Maintaining the HIV response in a world shaped by COVID-19

Although global attention is dominated by COVID-19, the HIV / AIDS pandemic, in its fifth decade, is far from over. Since the early 1980s, 75.7 million people have been infected with HIV. 32 · 7 million people have died from AIDS-related diseases. HIV / AIDS remains a major public health crisis and only a few countries will reach the 90-90-90 treatment target for 2020. Much has been done about how information systems and service models respond to HIV aided the COVID-19 response, but the COVID-19 pandemic could have ripple effects on the HIV response and be devastating to communities. How could the COVID-19 pandemic shape the future response of HIV / AIDS towards achieving the goal of ending HIV / AIDS by 2030?

The COVID-19 pandemic has strained health systems and exposed gaps in public health almost everywhere. From the highest levels of national leadership to community-based health care facilities, human, financial and research resources have been diverted from HIV efforts. Most health systems in regions with a high HIV burden are fragile, and several studies suggest that disruptions to HIV services could have adverse effects on medium- and long-term health outcomes. Modeling data published in The Lancet Global Health show that severe treatment interruptions in high-load settings could increase HIV mortality by 10% within 5 years. The HIV Modeling Consortium has shown that severe treatment interruptions in sub-Saharan Africa – for example, preventing HIV treatment for 50% of patients for 6 months – could lead to an excess of 296,000 HIV deaths within a year. UNAIDS models suggest that a 6-month disruption to services for mother-to-child transmission of HIV could increase new infections among children by 40-80% in high-burden countries.

While HIV prevention, testing and treatment have been halted in many countries due to strict lockdown policies and disruptions in drug supply chains, UNAIDS says the effects of COVID-19 on maintenance of services of treatment have so far been less severe than originally feared. Thanks to new approaches, such as home delivery of medicines and digital platforms for virtual patient support, HIV prevention services have increased in many communities.

A chilling pattern of inequity shapes the burden of COVID-19 and HIV. The negative effects of each disease are exacerbated by social and economic disparities and disproportionately affect the poor and marginalized, especially young women and girls. The socioeconomic impacts of the COVID-19 pandemic will be far-reaching and long-lasting. The World Bank warns that 115 million people were pushed into extreme poverty in 2020. COVID-19 is also poised to increase inequality as pandemic-related job loss and deprivation hit most poor and vulnerable people. Poverty could translate into additional barriers to involvement with the HIV care system.

December 1, 2020 is World AIDS Day. Against the backdrop of an extraordinary health crisis, this year’s campaign calls for global solidarity and shared responsibility. For healthcare leaders facing many competing priorities, what could this mean in practice? In 2018, the International AIDS Society-Lancet Commission envisioned a new era of global solidarity, in which the response to HIV would integrate with the broader field of global health. Built on the AIDS movement’s commitment to human rights, gender equality and equity in health, this new era could focus on developing robust, flexible and people-centered health systems, achieving universal health coverage and address the social and structural determinants of health. The Global Fund to Fight AIDS, Tuberculosis and Malaria adopted a systems-strengthening approach in 2016. For other institutions that have been instrumental in the AIDS response, this perspective should mean that fragmented and isolated approaches are being replaced with broader strengthening and preparedness of the health system than complementing HIV with other health priorities.