The available evidence indicates that PLWH may have a heightened risk of poor COVID-19 outcomes, in part due to social determinants of health and multi-morbidity . Historically, PLWH have been disproportionately affected by mental health problems, including substance misuse and dependence, compared to the general population and HIV-uninfected peers . On one hand, psychiatric illnesses can contribute to HIV infections . On the other hand, psychiatric disorders can develop or worsen in PLWH due to neurologic manifestations of HIV , antiretroviral therapy -related toxicity , and psychosocial stressors, such as HIV-related stigma and loss of social capital . That said, PLWH may benefit from psychological resilience developed through the process of adapting to and overcoming the adversities brought on by living with HIV . Resilience, in general terms, is the process of coping with stress or trauma . In other words, it is a positive adaptation to adverse events, and may act as a buffer against adverse mental health outcomes. In PLWH, high resilience has been associated with lower depression and anxiety , improved health behaviors leading to higher ART adherence and viral suppression , safer sexual practices , and higher health-related quality of life . In the Miami Adult Studies on HIV cohort, PLWH exhibited higher resilience than their HIV-uninfected peers during the early months of the pandemic . Additionally,vertical grow system higher resilience in part accounted for lower anxiety and stress in PLWH. Based on these findings and the theory of HIV resilience , we hypothesized that higher resilience in PLWH would predict lower risk of substance misuse. The study of resilience in the context of HIV infection and substance misuse may offer unique insights regarding public health emergencies related to infectious diseases, such as the COVID-19 pandemic. In this study, we conducted a multi-cohort investigation on the relationships between psychological resilience, anxiety, and substance misuse in people living with and without HIV.

Descriptive statistics are reported as percentages for categorical data, as means ± standard deviations for continuous variables with a normal distribution, and as medians with 25th and 75th percentiles for data with a non-normal distribution. The normality of the data’s distributions was first determined using the Kolmogorov Smirnov test, and the equality of variances was confirmed using Levene’s test. Between-group differences were tested with Chisquare test, T test, or Mann-Whitney U test as adequate. Primary analyses consisted of multivariate generalized linear mixed models with separate random intercepts using binary logistic regression. The random intercepts used were C3PNO cohort , survey wave, and month of survey. This model generates a flexible marginal correlation among the repeated binary outcomes, including a declining association with increasing time separation, while retaining the property that the marginal probabilities follow a logistic regression model. The fixed effects include HIV status, age, sex, race/ethnicity, employment, homelessness, mental health care prior to pandemic, and treatment for SUD prior to pandemic. Due to substantial losses to follow-up, we performed an additional cross sectional analysis using data from all participants during the 1st wave of the survey. Logistic regression parameters were summarized as odds ratios or relative risk with 95% confidence intervals and P-value. We conducted a multi-cohort study of the Collaborating Consortium of Cohorts Producing NIDA Opportunities to assess psychological resilience, anxiety, and substance misuse in people living with and without HIV during the COVID-19 pandemic. Resilience in this study refers to an individual’s “ability to bounce back or recover from stress” . In this analysis of the combined C3PNO cohorts, data collected during the COVD-19 pandemic indicated that PLWH had higher odds for high resilience than HIV-uninfected participants after controlling for important factors such as sociodemographic characteristics and cohorts within C3PNO. In turn, high resilience was associated with lower risk of anxiety and substance misuse during the same period of time. These findings suggest that strategies to identify and strengthen resilience resources may help mitigate mental health problems and substance misuse in vulnerable populations.

Further, learning from HIV resilience and the public health response to HIV may provide valuable insights for individual- and community-level resilience that could help increase preparedness for public health crises, such as the COVID-19 pandemic, potentially reducing the burden on the mental health and well being of marginalized populations. Among those disproportionately affected by the pandemic are PWUD, who are often highly vulnerable, underserved, and understudied . Distress directly related to COVID-19, as well as the unintended social and economic consequences of lock downs contributed to increased patterns of substance misuse, along with alcohol- and drug-related overdoses . This was foreseen by many, as stress has long been linked to substance abuse and risk of relapse . Alarmingly, a prevailing concern is that the pandemic will have long-lasting impacts on mental and behavioral health. For example, people who initiated misuse of substances during lock downs may develop an SUD that may persist long after pandemic recovery. Disruptions to health systems may also make it more difficult for people with psychiatric disorders to seek and obtain adequate care and treatment. Moreover, bidirectional associations between COVID-19 and psychiatric conditions have been noted . The data presented in this study was collected between May 2020 and March 2021, and is likely not representative of usual patterns of substance misuse among C3PNO participants. Changes to the drug supply, such as decreased availability and quality along with increased costs have been reported by PWUD . For instance, cocaine use in the MASH cohort declined by more than half during the early months of the pandemic . Therefore, some substances may have been less frequently used during the study period. Also, changes in the availability of some drugs may lead some individuals to shift towards more easily accessible substances, such as alcohol and prescription drugs. As such, changes in substance misuse may be due to changes in drug supply rather than personal choices. On the other hand, the United Nation’s World Drug Report 2021 found that, despite initial disruptions, the global drug trade was largely unaffected throughout 2020.

