HIV services in times of COVID-19

Hospitals across the globe have been facing great pressure during the COVID-19 pandemic due to an upsurge in cases of SARS-CoV-2. Other health services rendered, however, have been greatly disrupted (some even suspended) in order to meet the needs of this pandemic. People living with HIV (PLWH) constitute a vulnerable population and are one of the most affected with the disruption of these services.

Maintaining the HIV care continuum has been particularly difficult during this ongoing pandemic due to three main challenges, first, gaining access to HIV testing and diagnostic facilities for new entrants, second, the delay in initiating antiretroviral therapy (ART) and third, refilling of ART drugs due to potential shortages, lockdown and traffic controls1. During the COVID-19 lockdown, most infectious disease physicians in several European countries continued to provide care to both HIV and COVID-19 patients. However, at the start of the lockdown, some were afraid of an inadequate stock of drugs being available, hence there is a need to optimize HIV care with limited resources at the time of a pandemic2.

Some strategies to ensure continued care could include13; (i) telephone consultations with HIV doctors and nurses through hotlines with involvement of local non-governmental organizations (NGOs); (ii) dispensing of ART medications for three or more months at a time to reduce hospital pharmacy visits; (iii) postal express mail service (EMS) delivery of drugs for those unwilling or unable to go to hospital; (iv) contacting local HIV doctors/general practitioners for care and medications instead of travelling to a referral hospital.

A 90-90-90 target was adopted by UNAIDS in 2014 whereby 90 per cent of PLWH would know their status, 90 per cent of those diagnosed would have received sustained ART and 90 per cent of those on ART would have viral suppression by 20204. Adherence to this strategy was studied in a hospital in Italy during the early months of the COVID-19 pandemic. Firstly, it was observed that there was a reduction in the number of new HIV patients during these early months (March-April 2020) as compared to before the pandemic (October-November 2019). Second, telemedicine consultations during the months of the pandemic helped meet a large number of health needs and continuum of care for HIV patients; and third, a reduction in drug dispensation was observed in March 2020 with a trend towards normalization in April 2020. Local associations and NGOs helped deliver ART drug supplies to patients’ homes, thus avoiding hospital pharmacy visits5. This has led to a task shifting of clinical services from hospitals to the local communities leading to additional services such as availability of home testing HIV kits and HIV care rendered by local doctors to maintain the continuity of care for PLWH.

For those living in low- and middle-income countries, vulnerable individuals, especially those living on streets or informal housing and those without access to food and clean water must receive support from the respective governments6. The WHO has recommended that policies must be put in place to limit the number of hospital visits for PLWH, making it safe for those visiting with critical illness. Outreach centres or drop-in clinics could provide HIV prevention services such as the distribution of pre-exposure prophylaxis, condoms, needles and syringes7. Some of the ways of maintaining preventive services could include HIV home/self testing kits, distributing condoms alongside COVID-19 testing services, addressing domestic violence to vulnerable populations and paying attention to their needs, providing online support and delaying certain prevention interventions such as voluntary male medical circumcision8. Furthermore, PLWH visiting ART centres should follow measures such as social distancing, wearing masks and hand hygiene. ART centres should triage symptomatic patients (fever, cough, breathlessness, etc.) for fast tracking and separate seating arrangements should be made for such patients9.

Despite of the disruption of services in many countries along with adaptation to new services provided this ongoing pandemic has paved the pathway for global coordination along with lessons to learn. Some of these lessons include community-led services, destigmatization of certain sections of people, strategic resource allocations, flexibility, equity, innovation and tailoring of services to the most vulnerable10.

Thus, adapting to new services and devising strategies to maintain continuum of care for HIV patients has become a priority during this pandemic. Ensuring the well being of vulnerable populations such as PLWH should be the priority for all countries and the involvement of community teams has made it possible to a great extent to meet the needs of such a population subset.