• COVID-19 AND HIV: A TALE OF TWO PANDEMICS

    The world faces an unprecedented emergency – the most lethal pandemic since AIDS emerged nearly 40 years ago. In recent months, COVID-19 has swept across the globe, bringing immense challenges, including for the tens of millions of people living with or affected by HIV.

Executive summary

Some shifts that countries set in motion within their health systems and economies to adapt to the COVID-19 pandemic threaten to deprioritize the urgent, ongoing needs of people living with HIV and derail decades of hard-won progress in the response to HIV, TB and other diseases.

A survey of programmes supported by the Global Fund to Fight HIV, Tuberculosis and Malaria in 106 countries showed that disruptions to service delivery due to the COVID-19 pandemic have affected 85% of HIV programmes [1].

COVID-19 has highlighted pervasive and long-standing issues influencing exclusion from health services, notably of those most vulnerable to HIV, including men who have sex with men, people who inject drugs, sex workers and transgender people. These populations have experienced renewed stigma, persecution and economic hardship [2]. In some countries, human rights-related barriers to healthcare access in the name of COVID-19 “emergency” and “disaster” powers and social injustices, stigma and racial inequalities have made the most marginalized more vulnerable to HIV and COVID-19 [3].

Frequent disruptions to supply chains, logistics and reporting systems have limited countries’ ability to maintain or extend HIV-related services, as well as to set up adequate COVID-19 control measures.

The picture is complex: COVID-19 has catalysed rapid adaptations in healthcare while exposing inequities at the same time.

Over the past years, the HIV response has increasingly acknowledged the importance of person-centred care, including shifts from in-facility to community-based, at-home or virtual services. For example, differentiated service delivery for HIV has been applied to services for key populations, enabled multi-month refills of antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP), and facilitated social network-based adherence and peer-led psychosocial support services.

In the context of COVID-19, recommendations for the HIV response include accelerating and adapting differentiated service delivery for HIV by also increasing out-of-facility and decentralized service points, and safeguarding continuity of testing and prevention activities.

Recommendations for the COVID-19 response informed by HIV are grounded in rights-based and community-centred approaches. True progress will require addressing deep-seated structural inequalities to protect the most marginalized. Recent global events have shown an increased awareness and sense of urgency in addressing issues of inequity that cause ill-health, sexual and gender-based violence, or structural racism. COVID-19, HIV and the Black Lives Matter movement all demand attention to and transformation of structural inequalities. 

COVID-19 has been called “the most acute global health crisis since HIV” [4]. Countries’ efforts to save lives must encompass COVID-19 and HIV and ensure that health systems everywhere are strengthened to support the right to health for all [5,6].

  • HOW COVID-19 IS IMPACTING THE HIV RESPONSE

COVID-19 is impacting the HIV response in three key ways. First, the shift of health system resources to focus on COVID-19 and national lockdowns has severely affected HIV treatment and prevention services, including interrupting care and increasing obstacles to accessing treatment, clinical services and psychosocial support [7]. Second, COVID-19 has exacerbated challenges for people living with HIV and key populations who are experiencing renewed stigma, with evidence of increasing vulnerability to HIV in the lesbian, gay, bisexual, transgender and intersex (LGBTI) community [8]. Third, the COVID-19 pandemic is highlighting existing system-level weaknesses in healthcare and supply chains, adversely affecting people living with HIV [9].

1. Expanding obstacles to treatment access and HIV prevention services

There is limited data on health outcomes among people living with HIV who have COVID-19. Continuity of treatment for HIV is essential during the COVID-19 pandemic as scientists determine how COVID-19 affects people living with HIV [10,11]. Additional precautions should be taken for people with advanced or poorly controlled HIV [12].

