NAIROBI — As cases of COVID-19 rise globally, so are concerns about the toll this pandemic could have on populations living with HIV.
This alarm has been elevated in recent days, as cases of COVID-19 in South Africa, which has the largest HIV epidemic in the world, continue to escalate. The country currently has 1,380 COVID-19 cases — the most severe outbreak of coronavirus on the African continent.
"In every single link of the supply chain we are seeing disruption.”— Chris Purdy, president and CEO, DKT International
While it’s currently unclear whether HIV-positive individuals are more at risk for contracting the coronavirus, or developing a serious form of the disease, health practitioners are bracing for the possibility that the pandemic could disrupt access to treatment, testing, and supply chains.
The COVID-19 effect
“There's no doubt that if the pandemic becomes a significant issue in countries where there are a large number of people affected by HIV, [it will have] significant implications for their health and well-being,” said Clive Ingleby, lead advisor on health at the Voluntary Service Overseas.
In response, organizations are advocating for multimonth dispensing of drugs, strategizing on how to manage HIV testing, and expressing concern over supply chains.
Since COVID-19 cases need intensive care, organizations working with HIV populations have warned that patients might no longer be able — or willing — to access health facilities to pick up their medication.
“As health systems become more overwhelmed with the need to treat COVID-19, other things get deprioritized. The danger is that people who require access to [antiretroviral treatment], in order to keep themselves healthy, may find it harder and harder to access those drugs,” Ingleby said.
This is coupled with concerns that lockdowns in some countries could prevent people from leaving their homes to get medication, while health workers could either fall sick or be unwilling to continue working without necessary items, like personal protective equipment.
Because of this, NGOs and international agencies are advocating that governments quickly switch to multimonth dispensing of HIV treatment — to provide patients with at least three months’ supplies of their drugs.
“This will prevent people from running out of medication should travel restrictions arise, and would reduce the need for them to access the health system (and potentially increase their exposure to people who are ill [with COVID-19] at the health system),” wrote Sophie Barton-Knott, a spokesperson for the Joint United Nations Programme on HIV and AIDS, in an email to Devex.
Restricted access to medication has already proven true in places where governments have implemented lockdowns to contain the spread of the virus. In Wuhan, the Chinese city where the outbreak began, and India, for example, residents have faced problems accessing HIV drugs.
The U.S. President's Emergency Plan For AIDS Relief said its “working to provide at least three months (and ideally six months) of ART for our clients” in response to COVID-19. It noted that health professionals can use phone calls or electronic follow-up to support adherence to drugs and to give guidance on how to manage side effects.
Even before the pandemic hit, some countries already adopted this practice, while other countries have been hesitant. Supply chains in some countries revolve around one-month dispensing, whereas in others there are limited supplies of drugs. Some national authorities have only approved one-month dispensing, and patient visits are scheduled around one-month intervals. Some health professionals are also worried that patients might not have safe, dry places to store their meds.
“It's a change in practice. It's very difficult to get a large community of clinicians to change their practice quickly. And in some places where supply chains haven't always been stable, it's frightening for clinics to hand out that much drug supply because they fear that they're going to run out,” said Nina Hasen, vice president for HIV and TB Programs at Population Services International. “If countries haven't already gotten everybody on board with that, now is a tough time to do it.”
This change will also need education at community levels so that people proactively go to get their supplies of pills before health facilities fill up with COVID-19 patients, she added.
Giving a sufficient supply of syringes for drug users is also important right now for preventing HIV infection, said Emily Christie, senior adviser on human rights and law at UNAIDS, during a conference call last week.
Task-shifting health care to communities will also be crucial during this pandemic, said Patrick Fine, CEO at FHI 360.
One example of this would be community distribution of pre-exposure prophylaxis — a daily pill used to prevent HIV, he said. In some countries, this would require regulatory changes that allow community health workers to dispense these medicines.
People on PREP should also be given a three-month supply now, PEPFAR said.
“There is a real danger that rates of infection could go up again.”— Clive Ingleby, lead advisor on health, Voluntary Service Overseas
Limitations around outreach and testing
The circumstances around the pandemic are also expected to complicate efforts around identifying new HIV cases, including outreach activities and recruiting people to come into health facilities to get tested, according to organizations.
“The HIV response relies heavily on peer outreach and peer support,” Christie said. “It’s now a problem with social isolation having those people go out and make sure that everyone is OK, people have the drugs they need and that they are adhering to them.”
UNAIDS received reports that police in some countries with lockdowns have targeted HIV peer outreach groups, accusing them of spreading COVID-19.
“All around the world, our ability to go out and look for people who might be positive is constrained,” Hasen said.
PSI sees HIV self-test kits — which people can use at home — as one solution to keep testing ongoing throughout the pandemic. The organization is now working to increase access to self-testing, such as in pharmacies, in countries where it works. These would ideally be available at a subsidized cost, she added.
In Central America, PSI has outreach programs that operate virtually. This includes cyber educators, who reach out to people on WhatsApp chat groups and other kinds of social media, to advocate testing for HIV.
“We're hopeful that a lot of that can continue and that those cyber educators can become a key contact point for people living with HIV to help them to get challenges in service delivery or drug access resolved,” Hasen said.
There are some conversations among organizations around focusing efforts and resources on ensuring that those known to be HIV-positive remain on treatment, limiting outreach to find new people that have don’t yet know they are HIV-positive, with the understanding that it’s a time-bound strategy that will end once the crisis passes. But it’s not a strategy everyone agrees upon.
“It's a dangerous path to take. If you are not going to continue to test people, then it means that people are going to be living with HIV without realizing it for longer. There is a real danger that rates of infection could go up again,” Ingleby said.
Supply chain limitations
The impact on supply chains might in turn affect the process of getting essential medical supplies such as condoms and drugs into the hands of people, experts say.
"In every single link of the supply chain we are seeing disruption. This disruption, I fear, is going to result, if things aren't addressed quickly, in more stock outs, shortages, and a lack of access in coming months," said Chris Purdy, president and CEO at DKT International, during a conference call last week focused on how COVID-19 is impacting sexual and reproductive health, expressing concern over condom production.
In a March 20 entry of technical guidance from PEPFAR, it noted that antiretroviral treatment manufacturers, based largely in India, have reported that they have sufficient amounts of active pharmaceutical ingredients to produce the drugs. The organization acted early in the COVID-19 outbreak to move HIV drugs closer to people that will need them in the coming months, Hasan said.
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