At the Intersection of 2 Pandemics: The Impact of COVID-19 on HIV

Worldwide, there are currently 38 million people living with HIV (PLHIV).¹ The decades-long fight against HIV has overcome several hurdles, and its latest challenge is the concurrent COVID-19 pandemic.

The intersection of these 2 pandemics has led to disruptions in HIV services, accelerated the debut of telehealth into HIV care, and highlighted the vulnerability of Black/African American and Hispanic/Latino communities, which are populations at high risk for both HIV and COVID-19. A body of emerging research has resulted in an attempt to quantify these changes and predict the new trajectory of the HIV pandemic.

Disruptions to HIV Care

Government-mandated lockdowns, necessary to prevent the spread of COVID-19, have had wide-ranging effects on the delivery of health care. Around the world, PLHIV received fewer tests and had less access to treatment.^2,3  

Data collected by the Joint United Nations Programme on HIV/AIDS (UNAIDS) from March to September 2020 showed widespread declines in the numbers of patients initiating HIV treatment as well as declines in HIV testing.¹ In addition, of 13 countries reporting sufficient monthly data, 6 had 25% or greater decreases in the number of pregnant women tested for HIV, and 5 out of 10 countries had a 25% or greater decrease in the number of pregnant women initiated on antiretroviral therapy (ART). Although some of these declines were sharp and short lived, others persisted through September 2020.¹ 

A cohort study published in The Lancet HIV of 455 HIV-negative pregnant women in Cape Town, South Africa, evaluated the effect of a national COVID-19 lockdown on antenatal visits and pre-exposure prophylaxis (PrEP) prescriptions. The women were screened for PrEP eligibility at their first antenatal visit, and 91% opted to start PrEP. Overall, 34% of women missed their PrEP visits before the lockdown, and 57% missed their PrEP visits during the lockdown.²

“Frequent clinic visits were challenging for women before the lockdown,” noted Dvora Joseph Davey, PhD, lead author of the study, “especially in the postpartum period.” Women cited time and travel constraints, and some did not understand why they needed to continue PrEP after giving birth.

“But the proportion of women who reported those reasons increased significantly with the [COVID-19] lockdown. The health facility was perceived as a risky place to go, especially with a newborn baby,” said Dr Davey. Before the pandemic, “no one ever expressed fear of coming into the clinic”; however, COVID-19 has created a fear of coming into the clinic that still persists, she added.

To address this fear, Dr Davey and her team adapted their protocols. They switched lengthy health interviews to phone interviews, gave multimonth PrEP prescriptions, and applied a differentiated care model that delivered HIV testing and treatment outside the health clinic and into the community. “I think all of those things — differentiated care, shortened visits, multimonth prescriptions — should be continued even outside of a pandemic,” Dr Davey emphasized.

Supply chains for ART were disrupted by COVID-19, according to a survey conducted by the European AIDS Treatment Group in late April 2020 and early May 2020. The survey also found that PLHIV were asked to switch their treatment regimens to prioritize certain ART combinations for COVID-19 treatment instead. Some countries suspended voluntary medical male circumcision programs from April 2020 to June 2020 to focus on essential health services, and others suspended male and female condom programs, as well.¹

Yet despite the obstacles posed by COVID-19 measures, many countries were able to maintain patient access to ART long term. Among 25 countries reporting sufficient monthly data to UNAIDS, only 6 reported a sustained decline in the total number of PLHIV receiving ART as of April 2020.¹ Declining numbers in testing and PrEP or ART initiation were not solely due to restricted access. Changes in sexual practices from less socialization during the COVID-19 lockdown obviated some of the need for HIV services.⁴

A study published in The Lancet HIV conducted among 364 patients at the Melbourne Sexual Health Centre found that the number of postexposure prophylaxis (PEP) prescriptions decreased by 66% during 4 weeks of a COVID-19 lockdown compared with the 4 weeks before the lockdown. The study authors noted that this decrease was likely due to reduced sexual risk instead of reduced access because the health center remained open and accessible throughout the lockdown.⁵

Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, coauthored an article published in April 2021, HIV/AIDS in the Era of COVID-19: A Juxtaposition of 2 Pandemics, which outlined the effects that COVID-19 has had on the HIV pandemic.⁶ “There was a disruption in the normal behavior of life when people living with HIV were dealing with a pandemic that was threatening to kill them,” Dr Fauci said in an interview.

