Less SARS-CoV-2 Should Not Mean More HIV

The COVID-19 pandemic has swept across the planet, defying early warning systems, health systems and economies. The pandemic has deepened existing inequalities and exposed the shortcomings of public health systems both in low-and middle-income countries and in high-income countries which were thought best prepared to face outbreaks.

Experiences and epidemiological studies have demonstrated how the COVID-19 health crisis has disrupted basic services such as routine immunization, as well as continued health care provision for prevention and management of chronic conditions. HIV care and clinical management has been challenged worldwide by restricted movement, delayed drug shipments, overwhelmed clinics, re-allocation of resources, and shortage of health personnel.

HIV care and clinical management has been challenged worldwide by restricted movement, delayed drug shipments, overwhelmed clinics, re-allocation of resources, and shortage of health personnel

In the times of COVID-19, World Health Organization (WHO), UNAIDS, health ministries and other agencies have had to adapt health provider delivery of diagnostic tests, as well as lifesaving drugs and services to people living with HIV. However, a collateral yet important medium- and long-term effect of the COVID-19 crisis may be its impact on HIV acquisition and the incidence of new infections.

In 2019, 1.7 million new HIV infections occurred worldwide, a 23% decrease compared to the 2.1 million new infections in 2010. This was due in large part to a substantial decrease in new infections in Sub-Saharan Africa, the region most affected by HIV. The mainstay of prevention of new HIV infections is condom use, pre-exposure prophylaxis with antiretrovirals, voluntary male circumcision, and “test and treat” which translates into immediate antiretroviral treatment (ART) of people living with HIV after diagnosis.

 UNAIDS World AIDS Day 2020 campaign.

The WHO HIV test and treat strategy was scaled up after the groundbreaking studies in 2016 showing that viral load suppression through effective ART resulted in no transmission of HIV, and that undetectable viral load=untransmittable (U=U). The treatment as prevention strategy links HIV testing with immediate antiretroviral treatment and is a crucial stepping stone toward the ambitious UNAIDS target of 95-95-95 (95% of people living with HIV have a diagnosis, 95% of those diagnosed start ART, and 95% of those on ART have suppressed virus) aimed at eliminating HIV by 2030. This has nearly been achieved in several countries, including some of the most affected globally such as Eswatini, Uganda, Zambia and Zimbabwe.

However, events such as conflict, epidemics, political unrest and climate disasters can disrupt health services and drug access for people living with HIV. The COVID-19 pandemic and public health response measures have provided a perfect storm for disrupting HIV care. To this end, in June 2020, WHO developed guidance for safely maintaining access to essential health services during the COVID-19 pandemic, including for all people living with HIV.

The COVID-19 pandemic and public health response measures have provided a perfect storm for disrupting HIV care

National governments, international agencies and other stakeholders have been working round the clock to minimize the disruption by pushing to overcome logistic challenges and supply chains. Even so, surveys conducted in June and July 2020 in several sub Saharan African countries including South Africa, Zimbabwe and Nigeria revealed that 15-50% of people living with HIV reported having difficulties accessing antiretrovirals during the pandemic. This means that some people living with HIV experienced intervals of unsuppressed HIV viral load. Gaps in access to antiretrovirals not only jeopardize the health of this population, but these periods of unsuppressed viral load could lead to an increase in HIV transmission to sexual partners and through mother-to-child transmission.

In addition to a direct impact on HIV transmission, the COVID-19 crisis may indirectly contribute to a surge in new HIV infections by increasing social and economic risk factors for HIV acquisition. According to the World Bank, in 2021, it is estimated that the COVID-19 pandemic will have pushed as many as 150 million additional people worldwide into extreme poverty: living on less than 1.90 US$ /day, most living in low- and middle-income countries.

On the World AIDS Day, campaign by the Global Fund to Fight AIDS, Tuberculosis and Malaria.

The COVID-19 pandemic and the accompanying economic crisis are deepening inequalities, increasing gender violence and are thought to be associated with greater mental illness and substance abuse, all considered intertwined risk factors for HIV acquisition.

The COVID-19 pandemic and the accompanying economic crisis are deepening inequalities, increasing gender violence and are thought to be associated with greater mental illness and substance abuse, all considered intertwined risk factors for HIV acquisition

Poverty is an indirect driver of HIV infection. The relationship between poverty and HIV is multifaceted and context-specific. Poverty pushes people into migratory labor pools, seasonal work and unstable housing which increases risk of sexual violence, substance abuse and transactional sex. Substance abuse can lead directly to HIV infection through shared needles as well as indirectly through increased risky sexual behavior and trading sex for drugs.

The intersection between HIV infection and intimate partner violence against women is complex. It is thought that HIV transmission can occur directly through sexual violence or indirectly through increased risk-taking and an inability to negotiate condom use. Coronavirus related policy measures may also have undesired effects: girls out of school are at increased risk of exposure to sexual exploitation and secondary HIV risk, particularly in Sub- Saharan Africa where young women and adolescents account for one in four new HIV infections.

There is no vaccine for HIV, but over three decades of research and global solidarity have succeeded in decreasing the rate of new HIV infections and scaling up lifesaving treatment for millions. We hold the tools, the will and the momentum to eliminate HIV, the leading cause of death in women 15-24 years of age worldwide in 2019. As the pandemic and ensuing economic crisis unfold, the global community must align efforts to take on the shared responsibility of preventing millions from falling into poverty and protecting our youth from HIV. This is the only path to HIV elimination by 2030.