Introduction

Lesbian, gay, bisexual, and transgender (LGBT) communities experience disproportionately high rates of HIV [1], cancer [2], and behaviors such as smoking that can lead to worsened health [3] that may increase their risk for serious complications once contracting COVID-19 [4, 5]. Additionally, with reduced access to critical health services during the COVID-19 pandemic, such as testing for HIV and sexually transmitted infections (STIs) [6], any STIs may remain undiagnosed and untreated, leading to critical delays in accessing treatment that could contribute to worse health outcomes [7, 8]. Further, disruptions in access to critical medications–such as Pre-Exposure Prophylaxis (PrEP–a daily pill that if taken correctly and consistently can reduce the risk of HIV from sex by 99%) [9], could further increase the risk of transmission among groups who are disproportionately impacted by HIV and STIs compared to the general population.

Data are still limited regarding the impact of COVID-19 on racial/ethnic minority groups [10]. The reasons underlying existing health disparities [11], as well as the potentially disproportionate burden of COVID-19 infections among racial/ethnic minorities, are complex and relate to individual (e.g., higher rates of underlying comorbidities) [12] and structural (e.g., crowded living conditions and lower-paying jobs that limit physical distancing) [13] factors that challenge the risk and response to COVID-19 [14]. Further, among immigrant Latinx populations, the Supreme Court ruling regarding the Inadmissibility on Public Charge Grounds [15] (which significantly limits who can qualify for permanent residency) has further exacerbated existing fears that engaging with healthcare could negatively affect their immigration status. In an effort to expand the data available, a broad coalition of elected officials introduced a bill requiring the U.S. Department of Health and Human Services to collect and report racial and ethnic data related to COVID-19 [16]. Still, substantial data lags challenge ongoing attempts to concretely identify the pandemic’s impact on vulnerable communities. It is likely that the barriers complicating the risks of and response to COVID-19 are even greater among racial/ethnic sexual and gender minority individuals, such as Latinx sexual minority men (LSMM) and Latinx transgender women (LTGW) [17]. For example, since sexual and gender minority populations lack federal employment protections they may be at elevated risk for unemployment, and especially if undocumented, may have no access to financial relief offered by the federal government [14]. Further, being uninsured or underinsured will continue to serve as a barrier to general health services, in addition to new concerns introduced by COVID-19 testing and treatment [18]. These intersecting forms of marginalization underscore the need to identify and address the ways in which COVID-19 impacts particularly vulnerable communities such as LSMM and LTGW.

On March 19^th 2020, Los Angeles Mayor Garcetti issued a “Safer at Home” (SAH) emergency order requiring “all residents to stay inside their residences and limit all movement outside of their home beyond what is absolutely necessary to take care of essential needs” [19]. To expand the existing base of knowledge, we conducted a rapid, mixed-methods assessment by phone to understand how COVID-19 was impacting the health and wellbeing of LSMM and LTGW living in Los Angeles County (LAC).

Materials and methods

We used a mixed-method study design to quantify core domains and understand the frequency of responses, while also providing important context through open-ended qualitative questions [20, 21]. The following three core domains were examined quantitatively and qualitatively: 1) COVID-19 infection history and experiences with quarantine; 2) Health and healthcare access; 3) Employment and economic impact of COVID-19. We considered focusing only on LSMM to avoid combining populations with distinct needs based on sexual orientation and gender identity. However, information is urgently needed on both LSMM and LTGW, and the mixed-methods approach allows us to highlight the similarities and differences of these two vulnerable communities.

Procedures

Institutional Review Board approval was received for the study protocols and materials (RAND Human Subjects Protection Committee and The Los Angeles County Public Health, Ambulatory Care network and Health Services Administration Institutional Review Board). Data was collected between April 27 –May 18, 2020. We randomized the participant list from the completed study to contact participants. Interviews were conducted by phone in the participant’s preferred language (either Spanish or English) by a Latinx bilingual study coordinator. All participants were read a copy of the informed consent and provided verbal consent. The interviewer noted that verbal consent was attained before initiating the survey. The interview lasted between 20 and 30 minutes. The interview began with socio-demographic questions (Table 1), followed by quantitative questions regarding the impact of COVID-19 on health and wellbeing. The quantitative questions were based on the Epidemic–Pandemic Impacts Inventory [EPII], a tool designed to assess tangible impacts of COVID-19 across personal and social life domains. All candidate items from the EPII were constructed and tested by a team of clinical and developmental psychologist with feedback from professionals across multiple disciplines and finalized via expert consensus (Table 2) [24]. Following the quantitative questions, the interview included questions regarding PrEP disruptions [25] associated with COVID-19 (Table 3). The interview asked qualitative questions to provide context and nuance for the quantitative responses and highlight similarities and differences between LSMM and LTGW (Table 4). The complete interview scripts were programmed using Select Survey (a web-based survey software which can be used for computer-assisted telephone interviewing—CATI). Participants received a $15 electronic gift card via email or text message for participating in the interview. Additionally, participants were emailed a COVID-19-related resource sheet with LGBT-specific information.

