracial gay man),
and “automatically extending” their drug assistance program “by six months” (39-year-old Asian
bisexual man). In terms of negative case analysis, the one participant who reported no positive
experiences with HIV care stated that he was unable to get tested, his ART medication ran out,
he was unable to get in contact with his doctor, and he had no case manager.
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 18
Connecting to social, sexual, and health networks was complicated by burdens within the
individual and his immediate environment (n = 19). Many participants (n = 14) underscored the
stress resulting from COVID-19-related environmental changes (e.g., lockdown, self-isolation)
and social concerns (e.g., worry about older parents, talking to anxious friends). Greater
loneliness and social isolation were common reactions (n = 9), especially for MSM longing for
I feel particularly lonely because […] I’m nobody really. I feel like nobody wants me. So,
it’s hard to deal with, especially with this time. I have so much time on my hands, and
then I don’t have a love life. (39-year-old Asian bisexual man)
Whereas a desire for romantic and sexual companionship was most salient for some
participants, others identified a general lack of social support as the reason “why [their] anxiety
and depression [had] gone up” (45-year-old White gay man). With one exception (i.e., a 29-year-
old Latino gay man who continued to visit his boyfriend on weekends), self-isolation was
somewhat less shocking for participants living alone (n = 4) in comparison to participants
accustomed to being “very social” (31-year-old Latino gay man). Nonetheless, in the context of
pandemic-related distress, both groups experienced greater negative affect (e.g., apprehension,
sadness, boredom, loss of interest) and negative appraisal. In terms of negative appraisal,
harboring a harrowing attitude about the future (n = 9) ranged from worry about HIV–COVID-
19 coinfection to beliefs that COVID-19 was “not a pandemic [but] a plandemic” (35-year-old
White gay man). Some participants felt afraid of the possible interaction between HIV
seropositivity and COVID-19:
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 19
Well, me being positive, I was like, “is this…,” you know—“how is it gonna affect me?”
Because nobody’s talking about that. So, that was a little bit scary […] it was like an
extra layer. (31-year-old Latino gay man)
Uncertain outcomes and their attendant speculations, coupled with increased isolation,
negative affect, and distress provoked disengagement as an additional coping response. For
example, one participant reported:
I’m tired and I don’t care what happens […] I’m jaded, but with sadness. You cannot go
through feeling sad all the time. So, you just feel like it’s nothing. (29-year-old Latino
Another denied COVID-19 by emphasizing:
Everything’s still pretty much normal other than businesses being closed down […] it’s
like it’s not even real, it doesn’t even feel real. (28-year-old White gay man)
When the psychosocial burdens reached a crescendo, even disengagement seemed difficult:
Under all that extra stress from [COVID-19] and then from being back under the
influence and everything all at once together. On top of financial [stress…] and like all
this other stuff, it was really hard to keep any kind of physical—or, I mean a mental
block, or a filter, I guess. (29-year-old White gay man)
Finally, HIV stigma in the context of COVID-19 manifested in the lives of four
participants. A 35-year-old White gay man denied feeling “worried about COVID-19 […]
because I’ve already got the worst thing out there.” A 45-year-old White gay man did not
perceive the lack of access to sexual networks as a problem because his HIV status had
engendered internalized HIV stigma (e.g., “[my HIV is] just kind of devastating [… so] I’m
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 20
celibate”). Another participant continued to conceal his HIV status from his partner despite
spending increased time together due to stay-at-home recommendations.
