CORONAVIRUS DISEASE (COVID-19), caused by the SARS-CoV-2 virus, was classified as a pandemic by the World Health Organization on March 11, 2020.1 As of October 1, 2021, in Texas, there were more than 4 million confirmed COVID-19 cases and 65 191 deaths due to COVID-19.2 In Travis County, where the present study was conducted, there have been more than 115 000 confirmed cases and 1331 deaths to date.2 The Centers for Disease Control and Prevention (CDC) recommended several preventive measures to reduce the spread of COVID-19: wearing masks, physical distancing (≥6 ft) from other people, and washing hands and surfaces.3 Some states instituted “stay-at-home” orders and restricted gatherings of 10 or more people outside of the same household to curb the spread of the virus.4 The CDC also identified risk factors associated with increased severity of COVID-19 symptoms that include older age and chronic conditions such as diabetes and hypertension.5 COVID-19 affects the cardiovascular system, specifically the angiotensin-converting enzyme (ACE2) cells, which also are found in lungs, intestines, and kidneys.6 COVID-19 frequently causes intense but uncoordinated immune system responses.7 Therefore, people with comorbid conditions who have impaired cardiovascular or immune systems have been more negatively impacted by COVID-19, meaning higher incidence, worse symptoms, and increased risk for detrimental COVID-19 outcomes such as hospitalizations, intensive care unit admissions, mechanical ventilation, and death.8
People living with HIV (PLWH) are at a higher risk for contracting and being hospitalized with COVID-19 than those without HIV/AIDS (27.7 per 1000 vs 19.4 per 1000).9 Having a diagnosis of HIV/AIDS with weakened immune systems, and low CD4 white blood cell counts, increases risk of contracting COVID-19.9 In addition, PLWH have high rates of cardiometabolic comorbid conditions, such as diabetes, which adds to their high risk for worse outcomes from COVID-19. Along with general diabetes risk factors such as aging, PLWH are at an increased risk for developing diabetes than the general population due, in part, to chronic inflammation and mitochondrial damage caused by HIV/AIDS treatment.10 Even when PLWH have a viral load that is undetectable, meaning that the level of virus is so low that laboratory testing cannot detect it, they will still have some level of inflammation due to the HIV.11 About 12% to 19% of PLWH also have diabetes, which is higher than the prevalence in the general population.12
Self-management of chronic health conditions involves the daily tasks that individuals need to complete in order to manage their health and prevent disease-related complications including eating a specific diet, taking medications, monitoring symptoms, and keeping medical appointments.10,13 Poor self-management can lead to increased morbidity and mortality and decreased quality of life.14 People with multiple chronic conditions, such as the dual diagnoses of HIV/AIDS and diabetes, must include condition-specific self-management behaviors such as blood glucose monitoring and foot inspection for people with type 2 diabetes mellitus (T2DM) and harm reduction and managing symptoms for PLWH.12,15 Self-management of these dual diagnoses is even more complex because of the overlapping symptoms of diseases, polypharmacy, and the need to track multiple medical appointments.16 Self-management routines for PLWH and people with T2DM were likely impacted by the pandemic and stay-at-home orders. Self-management may have become more complicated due to fear of exposure to COVID-19, the need for physical isolation, and restricted health care access.17 Furthermore, PLWH and people with T2DM may have lost access to resources such as transportation or social support during the pandemic, making it difficult to effectively self-manage their diseases.
The research team was in prime position to explore the impact of COVID-19 because it was engaged in a larger study of how PLWH and people with T2DM self-manage their diseases. The team, which had already engaged the sample using ethnographic qualitative methods, was albeit to reconnect with the research participants to see how their self-management experiences had been affected by COVID-19. In May-June 2020, communities were still experiencing shortages of supplies, including masks and COVID-19 tests, as well as some groceries and personal supplies. The promise of a COVID-19 vaccine was still 6 months away. The purpose of this study was to describe the impact of the COVID-19 pandemic on self-management behaviors and practices for people living with the dual diagnoses of HIV/AIDS and T2DM and to identify pandemic-specific disruptions or changes to their established self-management practices.
Statements of Significance
What is known or assumed to be true about this topic?
People with cardiometabolic conditions are at a higher risk for negative outcomes due to COVID-19 and were advised to quarantine, wear masks, and physically distance to prevent contracting the virus. People with HIV/AIDS and people of Hispanic and Black populations are likely to believe in fatalism, the view that one's fate is not controllable but predetermined. Fatalism can be a barrier to preventive health.
What this article adds:
Some positive self-management behaviors, such as glucose testing, increased during the mandatory “stay-at-home” orders, overcoming some participants' concerns about exposing coworkers to HIV-positive blood droplets if they tested their glucose levels while at work.
People with the dual diagnoses of HIV/AIDS and diabetes do not always consider themselves at a high risk for COVID-19, though both conditions, and the age of the participants in the sample, would place all of them in the high-risk category. The inability to properly categorize the risk meant they often did not take the proper precautions to protect themselves from COVID-19.
This qualitative, exploratory study was conducted in May-June 2020 with a subsample of participants from a larger qualitative study of self-managing both diabetes and HIV/AIDS. As part of the larger study, participant had already been interviewed twice about their self-management behaviors and attitudes. A third interview opportunity was offered to all of the qualitative study participants via phone call or email. Data collection for this study included semisemistructured interviews with 2 research team members using videoconferencing, or, if there were technical difficulties, interviews were conducted by telephone. Both researchers wrote field notes during and after the interviews. The interview guide consisted of open-ended questions that were adapted from the parent study's interview guide to include questions about self-management during the COVID-19 pandemic, COVID-19 information-seeking behavior, and knowledge (Table 1). The parent study was guided by a model (unpublished data) that described diabetes and HIV/AIDS health outcomes as predicted by contextual (age, race/ethnicity), psychological (stress, anxiety), and motivational factors (self-efficacy, health beliefs). The current study used the model to develop the interview guide; the open-ended questions reflected each of these areas and the data analysis.18
Table 1. -
||How has it been going for you?
||How have you been since the COVID-19 crisis started in the United States?
||COVID-19 assessment and precautions
||What do you think about COVID-19? Do you think you had it? Did you/have you been tested?
||How is it making you feel? What do you think is going to happen?
||If they had COVID-19
||How was that for you? How are you feeling now?
Did your HIV/AIDS or diabetes get worse?
Get the story of getting diagnosed, treated, and getting well.
||If they didn't have COVID-19 already
||If you think you were showing symptoms of COVID-19, what would you do?
||COVID-19 assessment and precautions
||Do you feel your risk for getting COVID-19 is different compared with someone without a chronic condition? Can you tell me about that?
||If you feel more at risk—what are you doing to keep yourself safe?
||COVID-19 information seeking
||Where do you get your information about COVID-19?
||Examples of places you might get information are online, friends/family, newspapers.