Clients in 13 African countries [13] revealed that HIV-related stigma, exacerbated by lockdown orders, has deterred some people living with HIV from attempting to obtain their ARVs. Rapid assessments conducted in March and April 2020 among people living with HIV in Uganda and Zimbabwe showed COVID-19-related challenges to be low levels of ART on hand [14], difficulties in accessing facilities due to temporary closures, cost, healthcare workers’ attitudes, fear of police harassment and lack of public transport. In Malawi, viral load testing has been halted as it has been deemed as non-essential [15].

A study on the impact of COVID-19 on PrEP care at a Boston community health centre pointed to disruptions in care, especially among vulnerable populations, despite high use of telehealth [16]. Additionally, a number of the ongoing worldwide HIV vaccine and immunotherapy efficacy trials have been shortened, paused or postponed as a result of the COVID-19 pandemic, causing further disruptions to services for people affected by HIV [17].

A survey across 29 countries in Latin America and the Caribbean in April 2020 showed that 70% of people living with HIV did not have enough ART on hand for the next two months. Further, 37% did not have the option of services adapted to ensure access during COVID-19, including consultations over the phone or Internet, delivery of medications at home or extended ART refills. Among migrants (85% from Venezuela), more than three-quarters of people living with HIV had one month’s supply of ART (52%) or less (24%) and 21% did not know where to go to obtain ART [18].

2. Exacerbating social and structural barriers to care

In many countries, people living with HIV are no strangers to social and structural barriers that hinder access to HIV-related services, now aggravated by COVID-19. Emergency powers invoked during the pandemic have been abused to justify police brutality, ignore principles of disclosure and target the most vulnerable [19].

Key populations in Bangladesh, Belarus, Puerto Rico, South Korea and Uganda have experienced renewed persecution and discrimination under COVID-19 emergency powers [20]. This is predicted to worsen, with increasing rates of unemployment, housing instability and food insecurity [21]. A survey of 13,500 LGBTI+ people in 138 countries found that COVID-19 has increased socioeconomic vulnerability among the LGBTI+ community, threatened their health and increased their susceptibility to HIV infection. Of 1,140 participants with HIV, 26% reported interrupted or restricted access to refills of ART [22].

Criminalization of HIV transmission, exposure and non-disclosure continues, with rights infringements under COVID-19 emergency powers. In April, 19 people, including people living with HIV, were arrested at an LGBTI shelter in Uganda for “a negligent act likely to spread infection or disease”. They were imprisoned without access to medication, legal representation or due process. Poland has amended a law that increases penalties for HIV exposure, non-disclosure and transmission. And Hungary has introduced a bill that prohibits people from changing their name or gender on official documents [23].

Issues of social justice, including race and ethnicity, heavily influence increased vulnerability to HIV, and COVID-19 has further exposed the racial wound of health equity. In the US and the UK, Black people and ethnic minority people are disproportionately affected by HIV and have also reported higher death rates due to COVID-19 than for the total population [24,25,26,27,28].

3. Exposing vulnerabilities at the systems level

The COVID-19 pandemic has highlighted existing vulnerabilities in healthcare systems and their knock-on effects. The lack of serious investment in building functional and resilient health systems in many resource-limited countries has brought into sharp focus the challenges of providing quality routine healthcare [29]. The HIV response and the COVID-19 pandemic are testing the resilience of many systems.

Supply chains have experienced disruptions and sometimes complete stoppages as a result of strict lockdown periods. The Global Fund reports disruptions in the supply of materials, ingredients, finished health products, logistics and shipping due to port closures and suspension of air travel, aggravating the risk of stock-outs [30].

Stopping courier and postal services in some countries has prevented local deliveries of medicines. Other vulnerabilities in many countries include too few medical professionals, medical staff and laboratories diverted to COVID-19 activities, insufficient equipment and supplies, and poor confidence in public health systems and national governments [31].

There is not enough evidence yet in the COVID-19 pandemic to have certainty about the long-term impacts of disruptions to the HIV response. However, in modelling to assess the impact of a total interruption of six months of ART across Africa, an estimated 500,000 additional lives would be lost to HIV-related causes [32].