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Table 1. Socio-demographic characteristics of Latinx sexual minority men and transgender women (n = 52).

https://doi.org/10.1371/journal.pone.0244421.t001

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Table 2. Responses to the Epidemic–Pandemic Impacts Inventory (EPII) among Latinx sexual minority men and transgender women (n = 52).

https://doi.org/10.1371/journal.pone.0244421.t002

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Table 3. PrEP disruptions due to COVID-19 among Latinx sexual minority men and transgender women (n = 52).

https://doi.org/10.1371/journal.pone.0244421.t003

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Table 4. Exemplary quotes highlighting similarities and differences between Latinx sexual minority men and transgender women (n = 52).

https://doi.org/10.1371/journal.pone.0244421.t004

Results

The sociodemographic characteristics for LSMM and LTGW are reported in Table 1. More than two-thirds (69.0%) self-identified as being a sexual minority man (n = 36) and about a third (31.0%) self-identified as being a transgender woman (n = 16). LSMM and LTGW were similar across most sociodemographic characteristics such as age (mean age of 40.2 for LSMM vs. 39.4 for LTGW) and relationship status, as most reported being single (66.7% of LSMM vs. 73.3% of LTGW) or living with a partner (19.4% of LSMM vs. 20.0% LTGW). There were differences with respect to having at least a high school education (80.6% of LSMM vs. 50.0% of LTGW), being employed full-time (63.9% of LSMM vs. 43.8% of LTGW), and reporting an annual income greater than $35,000 (22.2% of LSMM vs. 6.3% of LTGW). While LSMM and LTGW participants reported similar percentages of U.S. citizenship or permanent residency (63.9% of LSMM vs. 50.0% of LTGW) and undocumented residency status (22.2% LSMM vs. 18.8% of LTGW), far more LTGW reported their documentation status as Deferred Action for Childhood Arrivals (DACA), asylum, or U visas for victims of violent crimes (25.0%) compared to LSMM (5.6%). Additionally, 21.2% of participants reported having at least one chronic health condition and 26.0% of participants consider themselves regular smokers–two characteristics known to increase the likelihood of complications if infected with COVID-19 [28].

Below, we report the quantitative results for each domain (Tables 2 and 3) and then complement it with qualitative findings (Table 4).

Discussion

Though no confirmed cases were noted, COVID-19 dramatically impacted other aspects of health and overall wellbeing of LSMM and LTGW. While research is generally limited, we explore similarities and differences with other published studies.

With respect to COVID-19 infection history and quarantine experience, a recent large online survey of sexual minority men across the U.S. (n = 1051) reported more symptoms of COVID (37.8%), and–similar to our study–reported a negligible number of confirmed COVID-19 cases (0.1%) [29]. Another small study also conducted among LSMM in Miami-Dade County (n = 12) suggests that despite low rates of confirmed COVID-19 cases among the sample, there is still fear and anxiety about spreading the infection [17]. Far more research is needed to more accurately understand the epidemiological landscape of COVID-19 infections, particularly in racial and ethnic communities. With respect to quarantining experiences, to our knowledge, there is no data reflecting the impact of SAH on conflict and arguments among LGBT communities. The World Health Organization made a statement in April 2020 highlighting a global increase in the reported rates of domestic violence since the COVID-19 outbreak began; however, it exclusively focused on violence against women [30]. Our data suggest participants were able to safely quarantine, though potential data collection challenges (e.g., transparent reporting of violence if quarantining with a perpetrator) may undermine our findings, and underscore the urgent need for additional research.