Can you describe how true or accurate you think the information you have been getting is?
||COVID-19 assessment and precautions
||What precautions are you taking?
||Examples of precautions are quarantining, practicing social distancing, and wearing masks or gloves.
||COVID-19 assessment and precautions
||How do you feel about different places in your life such as stores, restaurants, or the outdoors
||Are there some places that feel safer than others?
||COVID-19 assessment and precautions
||Can you tell me specifically about getting your groceries? What has this been like?
||COVID-19 assessment and precautions
Self-management habits & COVID-19
|What about getting your medications, has that changed? Has this changed your ability to take your medications regularly?
||Self-management habits and COVID-19
||Previously we talked about snacking and comfort food. Can you tell me about your eating habits now?
||Follow-up: Have you been cooking a lot or eating out?
||Self-management habits and COVID-19
||Some people have told us that they have had difficulty getting exercise during this time, how has that been for you?
||Can you remind us of your exercise regimen before COVID-19?
||Self-management habits and COVID-19
||Since COVID-19, have you had any difficulty with your diabetes in general? Can you tell me about it?
||Are you trying anything new to help with your diabetes?
||Accessing health care
||Have you seen your provider during this time, and if so, what was it for and how was that for you?
||Follow-up: Was the consultation in person, over the phone, or computer?
||Accessing health care
||If you got sick, not related to COVID-19, what would you do?
||Would you go to the hospital if you had a non–COVID-19 condition?
Has COVID-19 gotten in the way of you getting appointments or treatment?
||For a while we were told to shelter at home and now things are opening back up.
How has that been for you?
How are you interacting with your family and friends?
Some people are wearing masks, and some aren't, or keep social distance—what have you decided to do? How did you come up with that decision?
|Some people are reaching out to old friends, how has that been for you? Can you compare what it's like to check up on friends during COVID-19? How is it different?
How are you handling celebrations such as weddings, birthdays, and graduations?
||If you are in a support group, is that still meeting or how is that going?
||How has it been doing the support group remotely?
||Can you tell me if you are working and how COVID-19 has impacted your job or employment?
||Were you forced to stop working because of COVID-19 or could you work from home?
What about work during COVID-19? Have you worked from home using things like Zoom?
Follow-up: If you stopped working, were you able to obtain benefits?
||Has there been any change in housing for you?
||COVID-19 changes—Risk behaviors
||Can you tell me about any changes to your smoking, alcohol, and/or drug use?
||Are you smoking more, about the same, quit?
||Social media/technology use
||There is a lot of people using social media to stay connected to the larger world, what social media have you been using?
Are you using different or more technology to socialize because of COVID-19?
|Some examples of social media are Twitter, Instagram, and Facebook.
||Is there anything else about your life during COVID-19 that you think is important for me to know about?
The university's institutional review board approved the protocol before beginning study activities. Participants provided verbal consent to participate at the start of an interview with at least 2 members of the research team via videoconferencing software or phone. Research team members completed reflexive journaling directly following the interviews to note body language or emphasis on topics and identify potential researcher biases during the interview. The research team also reflected on the ethical and methodological challenges of conducting qualitative research during a pandemic with a sample that has multiple layered vulnerabilities. Participants received a $50 electronic gift card via email after the interviews.
The research team comprised primarily of people of color from various socioeconomic status levels. Team members reflected on their privilege and biases prior to data collection and during analysis. Their own experiences in addition to perspectives of other scholars of color informed the study design, data collection, interpretation, and conclusions reported in this article.
Recruitment and population
Participants were part of the convenience sample enrolled in the larger qualitative study (n = 21), all of whom were invited to be reinterviewed for this study. All participants lived in a central Texas county while a mask mandate was in effect, and residents were requested to stay at home when not engaged in essential work or health-seeking activities. Participants for the parent study had been recruited via flyers and in person from local organizations and clinics that served PLWH and people with T2DM and by word-of-mouth recommendations. Inclusion criteria for both this study and the parent study were as follows: people who (1) self-reported having been diagnosed with both HIV/AIDS and diabetes, (2) were 18 years or older, and (3) were taking prescribed medications to treat HIV/AIDS and diabetes. People with gestational diabetes were excluded.
The sample is drawn from a vulnerable population because PLWH have been stigmatized, have medical conditions that place them at a higher risk of COVID-19 infection and poor outcomes, are predominantly people of color, are drawn from clinics serving low-income populations, and are well documented as difficult to recruit into research.19 They were the ideal sample to speak about their experiences of HIV/AIDS and diabetes self-management during the pandemic because they met the inclusion criteria and because they had a preexisting relationship with the research time. When data were collected, our university and others around the country had just allowed research activities to start again, provided they were specific to COVID-19 and did not put participants at risk for infection. The research team leveraged the prior relationships with the parent study's sample and did not attempt to recruit additional participants during a peak time in the pandemic.
Data management and analysis
Information on the methods and activities used to ensure rigor are seen in Table 2. The interviews were audio recorded and professionally transcribed. The transcripts were analyzed using thematic content analysis.20 The transcripts were entered into NVivo software (version released March 2020) to organize and analyze the data and provide an audit trail of the codes, categories, and themes. The transcripts were each coded by 3 (J.A.Z., H.E.C., and E.M.H.) or more members of the research team. The first 3 transcripts were coded by the 3 research team members together during a 90-minute collaborative coding session in order to build a codebook. Subsequent coding was completed individually, with codes discussed in a weekly meeting and with any disputes resolved by a fourth researcher (A.A.G.). Once coding was completed, research team members met to combine codes into higher-level themes and categories. A final confirmability audit was completed by the fourth research team member to enhance rigor and ensure trustworthiness of findings.21
Table 2. -
Study Methods and Actions to Ensure Rigor
||Actions Associated With Each Method
Prolonged and varied field experience
Establishing authority of researcher/team
Triangulation of investigators
Previous study provided prolonged experience
All team members have different but relevant expertise
Research team members kept reflexive journals to record field notes, observations, and bracket (potential) biases; regular team/peer debriefing after interviews and during analysis
Semistructured; private online space; interviewer techniques such as rephrasing what was said to check understanding and accuracy in the moment
All raw data have been de-identified and kept in secure storage in order for future access by other researchers
Coding team (n = 3) included multiple researchers with diverse backgrounds and expertise
Dense description of data
Sufficient quantity (eg, thick) and quality (eg, rich) of description in raw data and reported in the article
Purposive sampling to ensure participants can speak to the research question (eg, critical case sampling)
Dense description of research methods
Sufficient quantity (eg, thick) and quality (eg, rich) of description in the article and
Each transcript was coded independently by at least 2 members of the coding team, with codes compared and consensus formed by the entire coding team
Qualitative software (NVivo) was used to maintain a clear audit trail
Discussion of final results and implications by the research team with a focus on ensuring researcher neutrality
A senior member of the team independently coded a representative sample of transcripts (33%) and compared the findings with the preliminary results from the coding team
Nine persons with HIV/AIDS and T2DM were interviewed for this study. Interviews lasted an average of 36.7 minutes (SD = 13). Participants reported the following racial/ethnic identities: Black (n = 4), White (n = 3), and Latinx (n = 2). Their mean age was 54.8 years (SD = 5.7), and the majority were men (n = 6). All participants had been diagnosed with HIV/AIDS for more than 20 years, and all had been diagnosed with diabetes subsequently to HIV/AIDS. None of the participants had been diagnosed with COVID-19, exhibited symptoms, or had been tested for COVID-19 at the time of the interviews.
