COVID-19-Compliant Strategies for Supporting Treatment Adherence Among People Living with HIV in Sub-Saharan Africa

Implementation of the Automated Medication Dispensing System-Early Lessons From Eswatini

Objectives: This article describes the implementation of an automated medication dispensing system (AMDS) in Eswatini to increase medication access and presents the early lessons from this implementation. Methods: The AMDS was installed at four health facilities across two regions through collaborative stakeholder engagement. Healthcare workers were trained, and clients who met the inclusion criteria accessed their medications from the system. Each step of the implementation was documented and summarised in this article. Results: Early lessons suggest that implementation of the AMDS is acceptable and feasible to clients and healthcare workers and that phased introduction of medication classes, commencing with antiretroviral therapy (ART) and incorporating other medications in later phases is feasible. Additionally, improved client-centred messaging and communication, consistent power supply and internet network connectivity, and scheduling medication pickup with other services increase AMDS system utilisation. Conclusion: Eswatini has many clients living with HIV and non-communicable diseases (NCDs). Easy, convenient, quick, non-stigmatising and client-centred access to ART and medication for NCDs is critical in addressing retention in care and achieving optimal treatment outcomes.

Place Visitation Data Reveals the Geographic and Racial Disparities of COVID-19 Impact on HIV Service Utilization in the Deep South

BACKGROUND

The COVID-19 pandemic has posed unprecedented pressure to health care systems, and interrupted health care delivery and access including HIV care in the United States' Deep South, which endures a double epidemic of HIV and COVID-19. Ryan White programs cover HIV care services for over half of PLWH in the Deep South. Given the important role of Ryan White programs, examining the visitation changes to Ryan White facilities during the pandemic offers insights into the impact of the pandemic on HIV healthcare utilization.

OBJECTIVES

Analyze the geographic distribution of HIV facility visitors at the county level before and during the pandemic in the nine US states of Deep South (Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Texas) to reveal the geographic and racial disparity in visitation disruption caused by the pandemic.

METHODS

We first extracted mobile device-based visitation data for Ryan White HIV facilities in the Deep South during 2019 and 2020. To quantify the disruption in visitations during 2020, we calculated the visitation reduction rate (VRR) for each county, using 2019 data as the baseline. Next, we conducted a spatial analysis of the VRR values to uncover geographical disparities in visitation interruptions. To investigate racial disparities, we performed spatial regression analyses with VRR as the dependent variable, and the percentages of Black, Hispanic, and Asian populations as the independent variables. In this analysis, we controlled for potential confounders.

RESULTS

Geographic disparities in visitation reduction were observed, with all nine Deep South states experiencing significant drops. Georgia experienced the highest visitation loss (VRR = -0.58), followed by Texas (-0.47), Alabama (0.47), and Tennessee (-0.46), while South Carolina had the smallest reductions (-0.11). All the regression models consistently revealed racial disparities in visitation interruption. That is, counties with a higher proportion of Black population tended to have higher RW facility visitation reductions.

CONCLUSIONS

Our analysis revealed distinct geographic disparities in visitation interruptions at Ryan White HIV facilities in the Deep South during the COVID-19 pandemic in 2020. Furthermore, we found that the Black/African American population experienced a greater disruption at the county level in the Deep South during this period.

Intersecting epidemics: COVID-19 and HIV in sub-Saharan Africa. A systematic review (2020-2022)

There has been significant progress with regards to winning the fight against HIV globally, particularly due to the introduction of antiretroviral therapy (ART). COVID-19 threatened to derail gains in the fight against HIV. As we have started to see with studies on COVID-19 and HIV, there is a need to 'provide an in-depth view' in understanding the dynamics between the two epidemics, especially in sub-Saharan Africa. We, therefore, undertook a systemic review of existing literature to synthesize the effects of COVID-19 on the utilization of HIV services in sub-Saharan Africa, the literature on the risks associated with HIV during the COVID-19 pandemic, and lastly, the innovations and strategies adopted to continue receiving treatment in sub-Saharan Africa. We conducted a systematic review of studies published between 2020 and April 2022. We searched for relevant sub-Saharan studies in the following databases: PubMed, Google Scholar, J-STOR, and Science Direct. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search identified 647 papers, and after screening, 41 were in line with the inclusion criteria and were included in the review. There was evidence of the negative effects of COVID-19 on reducing HIV testing, ART treatment, and HIV prevention services. There is evidence pointing to the need for people living with HIV to be prioritized for COVID-19 vaccinations. Innovations and strategies implemented to mitigate the effects of COVID-19 on HIV services include community-based ART distribution, multi-month ART dispensing, the use of digital technologies, and the use of the already existing HIV infrastructure to fight COVID-19. It is still imperative that future studies explore the predictors of utilization of HIV services in the advent of COVID-19.

The impact of COVID-19 on HIV treatment of adolescents in sub-Saharan Africa: A scoping review

Background

Adolescents living with HIV are a key population who are susceptible to poor health. The global coronavirus disease 2019 pandemic and widespread national COVID-19 restrictions has disrupted health service delivery and HIV support services, affecting treatment adherence among adolescents with HIV.

Aim

This study aimed to review the available literature on the impact of the COVID-19 pandemic on the HIV treatment of adolescents in sub-Saharan Africa.

Method

Seven online databases were searched for articles published between 2020 and 2022 that focused on the impact of COVID-19 on adolescents living with HIV on antiretroviral therapy. A data charting extraction form and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA) flowchart were used for screening and reporting the articles in this review. A narrative synthesis was conducted.

Results

Five overarching themes emerged from the articles in this review, which highlighted the mental, social, and economic impacts of the COVID-19 pandemic, as well as the impact of the reallocation of healthcare services and challenges to accessing HIV care services on the antiretroviral therapy (ART) adherence of adolescents living with HIV.

