HIV, COVID-19 and health and well-being: a mixed-methods exploration of the impact of structural and social determinants

Abstract

Advances made in the treatment and care of people living with HIV, including the ability to be ‘undetectable’, have shifted the focus of the HIV epidemic in the UK towards people living well beyond simply virological suppression. This mixed-methods thesis investigates the social and structural determinants influencing differences in health and well-being, with a focus on mental health, of people living with HIV in the UK. First, a systematic review identified a social gradient of health relating to social determinants and HIV clinical outcomes in high-income countries; people living with HIV who were more materially deprived were less likely to be virologically suppressed or adherent to ART, compared to those more advantaged. Secondly, online interviews with people living with HIV and/or working in HIV services during the COVID-19 pandemic shared diverse experiences including their perceptions of adaptions to HIV services and the impact on wider society. Concerns were raised about the emerging and widening health and social inequalities laid bare by the pandemic and the long-term impact on mental health and well-being. Thirdly, secondary data analysis of the 2017 Positive Voices study identified how individuals with poorer socioeconomic circumstances, including those unemployed or economically inactive, were significantly more likely to self-report poorer mental health as measured by the 12-item General Health Questionnaire (GHQ-12), than those socioeconomically advantaged. These associations remained after adjusting for demographics and clinical measures including age, gender identity and year of diagnosis. For instance, White British cisgender men who were unemployed were almost 4-times more likely to report GHQ-12≥4, compared to those employed (aOR 3.77; 95% CI 1.87, 7.63). Finally, I applied findings to a theoretical framework and propose potential causal pathways to be explored in future research. The thesis has been in collaboration with colleagues at the UK Health Security Agency and Positively UK.