Themes and categories
Five themes emerged from the analysis: (1) adjusting to living with HIV/AIDS and diabetes impacts beliefs about COVID-19 risk; (2) COVID-19 information seeking and accuracy; (3) trade-offs in self-managing multiple chronic conditions; (4) balance between safety, relationships, and the society at large; and (5) discordant perceptions and actions. Each of the themes is described in the following text.
Theme 1: Adjusting to living with HIV/AIDS and diabetes impacts Beliefs about COVID-19 risk
Participants described how having HIV/AIDS impacted their thinking and perceptions of risk regarding COVID-19. They drew parallels between their experiences of being diagnosed and living with HIV/AIDS and the emergence of COVID-19. Participant 1 shared that having HIV/AIDS had already prepared them to reflect on their mortality.
Even if I think—oh my God; I've got COVID-19, and I'm gonna die. Been there, done that ... this isn't my first rodeo at the deadly virus convention ... COVID-19—it's nature, you know? Sometimes a big storm blows through and the trees drop a few dead branches. Sometimes, nature decides to clear out some of the dead branches.
Participants considered SARS-CoV-2 to be like the early years of HIV. They recognized that the world was dealing with a novel, relatively unknown, and potentially deadly disease that can increase panic. Participant 4 reported that being diagnosed with HIV/AIDS in the early 2000s, when health care providers had learned about it and there were clearer treatment options for it, helped him feel less panic and fatalism than he might have experienced if he were diagnosed 10 years earlier. He compared that with the newness of COVID-19 and how little was known about it.
And I think that ... with the HIV, I always have thought that if I'd have known about this before 2003, then I may not have handled things so well just because the medication was not as good. I think a lot of people, when they got the news in the ‘80s and ‘90s, just gave up. And with the COVID thing too, I think it's the same. Once you realize what it is, then people panic.
About half of the participants believed they were at a higher risk for contracting COVID-19 and having poor outcomes due to their HIV/AIDS diagnosis, more so than their diabetes.
At first, it was harder than I thought it would be, but I get it. And I kinda miss the interaction working with the public. I know it's gonna change now with everything going on. I had an in-person face-to-face [job] working with customers and that was at 40 hours a week. So, working 100 percent of the time at home it's been different because I don't go out because of my HIV, not because of the diabetes. And I know that I'm one of the high factors, and I don't wanna be catching the virus. (Participant 5)
Others did not believe they were at a higher risk for COVID-19, because both their HIV/AIDS and diabetes were well controlled. Several participants were more concerned about the risk for older adults than themselves, with many specifically citing concerns for their aging parents.
I don't think [my risk is different compared to somebody else's]. I feel that I'm in really good health, so I had most of it under control.... The fact that my last doctor's visit, which was on the phone, he said, “Have you any symptoms of diabetes, at all?” So, I don't know if he remembered that I was diabetic or not, but he was just going by my blood reports. So, that was it. And that's been that way for a while. Most worried, my parents are 88, and that's what I was most worried about—the symptoms, that they would not recover. That held deeply on my mind. (Participant 19)
Theme 2: COVID-19 information seeking and accuracy
Participants accessed information about COVID-19 from many different sources and media. A few participants had difficulty assessing their level of COVID-19 risk because they were not confident about the information they were getting from the news and public officials. Participant 3 said,
I really don't know whether I am more at risk than somebody else or not. Like I say, you hear all this misinformation on the TV about what is going on or what's not going on. You really don't know what to think until you have it or something like that ... I don't know what to trust because our President say one thing, and then he turn right around and say something else. The governor will tell you one thing, and then he turn around and recants what he said. So, who are we supposed to believe?
Furthermore, many participants stated that they sought information only from sources that they trusted prior to COVID-19. They had confidence in the information shared by health care providers with whom they had long-standing relationships and from their accustomed news outlets.
The participants trusted the information they received from their health care providers. During a telemedicine visit, participant 6 was able to ask their HIV provider specific questions about what would happen during treatment of COVID-19.
I love all my doctors. They care so much about us. He just wanted to make sure I was okay. And I was, “Yeah, I am.” He was trying to calm me down ‘cause this was back when I was freaking. I was worried about that drug thing, people getting put on the ventilator. He was tellin’ me, “They'll put you to sleep. You're not gonna know you're on it.” I'm like, “Yeah, I'm not gonna ever wake up.” But, yeah, I've talked to him. (Participant 6)
Participant 4 described their trust in a local news source because it was well known to them and the information presented was consistent with their own beliefs.
So, I get most of it through [a local TV station] from here in town. Even though I work for (the city) and have been in some departments that are under investigation and they're throwing messes towards, still I think they do a good job of covering the news. And they don't sugar-coat things, and they just say what's up. And I would say that other news agencies are probably just as good, but I've just been watching [local TV station] for so long, I just feel like those anchors, the weather people that we ... I'm friends with some of them on Facebook. I chat with them. It feels like we're friends, to a certain extent. So, I believe what they're telling me. And I have not run across anything yet that I disagreed, as far as they all seem to be very pro-mask and pro-taking steps to be safe, as well, which is important. So, as long as they're preaching the same thing I'm thinking, then I really appreciate that. It cements my values and my thinking in that it's the right way to be thinking.
Many participants reported concerns about people, especially family members, and some news outlets giving contradictory COVID-19 information. Participant 4 described having to manage family members' discrepant information about how to keep his father safe.
My brother is very much conservative, right-wing, born-again Christian guy and that's great. That's the way I was brought up too, so I understand that. But he had a talk with me one day about how he doesn't feel like the COVID thing is that important. The majority of people who get it recover, so it's just like any other sickness. And I said, “Well, I get that. And, you're still of middle-age, and you're healthy, and you have no immune system problems.” And I said, “But my problem with you is that you're by Dad, who's 80 and you're giving him the same information.” And I said, “I don't think that's fair because Dad is in a higher-risk category, especially because now that Mom's died, he's very social.” So, I just asked him to be more considerate and more responsible in what he's saying to our dad.