Conclusion

The global COVID-19 pandemic affected adolescents living with HIV in sub-Saharan Africa in many ways, but very little research has been done to describe the various ways in which the physical and mental well-being of adolescents were impacted.

Contribution

The findings of this review can be used to further inform policies and interventions aimed at the care and well-being of adolescents on antiretroviral therapy within sub-Saharan Africa.

The Impacts of HIV-Related Service Interruptions During the COVID-19 Pandemic: Protocol of a Mixed Methodology Longitudinal Study

The global COVID-19 pandemic has imposed unprecedented pressure on health systems and has interrupted public health efforts for other major health conditions, including HIV. It is critical to comprehensively understand how the pandemic has affected the delivery and utilization of HIV-related services and what are the effective strategies that may mitigate the negative impacts of COVID-19 and resultant interruptions. The current study thus aims to comprehensively investigate HIV service interruptions during the pandemic following a socioecological model, to assess their impacts on various outcomes of the HIV prevention and treatment cascade and to identify resilience resources for buffering impacts of interruptions on HIV treatment cascade outcomes. We will assess HIV service interruptions in South Carolina (SC) since 2020 using operational report data from Ryan White HIV clinics and HIV service utilization data (including telehealth use) based on statewide electronic health records (EHR) and cellphone-based place visitation data. We will further explore how HIV service interruptions affect HIV prevention and treatment cascade outcomes at appropriate geospatial units based on the integration of multi-type, multi-source datasets (e.g., EHR, geospatial data). Finally, we will identify institutional-, community-, and structural-level factors (e.g., resilience resources) that may mitigate the adverse impacts of HIV service interruptions based on the triangulation of quantitative (i.e., EHR data, geospatial data, online survey data) and qualitative (i.e., in-depth interviews with clinic leaders, healthcare providers, people living with HIV, and HIV clinic operational reports) data regarding health system infrastructure, social capital, and organizational preparedness. Our proposed research can lead to a better understanding of complicated HIV service interruptions in SC and resilience factors that can mitigate the negative effects of such interruptions on various HIV treatment cascade outcomes. The multilevel resilience resources identified through data triangulation will assist SC health departments and communities in developing strategic plans in response to this evolving pandemic and other future public health emergencies (e.g., monkeypox, disasters caused by climate change). The research findings can also inform public health policymaking and the practices of other Deep South states with similar sociocultural contexts in developing resilient healthcare systems and communities and advancing epidemic preparedness.

"It reminds me and motivates me": Human-centered design and implementation of an interactive, SMS-based digital intervention to improve early retention on antiretroviral therapy: Usability and acceptability among new initiates in a high-volume, public clinic in Malawi

BACKGROUND

Early retention of people living with HIV (PLHIV) in antiretroviral therapy (ART) programs is critical to improve individual clinical outcomes and viral load suppression. Although many mobile health (mHealth) interventions aim to improve retention in care, there is still lack of evidence on mHealth success or failure, including from patient's perspectives. We describe the human-centered design (HCD) process and assess patient usability and acceptability of a two-way texting (2wT) intervention to improve early retention among new ART initiates at Lighthouse Trust clinic in Lilongwe, Malawi.

METHODS

An iterative HCD approach focused on patient and provider users' needs, incorporating feedback from multidisciplinary teams to adapt 2wT for the local, public clinic context. We present mixed-methods usability and acceptability results from 100 participants, 50 at 3-months and 50 at 6-months, post 2wT enrollment, and observations of these same patients completing core tasks of the 2wT system.

RESULTS

Among the 100 usability respondents, 95% were satisfied with visit reminders, and 88% would recommend reminders and motivational messages to friends; however, 17% were worried about confidentiality. In observation of participant task completion, 94% were able to successfully confirm visit attendance and 73% could request appointment date change. More participants in 4-6 months group completed tasks correctly compared to 1-3 months group, although not significantly different (78% vs. 66%, p = 0.181). Qualitative results were overwhelmingly positive, but patients did note confusion with transfer reporting and concern that 2wT would not reach patients without mobile phones or with lower literacy.

CONCLUSION

The 2wT app for early ART retention appears highly usable and acceptable, hopefully creating a solid foundation for lifelong engagement in care. The HCD approach put the local team central in this process, ensuring that both patients' and Lighthouse's priorities, policies, and practices were forefront in 2wT optimization, raising the likelihood of 2wT success in other routine program contexts.

Embracing e-health systems in managing the COVID 19 pandemic in Sub-Saharan Africa

The COVID-19 pandemic and the policy responses adopted to curtail it have drastically altered how health services are delivered around the globe. To enable the public to continue accessing health care, e-health innovations have become the most viable tool to provide convenient, timely, effective and safe care, while reducing the spread of the virus. This paper utilized data from existing literature to explore the benefits and challenges of implementing e-health technologies in Sub Saharan Africa (SSA) amid this pandemic. Evidence suggests that these technologies have the potential to strengthen public health systems in SSA as they have in First World countries. However, there are a number of challenges that need to be addressed first in order to realize the full promises of e-health on the continent. The paper proposes that African governments should come together and implement similar e-health policies, share software, expertise and other critical ICT infrastructure as it can result in the successful implementation of e-health innovations, while reducing the financial burden associated with their set up.

Impact of COVID-19 on Adolescent HIV Prevention and Treatment Services in the AHISA Network

We investigated perceived impacts of COVID-19 on the delivery of adolescent HIV treatment and prevention services in sub-Saharan Africa (SSA) by administering a survey to members of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) from February to April 2021. We organized COVID-19 impacts, as perceived by AHISA teams, under three themes: service interruptions, service adjustments, and perceived individual-level health impacts. AHISA teams commonly reported interruptions to prevention programs, diagnostic testing, and access to antiretroviral therapy (ART). Common service adjustments included decentralization of ART refills, expanded multi-month ART distribution, and digital technology use. Perceived individual-level impacts included social isolation, loss to follow-up, food insecurity, poverty, and increases in adolescent pregnancies and sexually transmitted infections. The need for collaboration among stakeholders were commonly cited as lessons learned by AHISA teams. Survey findings highlight the need for implementation science research to evaluate the effects of pandemic-related HIV service adaptations in SSA.