At the systemic level, most participants (n = 18) faced structural burdens while
attempting to access social, sexual, and health networks. Negative case analysis revealed that the
two participants who experienced no structural burdens were employed, had robust social
networks, no service disruption in their HIV care, and were in long-term relationships. For the
remaining HIV-positive MSM in this sample, environmental barriers, financial difficulties, poor
healthcare experiences, discrimination, and incarceration emerged in their lives. Significant
environmental barriers included lack of access to recreational opportunities, information,
healthcare services, and transportation (n = 9). For example, one recently incarcerated participant
desired connection with his partner, but the couple had limited options during stay-at-home
[My partner] went into a shelter program […] because he was in-between places—hotel
rooms—but they’re kind of strict on what time he has to be home […] and it’s so far
away from me. We like being with each other, but it was him having to ride the bus back
and forth; the long trip was scary. (34-year-old Latino gay man)
Financial difficulties, such as job loss, unemployment, lack of health insurance, homelessness,
poverty, and food insecurity, were also prominent in this sample (n = 12):
[I’m] trying to find a job. You know, like anything. The only thing in this area that’s
hiring right now is Amazon [… but] it’s not a field that I want to put myself into [during
COVID-19], especially with HIV. You know, I don’t want to: “hey, give me all your
other viruses,” you know? I think one’s enough. (36-year-old White gay man)
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 21
For one participant, the decision to connect to social networks resulted in a lack of access
to his health network due to environmental disadvantages:
COVID-19 happened […] and then I came back home to […] a very small town […] So
me moving states, I haven’t been able to get Ryan White, which is a [HIV/AIDS]
program […] I haven’t been able to get that or see a doctor yet. I haven’t taken my
medication since COVID-19 has started. […] Because […] me living in a small town, the
next closest big town is like an hour and a half away. And for me to do that, I would have
to go there, and I don’t have a license. [… And] living in a small town like this while
being gay? All this is very, very hard. (28-year-old White gay man)
Even for HIV-positive MSM who remained connected to their health networks, poor service
delivery intersected with financial difficulties to create barriers to maintaining a desired health
[I finally] had an appointment last week. We did it over the phone […] I had to take a
picture of my little rash […but] how can you tell me what this rash is if you can’t see it in
person? […] How you gonna check my vitals, how you gonna see if I maintain
undetectable—how you gonna check that? […Plus] you know that medication is so high.
What if I do lose my job [because of COVID] and can’t afford it? (41-year-old Black
Although this sample was concerned about COVID-19 and its impact on their connection to
health networks, there was a sense of disempowerment when structural burdens were salient:
I mean, I don’t ask questions […] you can’t really when you’re […] at the bottom of the
pyramid. (35-year-old White gay man)
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 22
The present study used team-based thematic analysis to generate six themes that describe
the ways in which HIV-positive MSM accessed social, sexual, and health networks during initial
stay-at-home recommendations of the COVID-19 pandemic in spring 2020. All participants
relied on social support networks to manage pandemic-based distress, using computer-mediated
communication as well as physical proximity. To connect to sexual networks, this sample
described adaptations to their partner selection strategies, such as enumerating harm reduction
approaches (e.g., inquiring about COVID-19 symptoms). To connect to health networks, HIV-
positive MSM depended on reassuring providers, resourceful and attentive case managers,
telehealth, and streamlined access to their ART medications. Nonetheless, stay-at-home
recommendations reduced community connection, sexual activity, and healthcare access for
many HIV-positive MSM, and perceptions of these losses were shaped by psychosocial burdens
(e.g., loneliness, resignation), structural burdens (e.g., environmental barriers, financial
difficulties), and health-protective factors (e.g., hopeful outlook, adherence to a regular routine).
HIV-positive MSM in the sample perceived interactions between these three forces and their
health status, with the majority reporting increased physical (e.g., weight gain) and mental health
(e.g., anxiety, depression) symptoms, and some reporting an increased risk for substance misuse.
Our findings support a COVID-19-specific syndemic framework (9), wherein for PLWH,
the co-occurring COVID-19 pandemic and HIV epidemic results in exacerbated physical and
mental health concerns, as well as social and structural marginalization. A syndemic framework
thus allows researchers to explore how the COVID-19 pandemic amplifies existing challenges
(i.e., loneliness, mental and physical health challenges), while also synergistically presenting
new challenges specific to those living with HIV (i.e., HIV care continuity issues, magnified
health concerns). The pandemic’s perceived effects on physical, mental, social, and sexual well-
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 23
being among our sample of HIV-positive MSM occurred largely as a result of the physical
distancing and isolation. Prior research (16,17,39) has identified how social isolation harms HIV-
positive MSM, as well as how increased physical isolation from social networks due to the
pandemic has exacerbated this existing phenomenon. These outcomes may have a lasting effect
on those living with HIV, as lost interpersonal connection with protective social networks, as
well as sexual networks, has the potential to prolong adverse effects on HIV-positive MSM
beyond the context of stay-at-home recommendations should isolation persist.
Moreover, our participants reported ART adherence challenges and forgone laboratory
testing to monitor viral loads, a result of impeded daily routines and in-person HIV-related
clinical appointments, which is consistent with prior work (8,40). Pandemic-based HIV care
disruptions raise concerns regarding lasting consequences for PLWH, as well for HIV prevention
at large. Indeed, modeling and clinic-based studies suggest that the COVID-19 pandemic has
deleteriously impacted viral suppression in the U.S. (41,42), although disruption and subsequent
impacts on viral load suppression have been mediated by engagement in care via telehealth (43).