Our results suggest that the toll of COVID-19 on the health and healthcare access of LSMM and LTGW is substantial. Study findings highlight increases in alcohol use, as well as mental health challenges and sleep problems. These results are largely consistent with the limited data that are currently available [29, 17]. The aforementioned national study did, however, also note an increase in drug use, a finding that did not bear out in our own study. Our results also highlighted disruptions in PrEP persistence. Other studies have noted similar disruptions in general health, and specifically for HIV prevention and treatment services, and suggest they may be further exacerbated as the pandemic continues [31–33]. While our results underscore the need for improved messaging around the availability of HIV testing, innovative ways to provide critical HIV prevention services are evolving: Home specimen collection kits and self-tests are being made available and telehealth visits (supported by HIPPA compliant technology), accompanied with longer prescription supplies, support continued PrEP use that are but a few examples [6]. However, efforts to appropriately scale these efforts require addressing several potential barriers such as achieving payment parity for telemedicine assessments, develop a unique workflow that clearly identifies if and when an in-person visit is required as well as what labs can (or cannot) be delayed [34]. While the results reported here highlight concerns that require focused responses to address PrEP disruptions, they also suggest potential ways for services to adapt going forward (e.g., telehealth). Of note, the main substantial difference between LSMM and LTGW emerged with respect to accessing healthcare for gender affirming hormones and procedures, an issue highlighted elsewhere [35, 36]. While efforts to determine what should be defined as ‘essential procedures’ are impacting a range of often politicized domains of care (e.g., access to pregnancy termination services), additional studies are needed to confirm the extent of this problem.

The financial impact of COVID-19 was widespread and is likely to have long-lasting affect: Half of those we interviewed reported job loss, and more than one third reported substantial challenges purchasing food and paying bills. Participants often referenced how the economic concerns negatively impacted their mental health and ability to sleep. The economic vulnerability of undocumented Latinx communities, and especially among those who identify as sexual and gender minorities, has already been noted [10]. Here, documentation status appeared particularly relevant for experiencing financial hardships and calls into question how an entire class of workers who contribute significantly to the economy can be supported at this unprecedented time [37]. Certain companies have taken steps to reduce payments (e.g., internet, electricity) [38] or provide free access to internet for a limited time [39]. Many of these efforts are impromptu, with an evolving list of resources being made publicly available [40]. Questions remain how these and other efforts can be tailored to address the unique needs faced by racial and ethnic minority LGBT communities such as LSMM and LTGW.

To our knowledge, this study is one of the first to provide empirical data regarding the wide range of health and wellbeing challenges faced by LSMM and LTGW during the SAH in response to COVID-19. However, the study has limitations. Our sample was based on participants from the parent study, however as noted elsewhere [41], change in phone numbers and non-response was common and may introduce selection bias (e.g., those facing a loss of employment may have more time to answer the phone, though conversely may lead someone to feeling sad or depressed and unwilling to answer their phone). While our sample size provides substantial depth for the qualitative analysis, we were limited in the range of statistical tests we could conduct with the quantitative data because of sample size. Further, though the mixed-methods design generally allowed for triangulation, it is possible that the qualitative responses with respect to their reported safety at home were limited due to an unwillingness of participants to expand on potential conflict or violence at home beyond their initial ‘yes’ or ‘no’ response to the quantitative question.

Conclusions

Though no infections were noted, COVID-19 has impacted other aspects of health and overall wellbeing of LSMM and LTGW. Public health responses to COVID-19 should address stressors noted in other general population studies (e.g., mental health concerns) as well as other stressors that may disproportionately impact LGBT communities (e.g., continued PrEP use, access to HIV/STI testing, and body affirming hormones and procedures for transgender women in particular). Further, a comprehensive response is needed to address individual-, programmatic- and structural-level barriers faced by LSMM and LTGW. For example, campaigns addressing individual behaviors to reduce the potential for contracting COVID-19 (e.g., extensive handwashing, physical distancing, and mask wearing) should not only be available in Spanish and represent a range of skin tones, but also include diverse relationships beyond heteronormative family structures. Programmatic-level action steps highlight how trusted community partners can play a vital role by helping to navigate the quickly changing policy landscape with regard to state [42] and federal aid [43] during this pandemic. Further, they can clarify ambiguities regarding SAH orders to explain which essential services (such as HIV testing) continue to be available, noting the time and location of such clinics. Structural-level action steps are simultaneously needed. For example, extensive steps should be taken to ensure aggressive immigration tactics–e.g., ICE targeting hospitals or clinics–are halted during the pandemic and beyond [14]. These efforts to address issues raised by COVID-19 can move forward in conjunction with ongoing endeavors to bolster non-discrimination protections and access to federally funded programs that have largely been undermined by current legislation. Across these levels, researchers have the responsibility to use measures that accurately assess race/ethnicity as well as sexual orientation and gender identity to ensure we appropriately document the extent to which COVID-19 impacts these communities [44], and with concerted action, can also track our progress at mitigating the pandemic’s devastating impact across Latinx LGBT communities. This study contributes to the growing base of evidence regarding the ways in which COVID-19 will exacerbate existing disparities and also provides concrete suggestions to move us beyond documenting these disparities and instead, actively address them.

Acknowledgments

We would like to thank Mary Vaiana for her quick and careful review.