AIDS and Behavior
https://doi.org/10.1007/s10461-021-03433-3
ORIGINAL PAPER
Differences in COVID‑19 Preventive Behavior and Food Insecurity
by HIV Status in Nigeria
Morenike Oluwatoyin Folayan1,2 · Olanrewaju Ibigbami3 · Brandon Brown1,4 · Maha El Tantawi1,5 ·
Benjamin Uzochukwu1,6 · Oliver C. Ezechi1,7 · Nourhan M. Aly1,5 · Giuliana Florencia Abeldaño1,8 ·
Eshrat Ara1,9 · Martin Amogre Ayanore1,10 · Oluwagbemiga O. Ayoola1,11 · Bamidele Emmanuel Osamika1,12 ·
Passent Ellakany1,13 · Balgis Gaffar1,14 · Ifeoma Idigbe1,7 · Anthonia Omotola Ishabiyi1,15 · Mohammed Jafer1,16 ·
Abeedha Tu‑Allah Khan1,17 · Zumama Khalid1,18 · Folake Barakat Lawal1,19 · Joanne Lusher1,20 ·
Ntombifuthi P. Nzimande1,21 · Bamidele Olubukola Popoola1,22 · Mir Faeq Ali Quadri1,23 · Maher Rashwan1,24,25 ·
Mark Roque1,26 · Anas Shamala1,27 · Ala’a B. Al‑Tammemi1,28 · Muhammad Abrar Yousaf1,29 ·
Roberto Ariel Abeldaño Zuñiga1,30 · Joseph Chukwudi Okeibunor1,31 · Annie Lu Nguyen1,32
Accepted: 7 August 2021
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021
Abstract
The aim of the study was to assess if there were significant differences in the adoption of COVID-19 risk preventive behaviors and experience of food insecurity by people living with and without HIV in Nigeria. This was a cross-sectional study
that recruited a convenience sample of 4471 (20.5% HIV positive) adults in Nigeria. Binary logistic regression analysis was
conducted to test the associations between the explanatory variable (HIV positive and non-positive status) and the outcome
variables—COVID-19 related behavior changes (physical distancing, isolation/quarantine, working remotely) and food
insecurity (hungry but did not eat, cut the size of meals/skip meals) controlling for age, sex at birth, COVID-19 status, and
medical status of respondents. Significantly fewer people living with HIV (PLWH) reported a positive COVID-19 test result;
and had lower odds of practicing COVID-19 risk preventive behaviors. In comparison with those living without HIV, PLWH
had higher odds of cutting meal sizes as a food security measure (AOR: 3.18; 95% CI 2.60–3.88) and lower odds of being
hungry and not eating (AOR: 0.24; 95% CI 0.20–0.30). In conclusion, associations between HIV status, COVID-19 preventive behaviors and food security are highly complex and warrant further in-depth to unravel the incongruities identified.
Keywords COVID-19 · Food security · HIV · Pandemic · Health behavior
Introduction
Coronavirus disease-2019 (COVID-19) is an infectious disease caused by a newly discovered coronavirus called severe
acute respiratory syndrome coronavirus-2 (SARS-CoV-2).
The severity of COVID-19 infection, including risk of death
increases with multiple co-morbidities [1]. People with
asthma, chronic lung disease, diabetes, serious cardiovascular conditions, chronic kidney disease, obesity, chronic
liver disease, and those who are immunocompromised
have a higher risk of the disease and are therefore asked
to take extra-cautionary measures to avoid contracting the
* Morenike Oluwatoyin Folayan
toyinukpong@yahoo.co.uk
Extended author information available on the last page of the article
SARS-CoV-2 infection [2, 3]. Likewise, there were initial
concerns that people living with HIV (PLWH) might be at
higher risk for COVID-19 outcomes due to the immunosuppressive effect of HIV, resulting in increased susceptibility
to opportunistic infections [4]. Prior evidence suggest that
HIV is less of a risk factor for severe COVID-19 compared
to other health conditions, such as high blood pressure,
heart diseases, lung diseases, cancers, overweight/obesity,
diabetes, or being over a certain age [5–8]. However, PLWH
with low CD4 cell count, advanced disease, high viral load,
and those not on antiretroviral treatment may have different
health risks [4]. As PLWH are living longer with antiretroviral therapy, many will also have developed the chronic
conditions that are associated with severe COVID-19 [9].
Thus, when PLWH contract COVID-19, they are then more
likely to have the severe form of the disease and may die at
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AIDS and Behavior
a younger age when compared to people not living with HIV
[4]. More recent evidence suggests that PLWH are not only
at a higher risk for mortality from COVID-19 but are also
at a higher risk of contracting SARS-CoV-2 infection than
people not living with HIV [10].
In view of PLWH increased risk for COVID-19, it is
possible that PLWH may adhere to COVID-19 preventive behaviors. Such COVID-19 preventive behaviors and
measures include mask-wearing, frequent hand washing and
sanitization, physical distancing, as well as self-quarantine
when the need arises. However, lockdown, isolation and
quarantine restrict movements making it difficult for PLWH
to reach medical clinics for routine care and medications [4,
11–13]. These restrictions can cause disruptions in the continuity of HIV care and cause emotional distress for those
who are unable to obtain medical care. Emotional distress
can also result from other multiple factors such as food
insecurity because of drastic reduction in income and the
increasing poverty rates in many countries resulting from
the COVID-19 pandemic [14].
Food insecurity, defined as limited or uncertain access to
sufficient, nutritious food for an active, healthy life [15], has
increased in many countries because of the pandemic [16,
17]. This has resulted in skipping meals or starvation among
the affected people because of challenges with accessing
basic food needs. The experience of food insecurity is stressful and associated with poorer mental health in the short
and long term [18, 19]; and there are indications that this
is worse for PLWH [20]. Food insecurity may provoke a
stress response that induces mental health conditions like
depression. Such stress stimulus may result from having to
acquire foods in socially unacceptable ways thereby inducing feelings of alienation, guilt, powerlessness and shame
that are associated with depression [20–23]. PLWH are more
prone to depression than people not living with HIV [24].
