COVID-19 & HIV/AIDS pandemics: Parallels & lessons

In March 2020, the World Health Organization (WHO) characterized severe acute respiratory syndrome coronavirus 2 or SARS-CoV-2 which caused COVID-19 as a global pandemic1. Currently, there is neither cure nor a vaccine proven to prevent COVID-19. Many features of this pandemic are in fact the reminiscent of early responses to AIDS, first reported in the USA in 1981 - caused by HIV, leading to a high mortality and presenting a major challenge to the society.

Incidentally, both AIDS and COVID-19 are caused by RNA viruses, originating from animals. HIV is a retrovirus and SARS-CoV-2 belongs to the family of Coronaviruses. The latter is known to predominantly infect the respiratory and enteric systems, with clinical presentation ranging from asymptomatic/mild symptoms to severe illness and mortality. While COVID-19 is transmitted through droplets, aerosols especially indoors, and by contaminated surfaces/fomites, HIV through exchange of body fluids including blood, semen, vaginal fluid etc. Both do not respect national boundaries, and have highly variable incubation period and communicability. While COVID-19 is highly contagious and has a shorter incubation period of 2-14 days, it has spread across the globe within a few weeks of the first case, AIDS which has much longer incubation period took nearly 10 years to do so.

Here we attempt to highlight some of the parallels between responses to these two viruses and to observe what lessons can be learnt. It is important, however, to note that the knowledge of COVID-19 continues to rapidly evolve globally and in India.

Origin and ultimate destiny of the novel viruses

While the origin of SARS-CoV-2 remains unclear and is currently under investigation, the rapid person-to-person transmission has led to the virus engulfing the globe within a short period of a few months. It remains to be seen whether this novel virus would ultimately disappear like SARS and MERS or will become endemic like HIV or H1N1. This also means that we have to live with COVID-19 in the foreseeable future and get used to the 'new normal'. In terms of preventive practices, we have to persist with physical distancing, wearing of masks and hand hygiene.

HIV continues to be a major global public health issue, having infected 75 million people and claimed almost 33 million lives since the beginning of the pandemic2. Over the years, we know a great deal about its transmission, prevention strategies and treatment and care aspects, resulting in remarkable success in curbing its transmission and in managing cases.

Risk communication and community engagement are key to prevention

Both the pandemics were characterized by rapidity of response. The advances in science and technology helped identify and characterize the viruses. This led to the rapid development of diagnostic tests and of drugs at a phenomenally fast pace for HIV compared with other diseases such as tuberculosis. Availability of antiretroviral drugs brought about a transformational change in HIV management, turning it from a 'death sentence' to a chronic manageable condition. Similarly, research on vaccine and drug development for COVID-19 is now moving at an unprecedented rapid pace.

In the absence of a vaccine to suppress SARS-CoV-2, many countries have resorted to lockdowns, either nationwide or partially. The main idea behind the lockdown (a drastic form of physical distancing) was to prevent the sudden and sharp increase in cases that would otherwise overwhelm the existing health system capacity and to buy time so that health system can be better prepared for the surge in case counts. While the lockdowns helped us curtail the spread of the coronavirus, it had a severe disruptive effect on social life and economy. In addition, the pandemic has contributed to a life of fear, mental stress and anxiety3.

Transmission of SARS-CoV-2 and HIV has a strong link with human behaviour. Like HIV/AIDS, bringing about behavioural change is crucial for COVID-19 prevention and in breaking the chain of transmission and ultimately in determining the course of the pandemic4. While education, information and communication have been the bedrock of HIV prevention, providing credible information and messages can clarify misconceptions and help people take informed decisions to protect themselves from COVID-19. Civil society organizations in China have taken the responsibility of educating the community about their role in preventing the virus from spreading and urging to comply with the national guidelines5.

Several systematic reviews and meta-analyses have demonstrated the effectiveness of evidence-based, interpersonal communication in preventing HIV transmission678. Such a public health action requires trust and confidence of the people to ensure that they participate fully, for example, in contact tracing and quarantine measures.

Social networks and opinion leaders can play a vital role under the larger ambit of risk communication and community engagement because of their influence in community9. In the case of COVID-19, popular opinion leaders can help support government efforts by guiding, educating and encouraging their communities to adopt safer behavioural norms and raise voice against stigma and discrimination against those infected with COVID-19 including healthcare workers.