A small number of participants who trusted their health care provider stated that they tried to make sense of conflicting information by triangulating information sources and checking the accuracy of information with experts.
I just read a lot about it, and I'm an avid news watcher, CNN, so I watch the news all the time. If there's something that I'm kind of like not so sure about or kind of hmmm, there's a lot of doctors here [at my job]. I can always talk to them, ask them, and they give me their opinion or their advice. I use that a lot, and I'm kind of glad I work in a medical facility because there are things a lot of times that happens. I Google something and then I'll take it to them and say, “Hey, I Googled this and I think something like this is happening to me?” They kind of sense it and they'll show it; no, it's not that. It's good to have that access here ... I've been working with them quite a while, so we've kind of established a relationship. I kind of fuss at them. I can ask them questions that I normally would feel embarrassed about asking my own doctor. Hmmm, that might be a dumb question. I'll ask them, and they'll be like, ‘No, that's not dumb.” It works out real well for me. (Participant 18)
Theme 3: Trade-offs in self-Managing multiple chronic conditions
Almost all participants reported changes they made to their self-management routines due to the pandemic. Many changes centered on their diabetes management, including behaviors related to healthy eating, staying active, and blood glucose monitoring. In addition, all participants reported changes in their workplace as a result of COVID-19; many transitioned to working remotely. Some participants reported that working remotely increased their time at home and allowed them to improve some diabetes self-management behaviors such as checking their glucose or using their medications more effectively.
One thing about being at home so much is I get to test [my blood glucose] more often, right? So, really, it's easier to keep track of. Even when I was garbage eating, a little more insulin. But, I mean, you just keep track of it better. It's not like I'm out somewhere and don't have my [blood glucose checking] kit with me ‘cause I hate dragging that around. But when you're home all the time, there's no excuse to not test and then give yourself a shot [of insulin] if you need it. (Participant 4)
However, all participants spoke about the negative impacts on their eating and exercise habits from COVID-19 and working from home. Some participants noted an increase in how much they snacked between meals and surmised that snacking was a way to ease the boredom of isolation and provide comfort. “I've gained some weight only because I find myself snacking on carbs or chips” (participant 5).
People with both HIV/AIDS and diabetes must keep appointments with several specialists. All participants experienced telemedicine since the start of COVID-19. They liked not having to take the time or trouble to travel to appointments but missed the physical contact and personal connection of in-person visits.
I just had a doctor's appointment, which we did like this [videoconference], and it went well. I'm kind of open with that in the future instead of having to drive there all the time. It was quicker, it was more convenient, so keep this going on.... It just cuts down on office visits and time. I was kind of [not] optimistic at first, like oh how is this going to work, but it worked out much better than what I had anticipated. I hope and I'm good with using it going forward. Only problem is we don't touch each other. (Participant 8)
Theme 4: Balance between safety, relationships, and the society at large
All the participants stated they were practicing physical distancing and following the city government's COVID-19 regulations and restrictions. Several participants described the mental toll this was taking and characterized their feelings as going through peaks and troughs. Participant 5 was partnered with a man from Mexico and expressed dismay that they were not going to be able to see each other for a long time due to the COVID-19 restrictions at the US-Mexico border.
It's been a battle. It's been an up and down issue, just because being quarantined, and because we're 100 percent working from home now. So, it's a bit of a challenge not to have good days and bad days, just a roller coaster some days ... I don't know when we'll be able to see each other until this whole thing passes by. So, he was kinda upset, kinda sad because we're separated at this point.
However, some of the participants were already accustomed to living an isolated life because they had not disclosed their HIV-positive status to many people. These participants reported little to no change in their lives even with the COVID-19 restrictions. Participant 3 described how they had been living a solitary lifestyle for some time so that the restrictions did not disrupt their daily routine.
I don't really change things because I don't do too much. I mean I'm usually around home anyway. And while I'm around home, no, I don't wear a mask or something like that because I'm at home. And the best I can do is walk out to the street, but I don't be around anybody. I usually be by myself or maybe a couple of other residents here. But they don't go anywhere. So, we all right here confined together.... Whether Texas was open or closed, it was about the same to me because I never went anywhere. And I never go and do anything. So, it's a regular day.
Participants also described the different rituals they had developed for staying safe from COVID-19, which centered on making less frequent shopping trips, cleaning practices, and wearing a mask.
Bigger shopping, like one time a month. And when I go in there, I do what I need to, I get out of the stores. When I come home, I separate everything and I disinfect everything with the spray. If it has a chemical—in a can or in a sealed bag, or some things I just wash and I dry everything and I put everything up. And my sister was going to make some masks right at the beginning, but she never did, so then, I made my own. I never went out without one. I don't think—felt it was advised to have one. Once in a while, I'll be in my car and I'll forget that I don't have it on when I'm driving in my car. I clean it all the time. (Participant 9)
Most participants reported how other people's behaviors and lack of safety negatively impacted their own health. Participant 2 said, “Everybody is not doing the safe thing. Everybody's not wearing masks.” Participant 4 pointed out the tensions between having personal freedom and participating in safe practices for the benefit of public health and the greater good.
I look at the news reports and see all these idiots out there with no masks, and I just think the masks are gonna be the thing that—and the hand sanitizer too—but especially the masks. I mean, really, with this COVID stuff, that's how it enters into the body is through your respiratory. It's your face. It's your mask. So, if it will keep you from touching your face. Or, I mean, I really think we can get numbers down if we make these masks mandatory.... You know, freedoms are great unless you're dying from the freedoms you're given. So, I think if we have to take precautions then in order to be free, we need to live up to those precautions.
Other historical events such as social unrest, protests for racial and civil rights, and widespread economic downturn unfolded during COVID-19 regulations and restrictions, prompting several participants to discuss how these events affected their own lives. Participant 4 was particularly concerned about the impact of the restrictions on the economy and the difficulty of balancing COVID-19–related health against economic health.
You know, now that we're having this spike of and return of it, it's really difficult to—well, the one thing I think is gonna happen is that we're not gonna see everything close down again. I don't think that governments can afford to watch the economy tank like that. It's very difficult to put everybody at risk with a bad economy, as opposed to a select part of the population with the sickness that you could get better from. So, for us to be closed as long as we were was one thing. But I don't think that—It may back up a couple of steps, but I don't think we're gonna see everything close down like it did. I just don't know that the economy can handle it because if we all become bankrupt as a nation, then it doesn't matter what's out there. It's gonna be horrible for everybody.