Depression is also associated with health-risk behaviors [25]
that increases the risk for non-adherence to COVID-19 precautionary measures.
Food insecurity is the predominant form of uncertainty
experienced in daily living in many countries in sub-Saharan Africa [26]. In Nigeria, 58% of households experienced
severe food insecurity during the pandemic [27]. This prevalence of household food insecurity increases to about 71.7%
for PLWH in Nigeria [28]. Nigeria also had the second highest burden of HIV in the world [29] with a HIV prevalence
of 1.4% [30], the highest tuberculosis burden in Africa [31]
and a high prevalence of HIV and tuberculosis co-morbidity
[32]. PLWH are also at high risk for obesity, diabetes mellitus and cardiovascular diseases [33]. The high prevalence of
infectious and non-communicable diseases in PLWH raises
concern about their increased risk to COVID-19 related
mortality [34] as observed in South Africa [35], a country
with a similar HIV, tuberculosis and food insecurity profile
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like Nigeria. The COVID-19 pandemic increased the risk
for food insecurity in Nigeria [36] and hence, a concern for
PLWH who often have worse food security problems than
the general population [37].
The study assessed if there were significant differences
in (1) the adoption of COVID-19 preventive behaviors; and
(2) experience of food insecurity among people living with
and without HIV in Nigeria. We draw on the stress process
model [38, 39] that identified the eventful experiences and
life strains that produces stress and psychological distress
(especially depression [40]) that increases the risk for food
insecurity. We hypothesized that PLWH are more likely to
adopt COVID-19 preventive behaviors and more likely to
experience food security challenges when compared to people not living with HIV.
Methods
Ethical approval of the current study was obtained from the
Human Research Ethics Committee at the Institute of Public
Health of the Obafemi Awolowo University Ile-Ife, Nigeria
(HREC No: IPHOAU/12/1557).
Study Design, Study Setting and Study Participants
This study was part of a larger cross-sectional study that
used an online survey (Survey Monkey®) to collect multicountry data to determine the impact of COVID-19 on the
mental health and wellness of adults from July to December
2020 [41]. The survey collected data from a convenience
sample of adults aged 18 years and above who provided
consent for study participation. There were no exclusion criteria for study participation. Data of participants resident in
Nigeria who participated in the online survey, were extracted
for this study.
Recruitment of Study Participants
Study participants were recruited through respondent driven
sampling. Initial participants reached by the 45 data collectors, were asked to share the survey link with their contacts
within their countries to facilitate recruitment. The survey
link was also posted on social media groups (Facebook,
Twitter, and Instagram) and network email lists and WhatsApp groups.
Data Collection Tool
Data was collected using a questionnaire that was initially
developed for a study that targeted a specific population in
the United States and was consequently adapted and validated for global use [42]. The survey questionnaire was
AIDS and Behavior
preceded by a brief introduction explaining the purpose of
the study, assuring participants of their voluntary participation, and confidentiality of their data. Study participants
provided consent before participating in the online survey.
The questionnaire was anonymous, closed-ended and was
administered in English and took an average of 11 min to
complete. Each participant could only complete a single
questionnaire through IP address restrictions, though they
could edit their answers freely until they choose to submit.
Study participants were asked to provide details about their
sociodemographic profile, medical health profile, COVID19 status, HIV status, feeling of being depressed, behavior
change during the pandemic, and COVID-19 impact on their
food security.
Control Variables
Sociodemographic Profile
The section on sociodemographic profile collected data on
age, sex at birth, highest level of education attained (none,
primary, secondary, college/university) and employment
status.
Medical Health Profile
The section on medical health profile required respondents
to tick one or more of 23 medical health conditions adapted
from the study by Marg et al. [43] and classified based on
the risk definition by the Centers for Disease and Prevention [44]. There was also an option to mention other health
conditions not in the list. The list was constructed to identify respondents whose medical conditions put them at high
(pneumonia, diabetes, cancer, heart condition), moderate
(hepatitis, hypertension, neurological problems, neuropathy, respiratory problems, stroke, depression) or low (herpes,
shingles and other sexually transmitted infections, dermatologic problems, migraines, arthritis, broken bones, hearing
loss and vision loss) risk for severe COVID-19.
COVID‑19 Status
Respondents were asked if they had tested positive for
COVID-19, had COVID-19 symptoms but did not test, had a
close friend who tested positive for COVID-19 and/or knew
someone who died from COVID-19.
Depression
Respondents were asked to indicate which of the eight
feelings they were experiencing during COVID-19. They
were required to tick a checkbox against any of the feelings they had experienced during the pandemic. One of the
eight feelings was depression. The questions were part of the
Pandemic Stress Index administered to study participants
that assessed the psychosocial impact of COVID-19 [45].
Outcome Variables
Behavior Changes
The questionnaire assessed behavior changes to public
health messaging (wearing of face masks, frequent washing
or sanitizing of the hand, physical distancing, been in isolation or quarantined) and the workplace modification (working remotely). Respondents were asked which of the listed
behaviors they had adopted during the pandemic; and were
required to check the box against any of the listed behaviors.
A check indicated they had adopted that behavior during the
pandemic. They questions were included as a component of
the Pandemic Stress Index [45].
Impact of Pandemic on Food Security
The second assessment was the impact of the pandemic on
access to food and meals with responses as either a ‘yes’ or
‘no’ to the following questions: Were you ever hungry but
did not eat because there wasn’t enough money for food? Did
you ever cut the size of your meals or skip meals because
there wasn’t enough money for food? The questions were
adapted from the US Department of Agriculture Household
Food Security Survey [46].
Explanatory Variable
HIV Status
A question was also asked about HIV status. Respondents
were required to identify if their HIV status was positive,
negative, unknown or if they were unwilling to declare.