Today, the epidemic of misinformation - often triggered by social media - poses a major barrier to accessing healthcare and disclosing health status, thus weakening the ability to protect oneself. To address these issues in the context of HIV, policy frameworks were backed by legal instruments to protect the rights of infected individuals10. To mitigate the adverse effect of COVID-19 on healthcare workers, the Government of India has amended Epidemic Disease Act 1897, making the act of violence against medical staff a cognizable and a non-bailable offence11.

Optimizing testing for early diagnosis

Preventing COVID-19 infection involves identifying infected individuals and isolating them so that they no longer can transmit infection to others. Taiwan and South Korea have proactively and rapidly responded to COVID-19 and contained the epidemic with sufficient testing and robust contact tracing12.

In HIV, testing had the following three specific purposes: (1) diagnosis of infection in an individual, using ELISA with Western blot as confirmatory test (testing was accompanied by a pre- and post-test counselling); (2) prevention by screening of the donated blood and finally for (3) surveillance purposes to better understand the prevalence, distribution and trends of HIV infection13. In COVID-19, the cases are classified as confirmed if a person receives a positive reverse transcription-polymerase chain reaction (RT-PCR) test result. RT-PCR remains the gold standard of frontline diagnostic testing for the novel SARS-CoV-2. This method requires nasal and throat swabs which are used to detect the current infection status of an individual. Some States such as Delhi have begun using rapid antigen detection test which is a rapid test to detect the virus in a sample from the respiratory tract of a person. It is a quicker and cheaper test giving result within less than half an hour. Because it has a low sensitivity (meaning that the test gives many false-negative results), the negative test results have to be sequentially tested by RT-PCR. On the other hand, an antibody test is not a diagnostic test but is used for surveillance purposes to measure past infection by the identification of antibodies present in a blood sample after 1-3 wk of acquiring the infection. It is helpful in understanding the extent of disease spread within a community.

Strategic information, research and evidence-based policymaking

Strategic information: Surveillance was identified by HIV programmes as an important priority, and considerable investments were made in data collection, analysis and use of data for policy and strategy development14. These include HIV and AIDS case reporting, HIV sentinel surveillance in defined sub-populations and integrated biochemical and behavioural surveillance on an ongoing basis to detect trends in disease incidence and prevalence over time.

For COVID-19 also, robust country-specific disease/infection surveillance data are critically important to monitor trends and mount an evidence-based proactive action. Prompt outbreak investigations can help not only identify local transmission in a community, but limit wider transmission through isolation of cases and a strong system for contact tracing. A detailed analysis of real-time data in each country can help identify populations at risk and vulnerable groups at greater risk of severe disease and poor health outcomes. In the situation of community transmission, the geographical spread, disease trends, virus hotspots and virological features need to be monitored15.

Vaccine and drug development research: The issue of HIV vaccine development was complicated as the virus attacked the very cells in the immune system that we tried to boost by means of a vaccine. The three decades of research and infrastructure put in place is helping scientists to accelerate the development of next-generation vaccine platforms as they seek to produce a viable COVID-19 vaccine in record time16.

According to the WHO, as of November 12, 2020 there are 48 COVID-19 candidate vaccines in clinical evaluation of which 11 are in Phase III trials including Covaxine from Bharat Biotech from India17. In addition, from India another vaccine from Zydus Cadila is in Phase 1 and 2 trials, and a third vaccine from AstraZeneca/Oxford University has been approved to move to Phase 3 trial, which is undertaken by the Serum Institute of India18. The Serum Institute also has a contract with AstraZeneca/Oxford University and a few other developers for mass production of vaccines. Alongside research, discussions are already underway as to how to ensure that, if and when ready, the vaccine can become accessible to all who need it. The National Expert Group on vaccine administration has begun discussions with the leading vaccine developers and manufacturers regarding their production capacity and plans on pricing19.

At global level, the WHO is leading a COVAX global vaccine programme in partnership with the Global Alliance for Vaccines and Immunization (GAVI) vaccine alliance, and the Coalition for Epidemic Preparedness Innovations (CEPI) which is designed to guarantee rapid, fair and equitable access to COVID-19 vaccine for every country in the world20.