Participant 2 spoke about the health disparities in COVID-19 cases and deaths experienced by African Americans and the impact of the protests on this same community.
Just seeing the people with the protests and seeing the people that have ... I mean, looking at the news you get all of these numbers [of COVID cases] and you can't imagine all these people have gotten sick and they are still trying to open the state back up. It's kind of leery to me. It's like something isn't right and then why is it more black people dying? Is it because they can't get medication, or they can't get tested and it's too late after they get tested? It's just leery.
Theme 5: Discordant perceptions and actions
Early in each interview, every participant reported they vigilantly practiced physical distancing and isolation, consistent with COVID-19 restrictions and regulations that were in place at the time of the interviews. However, as the interviews progressed, most participants let on that they visited with groups of friends from outside their households in person or that they attended in-person meetings or events. Some talked about plans to resume their jobs in person where they would come into contact with many people. While some of these behaviors were not outside the regulations and restrictions for small gatherings with masks, they did not align with the participants' earlier statements about having been completely isolated and quarantined from nonhousehold members. Participant 2 reported they were staying in isolation until they got a vaccine (expected to be at least 7 months in the future), but then talked about returning to in-person work before being vaccinated to sell concessions at large sports events.
Yeah, I'm stuck there until there's a vaccine. So, it doesn't matter what anybody says in government, I know what is being recommended for somebody with my underlying conditions and basically that's what I'm following or will continue to follow. Like I said, I am gonna go to work because I'm so excited.
Participant 1 initially talked about meeting with friends over Zoom, but then mentioned meeting with friends in person and in a manner that was not socially distant. Furthermore, participant 1 stated that although they were in the highest-risk category for severe COVID-19, they were going to leave isolation to volunteer with an organization when it opened again.
It [Zoom] was just a fun way to socialize, but not really be exposed in any way. So, anyway, yes, I went out to lunch. And, yes, I'm gonna start volunteering again but in an extremely controlled environment because I work in a food bank. And we're always gloved and sterilizing everything because of sanitary handling and cross-contamination. So, aside from putting a mask on to be in there, and they're limiting the number of people in the building and number of people in the kitchen and food bank area where I work.... So, whatever any government official says, I realize that I have diabetes. I have kidney disease. I've lost kidney function. I have advanced liver scarring, and I have HIV, even though it's undetectable at the moment. Once it breaks, it breaks good, usually. I'm still in the self-isolation category.
Participant 4 had talked about staying home until the vaccine arrived; however, they described having recently shared car rides and eating inside at restaurants with friends who were not members of their household.
It's weird ‘cause my friends here in Austin, we would go to dinner probably once a month or so, four or five of us. And now can't do that. I go out with one or two recently, but not very often. We've only been to two restaurants in the past three weeks, and one of them was in Lockhart [33 miles outside Austin] ‘cause there was a Mexican restaurant that I had went to before all this happened, which was really good. So, when they started opening restaurants again, especially with the lower numbers in Lockhart and that whole county, I was like, “Let's go eat there. And if there's a big spike, we're gonna know it's us that brought it. So, let's hope that doesn't happen.” Yeah, so when they finally opened up restaurants again and stuff, I said, “You guys, let's take a daytrip. Get out of town. We are gonna just be with each other pretty much in the car until we get there and have lunch. And then we're gonna come back home.” So, it's a pretty safe trip, and we haven't been together. There were four of us who went, and we had a nice time.
In-depth qualitative interviews were conducted with 9 people with the dual diagnoses of HIV/AIDS and T2DM to ask about their experiences with disease self-management during the early months of the COVID-19 pandemic. In contrast to the interviews conducted the year prior as part of the parent study, interviews for this study were conducted via videoconferencing or phone and the average interview time was shorter by about 30 minutes. Shorter interviews may have been due to a feeling of disconnect by the virtual interview, difficulties with technology (eg, weak internet or cell signals causing poor sound or video quality), or due to the focused scope of the interview that came after 2 more in-depth interviews in which detailed histories were already collected. The 2 participants with the shortest interview times were unfamiliar with the specific teleconferencing application provided by the university, which may have been a barrier to the participants. The teleconferencing platform was required by the university because it was the only HIPAA-compliant platform available at that time, when “Zoom-bombing” was a concern. Other videoconferencing applications that were more familiar to participants (eg, FaceTime) were not an option for this study.
In general, the participants described feeling like they already had insight into how to deal with aspects of COVID-19 as a result of their experiences living with HIV/AIDS. They spoke about the difficulties they had in discerning the accuracy of the information they received about COVID-19 and reported that they tended to seek out information from their long-standing, trusted sources, which was reminiscent of the lack of information or misinformation in the early days of the HIV epidemic. Most participants described how specific aspects of their diabetes self-management were suffering, such as healthy eating and exercise, but that other aspects, such as blood glucose monitoring and taking medications, had improved during the time of quarantining at home. While participants said they adhered to physical distancing, many also reported visiting with friends in person, indoors, without masks. This exploratory study illustrates issues and sentiments that were unique to people living with HIV/AIDS and diabetes and also universal to people diagnosed with multiple chronic conditions and, in some ways, to everyone navigating the early stages of the COVID-19 pandemic.
How living with HIV/AIDS and diabetes impacted COVID-19 risk beliefs
Participants voiced a sense of resignation regarding the possibility of contracting COVID-19 that they described in the context of already having significant experience with a “deadly virus,” meaning HIV. Interestingly, participants mentioned expectations of getting sick with COVID-19 in relation to having HIV/AIDS but not their diabetes, although feelings of fatalism about diabetes have been well documented. Feelings of fatalism are fairly common among people of racial/ethnic minority groups,22,23 are frequently linked to distress and depression,24 and to infrequent or inconsistent self-management behaviors, poorer glycemic control, and worse disease trajectories.25 Feelings of fatalism have also been well documented for people with HIV/AIDS, especially among Latino and Black communities.22,23 The participants might have expected to acquire COVID-19 because it is caused by a novel and potentially deadly virus, similar to HIV, whereas T2DM is not a communicable disease, progresses more slowly, and is not associated with major changes in public behavior or panic. For people who have experienced the reality of having HIV/AIDS, especially in the 1990s before HIV/AIDS was considered a chronic condition, COVID-19 seemed to cue strong feelings of fatalism related to HIV/AIDS.
Jimenez et al26 recently reported that people who associated COVID-19 with death were less likely to report intentions to perform preventive behaviors such as physical distancing and hand washing. This dissonance between fear of getting a disease and lack of prevention is consistent with fatalism. Furthermore, Jimenez et al26 reported that people identifying as Black were particularly likely to associate COVID-19 with death. While many of the participants in this study expressed fatalistic beliefs about COVID-19, none of them described being unlikely to take preventive action and all participants stated they were attempting to follow current regulations. However, some also engaged in somewhat riskier behavior of gathering indoors with nonfamily members, going to the gym, or eating inside a restaurant. The participants, who had all been diagnosed with HIV/AIDS for decades, may have processed their fatalistic feelings about COVID-19, either subconsciously or with intention.