  • RECOMMENDATIONS FOR HIV SERVICE DELIVERY IN THE CONTEXT OF COVID-19

It is critical that countries and healthcare providers take decisive evidence-based actions for responses to both HIV and COVID-19. The Ebola outbreak in West Africa in 2014-2015 had a substantial impact on the number of deaths from AIDS-related causes, TB and malaria because of reduced access to treatment as resources were focused on Ebola [33]. A published model predicts a similar outcome for COVID-19, but hopefully with the right public health responses, these predictions could prove to be a warning rather than reality [34].

Country- and community-based experience offers evidence of the impact of COVID-19 on HIV programmes. In some places, the COVID-19 pandemic and associated national lockdowns have led to increased innovations and ingenuity in HIV service delivery. This body of evidence gives clear strategies for policy makers, healthcare providers, researchers, scientists, healthcare workers, communities and funders.

  • 1.1 Reduce the frequency and duration of health facility visits.

    Core HIV services should not be disrupted due to COVID-19, but in-person visits to health facilities for people living with HIV should be limited [35]. Where visits are required, time spent in the facility should be reduced and the client should interact with the minimum number of providers.

  • 1.2 Implement extended refills of antiretroviral treatment.

    Public health authorities should enable the scaling up of multi-month dispensing of ART and PrEP, including up to six months, as recommended by WHO [36,37], in parallel with operational planning to minimize supply chain disruptions and ensure availability of medicines.

  • 1.3 Support out-of-facility pickup points for refills.

    HIV medication refills should be available through community pickup points, from drop-in centres and via “buddy” refills [38,39,40]. Service locations should be decentralized, including to key populations’ preferred community access points.

  • 1.4 Adapt health facilities to support core COVID-19 control measures.

    For essential health facility visits, triaging upon entry for COVID-19 symptomatic clients should be done, with physical distancing and other core COVID-19 control measures, such as hand hygiene, disinfection procedures and personal protective equipment (PPE) for health workers [41].

  • 1.5 Transition adherence support to virtual platforms, wherever possible.

    Providers should optimize consultations over the phone and the use of online platforms to maintain core HIV services and support community engagement during physical distancing [42]. With the increased need for psychosocial support, providers should find digital ways to create referral pathways and deliver support that responds to the evolving needs of communities.

  • 1.6 Adjust HIV prevention and testing.

    Prevention messaging should shift to virtual platforms and prevention supplies (condoms, lubricants, syringes) to decentralized service points. Multi-month prescribing and refills should be expanded for PrEP clients. HIV self-testing should be increased and prioritized for people taking PrEP, partners of people living with HIV and pregnant women [43], with appropriate messaging on where to access services.

  • 1.7 Assure quality linkage and ART initiation for those newly diagnosed with HIV.

    People newly diagnosed with HIV should be offered ART on the day of diagnosis, preferably at the location of testing with follow up and monitoring via digital platforms, where possible [44]. Immediate initiation on ART also provides an opportunity to refer or link people as needed to other services, such as harm reduction [45], prevention of mother-to-child transmission, psychosocial support services, contraceptive options, and sexual and reproductive health services.

  • 1.8 Continue to test for and treat HIV co-infections and co-morbidities.

     Treatment and preventive therapy for HIV co-infections, especially TB [46] and viral hepatitis, must continue, as must diagnosis and treatment of co-morbidities known to increase susceptibility to COVID-19, such as diabetes and other non-communicable diseases [47], with extended supplies of medicines, where possible.

  • 1.9 Ensure sexual and reproductive health and rights (SRHR).

    SRHR services have been disrupted alongside increases in sexual and gender-based violence since the start of lockdowns [48]. National efforts must ensure the continuity of SRHR services and continue addressing gender-based and sexual violence during the COVID-19 pandemic.

  • 1.10 Harness low-cost, accessible technologies to ensure digital access by all.

    Governments and healthcare providers must forge innovative partnerships with technology providers to enable uptake of digital health services. This should include use of low-cost and accessible technologies in low-bandwidth settings to reach as many people as possible [49].