Data Analyses
Raw data were downloaded, cleaned, and imported to
SPSS® Version 23.0 (IBM Corp. Released 2015. IBM SPSS
Statistics for Windows, Version 23.0. Armonk, NY: IBM
Corp) for analyses. As a best-practice procedure, we checked
to identify and remove any survey responses completed
below seven minutes—the lower limit of the time range to
answer the questionnaire during the pilot phase (n = 77); and
those with incomplete data with respect to responses on HIV
status (n = 220) [47, 48].
Descriptive analysis of all study variables was conducted.
PLWH and participants not living with HIV were compared
regarding background variables, COVID-19 status food
insecurity and adoption of precautionary measures using t
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AIDS and Behavior
test and chi square test. Logistic regression models were
constructed for five dependent variables (the adoption of
three precautionary measures and two food insecurity indicators). The COVID-19 precautionary measure variables
used to construct the logistic regression were three of the
five variables those that showed statistically significant associations with HIV status. The confounders for the study were
sociodemographic profile, COVID-19 status, medical status,
and depression. HIV status was the explanatory variable.
Adjusted odds ratios (AOR) for the binary logistic regression models and 95% confidence intervals (CIs) were calculated. The Omnibus test of model coefficients was used to
determine the significant difference between the Log-likelihoods (specifically the -2LLs) of the baseline model and the
new model inclusive of the explanatory variable. Statistical
significance was set at 5%.
Results
The mean age of the 4471 respondents was 38.3 years
(SD = 11.63) ranging from 18 to 85 years. More than half of
the respondents were female (52.9%), the majority had college/university education (80.9%), did not lose their job during the pandemic (91.9%), did not have reduced wages during the pandemic (73.2%). Also, 15.7% had moderate risk
of health problems and 91.3% reported not being depressed
during the pandemic. There were 110 (2.5%) respondents
who tested positive for COVID-19. Table 1 highlights the
demographic profiles of respondents.
There were 919 (20.5%) respondents who reported living
with HIV. PLWH were significantly older than respondents
who were not living with HIV (40.43 vs 37.75; p < 0.001).
Compared to respondents not living with HIV, a greater
number of PLWH were female (p = 0.001), had no formal
education or primary school education (p < 0.001), were
at high (p = 0.008) or moderate (p = 0.011) risk of health
problems, either lost their employment (p = 0.032) or had
reduced wages (p = 0.002) during the pandemic, and felt
depressed (p < 0.001).
Significantly fewer PLWH tested positive for COVID19 (p < 0.001), had a close friend who tested positive for
COVID-19 or knew someone who died from COVID-19
(p < 0.001), kept physical distance (p < 0.001), isolated/
quarantined (p < 0.001), and worked remotely (< 0.001).
Also, significantly more PLWH reported a decrease in food
intake (p < 0.001), feeling hungry but not eating (p < 0.001)
and cutting their size of meals or skipping meals (p < 0.001).
The omnibus test of model coefficients for the logistic
regression analysis highlighted in Table 2 indicates that the
current models outperformed the null models. The respondents’ HIV status was associated with adopting COVID-19
precautionary measures. PLWH had significantly lower odds
13
of physical distancing when compared with people not living with HIV (AOR: 0.67). The odds of adopting physical
distancing were also significantly lower for respondents who
were older (AOR: 0.97); had primary, secondary and college/university education when compared with respondents
with no formal education (p < 0.05); had lost a job (AOR:
0.70); had reduction in wages (AOR: 0.73); had a close
friend who had tested positive for COVID-19 (AOR: 0.64);
knew someone who had died from COVID-19 (AOR: 0.7);
and had increased access to food (AOR: 0.71). Factors significantly associated with higher odds of adopting physical
distancing were a high risk of health problems (AOR: 1.45);
having COVID-19 symptoms but not taking a test (AOR:
1.35); and having no change in food access (AOR: 1.42).
PLWH had significantly lower odds of being isolated or
quarantined (AOR: 0.62) when compared to people not living with HIV. Also, lower odds of isolating or quarantining
were significantly associated with low risk of health problems (AOR: 0.67); testing positive for COVID-19 (AOR:
0.18); having symptoms but not testing for COVID-19
(AOR: 0.29); having a close friend who tested positive for
COVID-19 (AOR: 0.40); knowing someone who died from
COVID-19 (AOR: 0.60); and being depressed (AOR: 0.58).
Older respondents had significantly higher odds of being
isolated or quarantined (AOR: 1.01).
PLWH had significantly lower odds of working remotely
(AOR: 0.37). Older respondents (AOR: 0.98); and respondents with college/university education (AOR: 0.30); reduced
wages (AOR: 0.61); who felt depressed (AOR: 0.77) had
significantly lower odds of working remotely. Respondents
who lost a job (AOR: 1.61) and who reported no change in
food access (AOR: 1.44) had significantly higher odds of
working remotely.
The omnibus test of model coefficients for the logistic
regression analysis highlighted in Table 3 indicates that the
current models outperformed the null models. The Table
presents the factors associated with food security indicators such as being hungry and not eating and having to cut
the size of meals/skip meals. PLWH had significantly lower
odds of being hungry and not eating compared to those not
living with HIV (AOR: 0.24). Also, respondents who were
younger (AOR: 0.98); had moderate risk of health problems (AOR: 0.77); had a close friend who tested positive
for COVID-19 (AOR: 0.47); and who knew someone who
died from COVID-19 (AOR: 0.76) had significantly lower
odds of being hungry and not eating. Respondents who had
lost a job (AOR: 14.06), had reduced wages (AOR: 5.70),
had COVID-19 symptoms but were not tested (AOR = 1.32)
and who felt depressed (AOR: 1.34) had significantly higher
odds of being hungry and not eating.