Effects of the COVID-19 pandemic on late postpartum women living with HIV in Kenya

Although an estimated 1.4 million women living with HIV (WHIV) are pregnant each year globally, data describing the effects of the COVID-19 pandemic on postpartum women in low- and middle-income countries (LMICs) are limited. To address this gap, we conducted phone surveys among 170 WHIV ≥18 years and 18-24 months postpartum enrolled in HIV care at the Academic Model Providing Access to Healthcare in western Kenya, and assessed the effects of the pandemic across health, social and economic domains. We found that 47% of WHIV experienced income loss and 71% experienced food insecurity during the pandemic. The majority (96%) of women reported having adequate access to antiretroviral treatment and only 3% reported difficulties refilling medications, suggesting that the program's strategies to maintain HIV service delivery during the early phase of the pandemic were effective. However, 21% of WHIV screened positive for depression and 8% for anxiety disorder, indicating the need for interventions to address the mental health needs of this population. Given the scale and duration of the pandemic, HIV programs in LMICs should work with governments and non-governmental organizations to provide targeted support to WHIV at highest risk of food and income insecurity and their associated adverse health outcomes.

Unintended pregnancies among HIV-positive women in sub-Saharan Africa: a scoping review protocol

BACKGROUND

Unintended pregnancies pose a severe threat to the well-being of HIV-positive women and their unborn children. Factors contributing to the high incidence of unintended pregnancies include contraceptive failure, low uptake of contraceptives, and misuse of contraceptives. Despite various contraceptive options, an increased incidence of unintended pregnancies is rampant among HIV-positive women in the region of sub-Saharan Africa. This study seeks to present evidence of unintended pregnancies among women living with HIV in sub-Saharan Africa, including those using contraceptives.

METHOD

This study entails a scoping review to survey and interrogate the literature to provide evidence for the incidence of unintended pregnancies among HIV-positive women in sub-Saharan Africa. A proposed framework by Arksey and O'Malley will guide this scoping review. Peer-reviewed articles which address the research questions will constitute the main search. Electronic databases such as EBSCOhost, Cochrane Library, World of Science, World Health Organization (WHO) library databases, Science Direct, Google Scholar PubMed, and gray literature search will be involved. Reference list from studies included will also be searched. The investigation of articles will be done employing keywords from the studies included. The inclusion and exclusion criteria will guide two separate reviewers with the screening of abstracts and full papers. To summarize the findings from this review, thematic content analysis will be done using NVivo version 11.

DISCUSSION

We expect that this review will add to the current body of knowledge on the incidence of unintended pregnancies among HIV-positive women, identify gaps for further future research, and show evidence that may contribute to strengthening the health system's regulations, guidelines, and policies that may help prevent unintended pregnancies among HIV-positive women.

SYSTEMATIC REVIEW REGISTRATION

10.17605/OSF.IO/EY3R5.

HIV care experiences and health priorities during the first wave of COVID-19: clients' perspectives - a qualitative study in Lusaka, Zambia

BACKGROUND

The novel COVID-19 pandemic threatened to disrupt access to human immunodeficiency (HIV) treatment for persons living with HIV (PLHIV), two-thirds of whom live in sub-Saharan Africa. To inform a health system response supportive of continuity of care, we sought to understand clients' HIV care experiences and health priorities during the first wave of COVID-19 outbreak in Lusaka, Zambia.

METHODS

Leveraging a study cohort of those who completed periodic SMS surveys on HIV care, we purposefully sampled 25 PLHIV after first confirmed COVID-19 case was reported in Zambia on 18^th March 2020. We phone-interviewed participants, iteratively refining interview guide to capture emergent themes on COVID-19 awareness, health facility interactions, and social circumstances, which we analyzed using matrix analysis.

RESULTS

All participants were aware of COVID-19, and HIV care experiences and health priorities of clients were affected by associated changes at health system, household, and individual level. The health system instituted early clinic visits to provide 6-months of antiretroviral therapy (ART) for stable patients and 3-months for unstable patients to reduce clinic visits and wait times. Most patients welcomed this long-desired extended appointment spacing. Some reported feeling respected and engaged when health care workers telephoned requesting their early clinic visit. However, others felt discouraged by an absence of physical distancing during their clinic visit due to 'severe acute respiratory syndrome coronavirus 2' (SARS-CoV-2) infection concerns. Several expressed a lack of clarity regarding next viral load monitoring date and means for receiving results. Patients suggested regular patient-facility communication by telephone and SMS. Patients emphasized that COVID-19 restrictions led to loss of employment and household income, exacerbating poverty and difficulties in taking ART. At individual level, most participants felt motivated to stay healthy during COVID-19 by ART adherence and regular laboratory monitoring.

CONCLUSIONS

Clients' HIV care and health priorities during the first wave of COVID-19 in Lusaka province were varied with a combination of positive and negative experiences that occurred especially at health system and individual levels, while at household level, the experiences were all negative. More research is needed to understand how patients practice resiliency in the widespread context of socio-economic instability. Governments and patients must work together to find local, health systems solutions to support ART adherence and monitoring. Additionally, the health system should consider how to build on changes for long-term HIV management and service delivery.

