Editor’s note: Find the latest COVID-19 news and guidance in Medscape’s Coronavirus Resource Center.
When the COVID-19 pandemic led to a blanket shelter-in-place order in California in March, it did more than shut down in-person visits at Ward 86, the HIV clinic for publicly insured patients at San Francisco General Hospital. It also led to a decrease in viral suppression among the clinic’s clients. By the end of June, the percentage of patients with an undetectable viral load had dropped by nearly one-third.
This is exactly what Monica Gandhi, MD, associate division chief of HIV, infectious diseases, and global medicine at the University of California, San Francisco, and medical director of the clinic, was afraid of.
“We’re profoundly worried about the impact of COVID-19 on actual treatment outcomes,” said Gandhi, cochair of the virtual International AIDS Conference (AIDS) 2020.
And it’s not just the clinic’s clients at risk. Of the 106 countries served by the Global Fund to Fight HIV, Tuberculosis, and Malaria, 85% saw disruptions in HIV programs, according to a report released last month.
These service disruptions are considerable and “life threatening,” affecting some of the people at greatest risk for HIV acquisition and poor outcomes — such as people engaged in transactional sex (40%), men who have sex with men (37%), and transgender people (31%) — the 2020 Global AIDS Update, released today by UNAIDS, reports.
“In sub-Saharan Africa alone, if there is a 6-month interruption in HIV treatment services, it will account for an additional 500,000 deaths. That doubles the number of deaths in sub-Saharan Africa alone and brings us back to 2008 mortality levels,” said Shannon Hader, MD, deputy executive director of UNAIDS. “We just can’t allow that to happen.”
In addition, 73 countries are at risk of running out of HIV medications, according to a World Health Organization report, also released today.
Quantifying the Impact
The impact is not the same for all patients, said Anton Pozniak, MD, consulting physician in HIV medicine at the Chelsea and Westminster Hospital in London, and international cochair of AIDS 2020.
For some, COVID-19 has not changed much. Their viral loads remain undetectable and all they need is multimonth supplies of their antiretroviral therapy (ART) medications, he told Medscape Medical News. Still, he said he worries about the well-documented effects that social isolation is having on the mental health of these patients, and the increase in substance use associated with the pandemic.
Then there is a small group of patients with HIV who had put off starting ART before the pandemic, but now want to start, he reported.
And finally, there are the people for whom the fear of COVID-19 has crippled their ability to get care.
There are people who have decided they don’t want to come to the hospital or come to the clinic because they’re scared of getting COVID-19.
“It’s really very striking,” said Pozniak. “There are people who have decided they don’t want to come to the hospital or come to the clinic because they’re scared of getting COVID-19. We’ve offered to deliver treatment, but they don’t want the stigma of parcels of drugs arriving.”
In a study presented at the conference, four of 12 care and substance-use treatment facilities in Europe and North America — including Seattle and Philadelphia — reported patients taking longer to fill ART prescriptions. And four of the 12 also reported that clients who injected drugs and were at risk for or living with HIV were having trouble adhering to prescribed therapies. In addition, at 11 of the sites, HIV testing has either nearly or completely shut down.
Structural Barriers to Telemedicine
And then there are structural barriers to care — poverty, lack of transportation, lack of or slow internet access, and lack of insurance — which affect 10% to 20% of the people with HIV that Jodie Dionne-Odom, MD, sees at the 1917 Ryan White HIV clinic at the University of Alabama at Birmingham.
These are the patients she said she worries about most, the ones who, even before COVID-19, were barely managing to pay their rent, car payments, and cell phone bills.
“With COVID-19 and being at home or being laid off, those things could no longer be paid. They’ve lost their phone, they’ve lost their car,” said Dionne-Odom, chief of women’s health services for the clinic. “That’s a really significant impact, because that’s exactly the group you can’t reach by telemedicine.”
In March, when the 1917 Clinic began providing the majority of services online, these people fell off the radar, said Aadia Rana, MD, associate professor of infectious diseases at the University of Alabama at Birmingham, who also works at the clinic.
This is not for lack of trying, she explained. Staff called patients weekly to check in and reschedule appointments, but there were some they just couldn’t reach.
Although the data for the second quarter have not yet been analyzed, “I would expect that our typically close to 90% viral suppression rate is going to decrease,” she said.
This decrease is likely widespread, said Rana, who is principle investigator of the Long-Acting Therapy to Improve Treatment Success in Daily Life (LATITUDE) study.
Many of the 33 sites involved in LATITUDE shut down in the early months of the pandemic, but some are now coming back online. In fact, “we are getting all these pleas from sites around the country saying, ‘Hey, once LATITUDE is open for enrollment, we have so many people who would now be eligible’,” she told Medscape Medical News.
