As the world marks the 40th anniversary of the HIV/AIDS epidemic, we ask what impact the COVID-19 pandemic is having on HIV programmes around the world. Talha Burki reports.
Last year, UNAIDS warned that if the COVID-19 pandemic interrupted access to antiretroviral therapy (ART) for 6 months, sub-Saharan Africa could see an additional 500 000 deaths from AIDS-related illnesses. Thankfully, the world has avoided such a catastrophe (at least, for now). The global HIV/AIDS data for 2020 have not yet been released, but the indications are that provision of ART has largely been maintained. Nonetheless, the pandemic has had a dramatic effect on HIV/AIDS programmes. Vital services have been suspended and fewer people have been initiated on ART. The Global Fund to Fight AIDS, Tuberculosis and Malaria has stated that “there is no scenario in which we can achieve the progress we want against HIV...while COVID-19 remains unchecked and systems for health are threatened”.
For the majority of high-burden countries, the most severe disruption occurred from March to July, 2020. HIV clinics closed or abbreviated their operating hours. Public transport was trickier to access, people with respiratory symptoms were discouraged from leaving their homes, and there was a general fear of being infected with SARS-CoV-2 at health-care institutions. Prevention and testing for HIV was drastically curtailed. Several nations experienced stock-outs of condoms. Voluntary male circumcision services were stopped. There were widespread shortages of personal protective equipment (PPE). “Infectious disease specialists and nurses have been providing COVID-19 care without PPE and without having been vaccinated; some of them have fallen ill and some of them have died”, said Chris Beyrer, professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. “We cannot afford to lose these people.”
Vulnerable groups have had a tough time. The closure of bars and brothels has deprived sex workers of much needed wages. In countries all over the world, gender-based violence has spiked. “There is no question that there has been an increase in sex work and survival sex, particularly in west Africa, over the past 18 months”, adds Beyrer. Reports emerged of sex workers in Uganda being excluded from food aid distribution.
COVID-19 has dominated the political agenda, making it harder to drum up interest in matters such as drug policy reform or the rollout of sex education. Then there is the colossal economic cost. According to the Overseas Development Institute, the COVID-19 pandemic could push 250 million people into extreme poverty by 2030. Funding for HIV/AIDS programmes in low-income and middle-income countries has plateaued over the past few years. The intervention of COVID-19 means that resources are likely to be constrained for the foreseeable future. For countries such as Malawi and Uganda, whose HIV/AIDS programmes are heavily reliant on donor funding, reductions in overseas aid could have serious consequences.
An abstract presented at the Conference on Retroviruses and Opportunistic Infections in March, 2021, outlined how HIV services in sub-Saharan Africa recovered from the initial upheaval caused by the COVID-19 pandemic. The falls in testing, positive tests, and numbers of people starting treatment that occurred from April to June, 2020, were matched by increases from July to September. Viral suppression was maintained and multi-month prescription of ART was stepped up. “Patients with HIV, who are virally suppressed and stable, do not need to be coming in every month to collect their medication”, explained Beyrer. “In the USA, we only ask to see these patients once a year. The COVID-19 pandemic has led to countries moving to 6-monthly prescriptions of ART; hopefully this will become permanent.”
Similar measures have been adopted for opioid substitution therapy (OST). Speaking to The Lancet Infectious Diseases, Michel Kazatchkine, special advisor to UNAIDS for Eastern Europe and Central Asia, said: “This is a region where you have to go every day, or twice a day, to your methadone clinic, even if it takes you 2 h by bus.Now we are seeing countries agree to prescriptions of a week or more, and home delivery of methadone by civil society organisations. This would have been unthinkable in the past”. Whether the innovations will outlast the pandemic remains to be seen. After Ukraine eased its lockdown, it discontinued 10-day-long prescriptions of OST.
Some governments have tried to cut the chances of COVID-19 rampaging through prisons by releasing the elderly or those serving short sentences, some of whom have been convicted of crimes related to drug use. Kazatchkine hopes the moves will spark a debate on treating non-violent drug offenders, rather than incarcerating them. The lockdowns have also led to increased uptake of telemedicine, something medical systems have historically been slow to rollout. Using apps to deliver services has clear benefits, although much depends on internet coverage.
“A lot of the positive developments have come from civil society”, adds Kazatchkine. Activists in Georgia have turned to Tinder to offer HIV services to people from the LGBT community. Examples abound of non-governmental organisations (NGOs) filling packages with items such as condoms, rapid HIV tests, and information booklets, and posting them to people's homes. “Governments all over the world need to recognise the importance of community organisations and support them financially; the work they have been doing is vital”, said Adeeba Kamarulzaman, professor of medicine and infectious diseases at the University of Malaya in Kuala Lumpur.
Kamarulzaman welcomes the increased use of self-testing kits for HIV. “In many settings, there is still a great deal of stigma associated with HIV/AIDS—people shy away from clinics”, she explained. “If we can encourage people to test themselves, and then link them to pre-exposure prophylaxis or treatment and care, that could help bring down infections and expand coverage of ART.”
Salim Abdool Karim, director of the Centre for the AIDS Program of Research in South Africa, points out that no pandemic in human history has been as closely monitored as COVID-19. “Every day, ministers for health are issuing statements about the number of cases, tests, and deaths”, he said. “It is a whole new way of thinking about how we communicate with the public.”
The strong emphasis on community mobilisation, and the recognition that everyone has to play their part in reducing the risk of transmitting the virus, is something Karim would like to see revived in HIV/AIDS. He believes the field has become fixated on technological solutions, to the detriment of basic prevention. “With COVID-19, the whole of society has been mobilised, everyone wears masks, and sanitises their hands and so on. The pandemic has reminded us of our fundamental interconnectedness”, explained Karim. “People realise that we can only deal with COVID-19 by standing together. We need to get back to this kind of thinking for HIV.”
The extra 500 000 deaths in sub-Saharan Africa might not have come to pass, but the COVID-19 pandemic is far from over. UNAIDS has cautioned that it could still cause up to 293 000 new HIV infections and 148 000 additional AIDS-related deaths worldwide by 2022. HIV/AIDS programmes and NGOs will have to continue adapting to shifting circumstances and limited resources. On the evidence so far, they seem up to the task.