Lost to follow up from chronic care services during COVID-19 from health facilities, in Northwest Ethiopia

Introduction

The COVID-19 pandemic and the responses to it have greatly altered individual lives, particularly those with chronic illnesses. The pandemic affected the processes of routine comprehensive care for patients. Because chronic illnesses depress the immune system, they make individuals more susceptible to infection as well as more sickly and less likely to recover from the COVID-19 pandemic. Because of this, the rate of loss to follow-up (LTFU) from chronic illness care is accelerated by the COVID-19 pandemic, and the number of patients receiving new treatments is decreased. Therefore this study aimed to assess the mean difference of loss to follow-up among HIV/AIDS, diabetes mellitus (DM), and hypertension patients during the COVID-19 period as compared to pre-COVID-19 at health facilities in Northwest Ethiopia.

Methods

An institution-based secondary data analysis of the Gondar city health report from October 2019 to Jun 2021 was done. Excel data were transformed to STATA 14 for analysis. An independent t-test was used to compare the mean difference of loss to follow-up and new initiation of treatment among HIV/AIDS, DM, and hypertension patients during the pre-COVID-19 and COVID-19 periods at facilities in Northwest Ethiopia. Variables with a mean difference of p < 0.005 with a 95% confidence interval were used to declare the significant level.

Result

There was a significantly higher mean difference in the number of patients with LTFU from Anti-Retroviral Therapy (ART) and antihypertensive treatment during COVID-19 as compared to the pre-COVID-19 period [μd =17.85, 95%CI: 3.25, 32.95] and [μd =17.31, 95%CI: 8.35, 26.97] respectively. The mean number of patients who were newly started anti-hypertensive treatment during the COVID-19 season was significantly decreased as compared to those who were before the COVID-19 period [μd = -32.94, 95%CI: -63.76, -2.12].

Conclusion

There was a significantly higher mean difference in the number of patients with LTFU from Anti-Retroviral Therapy (ART) and antihypertensive treatment during COVID-19 as compared to the pre-COVID-19 period. The mean number of patients who were newly started anti-hypertensive treatment during the COVID-19 season was significantly decreased as compared to the pre-COVID-19 period. Therefore the Ministry of Health Ethiopia (MOH) should update and prepare convenient care and follow-up such as remote chronic illness management methods during the ongoing COVID-19 pandemic in Ethiopia.

"Everything…Fell Apart Once COVID-19 Hit"-Leveraging the COVID-19 Response to Strengthen Public Health Activities toward Ending the HIV Epidemic: A Qualitative Study

COVID-19 caused widespread disruption of activities for Ending the HIV Epidemic (EHE). In this study we assessed public health perspectives on leveraging the COVID-19 response to advance the goals of EHE. We conducted a qualitative study with 33 public health partners in the Midwestern and Southern United States from October 2020 to February 2022. Participants were asked how the strategies developed for COVID-19 could be applied to the HIV epidemic. Interviews were recorded, transcribed, and examined using rapid qualitative analysis. Four themes emerged: (1) Rebuilding teams and adapting culture for success in EHE activities; (2) Recognizing and modernizing the role of disease intervention specialists (DIS); (3) Enhanced community awareness of the public health role in disease response and prevention; and (4) Leveraging COVID-19 data systems and infrastructure for EHE activities. The COVID-19 pandemic called attention to the dearth of public health funding and outdated information technology (IT) infrastructure used for HIV activities. It also led to greater public health knowledge, including increased familiarity with partner services and molecular epidemiology of HIV, and opportunities to develop new data systems for surveillance that can be applied to efforts for EHE.

Addressing the Syndemics of HIV, Mental Health, and COVID-19 Using the Health and Human Rights Framework among Youth Living with HIV, in Uganda: an Interpretive Phenomenological Study

Stigma and discrimination negatively impact the prevention, treatment, and care of HIV. The COVID-19 pandemic increased this complexity and created a cluster of synergistic health contexts, wherein the physiological aspects of HIV and the social and environmental conditions increased the vulnerability in health outcomes for youth living with HIV (YPLHIV) in Kampala, Uganda. We used interpretive phenomenological analysis (IPA) and the syndemics framework to understand the lived experiences of YPLHIV. From December 2020 to May 2021, six qualitative focus groups were held with 31 youth living with HIV to understand the lived experiences of YPLHIV. The guided questions used were audio-recorded, transcribed verbatim, and coded for thematic analysis. Findings highlight the complexity of intersecting stigma of HIV and COVID-19 that have worsened antiretroviral treatment adherence and mental health issues due to lack of access to critical needs such as fears of food insecurity, health-related worries, the fear of perishing due to COVID-19, and human rights concerns related to gender and sexual identity. The study recommends addressing human rights-related concerns in addition to health-related concerns to comprehensively mitigate the syndemics of HIV and COVID-19 for YPLHIV in Uganda.

Competing health risks associated with the COVID-19 pandemic and early response: A scoping review

BACKGROUND

COVID-19 has rapidly emerged as a global public health threat with infections recorded in nearly every country. Responses to COVID-19 have varied in intensity and breadth, but generally have included domestic and international travel limitations, closure of non-essential businesses, and repurposing of health services. While these interventions have focused on testing, treatment, and mitigation of COVID-19, there have been reports of interruptions to diagnostic, prevention, and treatment services for other public health threats.

OBJECTIVES

We conducted a scoping review to characterize the early impact of COVID-19 on HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

METHODS

A scoping literature review was completed using searches of PubMed and preprint servers (medRxiv/bioRxiv) from November 1st, 2019 to October 31st, 2020, using Medical Subject Headings (MeSH) terms related to SARS-CoV-2 or COVID-19 and HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition. Empiric studies reporting original data collection or mathematical models were included, and available data synthesized by region. Studies were excluded if they were not written in English.

