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The world faces an unprecedented emergency – the most lethal pandemic since AIDS emerged nearly 40 years ago. In recent months, COVID-19 has swept across the globe, bringing immense challenges, including for the tens of millions of people living with or affected by HIV.

Executive summary

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COVID-19 has highlighted pervasive and long-standing issues influencing exclusion from health services, notably of those most vulnerable to HIV, including men who have sex with men, people who inject drugs, sex workers and transgender people. These populations have experienced renewed stigma, persecution and economic hardship [2]. In some countries, human rights-related barriers to healthcare access in the name of COVID-19 “emergency” and “disaster” powers and social injustices, stigma and racial inequalities have made the most marginalized more vulnerable to HIV and COVID-19 [3].

Frequent disruptions to supply chains, logistics and reporting systems have limited countries’ ability to maintain or extend HIV-related services, as well as to set up adequate COVID-19 control measures.

The picture is complex: COVID-19 has catalysed rapid adaptations in healthcare while exposing inequities at the same time.

Over the past years, the HIV response has increasingly acknowledged the importance of person-centred care, including shifts from in-facility to community-based, at-home or virtual services. For example, differentiated service delivery for HIV has been applied to services for key populations, enabled multi-month refills of antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP), and facilitated social network-based adherence and peer-led psychosocial support services.

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Recommendations for the COVID-19 response informed by HIV are grounded in rights-based and community-centred approaches. True progress will require addressing deep-seated structural inequalities to protect the most marginalized. Recent global events have shown an increased awareness and sense of urgency in addressing issues of inequity that cause ill-health, sexual and gender-based violence, or structural racism. COVID-19, HIV and the Black Lives Matter movement all demand attention to and transformation of structural inequalities.

COVID-19 has been called “the most acute global health crisis since HIV” [4]. Countries’ efforts to save lives must encompass COVID-19 and HIV and ensure that health systems everywhere are strengthened to support the right to health for all [5,6].

海外npv加速器官网版下载

COVID-19 is impacting the HIV response in three key ways. First, the shift of health system resources to focus on COVID-19 and national lockdowns has severely affected HIV treatment and prevention services, including interrupting care and increasing obstacles to accessing treatment, clinical services and psychosocial support [7]. Second, COVID-19 has exacerbated challenges for people living with HIV and key populations who are experiencing renewed stigma, with evidence of increasing vulnerability to HIV in the lesbian, gay, bisexual, transgender and intersex (LGBTI) community [8]. Third, the COVID-19 pandemic is highlighting existing system-level weaknesses in healthcare and supply chains, adversely affecting people living with HIV [9].

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There is limited data on health outcomes among people living with HIV who have COVID-19. Continuity of treatment for HIV is essential during the COVID-19 pandemic as scientists determine how COVID-19 affects people living with HIV [10,11]. Additional precautions should be taken for people with advanced or poorly controlled HIV [12].

Clients in 13 African countries [13] revealed that HIV-related stigma, exacerbated by lockdown orders, has deterred some people living with HIV from attempting to obtain their ARVs. Rapid assessments conducted in March and April 2020 among people living with HIV in Uganda and Zimbabwe showed COVID-19-related challenges to be low levels of ART on hand [14], difficulties in accessing facilities due to temporary closures, cost, healthcare workers’ attitudes, fear of police harassment and lack of public transport. In Malawi, viral load testing has been halted as it has been deemed as non-essential [15].

A study on the impact of COVID-19 on PrEP care at a Boston community health centre pointed to disruptions in care, especially among vulnerable populations, despite high use of telehealth [16]. Additionally, a number of the ongoing worldwide HIV vaccine and immunotherapy efficacy trials have been shortened, paused or postponed as a result of the COVID-19 pandemic, causing further disruptions to services for people affected by HIV [17].

A survey across 29 countries in Latin America and the Caribbean in April 2020 showed that 70% of people living with HIV did not have enough ART on hand for the next two months. Further, 37% did not have the option of services adapted to ensure access during COVID-19, including consultations over the phone or Internet, delivery of medications at home or extended ART refills. Among migrants (85% from Venezuela), more than three-quarters of people living with HIV had one month’s supply of ART (52%) or less (24%) and 21% did not know where to go to obtain ART [18].

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In many countries, people living with HIV are no strangers to social and structural barriers that hinder access to HIV-related services, now aggravated by COVID-19. Emergency powers invoked during the pandemic have been abused to justify police brutality, ignore principles of disclosure and target the most vulnerable [19].

Key populations in Bangladesh, Belarus, Puerto Rico, South Korea and Uganda have experienced renewed persecution and discrimination under COVID-19 emergency powers [20]. This is predicted to worsen, with increasing rates of unemployment, housing instability and food insecurity [21]. A survey of 13,500 LGBTI+ people in 138 countries found that COVID-19 has increased socioeconomic vulnerability among the LGBTI+ community, threatened their health and increased their susceptibility to HIV infection. Of 1,140 participants with HIV, 26% reported interrupted or restricted access to refills of ART [22].

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3. Exposing vulnerabilities at the systems level

The COVID-19 pandemic has highlighted existing vulnerabilities in healthcare systems and their knock-on effects. The lack of serious investment in building functional and resilient health systems in many resource-limited countries has brought into sharp focus the challenges of providing quality routine healthcare [29]. The HIV response and the COVID-19 pandemic are testing the resilience of many systems.

Stopping courier and postal services in some countries has prevented local deliveries of medicines. Other vulnerabilities in many countries include too few medical professionals, medical staff and laboratories diverted to COVID-19 activities, insufficient equipment and supplies, and poor confidence in public health systems and national governments [31].

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海外npv加速器官网版下载

It is critical that countries and healthcare providers take decisive evidence-based actions for responses to both HIV and COVID-19. The Ebola outbreak in West Africa in 2014-2015 had a substantial impact on the number of deaths from AIDS-related causes, TB and malaria because of reduced access to treatment as resources were focused on Ebola [33]. A published model predicts a similar outcome for COVID-19, but hopefully with the right public health responses, these predictions could prove to be a warning rather than reality [34].

Country- and community-based experience offers evidence of the impact of COVID-19 on HIV programmes. In some places, the COVID-19 pandemic and associated national lockdowns have led to increased innovations and ingenuity in HIV service delivery. This body of evidence gives clear strategies for policy makers, healthcare providers, researchers, scientists, healthcare workers, communities and funders.

1.1 Reduce the frequency and duration of health facility visits.
Core HIV services should not be disrupted due to COVID-19, but in-person visits to health facilities for people living with HIV should be limited [35]. Where visits are required, time spent in the facility should be reduced and the client should interact with the minimum number of providers.

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