PLWH had significantly higher odds of cutting the
size of meals or skipping meals during the pandemic than
respondents not living with HIV (AOR: 3.18). Similarly,
AIDS and Behavior
Table 1 Profile of respondents who reported their HIV status (N = 4471)
Variables
Total
N = 4471
n (%)
Not living with HIV
N = 3552
n (%)
Age
38.30 (11.63)
37.75 (11.76)
Mean (SD) in years
Sex
Male
2076 (46.4)
1705 (48.0)
Female
2363 (52.9)
1822 (52.1)
Intersex
3 (0.1)
2 (0.1)
Decline to answer
29 (0.6)
23 (0.6)
Level of education
No Education
48 (1.1)
7 (0.2)
Primary
84 (1.9)
7 (0.2)
Secondary
724 (16.2)
386 (10.9)
College/university
3615 (80.9)
3152 (88.7)
Employment status
Job loss
No
4110 (91.9)
3281 (92.4)
Yes
361 (8.1)
271 (7.6)
Had reduced wages
No
3271 (73.2)
2636 (74.2)
Yes
1200 (26.8)
916 (25.8)
Health profile
High risk
No
4304 (96.3)
3433 (96.6)
Yes
167 (3.7)
119 (3.4)
Moderate risk
No
3770 (84.3)
3020 (85.0)
Yes
701 (15.7)
532 (15.0)
Low risk
No
4016 (89.8)
3197 (90.0)
Yes
455 (10.2)
355 (10.0)
COVID-19 status
Tested COVID-19 positive
No
4361 (97.5)
3450 (97.1)
Yes
110 (2.5)
102 (2.9)
Had symptoms but did not test
No
4004 (89.6)
3178 (89.5)
Yes
467 (10.4)
374 (10.5)
Had a close friend who tested positive for COVID-19
No
3753 (83.9)
2917 (82.1)
Yes
718 (16.1)
635 (17.9)
Knew someone who died from COVID-19
No
3098 (69.3)
2353 (66.2)
Yes
1373 (30.7)
1199 (33.8)
COVID-19 behavior changes
Physical distancing
No
1239 (27.7)
895 (25.2)
Yes
3232 (72.3)
2657 (74.8)
Wearing mask or face covering
Living with HIV
N = 919
n (%)
Chi square/t test
p-value
40.43 (10.84)
15.25
< 0.001
371 (40.4)
541 (58.9)
1 (0.1)
6 (0.7)
17.38
0.001
41 (4.5)
77 (8.4)
338 (36.8)
463 (50.4)
819.37
< 0.001
829 (90.2)
90 (9.8)
4.60/1
0.032
635 (69.1)
284 (30.9)
9.73
0.002
871 (94.8)
48 (5.2)
7.12
0.008
750 (81.6)
169 (18.4)
6.43
0.011
819 (89.1)
100 (10.9)
0.63
0.428
911 (99.1)
8 (0.9)
12.18
826 (89.5)
93 (10.1)
0.13
836 (91.0)
83 (9.0)
42.37
< 0.001
745 (81.1)
174 (12.7)
75.38
< 0.001
344 (37.4)
575 (62.6)
54.56
< 0.001
< 0.001
0.717
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AIDS and Behavior
Table 1 (continued)
Variables
No
Total
N = 4471
n (%)
Not living with HIV
N = 3552
n (%)
Living with HIV
N = 919
n (%)
941 (21.0)
759 (21.4)
182 (19.8)
Yes
3530 (79.0)
Washing or sanitizing hands more often
No
1005 (22.5)
Yes
3466 (77.5)
Isolation/quarantine
No
4128 (92.3)
Yes
343 (7.7)
Work remotely
No
3098 (69.3)
Yes
1373 (30.7)
Food access
Food intake
Decreased
913 (22.0)
Increased
1511 (36.3)
No change
1734 (41.7)
Hungry but did not eat
No
3183 (71.2)
Yes
1288 (28.8)
Cut the size of meals or skip meals
No
3942 (65.8)
Yes
1529 (34.2)
Depressed during the pandemic
No
4080 (91.3)
Yes
391 (8.7)
2793 (78.6)
737 (81.2)
785 (22.1)
2767 (77.9)
p-value
1.08
0.300
220 (23.9)
699 (76.1)
1.42
0.234
3251 (91.5)
301 (8.5)
877 (95.4)
42 (4.6)
15.71
< 0.001
2311 (65.1)
1241 (34.9)
787 (85.6)
132 (14.4)
145.24
< 0.001
629 (19.1)
1200 (36.5)
1461 (44.5)
284 (32.7)
311 (35.8)
273 (31.4)
103.16
< 0.001
2736 (77.0)
816 (23.0)
447 (48.6)
472 (51.4)
286.87
< 0.001
2515 (70.8)
1037 (29.2)
427 (46.5)
492 (53.5)
192.24
< 0.001
3299 (92.9)
253 (7.1)
781 (85.0)
138 (15.0)
57.00
< 0.001
male respondents (AOR: 1.19); and respondents who had
lost their jobs (AOR: 16.07), who had had their wages
reduced (AOR: 6.84), who adhered to physical distancing
(AOR: 1.19) and who felt depressed (AOR: 1.39) had significantly higher odds of cutting the size of meals or skipping
meals during the pandemic. Younger respondents (AOR:
0.98); and respondents with moderate risk of health problems (AOR: 0.77), had a close friend who tested positive to
COVID-19 (AOR: 0.45) and who knew someone that died
from COVID-19 (AOR: 0.84) had significantly lower odds
of cutting the size of meals or skipping meals during the
pandemic.
Discussion
This study findings indicates that PLWH were less likely to
adopt COVID-19 prevention behaviors—physical distancing, isolation/quarantine and working remotely—when compared to people not living with HIV. Also, while both people
living with and without HIV faced food security challenges
13
Chi square/t test
during the COVID-19 pandemic, the responses differed
between the two groups: people not living with HIV were
more likely to go hungry without food while PLWH were
more likely to cut food sizes and skip meals as a response
strategy. The study hypothesis that PLWH are more likely to
adopt COVID-19 risk preventive behaviors is not supported
by the findings; and the hypothesis that PLWH are more
likely to experience food security challenges when compared
to people not living with HIV is partially supported.