RESULTS

A total of 1604 published papers and 205 preprints were retrieved in the search. Overall, 8.0% (129/1604) of published studies and 10.2% (21/205) of preprints met the inclusion criteria and were included in this review: 7.3% (68/931) on HIV, 7.1% (24/339) on tuberculosis, 11.6% (26/224) on malaria, 7.8% (19/183) on sexual and reproductive health, and 9.8% (13/132) on malnutrition. Thematic results were similar across competing health risks, with substantial indirect effects of the COVID-19 pandemic and response on diagnostic, prevention, and treatment services for HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

DISCUSSION

COVID-19 emerged in the context of existing public health threats that result in millions of deaths every year. Thus, effectively responding to COVID-19 while minimizing the negative impacts of COVID-19 necessitates innovation and integration of existing programs that are often siloed across health systems. Inequities have been a consistent driver of existing health threats; COVID-19 has worsened disparities, reinforcing the need for programs that address structural risks. The data reviewed here suggest that effective strengthening of health systems should include investment and planning focused on ensuring the continuity of care for both rapidly emergent and existing public health threats.

Improving viral load utilisation to enhance care for Kenyan adolescents with HIV

Improving the use of viral load (VL) testing for adolescents and young people living with HIV (AYPLWH) is a priority for Kenya’s Ministry of Health (MOH). Despite expansion of VL testing coverage and rollout of national policies, guidelines and training, VL result utilisation for AYPLWH remains suboptimal, with inadequate adherence to national guidelines recommending everyone on antiretroviral therapy (ART) with unsuppressed viral load (UVL) (≥401 copies/mL) receive three enhanced adherence counselling (EAC) sessions and a repeat VL test within 3 months. In March 2019, ICAP at Columbia University partnered with the MOH to launch a Quality Improvement Collaborative (QIC) at 22 health facilities in the Eastern Province to optimise management of AYPLWH on ART with UVL. Over 17 months, facility QI teams tested interventions targeting client education, workflow modifications, commodity management, community engagement and improved documentation. The QIC led to marked improvement in the proportion of clients completing three EAC sessions and repeat VL testing. Median completion rate was 16% (n=479) at baseline (from March 2018 to February 2019) and rose to 73% (n=755) during the implementation period (from March 2019 to July 2020). In the final month (July 2020), rates rose to 90% (n=31). Another success was the increase in the proportion of clients whose VL was resuppressed on repeat testing, which improved from 34% (n=273) at baseline to 62% (n=710) during the implementation period and 77% (n=44) in the final month. The QIC also led to improvement in the proportion of AYPLWH on first-line ART whose regimens were switched within 2 months of recorded UVL results, which rose from 58% (n=48) at baseline to 94% (n=128) during the implementation period. In summary, the QIC helped facility teams to identify and prioritise local, contextually appropriate innovations which led to swift improvement in three critical indicators of VL utilisation.

Impact of COVID-19 pandemic in adolescents on HIV treatment

The COVID-19 pandemic and concomitant lockdown restrictions in South Africa pose critical challenges for adolescents living with HIV (ALHIV) and on ART, impacting their ability to remain engaged in care and adherent to antiretroviral therapy (ART). Not only has this pandemic directly impacted the health care that ALHIV receive, but it has also consequently had devastating effects on society and has negatively affected the mental health and well-being of ALHIV. The challenges associated with the impact of the COVID-19 pandemic on disadvantaged groups such as ALHIV on ART need to be further explored as it may offer hope to ALHIV and restore confidence in the health system.

Stay-at-Home: The Impact of the COVID-19 Lockdown on Household Functioning and ART Adherence for People Living with HIV in Three Sub-districts of Cape Town, South Africa

In March 2020, the South African government imposed a lockdown to control COVID-19 transmission. Lockdown may affect people living with HIV’s (PLWH) antiretroviral therapy (ART) adherence. Data from a cluster randomised control trial was collected from 152 PLWH in Cape Town sub-districts from October 2019–March 2020 when the lockdown halted collection. Subsequently, 83 PLWH were followed-up in June–July 2020. Random effects models were used to analyse: (1) changes between baseline and follow-up and (2) correlates of adherence during lockdown. At follow-up, there was an increase in the odds of being below the poverty line and the odds of experiencing violence decreased. Measures for well-being, household functioning, stigma and HIV competency improved. Violence, depression, food insecurity, and stigma were associated with poorer ART adherence; higher well-being scores were associated with better adherence. During lockdown, governments need to ensure financial support, access to (mental) health services, and services for those experiencing violence.

Clinical Trial Number: Pan African Clinical Trial Registry, PACTR201906476052236. Registered on 24 June 2019.

Two years after lockdown: reviewing the effects of COVID-19 on health services and support for adolescents living with HIV in South Africa

INTRODUCTION

South Africa's progress towards the 95-95-95 goals has been significantly slower among adolescents living with HIV (ALHIV), among whom antiretroviral therapy (ART) adherence, retention in care and viral suppression remain a concern. After 2 years of living with COVID-19, it is important to examine the direct and indirect effects of the pandemic on healthcare resources, access to HIV services and availability of support structures, to assess their impact on HIV care for ALHIV.

DISCUSSION

The COVID-19 response in South Africa has shifted healthcare resources towards combatting COVID-19, affecting the quality and availability of HIV services-especially for vulnerable populations, such as ALHIV. The healthcare system's response to COVID-19 has threatened to diminish fragile gains in engaging ALHIV with HIV services, especially as this group relies on overburdened public health facilities for their HIV care. Reallocation of limited health resources utilized by ALHIV disrupted healthcare workers' capacity to form and maintain therapeutic relationships with ALHIV and monitor ALHIV for ART-related side effects, treatment difficulties and mental health conditions, affecting their ability to retain ALHIV in HIV care. Prevailing declines in HIV surveillance meant missed opportunities to identify and manage opportunistic infections and HIV disease progression in adolescents. "Lockdown" restrictions have limited access to healthcare facilities and healthcare workers for ALHIV by reducing clinic appointments and limiting individual movement. ALHIV have had restricted access to social, psychological and educational support structures, including national feeding schemes. This limited access, coupled with reduced opportunities for routine maternal and sexual and reproductive health services, may place adolescent girls at greater risk of transactional sex, child marriages, unintended pregnancy and mother-to-child HIV transmission.