This may explain why patterns of reported substance misuse among the C3PNO participants who completed both surveys remained stable throughout the study period, besides a slight decline in hazardous drinking among HIV-uninfected participants. Nevertheless, losses to follow-up must be taken into consideration, as participants who were lost to follow-up were more likely to smoke cigarettes , use cannabis and heroin/fentanyl than those who completed both surveys. Given the rise in incidence of substance-related overdoses during the pandemic, it is possible that some of the attrition in this study may be related to overdoses. Continued monitoring of substance use patterns in the C3PNO cohorts and other at-risk groups is warranted. While there are several important distinctions between the HIV epidemic and the current COVID-19 pandemic, this study illustrates that lessons from HIV may extend to resilience and its impact on mental and behavioral health. Resilience has been conceptualized most commonly as the process of overcoming adversity, but it has also been used in reference to a trait and the outcome of such process . What is common in all conceptualizations of resilience is that adversity is an antecedent and usually consists of traumatic events, disease processes, and daily stressors . With the advent of highly effective ART, HIV infection has become a manageable, chronic illness rather than a deadly disease. PLWH develop resilience as they learn to manage the infection, which includes engaging with health care providers and adhering to treatment. de Santis et al. described the process of resilience in HIV as one that entails intrinsic and extrinsic motivation, management of the disease, and mastering of the disease. On the other hand, the circumstances that led to acquiring HIV, the unique trauma of an HIV diagnosis, along with the wide array of adversities brought on by it,mobile grow systems may make it more difficult for PLWH to build resilience when compared to other conditions . Our findings show that PLWH had higher resilience and were less likely to report anxiety and substance misuse during the pandemic as compared to HIV-uninfected peers. Methamphetamine use was more frequent among PLWH than HIV-uninfected participants, and the use of other substances was either similar or lower among PLWH. However, resilience consistently showed a protective effect against substance misuse, including methamphetamine use. Notably, the higher resilience among PLWH seen in this study may be in part susceptible to survivor ship bias, as those who build resilience by engaging in treatment and managing the disease are more likely to survive and participate in research studies. Nevertheless, since high resilience demonstrated a protective effect against anxiety and substance misuse, higher resilience may partly explain the lower risk of these among PLWH. Similarly, a study of PLWH in Argentina showed that resilience mitigated the impact of economic disruptions on mental health during the COVID-19 pandemic . Others have also shown that higher levels of resilience are associated with less perceived stress and higher life satisfaction in PWUD, two critical factors involved in SUDs . These results support the notion that psychological resilience serves as a buffer against poor mental health that may directly and indirectly protect from substance misuse. Similar to PLWH, PWUD may develop resilience as they overcome SUDs, yet the circumstances surrounding substance misuse may also pose a barrier for resilience. As such, the relationship between resilience and substance misuse can be reciprocal and bidirectional. However, in the substance use literature, resilience is most commonly conceptualized as an outcome determined based on the presence or absence of substance use.

An excessive focus on resilience as an outcome fails to recognize the impact of resilience on substance use, as well as its malleability over time depending on circumstances. Further research is needed to understand the complex pathways between resilience and substance misuse. For instance, the effect of resilience on substance misuse may be in part mediated by anxiety, with higher resilience acting as a safeguard against anxiety, thereby reducing the risk of substance misuse. The potential complexity of these pathways is exemplified in a study by Yang et al. , which found that positive affect, self-esteem, and social support partially mediated the effects of resilience on perceived stress and life satisfaction among PWUD. On the other hand, resilience may directly reduce the risk of substance misuse by enhancing cognitive control and mindfulness over urges to use and to avoid impulsive and social behaviors conducive to substance use . Efforts to foster resilience within marginalized communities may help reduce the burden of mental health problems and increase preparedness for future public health threats. An advantage of studying resilience in the context of substance misuse is its strength-based approach. Rather than emphasizing the vulnerabilities of PWUD, resilience focuses on facilitators of well-being and other protective factors that can help PWUD overcome their adversities. Particularly in marginalized populations, understanding social and cultural contexts may reveal hidden sources of resilience . Nevertheless, resilience in the context of substance use has received relatively little attention and research on resilience-focused interventions is greatly limited . Interventions must consider the multi-factorial nature of resilience. In the context of substance use, an array of internal resilience resources are cited, including self-esteem, self-efficacy, personal skills, intellectual ability, religiosity/spirituality, and personality traits . External resilience resources are often considered at the family, school, and community levels, while environmental and structural factors are often overlooked . Efforts to enhance community resilience, which is fundamental for preparedness and recovery from public health crises, must address social and health inequities. Indeed, a key aspect of community resilience is health promotion, as the level of physical and psychological health of a population impacts their needs and ability to recover after crisis events . Public health advocates and policymakers may foster community resilience by addressing social determinants of health and other sources of social, economic, and health disparities. These strategies will require the integration and involvement of governmental and non-governmental agencies. Several strengths and limitations of the study must be considered. The data presented was self-reported, collected from convenience samples across C3PNO cohorts via in-person and telephone-administered surveys. As such, it is possible that the use of substances was under reported.