A Mixed Methods Study of Mental Health among Female Sex Workers with HIV during the Covid-19 Pandemic

Background: Before the Covid-19 pandemic, female sex workers (FSW) with HIV experienced elevated stress, limited access to coping resources, and high risk for mental health disorders. The purpose of this dissertation was to understand how pre-pandemic stress and coping influenced mental health among FSW with HIV during the first year of the pandemic. Methods: For Aims 1 and 2, I analyzed two rounds of surveys conducted with a cohort of FSW with HIV in the Dominican Republic (n=186) before and after the start of the Covid-19 pandemic. I used multiple linear regression, mediation, and moderation analyses to assess the roles of pre-pandemic minority stress and coping resources, as well as adaptive coping behaviors during the pandemic, in predicting mental health during Covid-19. For Aim 3, I conducted longitudinal qualitative analysis of three rounds of in-depth interviews with a sub-cohort of FSW (n=20). I created narrative summaries, matrices, and memos to identify trajectories of mental health, stress, and coping before and during the pandemic. Results: Relative to participants with self-reported “good or better” economic security pre-pandemic, participants with “poor” economic security reported more mental health disorder symptoms during the pandemic (b=1.54, p=.03). Other pre-pandemic minority stress and coping resource indicators were not associated with mental health during Covid-19, and adaptive coping behaviors neither mediated nor moderated those relationships. In Aim 3, I identified four trajectories of mental health, stress, and coping over time. While participants experienced considerable stress from economic hardship, stigma, and other sources throughout the study, as well as stress from the social and economic impacts of Covid-19, most (n=14) reported improved mental health during the pandemic, which they credited to enhanced coping and/or reduced stressors. Conclusions: Economic insecurity was a critical determinant of mental health for FSW with HIV before and during the Covid-19 pandemic. Qualitative participants demonstrated a high level of resilience and agency in coping with pandemic stressors, which contributed to improved mental health over time. Overall, findings support the need for interventions to foster resilience while mitigating the economic and social marginalization of FSW with HIV.