CONCLUSIONS

Adolescent HIV care in South Africa is often overlooked; however, ART adherence among ALHIV in South Africa is particularly susceptible to the consequences of a world transformed by COVID-19. The current structures in place to support HIV testing, ART initiation and adherence have been reshaped by disruptions to health structures, new barriers to access health services and the limited available education and psychosocial support systems. Reflecting on these limitations can drive considerations for minimizing these barriers and retaining ALHIV in HIV care.

Experience of adherence to treatment among patients with coronary artery disease during the COVID-19 pandemic: A qualitative study

Background: The coronavirus disease 2019 (COVID-19) pandemic has caused patients with chronic diseases to face various challenges. The present qualitative study aimed to explore adherence to treatment in patients with coronary artery disease (CAD) during the COVID-19 pandemic. Methods: This qualitative content analysis was conducted from September 2020 to February 2021. Online in-depth interviews were conducted with 15 patients with CAD after discharge from Nemazi and Al-Zahra heart hospitals, Shiraz, Iran. Data management was done via MAXQDA 12 software using conventional content analysis based on the method proposed by Graneheim and Lundman. Results: The results revealed three main categories, nine subcategories, and 431 primary codes. The first category was 'improved self-care in the shadow of COVID-19' (Improving self-care due to fear of COVID-19, 'utilization of alternative strategies, and reinforcement of self-care beliefs). The second category was 'redefinition of support systems' (need for a support system, seeking for alternative support systems, and changes in social interactions). The last category was 'barriers to treatment adherence' (shortage of financial resources, need to adjust with working conditions, and mental conflicts). Conclusion: The results indicated that the COVID-19 threats encouraged the patients with CAD to adhere to their care principles. Nonetheless, the restrictions resulting from the pandemic caused problems in adherence to treatment. Thus, redefinition of the support systems in accordance with the present conditions are recommended.

Introducing the Disease Outbreak Resilience Index (DORI) Using the Demographic and Health Surveys Data from sub-Saharan Africa

Although most studies on disease emergencies underscore the need for household readiness for shocks associated with disease outbreaks, no study to date has provided a holistic measure for profiling households based on their readiness toward disease outbreaks. This paper introduces a novel Disease Outbreak Resilience Index (DORI) using a multidimensional approach that draws on the Alkire-Foster methodology. DORI measures disease outbreak resilience in four dimensions: (a) water and hygiene, (b) physical distancing, (c) energy and communication, and (d) economic security and resilience. The paper details the development of DORI and its use by presenting findings from ten countries in sub-Saharan Africa using data from the Demographic and Health Surveys (DHS) program. In addition to serving as a resilience index, we illustrate how DORI can be used to produce a disease outbreak vulnerability index (DOVI). As a versatile index, the indicators under each dimension can be tailored to meet country- and region-specific contexts based on indicators appropriate to each context.

ART Adherence Among People Living with HIV Seeking Services from Public Health Facilities in Western Ethiopia

Background

The burden of COVID-19 is more severe among the elderly and patients affected with chronic medical conditions like diabetes, cardiovascular diseases, and HIV/AIDS. There is no study regarding the level of adherence to antiretroviral therapy (ART) during the time of COVID-19 in Ethiopia. So, this study aimed to assess the level of HIV positive patient’s adherence to ART treatment and associated factors in Nekemte public health facilities, Western Ethiopia.

Methods

This study was conducted in Nekemte public health facilities, Western Ethiopia from August 1, 2020 to September 30, 2020. A facility-based cross-sectional study was employed among HIV positive patients on ART treatment. A single proportion formula was used to calculate a sample size of 384 . A systematic random sampling technique was employed to select the sample population. Face-to-face interview questionnaires were used during data collection. A binary logistic regression model was fitted to identify factors associated with dependent factor, and an adjusted odds ratio (AOR) was used to estimate the strength of the association between dependent and independent variables.

Results

A total of 361 HIV positive patients have participated in the study, yielding a response rate of 94%. The mean age of the participants was 33.8 (SD ±9.8) years. Seventy-seven (21.3%) HIV-positive patients had not adhered to ART follow-up. The study found that living in rural areas (AOR=3.37, 95% CI=1.80–6.24), age less than 25 years (AOR=3.41, 95% CI=1.26–9.21), and substance use (AOR=5.42, 95% CI=1.8–16.29) were independent predictors of poor adherence to ART.

Conclusion

Generally, non-adherence to antiretroviral treatment among people living with HIV during the pandemic outbreak was high in the study area. A home-based delivery of ART treatment and improving retention mechanism during pandemics is highly recommended for concerned bodies. In addition, counseling on avoidance of substance use should be strengthened to increase retention on treatment.

Competing Health Risks Associated with the COVID-19 Pandemic and Early Response: A Scoping Review

BACKGROUND

COVID-19 has rapidly emerged as a global public health threat with infections recorded in nearly every country. Responses to COVID-19 have varied in intensity and breadth, but generally have included domestic and international travel limitations, closure of non-essential businesses, and repurposing of health services. While these interventions have focused on testing, treatment, and mitigation of COVID-19, there have been reports of interruptions to diagnostic, prevention, and treatment services for other public health threats.

