Dangerous crossroads

Since the onset of the COVID-19 pandemic, some people aging with HIV have encountered challenging, harsh, and even dangerous medical, social, and emotional challenges. Especially among individuals who also misuse substances, the toll has been overwhelming, with rates of drug use, overdoses, and fatalities reaching new heights.

Drug and alcohol users find themselves at increased medical risk for the novel coronavirus. For example, those who vape or smoke tobacco or marijuana heighten their vulnerability to the effects of COVID-19. Those with opioid or methamphetamine use disorder are overrepresented among aging persons living with HIV, and are at heightened risk for respiratory and pulmonary complications because of their drug use. Methamphetamine, in particular, constricts blood vessels, causing pulmonary damage and (potentially) pulmonary hypertension, which can impact the severity of COVID-19.

At a practical level, the very real and warranted fear of going out has disrupted ongoing and essential treatment and care. A person aging with HIV may defer medical appointments due to concern about exposure at the doctor’s office. This, in turn, may lead to an interruption in care or medication refills. Efforts to increase the application of telemedicine have been impressive, but many aging persons, especially those with limited incomes, may lack the comfort or proficiency to easily maneuver such technology, even despite having a computer or smartphone and broadband service.

The social impact of this confluence of HIV, addiction, and aging in the midst of COVID-19 is equally consequential. Risk for homelessness and incarceration increase, and there may be decreased access to health care for several reasons. As hospitals fill to capacity, persons needing care for an addictive disorder, already stigmatized and underserved, may find even more barriers to care. Longstanding patterns of inequitable access to health care and housing have spiraled into a crisis. As the economy continues to falter, conditions worsen for those already marginalized who experience greater food insecurity, unstable housing, and inadequate funds to cover expenses. They are the first to fall through the tattered social safety net.

While there has long been a growing epidemic of loneliness, perhaps the most deleterious impact of life during COVID-19 is the catastrophic increase in isolation which has especially impacted persons living with HIV, including those who are aging or suffering addiction. The mandate for social isolation has exacerbated an unfortunate situation and resulted in worsening conditions that have negatively impacted everything from income to food and medical supply access.

When substance use is added to this complex scenario it becomes even more dire. Since the first lockdowns began, alcohol sales have nearly doubled and the reported use of other drugs has increased as well. The pandemic, along with restrictions of social movement, has disrupted illicit drug supply chains. Unable to get their drug of choice, many users take anything to numb themselves from emotional pain. Scrambling to obtain drugs from any source has raised the risk of exposure to adulteration (mixing or cutting) with fentanyl and increased overdose deaths. Sadly, among treatment professionals it is commonly assumed that a significant number of overdose deaths are in fact suicides.

Supports for recovery such as 12-step meetings have rapidly moved online and have been vital in saving lives. Social connection is a widely recognized element of addiction recovery, yet these online meetings can’t match the benefits of real-time gatherings. Some individuals may struggle with the technology and, even for those who are able to attend without issue, simply getting a hug, having an informal chat with someone, or enjoying the fellowship following a meeting is sorely lacking. One upside of the online meetings is the new ability to regularly attend recovery groups around the world. While global online recovery acquaintances are appealing, they can’t provide the level of real-time interaction and support required when someone is struggling or near a relapse.

Isolation has been recognized as a potential source of mental health concerns such as depression and anxiety, as well as a consequence of them. Aging persons living with HIV are at higher risk for such mental health problems, which have been even further aggravated by months of social isolation. Support networks and the protective power of robust social connections have begun to fray. Month after month of living apart has resulted in further withdrawal from society, medical care, and vital support.

Isolation has also resulted in expanding the divide between certain population groups and the society at large. For instance, aging persons living with HIV are already marginalized; meanwhile, younger people may perceive themselves to be at lower risk for COVID-19, and many appear to have just moved on with their lives. Facebook and Instagram are filled with images of maskless people celebrating birthdays or gathering at bars. This can cause aging persons and others who need to isolate for survival to feel even more lonely and devalued. The unstated policies that appear to sacrifice the aging population for the dubious goal of “herd immunity,” at least prior to the release of vaccines, give rise to a disturbing echo of selective discrimination toward a group or groups of people for those of us who survived the early years of HIV in the 1980s and ’90s.

Despite the promise of vaccines, we have months ahead of us that will largely resemble the past year. It is up to each of us to do what we can, both for ourselves and for others. Here are some actions we can take:

Prioritize self-care: Our normal lives have been transformed. The disruption of routines such as the closing of hair salons, churches, and gyms has thrown everyone off balance, requiring a recommitment to self-care. Whether protecting our physical health with adequate nutrition, sleep, exercise, and proactive management of any health conditions, our emotional wellbeing by giving or receiving social support and getting professional care when we need it, or spiritual support to help us grieve and find meaning in all that has happened, taking the best possible care of ourselves must remain a top priority.

Embrace technological alternatives: More than once I have heard people marvel that just a few years ago we would have had a much more difficult time functioning remotely to the extent that is common today. Video conferencing has enabled everything from online support groups to teletherapy and even Zoom dinner parties. But the digital divide creates a rift between those with adequate resources and those without, including those whose jobs can be managed from home versus those who need to put themselves at risk by going out to work.

To the greatest extent possible, it is important to prioritize connection in each domain of our lives and apply any tech solutions that are available. We all recognize that sharing screen time is not an ideal solution, but it is far better than no contact at all. Thankfully, today one can turn to YouTube tutorials to learn how to use these new technologies to best stay connected.

Practice kindness: Our world is filled with people on edge. Months of disruptions, fear, sickness, death, and economic and political instability have left us exhausted and short-tempered. Our limited emotional bandwidth along with social distancing has eroded common courtesies, compassion, and social pleasantries, all of which serve the vital function of preserving social order. Even the all-important mask hides facial expressions that help us read social cues and feel connected. To compensate, we need to consciously practice kindness for ourselves and others. The world sorely needs more compassion and connection to help us remember that our fate is truly in each other’s hands.

Invest in social outreach: In the early days of the AIDS epidemic, when there was no governmental or other support structure, people living with HIV took matters into their own hands. Call lists were created for daily telephone outreach. They identified buddies with whom they checked in, assisted with medical appointments, or for whom they simply became a good listener. Today, along with an epidemic of isolation, we have more communication options than ever before. Whether by text, phone, Zoom, or other means, a practice of daily outreach to a few people is incredibly healing for both the caller and the person called. There is an addiction recovery slogan that captures this sentiment: One call saves two lives.

Cherish your connections: We are constantly getting new evidence of the lifesaving power of connection. The nature of our early-life attachment (or lack thereof) with caregivers affects how we form relationships for the rest of our lives. Studies show that long-term couples begin to co-regulate heartbeat, respirations, and even pain levels. And copious work has been done proving that connection with others is essential to recovery from addiction. When we are connected we thrive, reminding us that we are loved, supported, and perhaps most of all, that we belong.

The months ahead will continue to challenge our spirits. But, by taking actions that are available to each of us, we can preserve our wellbeing and provide potentially life-saving support for those around us.