Many participants identified a collective belief that their HIV/AIDS diagnosis conferred them with a higher risk of getting COVID-19 and suffering with worse COVID-19 outcomes, but few participants cited their diabetes as placing them at significant risk. This is notable because T2DM actually confers greater risks related to COVID-19 than HIV/AIDS, which, when under control of antiretroviral therapy, adds less risk for negative outcomes than diabetes.27 People with diabetes have a 3-fold higher mortality rate from COVID-19 than those without diabetes.5,28 COVID-19 also contributes to worsening glucose levels beyond what is typically caused by the stress of a critical illness because the SARS-CoV-2 virus damages the pancreatic beta-cells.29 In contrast, the Hing et al30 study of 75 adults' experiences of living with HIV/AIDS and hypertension found that most participants were equally concerned about hypertension and HIV/AIDS because they were unable to predict consequences of hypertension in comparison with HIV/AIDS. Some participants in this study were more concerned about their older parents or did not identify themselves as having at higher risk than anyone else. People who are unable to gauge their own risk profiles may face challenges when implementing COVID-19 precautions for themselves.
COVID-19 information seeking and accuracy
From the onset of the COVID-19 pandemic, information about the virus and best practices related to safety precautions confused many people. For example, recommendations to wear masks and how to wear them changed often. Initially in the United States, the public was officially told not to wear masks. However, that recommendation quickly changed and many states or municipalities implemented mandates that people wear masks when in public. The changing information and restrictive policies led to a public backlash in some areas because people did not understand that the initial guidance was about saving masks for health care providers, not about their efficacy.31 Furthermore, the CDC later recommended wearing 2 masks instead of one.32 Given the frequently changing information, it is not surprising that participants in the present study had difficulty parsing and acquiring health information—often searching for information until they found a source that confirmed their already formed personal beliefs.
Clear, succinct, accurate health messaging from governmental agencies and shared by trusted local news sources would allow people to take appropriate precautions against COVID-19. For example, information about COVID-19 vaccines should be transparent about how the vaccines were developed, present facts and risks clearly without moralizing, and use modern communication channels such as social media to spread messages.33 Effective messaging in HIV campaigns has included intensive peer counseling delivered in community settings.34 Some participants in the present purposefully limited their exposure to news in order to decrease anxiety. As with the HIV information campaigns, COVID-19 information should be disseminated via focused community outreach with information provided by trained peers and neighbors, or community or religious leaders, to improve uptake of preventive measures.
Multiple chronic conditions and self-management trade-offs
Participants described better practice of some self-management behaviors during the pandemic, whereas other self-management behaviors became worse. The majority of participants reported snacking more while they were home out of boredom or eating more calorie-dense fast foods due to the convenience and perceived safety of the drive through pickup. Eating as a way of emotional coping has been well documented. People tend to eat high calorie food during times of stress and high negative emotions.35 Emotional eating is a challenge for people with diabetes who must maintain a balanced and nutritious diet to keep blood glucose levels stable.36 Some participants talked about not being able to go to the gym and being less physically active due to working from home. A recent study by Lin et al37 examined the effect of shelter-in-place (SIP) orders on weight in 269 adults and found that every month spent sheltering resulted in approximately 1.5 lb of weight gain. In contrast, Brand et al38 reported that people who rarely exercised before COVID-19 increased their exercise during COVID-19, although the increase in exercise may not have been adequate to counteract the caloric intake. It is highly likely that people may experience weight gain due to the COVID-19 restrictions and their changes in lifestyle and self-management, which may negatively impact their glucose control and blood pressure.39,40 Health care providers should note weight changes, but rather than stigmatizing their patients for gains that were relatively universal during the pandemic, health care providers should help patients return to positive prepandemic habits and provide individualized care and mental health resources.41
Some participants were able to check their blood glucose values more regularly when working from home, when not hindered by barriers, such as lack of breaks at work, feelings of stigma for asking for a break to check had been removed. People with a dual diagnosis of HIV/AIDS and diabetes were already challenged by feelings of additional stigma because their blood is “dirty” or infectious, leading them to not feel comfortable testing their glucose outside of their homes, and the COVID-19 pandemic may have added to that feeling.42 The privacy of working from home allowed participants to test their glucose levels more frequently and consistently, consistent with their preferences to routinely check their glucose and reinforcing the literature pointing to the numerous workplace barriers that interfere with glucose self-monitoring. As the pandemic begins to resolve, health care providers must help patients maintain the positive self-management habits fostered, in part, by COVID-19 restrictions. Patients and their advocates can promote workplace policies that support healthy self-management behaviors, such as glucose self-monitoring and physical activity breaks, by providing access to private spaces for glucose checks and regular breaks and places to be physically active.
Balance between safety, relationships, and economics
The participants not only reported adhering to safety protocols but also adapted others to maintain relationships. Concerns about COVID-19 transmission led participants to limit their interactions and to engage in thorough and systematic cleaning routines, especially at the beginning of the pandemic. Taking such precautions strained personal and familial relationships, especially when there was a disagreement among friends and family about perceived COVID-19 risk. Similar findings have been reported in a study of family discord (742 co-parents) in the United States, which found that increased COVID-19 stress was associated with psychological inflexibility and family discord.43
Many participants reported they were “homebodies” before the pandemic; some were already self-isolated because of their health, physical limitations, or perceptions of stigma about their HIV/AIDS or diabetes. It is common that people with multiple chronic conditions, including HIV/AIDS, feel stigma that undermines their physical and psychological well-being.44 Feeling stigmatized has persisted despite educational campaigns for the general public to increase knowledge about HIV/AIDS.45 During the pandemic, feelings of stigma may have increased because of fears of an unknown emerging communicable disease such as COVID-19. Although no participants reported absolute isolation, participants kept in physical contact with close friends and family members often without precautions such as masks. This level of risk outweighed the benefit of social support for the participants. The participants were keenly aware of the impact of others' behaviors on their own safety. As COVID-19 is a highly communicable virus disease, they were dependent on community members to take preventive measures. Rates of COVID-19 were high in the areas of town where the participants lived.