OBJECTIVES

We conducted a scoping review to characterize the early impact of COVID-19 on HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

METHODS

A scoping literature review was completed using searches of PubMed and preprint servers (medRxiv/bioRxiv) from January 1st to October 31st, 2020, using Medical Subject Headings (MeSH) terms related to SARS-CoV-2 or COVID-19 and HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition. Empiric studies reporting original data collection or mathematical models were included, and available data synthesized by region. Studies were excluded if they were not written in English.

RESULTS

A total of 1604 published papers and 205 preprints met inclusion criteria, including 8.2% (132/1604) of published studies and 10.2% (21/205) of preprints: 7.3% (68/931) on HIV, 7.1% (24/339) on tuberculosis, 11.6% (26/224) on malaria, 7.8% (13/166) on sexual and reproductive health, and 9.8% (13/132) on malnutrition. Thematic results were similar across competing health risks, with substantial indirect effects of the COVID-19 pandemic and response on diagnostic, prevention, and treatment services for HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

DISCUSSION

COVID-19 emerged in the context of existing public health threats that result in millions of deaths every year. Thus, effectively responding to COVID-19 while minimizing the negative impacts of COVID-19 necessitates innovation and integration of existing programs that are often siloed across health systems. Inequities have been a consistent driver of existing health threats; COVID-19 has worsened disparities, reinforcing the need for programs that address structural risks. The data reviewed here suggest that effective strengthening of health systems should include investment and planning focused on ensuring the continuity of care for both rapidly emergent and existing public health threats.

Impact of the COVID-19 Pandemic on Use of HIV Care, Antiretroviral Therapy Adherence, and Viral Suppression: An Observational Cohort Study From Uganda

INTRODUCTION

Recent studies project thousands of additional AIDS-related deaths because of COVID-19-related disruptions in HIV care. However, the extent to which disruptions in care have materialized since the start of the pandemic is not well understood.

METHODS

We use electronic health records to investigate how the pandemic has affected clinic visits, patients' antiretroviral therapy (ART) supply, and viral suppression for a cohort of 14,632 HIV clients from a large HIV clinic in Kampala, Uganda. We complement this with an analysis of electronically measured longitudinal ART adherence data from a subcohort of 324 clients.

RESULTS

Clinic visits decreased by more than 50% after a national lockdown started. The risk of patients running out of ART on a given day increased from 5% before the lockdown to 25% 3 months later (Relative Risk Ratio of 5.11, 95% confidence interval: 4.99 to 5.24) and remained higher than prelockdown 6 months later at 13% (Relative Risk Ratio of 2.60; 95% confidence interval: 2.52 to 2.70). There was no statistically significant change in electronically measured adherence or viral suppression.

CONCLUSION

We document substantial gaps in HIV care after the start of the COVID-19 pandemic in Uganda. This suggests that measures to improve access should be explored as the pandemic persists. However, ART adherence was unaffected for the subcohort for whom we measured electronic adherence. This suggests that some clients may have stockpiles of ART tablets from previous prescriptions that allowed them to keep taking their medication even when they could not visit the clinic for ART refills.

Distribution of antiretroviral therapy through private pharmacies and postal courier services during COVID-19 in Botswana: acceptability and reach of two out-of-facility individual differentiated service delivery models

INTRODUCTION

The advent of COVID-19 has put pressure on health systems as they implement measures to reduce the risk of transmission to people living with HIV (PLHIV) and healthcare workers. For two out-of-facility individual differentiated service delivery (DSD) models, we assessed acceptability of antiretroviral therapy (ART) distribution through private pharmacies and reach of home delivery of ART through courier services during the COVID-19 pandemic in Botswana.

METHODS

From 24 July to 24 August 2020, we conducted exit interviews with PLHIV receiving ART from 10 high-volume public facilities in Gaborone, and mapped and conducted an online survey with private pharmacies to assess willingness and capacity to dispense ART to PLHIV enrolled in the Botswana national ART program. We piloted ART home delivery from September 2020 to January 2021 in Gaborone and Kweneng East districts for PLHIV accessing ART at two Tebelopele Wellness Clinics. We used cascade analysis to measure the enrolment and eventual reach (percentage of those reached amongst those who are eligible) of ART home delivery.

RESULTS

Sixty-one PLHIV and 42 private pharmacies participated. Of the PLHIV interviewed, 37 (61%) indicated willingness to access ART from private pharmacies and pay BWP50 (∼US$4) per refill for a maximum of two refills per year. All private pharmacies surveyed were willing to provide ART, and 26 (62%) would charge a dispensing fee (range = BWP50-100; ∼US$4-8) per refill. All pharmacies operated 12 h/day, 6 days/week and on public holidays. In the home delivery pilot, 650 PLHIV were due for refills, 69.5% (n = 452) of whom were eligible for home delivery. Of these, 361 were successfully offered home delivery and 303 enrolled (enrolment = 83.9%: female = 87.2%, male = 77.8%, p = 0.013). A total of 276 deliveries were made, a reach of 61%.

CONCLUSIONS

Providing ART through private pharmacies and home delivery was acceptable in Botswana during COVID-19. Surveyed pharmacies were willing and able to dispense ART to PLHIV attending public sector facilities for free or for a nominal fee. Additionally, using courier services for ART home delivery is a novel and viable model in countries with a reliable courier service like Botswana and should be scaled up, particularly in urban areas.

Assessing the Potential Impact of Disruptions Due to COVID-19 on HIV Among Key and Lower-Risk Populations in the Largest Cities of Cameroon and Benin

BACKGROUND

The COVID-19 pandemic indirectly impacts HIV epidemiology in Central/West Africa. We estimated the potential impact of COVID-19-related disruptions to HIV prevention/treatment services and sexual partnerships on HIV incidence and HIV-related deaths among key populations including female sex workers (FSW), their clients, men who have sex with men, and overall.

SETTING

Yaoundé (Cameroon) and Cotonou (Benin).