One of the strengths of the study is the insightful analysis on the impact of the COVID-19 pandemic on the preventive behavior and food security of people living with
and without HIV in Nigeria. It is one of the few studies
on the impact of COVID-19 on PLWH in Africa; and an
important contribution to the literature to help inform strategic actions for providing care and support for PLWH
during the pandemic. The study however has a few limitations which suggest the need for cautious interpretation
of the results. Firstly, the cross-sectional nature of the
study makes it difficult to establish causality. In addition,
the pandemic had multiple phases which may have had
AIDS and Behavior
Table 2 Logistic regression analysis of factors associated with adopting COVID-19 precautionary measures (physical distancing, isolation/quarantine and working remotely) by adults in Nigeria (N = 4471)
Variables
Physical distancing
AOR (95% CI)
Age in years
0.97 (0.97–0.98)
Sex
Male (ref: Not male)
0.94 (0.82–1.08)
HIV status
Living with HIV (ref: Not living with HIV)
0.67 (0.55–0.81)
Level of education
No education
1.00
Primary
0.41 (0.19–0.89)
Secondary
0.20 (0.11–0.39)
College/university
0.14 (0.07–0.26)
Employment status
Job loss
Yes (ref: No)
0.70 (0.53–0.93)
Had reduced wages
Yes (ref: No)
0.73 (0.61–0.87)
Medical health profile
High risk
Yes (ref: No)
1.45 (1.00–2.09)
Moderate risk
Yes (ref: No)
1.08 (0.88–1.33)
Low risk
Yes (ref: No)
0.82 (0.64–1.05)
COVID-19 status
Tested COVID-19 positive
Yes (ref: No)
1.54 (0.99–2.40)
Had symptoms but did not test for COVID-19
Yes (ref: No)
1.35 (1.08–1.69)
Had a close friend who tested positive for COVID-19
Yes (ref: No)
0.64 (0.51–0.79)
Knew someone who died from COVID-19
Yes (ref: No)
0.71 (0.60–0.83)
Food access
Food intake
Decreased
1.00
Increased
0.71 (0.58–0.86)
No Change
1.42 (1.18–1.71)
Hungry but did not eat
Yes (ref: No)
1.07 (0.81–1.41)
Cut the size of meals or skip meals
Yes (ref: No)
0.84 (0.65–1.10)
Depression
Yes (ref: No)
0.84 (0.65–1.10)
0.106
Nagelkerke R2
Omnibus test of model coefficients
342.52
Isolation/quarantine
Work remotely
p value
AOR (95% CI)
p value
AOR (95% CI)
p value
< 0.001
1.01 (1.00–1.03)
0.039
0.98 (0.98–0.99)
< 0.001
0.412
0.92 (0.72–1.17)
0.481
0.90 (0.79–1.03)
0.128
< 0.001
0.62 (0.42–0.92)
0.018
0.37 (0.30–0.46)
< 0.001
–
0.024
< 0.001
< 0.001
1.00
3.87 (0.60–24.80)
1.73 (0.53–5.61)
1.39 (0.44–4.38)
–
0.153
0.362
0.577
1.00
0.98 (0.29–3.35)
0.67 (0.25–1.79)
0.30 (0.11–0.78)
–
0.971
0.424
0.014
0.013
1.13 (0.70–1.81)
0.617
1.61 (1.20–2.18)
0.002
0.001
0.86 (0.65–1.14)
0.290
0.61 (0.52–0.71)
< 0.001
0.050
1.17 (0.63–2.19)
0.622
0.94 (0.66–1.34)
0.742
0.460
0.83 (0.60–1.14)
0.252
1.01 (0.83–1.23)
0.905
0.114
0.67 (0.48–0.94)
0.020
0.89 (0.71–1.11)
0.315
0.056
0.18 (0.12–0.28)
< 0.001
1.10 (0.71–1.69)
0.673
0.009
0.29 (0.23–0.40)
< 0.001
1.04 (0.83–1.31)
0.707
< 0.001
0.40 (0.31–0.53)
< 0.001
1.02 (0.84–1.23)
0.866
< 0.001
0.60 (0.47–0.78)
< 0.001
0.93 (0.80–1.08)
0.335
< 0.001
< 0.001
1.00
1.19 (0.86–1.63)
1.36 (0.98–1.87)
0.294
0.063
1.00
0.87 (0.72–1.05)
1.44 (1.19–1.74)
0.136
< 0.001
0.640
1.28 (0.82–2.02)
0.282
0.83 (0.65–1.07)
0.153
0.250
0.80 (0.51–1.24)
0.314
1.08 (0.85–1.37)
0.544
0.199
< 0.001
< 0.001
0.58 (0.40–0.84)
0.184
357.59
0.004
< 0.001
< 0.001
0.77 (0.60–0.99)
0.124
410.13
0.047
< 0.001
< 0.001
AOR adjusted odds ratio, CI confidence interval
13
AIDS and Behavior
Table 3 Logistic regression analysis of factors associated with food insecurity (hungry but did not eat, cut the size of meals or skip meal) during
COVID-19 by adults in Nigeria (N = 4471)
Variables
Age in years
Sex
Male (ref: Not male)
HIV status
Living with HIV (ref: Not living with HIV)
Level of education
No formal education
Primary
Secondary
Tertiary
Employment status
Job loss
Yes (ref: No)
Had reduced wages
Yes (ref: No)
Medical health profile
High risk
Yes (ref: No)
Moderate risk
Yes (ref: No)
Low risk
Yes (ref: No)
COVID-19 status
Tested COVID-19 positive
Yes (ref: No)
Had symptoms but did not test for COVID-19
Yes (ref: No)
Had a close friend who tested positive for COVID-19
Yes (ref: No)
Knew someone who died from COVID-19
Yes (ref: No)
COVID-19 related behavioral changes
Physical distancing
Yes (ref: No)
Isolation/self-quarantine
Yes (ref: No)
Working from home
Yes (ref: No)
Depression
Yes (ref: No)
Nagelkerke R2
Omnibus test of model coefficients
Hungry but did not eat
Cut the size of meals or skip meals
AOR (95% CI)
P value
AOR (95% CI)
P value
0.98 (0.97–0.99)
< 0.001
0.98 (0.98–0.99)
< 0.001
1.15 (0.98–1.34)
0.083
1.19 (1.02–1.38)
0.023
0.24 (0.20–0.30)
< 0.001
3.18 (2.60–3.88)
< 0.001
1.00
0.73 (0.33–1.61)
0.77 (0.39–1.50)
0.75 (0.38–1.45)
–
0.437
0.440
0.394
1.00
0.47 (0.21–1.07)
0.54 (0.27–1.07)
0.58 (0.29–1.13)
–
0.073
0.079
0.109
14.06 (10.67–18.53)
< 0.001
16.07 (11.95–21.63)
< 0.001
5.70 (4.84–6.72)
< 0.001
6.84 (5.83–8.01)
< 0.001
1.18 (0.77–1.80)
0.456