  • RECOMMENDATIONS FOR THE COVID-19 RESPONSE INFORMED BY THE HIV RESPONSE

  • 2.1 Establish a rights-based approach to COVID-19.

    The HIV response has shown how public health and human rights approaches can be effective together [50]. Responses to COVID-19 can learn from HIV and focus on reducing some of the structural barriers to health and enabling access to essential health services for all. Key populations, homeless people and marginalized people living with HIV require support in the context of COVID-19 to ensure that their right to health is upheld [51].

  • 2.2 Address issues of social justice in healthcare settings.

    Issues of social justice, notably around race and ethnicity, increase vulnerability to HIV and COVID-19. The adverse health consequences of structural racism must be fully understood and addressed. Public health authorities should commit to disaggregating data, including by race and ethnic group, gender, age and other sociodemographic characteristics, and monitoring of ethnic groups’ health outcomes and experience of health systems.

  • 2.3 Enable and strengthen civil society-driven and community-led responses.

    These are some of the most effective ways to reach people, the HIV response has shown. Strengthening and integrating the voices and perspectives of clients and communities into public health policy will be essential for more effective and accountable COVID-19 responses.

  • 2.4 Address stigma against people with COVID-19.

    Much can be drawn from HIV-related stigma-reduction interventions [52] for COVID-19-related interventions to expose and eliminate the social processes that rely on racism, xenophobia and the blaming of “others” for epidemics [53,54]. Understanding the internalization of stigma in the context of COVID-19, and promoting mental health for those who have recovered from the virus, could also build on established methods from the HIV response.

  • 2.5 Continue to leverage HIV funding mechanisms for the COVID-19 response.

    HIV funding streams have proven their efficacy and are leveraging systems and tools to support COVID-19 responses in parallel with existing HIV programmes [55]. Funding mechanisms must continue to support health system strengthening while addressing COVID-19 and HIV, including the removal of user fees for essential health services [56].

  • 2.6 Strengthen supply chains.

    Supply chain challenges, including inaccurate forecasting, have been longstanding for HIV. Some issues have recurred in the COVID-19 context, with new pressures from expanding multi-month dispensing and new supply chain issues (for PPE and COVID-19 test kits) due to surges in demand and travel or cargo restrictions. Supply chain improvements achieved for HIV programmes can be leveraged for COVID-19 and broader health system support.

  • 2.7 Intensify collaboration on vaccine development for COVID-19

    Approaches to vaccine development should draw from the HIV response, including models, ethics and trial networks, that have laid the groundwork for COVID-19 vaccine development [57]. When a COVID-19 vaccine exists, it is likely to bring benefits for HIV vaccine development.

  • 2.8 Support equitable systems in the global allocation of supplies, tools and medicines for COVID-19.

    The HIV response caused a shift towards the right to equitable access to healthcare. For the first time, the WHO-convened Access to COVID-19 Tools (ACT) Accelerator commits the world to equitable access to diagnostics, treatment and vaccines for COVID-19. Concerted action must follow.

  • 2.9 Strengthen the multilateral system and equip institutions to inform a global response.

    Global cooperation and the establishment of global health coordination mechanisms remain crucial to push back public health threats, including HIV. Strengthening global cooperation and multilateral institutions working to this end will be key in overcoming both COVID-19 and HIV.

  • 2.10 Secure political commitment to implement evidence-based recommendations.

    With the newness and evolving knowledge about COVID-19, some leaders have made politicized decisions on managing the pandemic that are not based on the best available scientific evidence. Countries and communities should advocate for verified scientific processes to underpin policies and strategies in response to COVID-19.

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Photo credits

Photo 2: The Global Fund / Ricci Shryock

Photo 3: The Global Fund / John Rae

Photo 5: The Global Fund / Atul Loke / Panos

Photo 6: The Global Fund / Atul Loke / Panos

Photo 7: The Global Fund / Ricci Shryock