Sara Wallach, Alex Garner, Sean Howell, Tyler Adamson, Stefan Baral, and Chris Beyrer
As of August 12, 2020, there are over 20 million confirmed cases of novel coronavirus disease (COVID-19) worldwide with over 744,000 deaths. Due to existing disparities in health outcomes, the consequences of this pandemic for LGBTQ+ individuals could be magnified in scope and severity. Gay, bisexual, and other men who have sex with men (MSM), particularly those who inhabit multiple minority identities (that is, racial/ethnic minorities, immigrants), are already at greater risk for suicide, HIV, and unemployment, and commonly face systematic, institutional discrimination in the form of criminalization and other human rights violations. Vulnerable subgroups, such as unstably housed or informally employed LGBTQ+ individuals, may struggle to practice social distancing and prescribed sanitation measures. The recommendations presented here are data-driven and informed by a cross-sectional survey implemented by the free gay social networking app, Hornet, from April 16 to May 4, 2020. Hornet has over 25 million global users, and over 4,000 users from more than 150 countries completed this survey. The most responses were from Brazil, France, Russia, Turkey, Indonesia, and Mexico; the largest number of MSM responses were from Brazil, France, Mexico, Taiwan, and Russia.
Stigma, discrimination, and human rights
Global evidence demonstrates that governments are using COVID-19-related restrictions as an excuse to perpetuate stigma, acts of discrimination, and violence against LGBTQ+ persons. The South Korean government used cellular phone GPS, transportation history, and credit card transactions to “contact trace,” seemingly targeting the LGBTQ+ community. After COVID-19-related restrictions were relaxed, and supposedly gay nightclubs reopened, this community was blamed and harassed for an increase in new cases. The survey found similar incidents were reported in Belize, Uganda, and the Philippines. These acts of discrimination and violence, all too often perpetrated by governments, religious leaders, and healthcare institutions, are clear human rights violations. They thwart the Yogyakarta Principles, as well as the International Covenant on Civil and Political Rights, the International Covenant on Economic, Social and Cultural Rights, and others. Furthermore, fear of discrimination and abuse can itself significantly deter accessing healthcare. In the cross-sectional survey, 24% of the 2732 MSM respondents reported being worried they would face discrimination or violence based on their sexual orientation and/or gender identity if they accessed government resources or healthcare.
HIV prevention and care
Throughout the COVID-19 crisis, non-COVID-19-related healthcare has been deprioritized, restricted, or even completely unavailable. Access to HIV prevention and care, often already limited for LGBTQ+ persons, may be hindered further. This increases the likelihood of disease progression for persons living with HIV (PLWH) and HIV transmission to sexual and/or needle-sharing partners. In the survey, MSM reported feeling they had considerably less access to HIV testing, pre-exposure prophylaxis (PrEP), and post-exposure prophylaxis (PEP) since the start of the pandemic. Those with additional minority identities reported significantly less access to condoms and medications than their non-minority counterparts.
Nearly 25% of respondents could not access their HIV providers, and 20% could not refill their HIV medications. Only 17% of respondents indicated they could reach their HIV providers via telemedicine. COVID-19 is clearly exacerbating disparities in healthcare access, especially for those without access to technology. Telemedicine is not a panacea that overcomes healthcare access restrictions for all. Moreover, if global funding for the HIV response is reallocated to COVID-19 initiatives, the effects could be catastrophic to the remarkable progress made towards addressing HIV thus far. WHO and UNAIDS warn that a resurgence of the epidemic is likely. Ignoring this threat will have potentially deadly consequences for MSM and the global HIV response.
