As the world responds to COVID-19, people living with HIV and/or tuberculosis (TB) are facing major barriers to accessing the care and the medicine they need to survive.
Health personnel and infrastructure are being diverted for COVID-19. Hospitals and clinics are dramatically scaling back hours for services. Transportation restrictions are making it harder to seek services. Perhaps the greatest barrier of all? HIV and TB medicines are largely manufactured in India, where stay-at-home orders have slowed production. As a result, some countries are facing dwindling supplies with no certainty when the next shipment will arrive.
Lockdown orders don’t just impact production lines, they’re associated with increases in partner violence, mental health issues, and other challenges. In low- and middle-income countries (LMICs), these measures are increasing the risk of HIV, TB, malnourishment, and abuse. Adolescent girls and young women in sub-Saharan Africa are particularly affected. Many were already at risk of HIV and violence. Now, with schools closed and essential health services more difficult to access, they find themselves at even greater risk.
People who experience stigma receiving health care services and social benefits face compounding challenges. There are reports of transgender people encountering difficulties accessing hormone therapy, and people who inject drugs having decreased access to opioid substitution therapy. With incomes profoundly reduced, sex workers can struggle to meet basic needs and can face greater criminalization due to the restrictions of lockdown measures.
Among prisoners, who by definition are in confined settings and who have higher rates of HIV, TB, and noncommunicable diseases than the general population, there are several reports of a complete breakdown in medical supplies and services, resulting in a perfect storm for transmission of SARS-CoV-2 and poorer health outcomes overall.
In the face of COVID-19 and the many challenges it creates, how can the world maintain lifesaving HIV and TB services for the people and communities who need them?
Holistic adaptation
PATH is taking a holistic, people-first approach to adapting our HIV and TB programs in countries such as China, the Democratic Republic of the Congo, India, Kenya, Ukraine, Vietnam, and Zambia. This work is grounded on three pillars:
- Protecting frontline care providers by equipping and training them to deliver essential services and safely triage those exposed to, or having symptoms of, COVID-19. We’re also training providers to actively assess and respond to intimate partner violence, socioeconomic harms, and mental health issues experienced by those in their care.
- Mitigating COVID-19’s impact on HIV and TB service delivery by rapidly adapting how and where clients receive services, while ensuring both continuity and confidentiality and addressing exacerbated gender inequities. We are:
• Increasing the availability of information using existing social media or SMS channels to rapidly share information on the intersection of COVID-19, HIV, and TB.
• Offering telemedicine HIV and TB services by phone, SMS, or video, depending on accessibility and client preference. For TB, we are continuing to use digital adherence tools such as video DOTS (directly observed therapy, short course) and electronic pill boxes.
• Making HIV self-tests and other commodities available online and delivered to the home by courier, postal service, or peer network/treatment supporter.
• Ensuring home delivery of a multi-month supply of essential medicines including TB medicines, antiretroviral therapy, and pre-exposure prophylaxis (PrEP), whether by courier, postal service, or peer network/treatment supporter.
• Enabling flexible laboratory services including home collection of dried blood spot tests, HIV self-tests, and sexually transmitted infection self-sampling tests.
• Combining health care touchpoints by integrating health services to minimize visits to facilities. This has included offering HIV testing, family planning, well-baby, and PrEP services in one appointment for adolescent girls and young women.
• Adapting outreach and case management services to meet intersectional needs. Community health workers and peer educators are the backbone of the community in times of crisis. We’re standing up community hotlines and task forces to field a range of concerns and needs for those affected by HIV and TB. - Supporting the COVID-19 response by leveraging existing HIV and TB service delivery platforms without jeopardizing core services. Right now, PATH is doing this in several key ways:
- Applying expertise in HIV and TB contact tracing to COVID-19.
- Using existing laboratory infrastructure to diagnose and monitor SARS-CoV-2 infections.
- Adapting infection prevention and control protocols.
- Advising governments on how to engage the private sector as part of the response.
- Applying learnings from HIV destigmatization to ensure that people with COVID-19 are not discriminated against.
A virtual co-creation meeting between PATH, Pharmacity, and community leaders from key populations to design a launch event and roll-out plan for a blood-based HIV self-test. Photo: PATH/Phan Minh Thai.
Thinking long term
Despite decades of effort by world-class scientists, no vaccine exists for HIV, and the Bacillus Calmette–Guérin vaccine for TB confers only limited protection. Without the full force of active case finding, testing, treatment, and follow-up, HIV and TB will rebound.
Imperial College London estimates that in LMICs, the COVID-19 pandemic could cause a 10 and 20 percent increase in deaths from HIV and TB (respectively) over the next five years. The World Health Organization and UNAIDS have estimated an additional 500,000 deaths in sub-Saharan Africa alone over just the next two years.
So, what is needed to hold our ground?
A lot of endurance and a holistic, compassionate approach to the challenges facing people with HIV and tuberculosis. Drawing attention to the human rights, mental health, and socioeconomic needs of people living with HIV and TB must be a core part of the response; otherwise, the test-and-treat strategies central to epidemic control won’t work the way they’re intended.
Seizing the opportunity
COVID-19 has demonstrated the incredible speed at which the global community can mobilize to fight disease. We may be able to make up for the pandemic’s setbacks if the same timelines were applied to ramping up proven HIV and TB tools and technologies—easier-to-use, lower-cost point-of-care tests for HIV and TB, multi-disease self-tests, shorter-course TB preventive therapy, and long-acting PrEP products such as the cabotegravir injectable.
Perhaps most importantly, we could accelerate progress of essential tools still under development—such as effective vaccines for both diseases.
The current crisis is spotlighting the fact that health care is more than what happens in clinics or hospitals. With renewed creativity, countries around the world are discovering that good health care can be achieved with a flexible system that prioritizes client preferences, holistic needs, and access from their own homes.
COVID-19 is forcing new ways of thinking about how health care is delivered. If we take these learnings forward, we might yet reverse course and accelerate global progress toward ending HIV and TB for good.
