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

Although global attention is dominated by COVID-19, the HIV/AIDS pandemic, as it enters its fifth decade, is far from over. Since the early 1980s, 75·7 million people have become infected with HIV. 32·7 million people have died from AIDS-related illnesses. HIV/AIDS remains a major public health crisis and only a few countries will meet the 90–90–90 treatment target for 2020. Much has been made of how information systems and service models in the HIV response have helped the COVID-19 response, but the COVID-19 pandemic could have knock-on effects on the HIV response and be devastating for communities. How might the COVID-19 pandemic shape the future HIV/AIDS response towards reaching 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 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 negative effects on health outcomes in the medium and long term. Modelling data published in The Lancet Global Health show that severe treatment disruptions in high-burden settings could increase HIV mortality by 10% within 5 years. The HIV Modelling Consortium has shown that severe treatment disruptions in sub-Saharan Africa—eg, 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 6-month interruptions to services for mother-to-child transmission of HIV could increase new infections among children by 40–80% in high-burden countries.
While in many countries, HIV prevention, testing, and care have been disrupted because of strict lockdown policies and breaks in medicine supply chains, UNAIDS says the effects of COVID-19 on maintaining treatment services have so far been less severe than originally feared. Thanks to novel approaches, such as home deliveries of medicines and digital platforms for virtual patient support, HIV prevention services have rebounded in many communities.
A chilling pattern of inequity shapes the burden of COVID-19 and HIV. The adverse effects of each disease are exacerbated by social and economic disparities and disproportionately affect poor and marginalised people—young women and girls in particular. 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 inequity as pandemic-related job losses and deprivation affect poor and vulnerable people most acutely. Poverty could result in further barriers to engaging with the HIV care system.
Dec 1, 2020, is World AIDS Day. Against the backdrop of an extraordinary health crisis, this year’s campaign calls for global solidarity and joint responsibility. To health leaders facing many competing priorities, what might this entail in practice? In 2018, the International AIDS Society-Lancet Commission envisioned a new era of global solidarity, in which the HIV response would integrate with the broader global health field. Built on the AIDS movement’s commitment to human rights, gender equality, and health equity, this new era could focus on developing robust, flexible, people-centred health systems, achieving universal health coverage, and addressing 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 outlook should mean that fragmented, siloed approaches are replaced with broader health system strengthening and preparedness that integrate HIV with other health priorities.

The integration of HIV with COVID-19 is already happening. COVID-19 has compelled numerous countries to accelerate the scale-up of differentiated service delivery for HIV by expediting multi-month dispensing of HIV medicine, which they otherwise may not have done. COVID-19 is imperilling HIV services and forcing health systems to adapt. But adaptations need not always be harmful. Looking for opportunities to prioritise people-centred strategies could empower patients and help to address issues such as stigma, discrimination, and poverty, in addition to reducing contact with health facilities and so freeing up capacity. Such an approach is needed to rejuvenate the HIV response and get ending the HIV pandemic back on track.

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