During the time of the interviews, there were local protests in response to the killing of George Floyd and other people of color. There was a confluence of community stress and civil unrest in a population that is already negatively impacted by racism. At the time of the interviews, there were large demonstrations against racism and many feared the protesters would be at risk of acquiring COVID-19.46 Areas with high rates of structural racism are associated with health disparities, including disproportionately high rates of COVID-19.47 Interventions to disrupt racism include addressing multiple sectors, for example, housing, economic and justice reform, health care policies (eg, COVID-19 testing), and training health care providers and first responders.48
Discordance of perceptions and actions
Participants reported knowledge of and strict adherence to local pandemic guidelines. However, this did not result in all their described actions aligning with their stated perceptions about their risk behaviors. For example, participants would state they were high-risk individuals but ready to return to work in person. Participants most often described leaving isolation to socialize, although they did so sparingly and usually with masks. Since the interviews, there have been reports that COVID-19 “bubbles”—a group of people who mutually agree to semi-isolate together during COVID-19 isolation restrictions—are not as safe as people believed them to be because there are more interactions within a bubble than people realized; therefore, interacting with people within bubbles actually confers a higher risk.49 Despite the efforts to vaccinate the general public, which began months after the interviews were conducted, it will be important to continue research on the safety of COVID-19 bubbles, which will likely continue to be important until communities attain herd immunity and children become vaccinated. Continued education regarding COVID-19 safety and risk factors that encourage and facilitate vaccinations is needed to halt COVID-19 transmission. Instructions and worksheets are available on which people can map out bubbles that illustrate social contacts and potentially help people manage their exposure.50
Even with clear and consistent information, health care providers and public health officials must recognize that people's perceptions of their behaviors do not always align with their actions. In the best of times, people often struggle with eating healthy foods, getting enough physical activity, and taking precautions such as wearing seat belts or helmets or using condoms. The COVID-19 pandemic added a significant layer of confusion, anxiety, and stress that likely contributed to more erratic self-management. Rather than expect the majority of people to adhere perfectly to guidelines and recommendations, health care providers should recognize the additional strain the pandemic placed on disease self-management.
The COVID-19 pandemic and resulting restrictions changed everyone's lifestyle behaviors, especially for people with the dual diagnosis of HIV/AIDS and diabetes. For this higher-risk group, by examining their perceptions and beliefs related to COVID-19 and learning about alterations in their self-management, highlighting important insights into how to optimize their self-management. Furthermore, these lessons learned may be relevant for other groups at a higher risk for COVID-19.
1. Cucinotta D, Vanelli M. WHO declares COVID-19 a pandemic. Acta Biomed. 2020;91(1):157–160. doi:10.23750/abm.v91i1.9397
2. Texas Department of State Health Services. Texas COVID-19 data. Accessed October 12, 2021. https://dshs.texas.gov/coronavirus/additionaldata.aspx
5. Clark A, Jit M, Warren-Gash C, et al. Global, regional, and national estimates of the population at increased risk of severe COVID-19 due to underlying health conditions in 2020: a modelling study. Lancet Glob Health. 2020;8(8):e1003–e1017. doi:10.1016/S2214-109X(20)30264-3
6. Chung MK, Zidar DA, Bristow MR, et al. COVID-19 and cardiovascular disease: from bench to bedside. Circ Res. 2021;128(8):1214–1236. doi:10.1161/CIRCRESAHA.121.317997
7. Moderbacher CR, Ramirez SI, Dan JM, et al. Antigen-specific adaptive immunity to SARS-CoV-2 in acute COVID-19 and associations with age and disease severity. Cell. 2020;183(4):996–1012.e19. doi:10.1016/j.cell.2020.09.038
8. CDC COVID-19 Response Team; Chow N, Fleming-Dutra K, et al. Preliminary estimates of the prevalence of selected underlying health conditions among patients with coronavirus disease 2019—United States, February 12-March 28, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(13):382–386. doi:10.15585/mmwr.mm6913e2
9. Tesoriero JM, Swain C-AE, Pierce JL, et al. COVID-19 outcomes among persons living with or without diagnosed HIV infection in New York State. JAMA Netw Open. 2021;4(2):e2037069. doi:10.1001/jamanetworkopen.2020.37069
10. Sarkar S, Brown TT. Diabetes in people with HIV. Curr Diab Rep. 2021;21(5):1–8.
11. Falasca F, Di Carlo D, De Vito C, et al. Evaluation of HIV-DNA and inflammatory markers in HIV-infected individuals with different viral load patterns. BMC Infect Dis. 2017;17(1):581. doi:10.1186/s12879-017-2676-2
12. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2020. Centers for Disease Control and Prevention, US Department of Health and Human Services; 2020:12–15.
13. American Diabetes Association. 3. Foundations of care and comprehensive medical evaluation. Diabetes Care. 2016;39(suppl 1):S23–S35. doi:10.2337/dc16-S006
14. Strawbridge LM, Lloyd JT, Meadow A, Riley GF, Howell BL. One-year outcomes of diabetes self-management
training among Medicare beneficiaries newly diagnosed with diabetes. Med Care. 2017;55(4):391–397. doi:10.1097/MLR.0000000000000653
15. Beck J, Greenwood DA, Blanton L, et al. 2017 National standards for diabetes self-management
education and support. Diabetes Educ. 2018;44(1):35–50. doi:10.1177/0145721717722968