Telehealth: The New Face of HIV Care?

Telehealth was difficult to implement before the COVID-19 pandemic because of numerous regulations. Patients had to live in designated rural or medically underserved areas, only certain providers could bill for telehealth visits, and patients could not join telehealth visits from their homes but needed to travel to an approved location to connect with a visit. Private insurance payors restricted reimbursement, cost sharing, and prescription refills for telehealth visits.⁷

Yet telehealth has emerged as a way to avoid HIV care disruptions due to COVID-19 measures. In March 2020, the Department of Health and Human Services (DHHS) and the Centers for Medicare and Medicaid Services enacted several emergency waivers to lift restrictions on telehealth.⁸ The DHHS now recommends telephone or virtual visits for routine, non-urgent HIV care and counseling instead of in-person encounters.⁸ In February 2020, 0.1% of Medicare visits were done via telehealth; in April 2020, 43.5% of Medicare visits were conducted via telehealth.⁷

There were conflicting data from studies on HIV telehealth during the COVID-19 pandemic. Some studies reported higher patient engagement,⁹ while others reported more patients lost to follow-up.¹⁰

Issues with HIV telehealth exist, including concerns about quality of care, privacy, reimbursement, cost, medicolegal risks, and a diminished personal connection between patient and provider. A very prominent issue is the “digital divide” that separates HIV patients along socioeconomic lines: those with access to adequate technology and those without.⁷ Yet most PLHIV and providers in these studies reported positive attitudes toward telehealth, citing the ability to avoid both travel and the fear of stigma with in-person HIV clinic visits.

Dr Davey and her team in South Africa found that health interviews via telephone were “pretty effective at shortening visits and shortening contact in terms of the pandemic.”

She is preparing to publish a study on the role of stigma in HIV care for women in South Africa.

“A big issue [among women in the study] is the fear of even talking with their partner about HIV,” said Dr Davey. Since HIV is hyperendemic in South Africa, “PrEP is a way to protect them and their infant from getting HIV,” Dr Davey explained. “That stigma of seeking PrEP is still a problem.”

Therefore, telehealth will likely continue to be a mainstay of HIV care, and further study of the issues mentioned here will be necessary in the approaching era of post-COVID-19 HIV care.⁷

Black/African American and Hispanic/Latino Populations

Individuals in Black/African American and Hispanic/Latino communities have higher rates of HIV,⁶ COVID-19 infections, and worse COVID-19 clinical outcomes,¹¹ warranting special attention during the intersection of the 2 pandemics. Yet does HIV predispose these individuals to COVID-19 infection and worse clinical outcomes, or not?

A systematic review of 25 studies published in AIDS and Behavior found that coinfection with HIV is not a risk factor for COVID-19.¹² Regarding COVID-19 clinical outcomes, the research is mixed. Some studies reported a significant difference in the severity of COVID-19 infection in PLHIV.¹¹ However, the largest US cohort-based study of COVID-19 patients with and without HIV found similar rates of SARS-CoV-2 infection, hospitalization, intensive care unit admission, intubation, and death between both cohorts.⁶

“Not every person living with HIV is the same,” noted Dr Fauci. “There are some persons living with HIV who are on [ART], they have normal CD4 counts, and they have a virus that is below detectable levels; their risk of getting a severe outcome of SARS-CoV-2 is very, very low.”