1.05 (0.70–1.58)
0.807
0.77 (0.61–0.97)
0.025
0.77 (0.61–0.95)
0.017
1.15 (0.89–1.48)
0.275
1.12 (0.88–1.43
0.375
1.12 (0.65–1.95)
0.682
1.07 (0.63–1.82)
0.795
1.32 (1.02–1.70)
0.032
1.11 (0.87–1.43)
0.412
0.47 (0.37–0.61)
< 0.001
0.45 (0.35–0.57)
< 0.001
0.76 (0 .63–0.91)
0.003
0.84 (0.70–0.99)
0.044
1.14 (0.95–1.35)
0.161
1.19 (1.00–1.41)
0.050
1.11 (0.82–1.50)
0.514
0.97 (0.72–1.31)
0.839
0.91 (0.77–1.09)
0.312
0.99 (0.84–1.17)
0.901
1.34 (1.03–1.74)
0.349
1250.16
0.031
< 0.001
< 0.001
1.39 (1.07–1.80)
0.356
1329.97
0.015
< 0.001
< 0.001
AOR adjusted odds ratio, CI confidence interval
different effects on the population. Though the data was
collected across these phases, the study could not capture the dynamics happening across the different phases
13
due to the cross-sectional study design. Secondly, selfreport of depression is a more sensitive way of identifying
non-depressed than depressed individuals [49] and this
AIDS and Behavior
introduces potential underestimation of the proportion of
respondents who are depressed. Thirdly, the sample was
also skewed towards having higher levels of education,
possibly a reflection of the web-based data collection strategy requiring respondents to have reliable access to the
internet. The need for access to internet services may also
have resulted in the exclusion of residents in rural Nigeria where internet infrastructure is poor. Fourthly, study
participants were self- rather than randomly selected since
the survey was distributed through social networks. However, we could only conduct a web-based survey during
the pandemic because of the need for physical distancing
recommended by health authorities [50]. Finally, the question asked about whether a close friend (and not about
a family member) had contracted COVID-19 limited the
ability of the study to assess the COVID-19 experience
with family members since real-life interaction occur more
often with family members than friends. Also, questions
on COVID preventive measures adopted only had a ‘yes’
or ‘no’ response with no reflection on how often such precautions were used. Despite these limitations the study
findings can still inform strategic decision-making.
First, the low level of adherence to COVID-19 prevention
strategies among PLWH despite being at potentially greater
risk for severe COVID-19 than people not living with HIV
is a cause for concern. We noticed that a greater proportion
of PLWH had no formal education or had primary school
education increasing the possibility of them working in the
large informal income sector in Nigeria [51]. The lockdown
had a significant hard toll on people in the informal sector
who survive on daily income [52]. The study result suggests that more PLWH lost their jobs and had reduced wages
than people not living with HIV; and this implies PLWH
may had had worse financial insecurity during the pandemic
than people not living with HIV. This financial insecurity
may be associated with inability to comply with COVID19 prevention strategies: physical distancing, isolation and
quarantining will be challenging for individuals who live in
crowded residential areas; the likely typology of residential
areas people with poor financial security live [53]. Also, job
opportunities available for the level of education of PLWH
as portrayed in the present study reduce the prospect of
working remotely.
PLWH are likely aware of their risk for contracting
COVID-19 because of their immunocompromised status
and associated risk of comorbidities [10]. Their inability to
follow preventive measures despite their awareness of their
risk suggests that PLWH may be facing more challenges
than people not living with HIV. PLWH are at higher risk
of depression than people not living with HIV [24] and food
insecurity [20]; and the study showed that those who felt
depressed were less likely to adopt COVID-19 prevention
strategies and more likely to face food insecurity. This is
further justifiable reason to increase support provided for
PLWH during the pandemic.
We noticed that significantly fewer PLWH reported testing positive for COVID-19 in this study although there was
no difference between both groups in reporting that they
had the symptoms but did not take the test. This does not
indicate that there are fewer PLWH who had contracted
SARS-CoV-2 infection. Rather, this may be explained by
lesser percentage of PLWH taking the COVID-19 test and
suggesting the presence of structural barriers to COVID-19
testing for PLWH. In view of the higher risk of PLWH to
SARS-CoV-2 infection and the higher risk of mortality [10],
it is important to further study the reasons for the significantly lower percentage of positive COVID-19 test results
reported for PLWH in this study. Where possible, PLWH
should be prioritized for access to COVID-19 screening tests
using structures through which they access their antiretroviral therapy.
