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(MENAFN – The Conversation) Since 2013, global efforts have been made to gain control over the AIDS epidemic by 2020 through https://www.unaids.org/sites/default/files/media_asset/201506_JC2743_Understanding_FastTrack_en.pdf 90- 90 of UNAIDS -90 objectives. 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. https://www.who.int/hiv/mediacentre/news/viral-supression-hiv-transmission/en/ Viral suppression 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, https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2020/july/20200706_global-aids-report missed targets in other countries and resulted in 3.5 million HIV infections and 820,000 AIDS-related deaths since 2015.
One of the countries that lacks the branding is South Africa, which carries https://www.hsrcpress.ac.za/books/south-african-national-hiv-prevalence-incidence-behaviour-and-communication-survey-2017 20% of the global HIV burden. By 2018, encouragingly, 90% of all people with HIV in South Africa knew their state. However, only 68% who knew their status were on ART; and of these, 87% were virally suppressed. This equated to 61% of all people with HIV in South Africa who started 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 AIDS Council fears that the progress of the multiannual strategic plans https://sanac.org.za/the-national-strategic-plan/ has been 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
Strict national blockades around the world including South Africa’s https://mg.co.za/article/2020-03-23-ramaphosa-announces-21-day-lockdown-to-curb-covid-19/ , 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 for https://theconversation.com/covid-19-promotes-innovative-hiv-service-delivery-in-cape-town-142583 to collect medication. The trepidation was caused by the fear of contracting COVID-19, but also by the threat of https://www.iol.co.za/news/politics/49-cases-of-police-brutality-reported-since-start – of-lockdown-dice-bheki-cele-50160784 police brutality or https://www.enca.com/news/summary-cele-briefs-media-covid-19-level-1-regulations incarceration through strengthened quarantine . For patients who have come to ART dispensaries, many https://www.iol.co.za/the-star/news/south-africa-facing-arv-shortages-as-covid-19-fight-disrupts -supply -50741964 facilities have experienced – and are still experiencing – deficiencies in supply chain management that cause drug stocks to run out. Additionally, due to the influx of COVID-19 patients, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7433230/ other services (such as reproductive health services) may not have been available.
The World Health Organization and UNAIDS https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2020/may/20200511_PR_HIV_modelling have predicted that a complete interruption of HIV treatment for six months could lead to an excess of over 500,000 AIDS-related deaths in sub-Saharan Africa over the next year. This is an important step back. In 2018, https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2020/may/20200511_PR_HIV_modelling 470,000 AIDS-related deaths were reported in the region.
South Africa has one of https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7564522/pdf/main.pdf highest number of HIV cases and people in 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 that https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7564522/pdf/main.pdf the disease progresses to a point where the CD4 count is too low to be replenished or the opportunistic infections become unmanageable.
These projections should scare everyone. At present, https://theconversation.com/how-covid-19-threatens-efforts-to-contain-hiv-aids-in-south-africa-142575 as of April 2020, 36 countries containing 45% of the Global ART patient population reported disruptions in ART supply. Twenty-four countries are fighting the depletion of stocks of first-line treatment regimes. Other https://theconversation.com/how-covid-19-threatens-efforts-to-contain-hiv-aids-in-south-africa-142575 byproducts of a disrupted health system are that 38 countries reported a substantial decline in adoption of the HIV test.
South Africa is already seeing a near https://theconversation.com/how-covid-19-threatens-efforts-to-contain-hiv-aids-in-south-africa-142575 decrease of 20% in ART collection in key provinces and one https://bhekisisa.org/multimedia/2020-06-09-standing-by-when-epidemics-collide-does-hiv-tb-cause-worse-covid-19/ 10% decrease in testing viral load of ART patients since the introduction of the block 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 https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2020/may/20200511_PR_HIV_modelling future success of treatment.
HIV and COVID-19
Globally, scientists have mainly focused on https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1198/5899044 increased risk of COVID-19-related diseases and death associated with non-communicable 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 indicate that people with HIV have an increased risk of inflammation and metabolic syndrome at https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1198/5899044 . This puts them at risk for chronic noncommunicable diseases – a risk factor for COVID-19 https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precutions/people-with-medical-conditions.html . Additionally, ART has allowed people with HIV to live longer and naturally develop these comorbidities as they age. People with active tuberculosis (TB) are 2.5 times more likely to die from COVID-19 than https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1198/5899044. In South Africa, the TB / HIV coinfection rate is higher than https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1198/5899044 60%.
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 https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1198/5899044 2.75 times greater risk of dying from COVID-19 than those without HIV. Viral suppression does not appear to affect health outcomes, with HIV accounting for approximately https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1198/5899044 8% of all COVID-related deaths. There is greater cause for concern when considering the high levels of HIV comorbidity with noncommunicable diseases and TB.
Forward
The models designed need to be taken seriously and strategies are needed to support all vital health services.
There is an urgent need for https://sajhivmed.org.za/index.php/hivmed/article/view/1118/1942 provision of global and local differentiated services to 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 ease 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 https://sajhivmed.org.za/index.php/hivmed/article/view/1118/1942 locally produced drugs within their national ART regimes. Governments, suppliers and donors must avoid an excessive number of HIV-related deaths by creating an https://www.thelancet.com/action/showPdf?pii=S2352-3018%2820%2930211-3 uninterrupted supply of ART.
If the world is steadfast and focuses solely on fighting 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.
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