A number of studies indicate that HIV-associated comorbidities, rather than HIV itself, puts PLHIV at risk for worse COVID-19 outcomes. These include certain cancers, chronic kidney disease, chronic obstructive pulmonary disease, certain cardiovascular diseases, obesity, and type 2 diabetes.⁶

“If you look at all HIV-infected people, all other things being equal, the fact that someone has a greater likelihood of getting a severe outcome is mostly related to the fact that they have more of an incidence of the underlying conditions leading to a more serious COVID-19 outcome,” Dr Fauci continued.

All of these comorbidities are also risk factors for severe COVID-19 in the general population¹³ and are particularly common among Black/African American and Hispanic/Latino communities. These conditions, rather than HIV, may predispose Black/African American and Hispanic/Latino PLHIV to severe COVID-19 infection outcomes.⁶

Yet disruptions in HIV care during the COVID-19 pandemic increased the disease burden of Black/African American and Hispanic/Latino PLHIV. A survey of 2732 men who have sex with men and other gay men, the results of which were published in AIDS and Behavior, found that those who identified as racial or ethnic minorities vs those who did not felt less definite in their ability to access condoms (62% vs 68%; P <.001) and HIV self-tests (17% vs 20%; P =.03), and more difficulty accessing or refilling ART prescriptions (25% vs 15%; P =.004) as a result of the COVID-19 pandemic.¹⁴

“Black and Hispanic people generally have essential jobs that put them into direct contact with other people,” explained Dr Fauci. “Therefore, they have a greater likelihood of being exposed to SARS-CoV-2.”

Progress in the HIV Pandemic

Will COVID-19 stall progress in the fight against HIV/AIDS? Projections from UNAIDS show that COVID-19-related disruptions in HIV care may lead to 123,000 to 293,000 additional HIV infections and 69,000 to 148,000 additional AIDS-related deaths globally from 2020 to 2022.¹ About 26 million people were on ART as of mid-June 2020, reflecting only a 2.4% increase from the end of 2019, compared with a 4.8% treatment coverage increase from January 2019 to June 2019.¹

A modeling study published in The Lancet HIV found that a 6-month interruption in the ART supply to 50% of PLHIV in sub-Saharan Africa could result in a 1.63 (range, 1.39-1.87) times increase in HIV-related deaths over a 1-year period compared with no disruptions, yielding 296,000 (range, 229,023-420,000) excess deaths.¹⁵ Disruptions of various HIV services due to COVID-19-prevention programs, testing, treatment, and care could lead to an increase in deaths from HIV, tuberculosis, and malaria.¹⁵

“You have everything from a lack of services for the prevention to a lack of implementation of the interventions such as PEP, PrEP, and treatment,” said Dr Fauci. “When you don’t treat people who are infected, you don’t get the viral load below detectable levels; they wind up infecting other people, and you have a propagation of the outbreak.”

There is a bright side, however. With large-scale COVID-19 vaccination, UNAIDS projects that HIV services will rebound quickly, and the COVID-19 pandemic’s effect on the HIV pandemic will be relatively short lived.¹

Therefore, UNAIDS developed new targets for 2025 in order to achieve their 2030 goal of 90% reduction in annual HIV infections and AIDS-related deaths. The 2025 targets focus on providing a core combination of HIV services, including multiple HIV prevention options, HIV testing, ART, and support for achieving and sustaining viral suppression.¹

Going forward, Dr Fauci feels that investing in science and research is the highest priority for staving off future pandemics and ending the current ones. “It was decades of investment in science — both clinical, preclinical, and basic science — which led to the development of highly successful, highly effective, and very safe vaccines,” he pointed out. “The greatest argument for investment in biomedical research is the fact that we’ve been able to very expeditiously develop effective vaccines for SARS-CoV-2,” Dr Fauci concluded.