16. Buttorff C, Ruder T, Bauman M. Multiple Chronic Conditions in the United States. Vol 10. RAND Corporation; 2017.
17. Banerjee M, Chakraborty S, Pal R. Diabetes self-management
amid COVID-19 pandemic. Diabetes Metab Syndr. 2020;14(4):351–354. doi:10.1016/j.dsx.2020.04.013
18. Brown SA, García AA, Brown A, et al. Biobehavioral determinants of glycemic control in type 2 diabetes: a systematic review and meta-analysis. Patient Educ Couns. 2016;99(10):1558–1567. doi:10.1016/j.pec.2016.03.020
19. George S, Duran N, Norris K. A systematic review of barriers and facilitators to minority research participation among African Americans, Latinos, Asian Americans, and Pacific Islanders. Am J Public Health. 2014;104(2):e16–e31. doi:10.2105/AJPH.2013.301706
20. Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–1288. doi:10.1177/1049732305276687
21. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105–112. doi:10.1016/j.nedt.2003.10.001
22. Kissinger P, Kovacs S, Anderson-Smits C, et al. Patterns and predictors of HIV/STI risk among Latino migrant men in a new receiving community. AIDS Behav. 2012;16(1):199–213. doi:10.1007/s10461-011-9945-7
23. Craig-Kuhn MC, Schmidt N, Lederer A, et al. Sex education and STI fatalism, testing and infection among young African American men who have sex with women. Sex Educ. 2021;21(4):404–416. doi:10.1080/14681811.2020.1809369
24. Shahid F, Beshai S, Del Rosario N. Fatalism and depressive symptoms: active and passive forms of fatalism differentially predict depression. J Relig Health. 2020;59(6):3211–3226. doi:10.1007/s10943-020-01024-5
25. Walker RJ, Smalls BL, Hernandez-Tejada MA, Campbell JA, Davis KS, Egede LE. Effect of diabetes fatalism on medication adherence and self-care behaviors in adults with diabetes. Gen Hosp Psychiatry. 2012;34(6):598–603. doi:10.1016/j.genhosppsych.2012.07.005
26. Jimenez T, Restar A, Helm PJ, Cross RI, Barath D, Arndt J. Fatalism in the context of COVID-19: perceiving coronavirus as a death sentence predicts reluctance to perform recommended preventive behaviors. SSM Popul Health. 2020;11:100615. doi:10.1016/j.ssmph.2020.100615
27. Mirzaei H, McFarland W, Karamouzian M, Sharifi H. COVID-19 among people living with HIV: a systematic review. AIDS Behav. 2020:1–8. doi:10.1007/s10461-020-02983-2
28. Gregory JM, Slaughter JC, Duffus SH, et al. COVID-19 severity is tripled in the diabetes community: a prospective analysis of the pandemic's impact in type 1 and type 2 diabetes. Diabetes Care. 2021;44(2):526–532. doi:10.2337/dc20-2260
29. Pal R, Bhadada SK. COVID-19 and diabetes mellitus: an unholy interaction of two pandemics. Diabetes Metab Syndr. 2020;14(4):513–517. doi:10.1016/j.dsx.2020.04.049
30. Hing M, Hoffman RM, Seleman J, Chibwana F, Kahn D, Moucheraud C. “Blood pressure can kill you tomorrow, but HIV gives you time”: illness perceptions and treatment experiences among Malawian individuals living with HIV and hypertension. Health Policy Plan. 2019;34(suppl 2):ii36–ii44. doi:10.1093/heapol/czz112
31. World Health Organization. Advice on the Use of Masks in the Context of COVID-19: Interim Guidance, 6 April 2020. World Health Organization; 2020.
32. Runde DP, Harland KK, Van Heukelom P, Faine B, O'Shaughnessy P, Mohr NM. The “double eights mask brace” improves the fit and protection of a basic surgical mask amidst COVID-19 pandemic. J Am Coll Emerg Physicians Open. 2020;2(1):e12335. doi:10.1002/emp2.12335
33. Cohen AF, van Gerven J, Burgos JG, et al. COVID-19 vaccines: the importance of transparency and fact-based education. Br J Clin Pharmacol. 2020;86(11):2107–2110. doi:10.1111/bcp.14581.
34. Lorenc T, Marrero-Guillamón I, Aggleton P, et al. Promoting the uptake of HIV testing among men who have sex with men: systematic review of effectiveness and cost-effectiveness. Sex Transm Infect. 2011;87(4):272–278. doi:10.1136/sti.2010.048280
35. Janet Tomiyama A, Finch LE, Cummings JR. Did that brownie do its job? Stress, eating, and the biobehavioral effects of comfort food. In: Emerging Trends in the Social and Behavioral Sciences: An Interdisciplinary, Searchable, and Linkable Resource. Wiley; 2015:1–15.
36. Evert AB, Dennison M, Gardner CD, et al. Nutrition therapy for adults with diabetes or prediabetes: a consensus report. Diabetes Care. 2019;42(5):731–754. doi:10.2337/dci19-0014
37. Lin AL, Vittinghoff E, Olgin JE, Pletcher MJ, Marcus GM. Body weight changes during pandemic-related shelter-in-place in a longitudinal cohort study. JAMA Netw Open. 2021;4(3):e212536. doi:10.1001/jamanetworkopen.2021.2536
38. Brand R, Timme S, Nosrat S. When pandemic hits: exercise frequency and subjective well-being during COVID-19 pandemic. Front Psychol. 2020;11:570567. doi:10.3389/fpsyg.2020.570567
39. Reisin E, Abel R, Modan M, Silverberg DS, Eliahou HE, Modan B. Effect of weight loss without salt restriction on the reduction of blood pressure in overweight hypertensive patients. N Engl J Med. 1978;298(1):1–6. doi:10.1056/NEJM197801052980101
40. Annesi JJ, Johnson PH. Relative effects of reduced weight and increased physical activity on hemoglobin A1c
: suggestions for behavioral treatments. Int J Clin Health Psychol. 2013;13(2):167–170. doi:10.1016/S1697-2600(13)70020-6
41. American Diabetes Association. 5. Facilitating behavior change and well-being to improve health outcomes: standards of medical care in diabetes—2020. Diabetes Care. 2020;43(suppl 1):S48–S65. doi:10.2337/dc20-S005
42. Navis JP, Leelarathna L, Mubita W, et al. Impact of COVID-19 lockdown on flash and real-time glucose sensor users with type 1 diabetes in England. Acta Diabetol. 2021;58(2):231–237. doi:10.1007/s00592-020-01614-5
43. Daks JS, Peltz JS, Rogge RD. Psychological flexibility and inflexibility as sources of resiliency and risk during a pandemic: modeling the cascade of COVID-19 stress on family systems with a contextual behavioral science lens. J Contextual Behav Sci. 2020;18:16–27. doi:10.1016/j.jcbs.2020.08.003
44. Idemudia ES, Olasupo MO, Modibo MW. Stigma and chronic illness: a comparative study of people living with HIV and/or AIDS and people living with hypertension in Limpopo Province, South Africa. Curationis. 2018;41(1):1879. doi:10.4102/curationis.v41i1.1879
45. Maughan-Brown B. Stigma rises despite antiretroviral roll-out: a longitudinal analysis in South Africa. Soc Sci Med. 2010;70(3):368–374. doi:10.1016/j.socscimed.2009.09.041
46. Walters E. “I didn't care if I was exposed to COVID”: protesters' anger outweighed their fear of getting sick. The Texas Tribune. June 2, 2020. Accessed October 12, 2021. https://www.texastribune.org/2020/06/02/texas-protests-george-floyd-coronavirus
47. Tan SB, DeSouza P, Raifman M. Structural racism and COVID-19 in the USA: a county-level empirical analysis. J Racial Ethn Health Disparities. 2021:1–11. doi:10.1007/s40615-020-00948-8
48. Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017;389(10077):1453–1463. doi:10.1016/S0140-6736(17)30569-X
49. Gutman R. Sorry to burst your quarantine bubble. The Atlantic. December 2, 2020. Accessed November 30, 2021. https://www.theatlantic.com/health/archive/2020/11/pandemic-pod-bubble-concept-creep/617207/
50. Fairfield Medical Center. COVID-19: how big is your bubble? Accessed February 22, 2021. https://www.fmchealth.org/articles/covid-19/covid-19-how-big-is-your-bubble