Current circumstances pose new threats amid the ongoing mental health pandemic. Disease outbreaks such as COVID-19, the mitigation strategies to slow them, and the subsequent employment losses can cause stress that manifests in various ways—anxiety and worry, exacerbation of existing mental health conditions, changes in eating or sleeping, substance use for coping, and more. For the LGBTQ+ community, and particularly for MSM, this current crisis may be a painful—and re-traumatizing—reminder of the devastating effects of the early HIV epidemic. This is a population already disproportionately affected by negative mental health outcomes; according to the American Psychological Association, LGBTQ+ youth have higher rates of suicidal thoughts and attempts than their heterosexual, cisgender peers. Thirty-one per cent of MSM cross-sectional survey respondents reported experiencing moderate to severe psychological distress. Thirty-five per cent screened positive for depression, and 34% screened positive for anxiety; this was positively correlated with loss of employment. Additionally, access to mental health services, like access to HIV services, is already limited for members of the LGBTQ+ community and may be further hindered. This pandemic, and governments’ social distancing measures, also restricts individuals’ access to sex. Sixty-one per cent of survey respondents indicated they were currently not having sex because of COVID-19, and 49% were somewhat or extremely dissatisfied with their sex lives. While an important aspect of health in and of itself, sexual intimacy may also affect mental health, as sex can boost self-esteem and mood, act as stress relief, help with sleep, and ease anxiety and depression, rates of which may be elevated in a pandemic.
Stigma, discrimination, and human rights
- Public statements condemning stigma and discrimination toward the LGBTQ+ community during this pandemic are necessary; public officials should make, or continue to make, these statements.
- Public institutions, including hospitals and social services, should indicate to LGBTQ+ individuals, including migrants and other non-citizens, that they are welcome. They must acknowledge their role with regard to structural oppression and cultivate safe environments in which members of this community feel comfortable seeking services.
- States must protect, respect, and fulfill the rights of all their LGBTQ+ inhabitants. Such rights include, but are certainly not limited to, the right to privacy, bodily integrity, and health.
- Police brutality, particularly toward LGBTQ+ individuals with additional minority identities, is a social determinant of health that must be addressed. Additionally, law enforcement cannot be permitted to harass members of this community under the pretext of epidemic control.
- The creation of COVID-19 policies and protocols, like those for contact tracing, must involve LGBTQ+ persons. Lessons from the international HIV response should be used.
- Jailing individuals for not socially/physically distancing is antithetical to efforts to limit COVID-19 exposure, as socially distancing and sanitation resources in incarceration are limited, violating individuals’ right to health.
HIV prevention and care
- Maintain or increase global HIV response funding to mitigate the detrimental consequences COVID-19 will have on PLWH or those at risk of acquisition.
- Support and prioritize localized, innovative methods of HIV healthcare delivery during this pandemic; develop protocols to sustain HIV prevention and treatment in future crises and include PLWH in this planning.
- Issue guidance about reducing harm and exposure in pandemic conditions to PLWH, HIV and TB co-infection, and unsuppressed viral loads.
- Reconsider protocols that limit prescription medications (for example, prescriptions are often limited to three-month supplies for PrEP medications and/or only after an HIV test) and work with insurance companies to support on these issues during emergencies.
- Include mental health in all pandemic-related policies; remote resources must be created and made widely available.
- The unique mental health challenges of LGBTQ+ persons, including associations of COVID-19 with the early HIV epidemic, must be considered in COVID-19 mental health resources and policies. This population should be included in formulating any guidance, and their experience with the ongoing HIV epidemic, and the potential compounded stress of both epidemics, should be recognized and respected.
- Sex must be recognized as an important aspect of mental health, and sexual health should be considered in pandemic-related policies. Policies should be sex positive, destigmatize sex generally, and concentrate on celebration rather than risk mitigation. Lessons learned from the HIV epidemic, like the ineffectiveness and stigmatization of fear-based public health campaigns, should be utilized.
Thank you to all the hard-working individuals in the COVID-19 Disparities Working Group.
Human Subjects Research
The secondary data analysis protocol for the cross-sectional survey cited in this paper was reviewed by the Johns Hopkins School of Public Health Institutional Review Board, which determined that the protocol qualitied for Exempt status under Category 4.
Sara Wallach, Tyler Adamson, Stafan Baral, and Chris Beyrer are all at the Johns Hopkins School of Public Health, Baltimore, USA.
Alex Garner is with Hornet, USA.
Sean Howell is CEO of the LGBT Foundation, USA.
Please address correspondence to Sara Wallach. Email: firstname.lastname@example.org
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