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The conversation01 December 2020 11:00:08 IST
Since 2013, global efforts have been made to gain control over the AIDS epidemic by 2020 through UNAIDS ‘ 90-90-90 targets. The goal was to make sure that 90% of all people living with HIV know their status; and of these, 90% started antiretroviral therapy (ART); and of these, 90% achieve viral suppression through adherence to ART. Viral suppression it means that the virus in their blood is undetectable and they cannot transmit HIV sexually.
Much has been done to achieve these goals. To date, 14 countries have met the 90-90-90 targets. However, missed goals in other countries since 2015, they have resulted in 3.5 million HIV infections and 820,000 AIDS-related deaths.
Indian volunteers and members of the West Bengal Voluntary Health Association (WBVHA) light candles in the shape of a red ribbon during the closing ceremony of an AIDS awareness campaign on the occasion of “World AIDS Day” in Siliguri on 2 December 2013 Image credit: AFP PHOTO / Diptendu DUTTA. / AFP / DIPTENDU DUTTA
One of the countries missing the mark is South Africa, which carries 20 percent of the global HIV burden. By 2018, encouragingly 90% of all people with HIV in South Africa knew their state. However, only 68 percent knew their status was in ART; and of these, 87% were virally suppressed. This equated to 61% of all people with HIV in South Africa who started receiving prolonged ART and 53% of all people with HIV virally suppressed.
Then, at the end of 2019, COVID-19 emerged and has now swept the globe. This new pandemic has shifted the expected course of public health resources and existing campaigns against HIV. The South African National Council for AIDS fears that the progress of multi-year strategic plans was overturned. This is a concern shared by many countries with a high HIV burden.
COVID-19 has put a strain on the country’s already tense health system. Measures taken to curb the spread have made it difficult for people to access health care and routine medicines for chronic noncommunicable diseases and HIV. Strategies are needed to optimize health-related outcomes for all conditions, while still allowing the health system to fight the new pandemic.
COVID-19 and health systems
Strong national blocs around the world, including South Africa, were essential to slow the transmission of COVID-19 and enable health systems to prepare for the impending wave of critically ill patients.
Unfortunately, these unprecedented nationwide arrests have had downstream effects on other aspects of public health systems. They have created a serious threat to countries with a high HIV prevalence. People who rely on HIV prevention, care and treatment services have become even more vulnerable.
People with HIV need ART to survive, because there is no cure or vaccine. During the lockdown, patients were afraid to leave their homes collect medications. The trepidation was caused by the fear of contracting COVID-19, but also by the threat of police brutality or incarceration through the strengthening of the quarantine. For patients who have come to ART dispensaries, many expert facilities – and they are still experiencing – deficiencies in supply chain management that cause drug stocks to run out. Also, due to the influx of COVID-19 patients, other services (such as reproductive health services) may not have been available.
World Health Organization and UNAIDS projected that a complete six-month discontinuation of HIV treatment could lead to an excess of more than 500,000 AIDS-related deaths in sub-Saharan Africa over the next year. This is an important step back. In 2018, 470,000 related to AIDS deaths have been reported in the region.
South Africa has one of the highest number of HIV cases and people on ART. The country would experience the greatest changes in both HIV incidence and mortality due to interruptions in ART. Interruptions or delays in treatment will further compromise the immune systems of people with HIV. This could mean the disease progresses where the CD4 count is too low to reconstitute or opportunistic infections become unmanageable.
These projections should scare everyone. As well as, from April 2020, 36 countries containing 45% of the world population of ART patients reported disruptions in ART supply. Twenty-four countries are fighting the depletion of stocks of first-line treatment regimes. Other by-products of a disrupted health system is that 38 countries have reported a substantial decrease in the adoption of HIV testing.
South Africa is already seeing a near 20 percent decrease in the ART collection in the key provinces ea 10% decrease in viral load tests of ART patients since the introduction of the blockade in March. Shorter and sporadic interruptions to treatment can also produce further complications. These include an increase in the spread of HIV drug resistance, which has long-term consequences for future success of the treatment.
HIV and COVID-19
Globally, scientists have focused primarily on increased risk of COVID-19 related disease and death associated with noncommunicable diseases such as hypertension and diabetes.
Unfortunately, the role that other infectious diseases play in health outcomes is largely forgotten. Successes to established HIV programs make people with HIV even more vulnerable to adverse health events. Therefore, it is also important to understand that this same population is at increased risk for COVID-19-related morbidity and mortality.
There is an intersection between non-communicable and infectious diseases, with HIV at the center. The nature of the virus and the treatment required means that people with HIV are found increased risk of inflammation and metabolic syndrome. This puts them at risk for chronic noncommunicable diseases – a risk factor for COVID-19. Additionally, ART has allowed people with HIV to live longer and naturally develop these comorbidities as they age. People with active tuberculosis (TB) are gone 2.5 times more likely to die from COVID-19. In South Africa, the TB / HIV co-infection rate is higher 60 percent.
The first published study on the effects of COVID-19 infection among people with HIV in sub-Saharan Africa was reported from the Western Cape, South Africa. People with HIV have a 2.75 times higher risk of dying from COVID-19 than those without HIV. Viral suppression does not appear to affect health outcomes, with HIV accounting for about eight percent of all COVID-related deaths. There is greater cause for concern when considering the high levels of HIV comorbidity with noncommunicable diseases and TB.
Go on like this
The models designed need to be taken seriously and strategies are needed to support all vital health services.
There is an urgent need for global and local differentiation the provision of services ensure continuity of HIV service – the most critically uninterrupted ART supply – during the COVID-19 pandemic. These strategies could include a change in the place where HIV testing is provided and treatment is delivered. Patients may be given longer treatment refills or bulk treatment packs.
Community-based services could serve both pandemics. Such a strategy could alleviate the pressure on public health facilities while protecting the most vulnerable populations who need to stay at home to minimize the risk of exposure.
With the limited global movement comes the limited import of HIV tests and treatments. Countries must include locally produced medicines under their national ART regimes. Governments, suppliers and donors must avoid excessive numbers of HIV-related deaths by creating a uninterrupted supply of ART.
If the world is steadfast and focused solely on combating one pandemic (COVID-19), while forgetting the others, the effects of other morbidities and mortalities on health systems will be visible for a long time to come.
Kathryn L Hopkins, Perinatal HIV Research Unit, University of the Witwatersrand e Glenda Gray, Research Professor, Perinatal HIV Research Unit and President, South African Council for Medical Research
This article was republished by The conversation under a Creative Commons license. Read the original article.
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