The 90-90-90 goals to tackle HIV/AIDS have been jeopardized by COVID-19, according to Dr. Jun Yong Choi, director of the AIDS Research Institute at Yonsei University and chief of division of infectious diseases at Severance Hospital in South Korea.
Set by UNAIDS, the goals aim to have 90% of all people living with HIV knowing their status, 90% of those diagnosed receiving sustained antiretroviral therapy, and 90% of those receiving ART achieving viral suppression — all by the end of 2020.
While their preexisting condition does not necessarily make those living with HIV more susceptible to COVID-19, the subsequent lockdowns and travel restrictions affect people’s ability to access regular treatment.
The first-of-its-kind data shows a slightly increased death rate for people living with HIV and tuberculosis in Western Cape province.
“Due to the COVID-19 outbreak, some people living with HIV have had to delay their appointments at clinics [to receive ART],” Choi said, adding that the break in treatment is harmful both to the individual and to public health.
Sharing his thoughts in an email, Choi discussed the challenges that COVID-19 presents for the HIV/AIDS epidemic and how to address the stigma that both COVID-19 and HIV can cause.
This conversation has been edited for length and clarity.
What challenges has COVID-19 posed in tackling HIV, and how can these be overcome?
Given the magnitude of this public health emergency, it is expected that other health programs will be affected, including the ability of HIV care and treatment programs to meet global targets of ensuring early identification of people living with HIV, timely initiation of combination antiretroviral therapy, and sustained viral suppression.
HIV programs need strong and sustained supply-chain management to ensure crucial supplies are available to patients when they need them, along with an adherence support system — a system which helps patients maintain their adherence to ART and which may include family support, measurement and advice of health care workers, and psychosocial support.
The World Health Organization has stated that people living with HIV whose HIV is controlled are at no greater risk for severe COVID-19 outcomes than persons without HIV. However, regular HIV clinic attendance, including picking up ART, could put people living with HIV at higher risk for acquiring SARS-CoV-2. On the other hand, not attending the HIV clinic and missing ART medication refills could put PLWH [people living with HIV] at risk as well.
A lot of your work has been focused on improving the local understanding of the HIV epidemic in South Korea. Do you have any advice on how others can do this, and has there been an intersection at all with COVID-19?
For HIV-positive individuals, there is concern that the pandemic could disrupt access to treatment, testing, and supply chains.
Because the characteristics of infectious diseases vary widely from region to region, infectious diseases experts need to create their own data specific to the region. For example, main modes of transmission, the prevalence, incidence, risk factors of opportunistic diseases, and noncommunicable diseases are different according to region.
I am involved in a HIV/AIDS cohort study within Asian countries, including South Korea. Data from such cohort studies can be used to develop strategies for overcoming HIV/AIDS in the region. Molecular epidemiology studies can provide information on transmission networks and can be used to combat HIV/AIDS in the region. Scientific research to produce evidence must go along with policy development.
Many health workers have faced stigma as a result of COVID-19. Are there lessons in the way this has been handled that could help to address stigma surrounding HIV?
Stigmatization does not help at all to overcome the epidemic of infectious diseases. Stigmatization can delay diagnosis of infectious diseases. Even though HIV infection is currently a controllable disease for patients on successful ART, people living with HIV/AIDS are still suffering from social stigmatization in many countries, including South Korea.
From the perspective of public health, HIV-related stigma is a major barrier for people to access HIV testing, care, and treatment services. Late presentation into care and delay in ART initiation likely generates more secondary HIV infections, increases morbidity and mortality, diminishes responses to ART, and causes higher health care expenditures. Interventions to reduce HIV-related stigma are associated with improvements in access to HIV prevention and care services.
People need to realize viruses can infect anyone, and the media should not make moral judgments when dealing with an epidemic.
We are nearly a decade away from the 2030 HIV elimination goal. How realistic do you think the 2030 elimination goal is for South Korea and beyond?
As of December 2019, the total number of diagnosed Koreans with HIV/AIDS was 13,957. Among those, the proportion of male persons living with HIV is 93.3%. In 2019, 1,222 cases were diagnosed. Although the prevalence is still low — less than 0.05% — the annual number of confirmed cases is increasing. Many experts think that sexual transmission among men who have sex with men population is the major mode of transmission in South Korea.
“Stigmatization does not help at all to overcome the epidemic of infectious diseases. Stigmatization can delay diagnosis of infectious diseases.”— Dr. Jun Yong Choi, director of the Yonsei University AIDS Research Institute and chief of division of infectious diseases at Severance Hospital
To achieve the elimination goal, UNAIDS set up the 90-90-90 goals. The goals are to have 90% of people living with HIV knowing their HIV status, 90% of diagnosed people living with HIV on sustained antiretroviral therapy, and 90% of people on ART achieving viral load suppression, all by 2020. The UNAIDS global HIV targets reflect the cascade of HIV diagnosis, care, and treatment.
Many countries are evaluating their achievement for the targets. Accurate measurement of the achievements is necessary to assess progress and to implement interventions to improve the cascade. Among the UNAIDS 90-90-90 goals, the second and third goals are almost achieved in Korea, but the first one — to have 90% of people living with HIV knowing their HIV status — has not been achieved yet.
A study suggested the proportion of undiagnosed people estimated to decrease from 77.8% in 2009 to 41.8% in 2015. Although the data source and used method might have several limitations, the study showed there might be a large proportion of undiagnosed people living with HIV in South Korea. To achieve the elimination goals eventually, we need more efforts for early diagnosis.