Second, the study findings provide some insight into how
PLWH manage their food security challenges: PLWH will
rather cut down on size of the meals or number of rations
and thereby save on food for another mealtime than go
hungry. Although it may seem contradictory that PLWH
had higher odds of reported cutting down on the size of
the meals and number of rations than non-PLWH while the
converse was the case for reporting on hunger, it is possible to reduce food portions without increasing hunger
[54]. Skipping meals, however, has deleterious effects as its
causes the metabolism to slow down with resultant weight
gain over time [55]. PLWH may have adopted this food security measure as a strategy to ensure that antiretrovirals are
not taken on an empty stomach. PLWH are often educated
about the interactions between antiretrovirals and food and
nutrition; and are educated about how to address nutritional
issues to reduce their risk of poor food access. PLWH on
antiretroviral therapy are prone to malnutrition due to inadequate appetite, dietary intake, nutritional losses, metabolic
changes, and increased requirements for both macro- and
micro-nutrients [56]. Poor food security may hasten progression to AIDS-related illnesses, undermine adherence and
response to antiretroviral therapy which makes nutritional
counselling an essential component of antiretroviral therapy
[57]. Food security challenges for PLWH is a universal phenomenon [58] and thus, nutrition and food security counselling should be part of the routine therapy for PLWH. Having
faced a life of food insecurity, PLWH may, therefore, be better prepared to manage food insecurity during this pandemic
than people not living with HIV. Further studies are needed
to validate the postulations generated from the study findings
highlighted here.
Third, age was associated with COVID-19 related prevention behavior changes: older respondents were less likely to
adopt physical distancing and to work remotely than younger
13
AIDS and Behavior
respondents; while older respondents were more likely to
adopt isolation/quarantine than younger respondents. Age
is an independent risk factor for mortality in patients with
COVID-19 being more fatal for older age groups because
of their increased risk of comorbidities that can increase
the risk of severe disease [59]. Age-dependent distancing
measures focused on older population such as physical distancing and working remotely, could achieve a better balance
between COVID-19 mortality and economic activity during
the COVID-19 pandemic [60]. The study found that adoption of physical distancing measures (as well as working
remotely) was more likely with younger than older adults in
Nigeria. This finding indicates the need for strategic actions
to improve adoption of COVID-19 preventive measures by
older residents in Nigeria to balance COVID-19 mortality
and economic activity during the pandemic.
Also, older respondents were less likely to be starve, cut
the size of meals or skip meals. This finding may reflect the
nature of African society where the care, including nutritional care, of older ones are prioritized. However, gender
tends to moderate food security of persons in households in
sub-Saharan Africa where males may be more food secure
when families have fewer economic resources and females
are more food secure when families have greater economic
resources [61]. The only gender disparity observed in the
current study was that male respondents were more likely
to cut the size of meals or skip meals compared to non-male
respondents during the pandemic. There is a need to further
understand how Nigerians were protected from food insecurity during this pandemic.
Fourth, COVID-19 status was also associated with the
adoption of COVID-19 preventive behaviors. Though we
found that respondents who had symptoms but did not test
for COVID-19 were more likely to adopt physical distancing,
paradoxically, being tested positive to COVID-19 associated
with lower odds of being isolated/quarantine. We posit that
physical distancing may be perceived as a self-protecting
practice likely to be adopted by those who suspect themselves of being infected in the hope that reducing additional
risk of infection from others may avert disease progress. The
decision to isolate or quarantine mainly protects others and
may be more challenging to make for various reasons including stigma [62] and challenges with food access [63]. The
study findings may also be a pointer to poor contact tracing
and management in Nigeria [64]. Further studies are however needed to understand why people who had symptoms
but did not test for COVID-19 were keep physical distancing
as they may have had to struggle with structural barriers to
COVID-19 testing [65].
Fifth, people who felt depressed were less likely to isolate/quarantine and more likely to face food insecurity than
those who were not. Isolation is regarded as a public health
infection control measure for persons who have contracted
13
COVID-19 while quarantine is for those in close contact
with someone who may have had COVID-19 [66]. While
there is information on COVID-19 being a risk factor for
depression [67], there is little know about depression being
a risk factor—mediator or moderator—for COVID-19. The
study finding suggests that it is possible that people who
are depressed who are made to isolate or quarantine may
not adhere to this instruction. It may therefore be better to
hospitalize persons with COVID-19 who feel depressed,
irrespective of the severity of the COVID-19—to reduce
the risk for spreading infection. Also, depression may reduce
motivation to carry out daily activities, such as obtaining
food or resources to get food thereby increasing the risk for
food insecurity [68]. The study findings may suggest that
persons who feel depressed during the pandemic need support to address food insecurity challenges, as well as compliances with isolation or quarantine directives.
Finally, some of the study findings were not unusual.
People who lost their job and those who had a decrease in
wage had significantly high risk for food insecurity. We also
noticed what we identified unusual findings: respondents
who had a close friend who tested positive for COVID-19
and those who knew someone who died from COVID-19
were less likely to have food security challenges; while
respondents who had symptoms but did not test for COVID19 were more likely to be hungry and do not eat. We are
unable to explain these unusual finding and suggest further
studies to explore these findings considering the dynamic
nature of the pandemic and the possible changes in the study
outcomes as the pandemic unfolded.
Conclusion
In summary, the present study provides novel evidence that
may explain the reported high risk of PLWH to a SARSCoV-2 infection: less PLWH than people without HIV adopt
COVID-19 preventive behaviors. We also observed that
older and depressed persons were less likely to adhere to
COVID-19 preventive behaviors indicating the need for care
and support of some sub-populations in the country. Also,
PLWH were more likely than people not living with HIV to
take food security measures that involved skipping a meal or
cutting the size of food eaten rather than starve. The findings
indicate that associations between adoption of COVID-19
preventive behaviors, mental and physical health, and food
insecurity are highly complex; and in the light of some of
the limitations acknowledged here, warrant further in-depth
qualitative research that can unravel these incongruities.