In the area of treatment, a recent study has identified 21 drugs to be effective in blocking the replication of the SARS-CoV-2 virus21. Referred to as repurposed drugs or drugs approved for other diseases are now under investigation for their effectiveness against COVID-19. Clofamazine - an antileprosy drug for which safety data are already available - has been used in India for decades. The WHO has recently recommended systemic corticosteroid therapy (e.g. dexamethasone) for patients with severe and critical COVID-1922.

On March 18, 2020, the WHO announced an international clinical trial called SOLIDARITY trial to evaluate the effectiveness of four different drugs or drug combinations for efficacy against COVID-19. The drugs included were remdesivir, lopinavir-ritonavir with or without interferon and hydroxychloroquine. However, Interim results from the SOLIDARITY Therapeutics Trial, indicate that remdesivir, hydroxychloroquine, lopinavir/ritonavir and interferon regimens appeared to have little or no effect on 28-day mortality or the in-hospital course of COVID-19 among hospitalized patients23.

One remarkable aspect is that the pandemic has catalyzed the unusual level of communication and collaboration among scientists across the world along with the growing financial investments and sharing of data, enabling research to move forwards faster than any time in the past. The availability of gene sequence data of COVID-19 virus is case in point. It has enabled scientists around the world to quickly work on vaccine development

Need for a whole-of-society approach, with health at the centre

Because both COVID-19 and HIV/AIDS uniquely affect every sector of the society and pose a grave threat to economic development, they require an intersectoral or 'the whole-of-society' approach. HIV was perhaps the first programme to actively engage with non-governmental organizations, civil societies, private sectors and other stakeholders. Campaigns by AIDS activist groups were instrumental in accelerating FDA approval for licensing of life-saving antiretroviral drugs and in ensuring that effective treatment was made available to all those who needed it the most.

To combat the COVID-19 pandemic, all sectors must play their role in a collective and coordinated manner. The government has the fundamental responsibility to plan, coordinate, mobilize and facilitate various COVID-19 prevention, treatment, care and support activities. It must further strengthen the epidemiological surveillance, laboratory capacity, research and human resources at all levels of health services. While broad-based consultation with the experts and communities was an important component in the fight against HIV, it appeared missing in many countries. The initial global response to HIV was coordinated by the WHO's Global Programme on AIDS, and subsequently from 1995 onwards by UNAIDS24. Contrary to HIV, the response to COVID-19 has been uncoordinated and fragmented, with different countries doing their own activities.

For Indian pharmaceutical industries, the COVID-19 pandemic came as an opportunity to play a crucial role in scaling up the manufacturing of COVID-19 vaccines and drugs. For years, the generic manufacturers of India have played a stellar role in making effective yet affordable vaccines and drugs available to the world. The India's manufacturers also need to maintain the global position by strengthening capabilities and becoming self-reliant in producing lifesaving medicines, by producing active pharmaceutical ingredients (API). In this context, India has to depend on imports of over 95 per cent of API for paracetamol and azithromycin from China25. To overcome this overdependence on a foreign country and to build self-reliance on raw materials, Indian pharma industries need to build up domestic manufacturing of API and for this to happen, the government needs to grant infrastructure status to API industries and push innovation by providing incentives and streamlining approval process.

HIV programmes during the 1990s helped strengthen health system capacities in the area of blood safety, laboratory diagnosis and engagement of community-level organizations in public health. Similarly, COVID-19 is an opportunity to seize and convert this crisis as a turning point towards establishing a strong, robust and responsive health system in the country.

Finally, considerable international cooperation and co-ordination has been forged especially for COVID-19 vaccine development. An example of international cooperation and global alliance is global health actors such as the Bill and Melinda Gates Foundation, Coalition for Epidemic Preparedness Innovations. GAVI, Global Fund, WHO, private sector partners and other stakeholders have come together to accelerate the development, production and equitable global access to new COVID-19 essential health technologies.

In conclusion, we would like to re-assert some of the key lessons from the HIV/AIDS pandemic which can be helpful in planning and implementing our response to the COVID-19 pandemic. These include the fundamental importance of a well-coordinated intersectoral response with health sector playing a central role; a need for comprehensive strategy including prevention and clinical management and importance of communication, building trust and community engagement as a part of the whole-of-society approach. A strong and robust health system is most critical especially the human resources. This and the primacy of ramping up research and innovation with focus on the development of new drugs, vaccines and diagnostics can help formulate and implement appropriate public health policy and action to combat this unprecedented public health challenge confronting the human society.