“Why are they now eligible and they weren’t eligible before? I’m assuming it’s because they now have a detectable viral load,” which is one of the requirements for enrollment in LATITUDE, she explained.
Impact on the LGBTI Community
At the onset of the COVID-19 pandemic, Erik Lamontagne, senior economist at UNAIDS, wondered how the quarantine was affecting LGBTI people.
To find out, he and his colleagues launched a survey asking just that. He is also coprinciple investigator of the LGBT Happiness Survey, a multicountry survey of LGBTI people launched last year.
The 13,562 LGBTI respondents came from 138 countries or territories. Of the 1,140 respondents living with HIV, 26% had seen their HIV care disrupted or restricted in some way during the pandemic, and 55% of those had no more than a month’s worth of HIV medications on hand.
But the pandemic hasn’t just affected people already living with HIV, Lamontagne reported. Nine of 10 respondents were living under some form of stay-at-home order, 73% were not meeting their basic needs, 37% had missed meals as a result of economic hardship, and half of those who were still working expected to lose their jobs.
Many could not afford to quarantine, Lamontagne told Medscape Medical News. And financial resources were stretched so thin that about 1% of respondents reported engaging in transactional sex for the first time. Some reported that their economic circumstances were so dire that they couldn’t require clients to wear condoms, increasing their risk for both COVID-19 and HIV.
“What they can eat in the evening is what they can earn during the day,” Lamontagne explained.
Unfortunately, it is the people already in a situation of economic vulnerability — often those from the LGBTI community — who are most affected by COVID-19, he added.
PrEP Use Changing
The pandemic has also affected the use of pre-exposure prophylaxis (PrEP).
South African women taking PrEP to protect themselves from HIV during pregnancy were 2.36 times more likely to miss a clinic visit to refill their prescription after COVID-19 lockdowns began than before, data presented at the conference showed. The women cited fear of acquiring COVID-19 at the medical facility, fear of police, transportation barriers, and long clinic wait times to explain the missed visits.
A study on the use of PrEP at Fenway Health, a sexual health clinic in Boston, showed a 278% increase in unfilled PrEP prescriptions after stay-at-home orders and a 72.1% drop in new PrEP prescriptions.
It’s unclear what these data, which will be presented at the conference later this week, mean, said Douglas Krakower, MD, assistant professor of medicine and population medicine at Harvard Medical School in Boston.
“We don’t know whether this represents people having trouble accessing PrEP” out of concern about getting COVID “or concerns about financial implications,” he explained.
“They may have had hardships from unemployment or other financial constraints” and have lost insurance or are still having to pay copays, he told Medscape Medical News. Or it could just be that they’re not going out or having sex, so they’ve discontinued the medication.
“Anecdotally we’ve heard that some patients are sheltering in place and not having sex and so have chosen not to use PrEP,” he added.
It’s also possible that people are rationing pills or have moved themselves to the PrEP 2-1-1 protocol, which is used only when someone is having sex, said Krakower, citing a study showing that sexual behavior is continuing as usual during quarantine for about half the gay men in the United States.
Resilience and Fragility
It’s not just people living with HIV whose routines have changed during the pandemic. A survey of HIV clinicians around the world conducted by the International Association of Providers of AIDS Care (IAPAC) showed that 88% of HIV clinicians have been pulled away from their regular work to manage COVID-19 in their communities.
But the COVID-19 pandemic shows no signs of stopping, and clinicians are now having to re-engage with their HIV patients.
“What COVID-19 has represented for us is a looking glass to see the resilience, but also the fragility, in HIV responses, not just in the global south, but also in the global north,” José Zuniga, PhD, IAPAC president and chief executive officer, said during a preconference session on controlling the HIV epidemic.
For Dionne-Odom, reopening the 1917 Clinic in Alabama meant tracking down patients who could not participate in telemedicine. Fortunately (or unfortunately, depending on how you look at it), the clinic, which serves a population with a high level of economic insecurity, has worked to get as many phone numbers as possible for each patient. So when the clinic opened back up, staff was able to call family members, friends, and trusted contacts to bring their patients back into the clinic.
“No one wanted to reopen too quickly,” said Dionne-Odom. “But having people come in allowed us to do all the other things that are the key part of HIV care: getting them connected with a social worker and making sure they have enough food, helping them with their electricity bills and their housing issues, all the wrap-around services that are so crucial for these patients.”
International AIDS Conference (AIDS) 2020: Abstracts E11633 and C56 1755; Posters 3921 and 3923.