References

1. UNAIDS. Prevailing against pandemics by putting people at the centre. World AIDS Day Report 2020. Published November 2020. Accessed June 16, 2021. https://www.unaids.org/sites/default/files/media_asset/prevailing-against-pandemics_en.pdf

2. Davey DLJ, Bekker L-G, Mashele N, Gorbach P, Coates TJ, Myer L. PrEP retention and prescriptions for pregnant women during COVID-19 lockdown in South Africa. Lancet HIV. 2020;7(11):e735. doi:10.1016/S2352-3018(20)30226-5

3. Krakower D, Solleveld P, Levine K, Mayer K. Impact of COVID-19 on HIV preexposure prophylaxis care at a Boston community health center. Abstract 11755 presented at: AIDS 2020: 23rd International AIDS Conference; July 6-10, 2020; virtual.

4. Chow EPF, Hocking JS, Ong JJ, et al. Changing the use of HIV pre-exposure prophylaxis among men who have sex with men during the COVID-19 pandemic in Melbourne, Australia. Open Forum Infect Dis. 2020;7(7):ofaa275. doi:10.1093/ofid/ofaa275

5. Chow EPF, Hocking JS, Ong JJ, Phillips TR, Fairley CK. Postexposure prophylaxis during COVID-19 lockdown in Melbourne, Australia. Lancet HIV. 2020;7(8):e528-e529. doi:10.1016/S2352-3018(20)30204-6

6. Eisinger RW, Lerner AM, Fauci AS. Human immunodeficiency virus/AIDS in the era of COVID-19: a juxtaposition of 2 pandemics. J Infect Dis. Published online April 7, 2021. doi:10.1093/infdis/jiab114

7. Budak JZ, Scott JD, Dhanireddy S, Wood BR. The impact of COVID-19 on HIV care provided via telemedicine—past, present, and future. Curr HIV/AIDS Rep. 2021;18(2):98-104. doi:10.1007/s11904-021-00543-4

8. Department of Health and Human Services. Interim guidance for COVID-19 and persons with HIV. Clinical info HIV.gov website. Updated February 26, 2021. Accessed June 16, 2021. https://clinicalinfo.hiv.gov/en/guidelines/covid-19-and-persons-hiv-interim-guidance/interim-guidance-covid-19-and-persons-hiv

9. Mayer KH, Levine K, Grasso C, Multani A, Gonzalez A, Biello K. Rapid migration to telemedicine in a Boston community health center is associated with maintenance of effective engagement in HIV care. Abstract 541 presented at: ID Week Conference; October 21-25, 2020; virtual.

10. Fadul N, Regan N. A quality management project of a midwestern academic HIV clinic operation during COVID-19: implementation strategy and preliminary outcomes. Abstract 112 presented at: ID Week Conference; October 21-25, 2020; virtual.

11. Pan D, Sze S, Minhas JS, et al. The impact of ethnicity on clinical outcomes in COVID-19: a systematic review. EClinicalMedicine. 2020;3(23):100404. doi:10.1016/j.eclinm.2020.100404

12. Mirzaei H, McFarland W, Karamouzian M, Sharifi H. COVID-19 among people living with HIV: a systematic review. AIDS Behav. 2021;25(1):85-92. doi:10.1007/s10461-020-02983-2

13. Centers for Disease Control and Prevention. Science brief: evidence used to update the list of underlying medical conditions that increase a person’s risk of severe illness from COVID-19. COVID-19 website. Updated May 12, 2021. Accessed June 16, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/underlying-evidence-table.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fneed-extra-precautions%2Fevidence-table.html

14. Santos G-M, Ackerman B, Rao A, et al. Economic, mental health, HIV prevention and HIV treatment impacts of COVID-19 and the COVID-19 response on a global sample of cisgender gay men and other men who have sex with men. AIDS Behav. 2021;25(2):311-321. doi:10.1007/s10461-020-02969-0

15. Jewell BL, Mudimu E, Stover J, et al. Potential effects of disruption to HIV programmes in sub-Saharan Africa caused by COVID-19: results from multiple mathematical models. Lancet HIV. 2020;7(9):e629-e640. doi:10.1016/S2352-3018(20)30211-3