Author Contributions MOF conceptualise the study and developed the
first draft of the manuscript. OI conducted the statistical analysis. BB,
AIDS and Behavior
MET, BU, OCE, NMA, GFA, EA, MAA, OOA, BEO, PE, BG, II,
AOO, MJ, AT-AK, ZK, FBL, JL, NPN, BOP, MFAQ, MR, MRo, AS,
ABA-T, MAY, RAAZ, JCO and ALN reviewed the multiple drafts of
the manuscript and made intellectual inputs. All the authors agreed
for the final version to be submitted for peer review and possible
publication.
Funding Funding for the study was provided by the authors. Additionally, ALN was supported by the National Institutes of Health/National
Institute on Aging (K01 AG064986).
Data Availability The data is accessible on request from the principal
investigator.
Code Availability Not applicable.
Declarations
Conflict of interest The authors declare no conflict of interest.
Ethical Approval Ethical approval for the study was provided by the
Institute of Public Health of the Obafemi Awolowo University Ile-Ife,
Nigeria (HREC No: IPHOAU/12/1557).
Consent to Participate Study participants were required to tick a
consent before proceeding to complete the survey after being duly
informed about the study.
Consent for Publication Not applicable.
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AIDS and Behavior
Authors and Affiliations
Morenike Oluwatoyin Folayan1,2 · Olanrewaju Ibigbami3 · Brandon Brown1,4 · Maha El Tantawi1,5 ·
Benjamin Uzochukwu1,6 · Oliver C. Ezechi1,7 · Nourhan M. Aly1,5 · Giuliana Florencia Abeldaño1,8 ·
Eshrat Ara1,9 · Martin Amogre Ayanore1,10 · Oluwagbemiga O. Ayoola1,11 · Bamidele Emmanuel Osamika1,12 ·
Passent Ellakany1,13 · Balgis Gaffar1,14 · Ifeoma Idigbe1,7 · Anthonia Omotola Ishabiyi1,15 · Mohammed Jafer1,16 ·
Abeedha Tu‑Allah Khan1,17 · Zumama Khalid1,18 · Folake Barakat Lawal1,19 · Joanne Lusher1,20 ·
Ntombifuthi P. Nzimande1,21 · Bamidele Olubukola Popoola1,22 · Mir Faeq Ali Quadri1,23 · Maher Rashwan1,24,25 ·
Mark Roque1,26 · Anas Shamala1,27 · Ala’a B. Al‑Tammemi1,28 · Muhammad Abrar Yousaf1,29 ·
Roberto Ariel Abeldaño Zuñiga1,30 · Joseph Chukwudi Okeibunor1,31 · Annie Lu Nguyen1,32
1
Mental Health and Wellness Study Group, Ile-Ife, Nigeria
17
2
Department of Child Dental Health, Obafemi Awolowo
University, Ile-Ife, Nigeria
School of Biological Sciences, University of the Punjab,
Quaid-i-Azam Campus, Lahore 54590, Pakistan
18
Department of Mental Health, Obafemi Awolowo University,
Ile-Ife, Nigeria
School of Biological Sciences, University of the Punjab,
Lahore 54590, Pakistan
19
Department of Social Medicine, Population and Public
Health, Center for Healthy Communities, UCR School
of Medicine, Riverside, CA, USA
Department of Periodontology and Community Dentistry,
College of Medicine, University of Ibadan, Ibadan, Nigeria
20
School of Health and Life Sciences, University of the West
of Scotland, London, UK
21
Department of Economic and Human Geography, University
of Szeged, Szeged 6722, Hungary
3
4
5
Department of Pediatric Dentistry and Dental Public Health,
Faculty of Dentistry, Alexandria University, Alexandria,
Egypt
22
6
Department of Community Medicine, University of Nigeria
Nsukka (Enugu Campus), Nsukka, Nigeria
Department of Child Oral Health, University of Ibadan,
Ibadan, Nigeria
23
7
Department of Clinical Sciences, Nigerian Institute
of Medical Research, Lagos, Nigeria
Department of Preventive Dental Sciences, Jazan University,
Jizan, Saudi Arabia
24
8
School of Medicine, University of Sierra Sur, Oaxaca,
Mexico
Centre for Oral Bioengineering, Barts and the London,
School of Medicine and Dentistry, Queen Mary University
of London, Mile End Road, London E1 4NS, UK
9
Department of Psychology, Government College for Women,
Moulana Azad Road, Srinagar, Kashmir (J&K) 190001, India
25
Department of Conservative Dentistry, Faculty of Dentistry,
Alexandria University, Alexandria, Egypt
10
Department of Health Policy Planning and Management,
University of Health and Allied Sciences, Ho, Ghana
26
11
Department of Radiology, Obafemi Awolowo University,
Ile-Ife, Nigeria
Maternity & Childhood Department, College
of Nursing, Taibah University, Madinah 42356,
Kingdom of Saudi Arabia
27
Department of Preventive and Biomedical Science, College
of Dentistry, University of Science & Technology, Sanaa,
Yemen
28
Department of Family and Occupational Medicine, Faculty
of Medicine, Doctoral School of Health Sciences, University
of Debrecen, Debrecen, Hungary
29
Institute of Zoology, University of the Punjab, Quaid-i-Azam
Campus, Lahore 54590, Pakistan
30
Postgraduate Department, University of Sierra Sur, Oaxaca,
Mexico
31
World Health Organisation, AFRO, Addis Ababa, Ethiopia
32
Department of Family Medicine, Keck School of Medicine,
University of Southern California, Los Angeles, CA, USA
12
Department of Psychology, Lead City University, Ibadan,
Nigeria
13
Department of Substitutive Dental Sciences, College
of Dentistry, Imam Abdulrahman Bin Faisal University,
Dammam, Saudi Arabia
14
Department of Preventive Dental Sciences, College
of Dentistry, Imam Abdulrahman Bin Faisal University,
Dammam, Kingdom of Saudi Arabia
15
16
Centre for Rural Health, School of Nursing and Public
Health, University of KwaZulu-Natal, Durban, South Africa
Department of Health Promotion, Faculty of Health,
Medicine, and Life Sciences, Maastricht University,
Maastricht, The Netherlands
13