Impaired viral suppression not only harm PLWH but may delay national HIV prevention goals,
such as ending the HIV epidemic by 2030 (44). Thus, our findings suggest that the adverse
effects of the pandemic on PLWH will rely on coordinated efforts from mental health providers,
social support networks, and HIV providers to obviate the worst outcomes.
At the same time, the pandemic may have facilitated the rapid expansions of telehealth.
In our sample, telehealth sustained care continuity for many HIV-positive MSM. Our findings
expand upon previous work (9,18,20,45), which identified telehealth as influential in maintaining
HIV care in the U.S. Similarly, reimaginations and expanded use of existing videoconferencing
software (i.e., Zoom, FaceTime) and other technologies (geosocial networking apps) aided in
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 24
maintaining social and sexual connection for HIV+ MSM in this study, although in-person
connection remained vitally important for participants. Thus, although the co-occurring COVID-
19 pandemic and HIV epidemic synergistically created new structural and psychosocial burdens,
as well as barriers to care and interpersonal connection, these unique conditions also enhanced
existing avenues for connection via technology. Building upon these findings to support the
physical and mental health of PLWH will be integral for ameliorating the harmful effects of the
COVID-19 pandemic on healthcare access going forward. These efforts should include policies
that help to sustain access to telehealth and replace regulations that limited the reach of telehealth
in the past (e.g., cross-state care delivery restrictions; 46).
Finally, our participants discussed the work of case managers in connecting them to
medical and non-medical services during the early pandemic. To our knowledge, only one study
(45) has reported on the provision of non-medical services for PLWH during COVID-19. Further
research in this area is needed to better understand the experiences and acceptability of remotely
delivered non-medical services for PLWH during the ongoing pandemic. An ever growing body
of literature (47–49) has underscored the importance of comprehensive “wraparound”
programming that meets the complex socioeconomic needs of PLWH. Expansions to this body
of work could provide critical information for supporting PLWH as they experience structural
barriers to necessary services (e.g., sustainable housing), which in turn may impact HIV
Our findings should be considered in light of our study’s limitations. First, although
generalizability is not the of purpose of qualitative research, it is worth emphasizing that (a) this
sample trended towards mid-life adults, (b) primarily included gay men, and (c) featured data
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 25
from men in long-term, monogamous relationships who (d) were primarily White and Latino.
We also had fewer participants from the Midwest. Thus, findings from younger, bisexual, single,
Black and Asian, and midwestern participants are undersaturated. Second, although a
postpositivist, realist approach to inquiry enabled us to document specific challenges and to
describe direct experience through the lens of syndemic theory, a constructivist approach may
have generated latent interpretations of how the themes intertwined. Finally, these data were
collected during the early months of the pandemic in 2020, and the pandemic has continued to
evolve and change meaningfully over time. Thus, there is a need for future research to evaluate
the experiences of HIV-positive MSM during other phases of the pandemic (e.g., after vaccine
access and uptake increased nation-wide).
While coping with psychosocial and structural burdens, changes to their health status, and
pandemic-based experiences of disconnection, this sample of HIV-positive MSM used a diverse
set of strategies to remain connected to social, sexual, and health networks during stay-at-home
recommendations. Public health officials and clinicians might recommend these adaptive
strategies to other HIV-positive MSM or incorporate them into organizational practice. Given the
ongoing COVID-19 mutations, community-based organizations, clinicians, and researchers
might use these findings to modify HIV prevention and intervention efforts to be responsive to
future pandemic-related disruptions.
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 26
The authors would like to thank Gamille Gallus and Sabrina Rios for their assistance during the
quality assurance phase of transcription. Special thanks to additional members of the T5K study
team: David Pantalone, Denis Nash, Sarit A. Golub, Viraj V. Patel, Gregorio Millett, Don
Hoover, Sarah Kulkarni, Matthew Stief, Chloe Mirzayi, Javier Lopez-Rios, Fatima Zohra, &
Pedro Carneiro. Thank you to the program staff at NIH: Gerald Sharp, Sonia Lee, and Michael
Stirratt. And thank you to the members of our Scientific Advisory Board: Michael Camacho,
Demetre Daskalakis, Sabina Hirshfield, Jeremiah Johnson, Claude Mellins, and Milo Santos.
While the NIH financially supported this research, the content is the responsibility of the authors
and does not necessarily reflect official views of the NIH.
HIV-POSITIVE MSM, NETWORKS, AND COVID-19 27
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