METHODS

We used mathematical models of HIV calibrated to city population-specific and risk population-specific demographic/behavioral/epidemic data. We estimated the relative change in 1-year HIV incidence and HIV-related deaths for various disruption scenarios of HIV prevention/treatment services and decreased casual/commercial partnerships, compared with a scenario without COVID-19.

RESULTS

A 50% reduction in condom use in all partnerships over 6 months would increase 1-year HIV incidence by 39%, 42%, 31%, and 23% among men who have sex with men, FSW, clients, and overall in Yaoundé, respectively, and 69%, 49%, and 23% among FSW, clients, and overall, respectively, in Cotonou. Combining a 6-month interruption of ART initiation and 50% reduction in HIV prevention/treatment use would increase HIV incidence by 50% and HIV-related deaths by 20%. This increase in HIV infections would be halved by a simultaneous 50% reduction in casual and commercial partnerships.

CONCLUSIONS

Reductions in condom use after COVID-19 would increase infections among key populations disproportionately, particularly FSW in Cotonou, who need uninterrupted condom provision. Disruptions in HIV prevention/treatment services have the biggest impacts on HIV infections and deaths overall, only partially mitigated by equal reductions in casual/commercial sexual partnerships. Maintaining ART provision must be prioritized to minimize short-term excess HIV-related deaths.

The Synergistic Relationship Between Climate Change and the HIV/AIDS Epidemic: A Conceptual Framework

Climate change and HIV/AIDS represent two of the greatest threats to human health in the 21st century. However, limitations in understanding the complex relationship between these syndemics continue to constrain advancements in the prevention and management of HIV/AIDS in the context of a rapidly changing climate. Here, we present a conceptual framework that identifies four pathways linking climate change with HIV/AIDS transmission and health outcomes: increased food insecurity, increased prevalence of other infectious diseases, increased human migration, and erosion of public health infrastructure. This framework is based on an in-depth literature review in PubMed and Google Scholar from June 6 to June 27, 2019. The pathways linking climate change with HIV transmission and health outcomes are complex with multiple interacting factors. Food insecurity emerged as a particularly important mediator by driving sexual risk-taking behaviours and migration, as well as by increasing susceptibility to infections that are common among people living with HIV (PLWHIV). Future interventions should focus on decreasing carbon dioxide emissions globally and increasing education and investment in adaptation strategies, particularly in those areas of sub-Saharan Africa and southeast Asia heavily impacted by both HIV and climate change. Environmentally sustainable interventions such as urban gardening and investing in sustainable agriculture technologies also have significant health co-benefits that may help PLWHIV adapt to the environmental consequences of climate change.

Alleviating psychological distress and promoting mental wellbeing among adolescents living with HIV in sub-Saharan Africa, during and after COVID-19

COVID-19 social control measures (e.g. physical distancing and lockdowns) can have both immediate (social isolation, loneliness, anxiety, stress) and long-term effects (depression, post-traumatic stress disorder) on individuals' mental health. This may be particularly true of adolescents living with HIV (ALHIV) and their caregivers - populations already overburdened by intersecting stressors (e.g. psychosocial, biomedical, familial, economic, social, or environmental). Addressing the adverse mental health sequelae of COVID-19 among ALHIV requires a multi-dimensional approach that at once (a) economically empowers ALHIV and their households and (b) trains, mentors, and supervises community members as lay mental health services providers. Mental health literacy programming can also be implemented to increase mental health knowledge, reduce stigma, and improve service use among ALHIV. Schools and HIV care clinics offer ideal environments for increasing mental health literacy and improving access to mental health services.

Things must not fall apart: the ripple effects of the COVID-19 pandemic on children in sub-Saharan Africa

Zero to 19 year-old children in sub-Saharan Africa bear a disproportionate proportion of the global burden of communicable and non-communicable diseases. Significant public health gains have been made in the fight against these diseases, however, factors such as underequipped health systems, disease outbreaks, conflict, and political instability continue to challenge prevention and control. The novel coronavirus disease (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) introduces new challenges to public health programs in sub-Saharan Africa. Of particular concern are programs targeting major conditions among children, such as undernutrition, vaccine-preventable pneumonia and diarrhea, malaria, tuberculosis, HIV, and sickle cell disease. This article focuses on the impact of the COVID-19 pandemic on child health in sub-Saharan Africa. We review the epidemiology of major pediatric diseases and, referencing modeling projections, discuss the short- and long-term impact of the pandemic on major disease control. We deliberate on potential complications of SARS-CoV-2 co-infections/co-morbidities and identify critical social and ethical issues. Furthermore, we highlight the paucity of COVID-19 data and clinical trials in this region and the lack of child participants in ongoing studies. Lastly, approaches and interventions to mitigate the pandemic's impact on child health outcomes are discussed. IMPACT: Children in sub-Saharan Africa bear a disproportionate burden of communicable and non-communicable diseases globally; this remains true even as the COVID-19 pandemic persists. Amidst the fast-expanding COVID-19 literature, there is little comprehensive coverage of the pandemic's indirect impact on child health in sub-Saharan Africa. This article comprehensively outlines the threat that the pandemic poses to major disease prevention and control for children in sub-Saharan Africa. It discusses the potential impact of SARS-CoV-2 co-infections/co-morbidities, highlights research gaps, and advocates for data and action to mitigate the ripple effects of the pandemic on this population.

Cash Transfers and Health

Financial resources are known to affect health outcomes. Many types of social policies and programs, including social assistance and social insurance, have been implemented around the world to increase financial resources. We refer to these as cash transfers. In this article, we discuss theory and evidence on whether, how, for whom, and to what extent purposeful cash transfers improve health. Evidence suggests that cash transfers produce positive health effects, but there are many complexities and variations in the outcomes. Continuing research and policy innovation-for example, universal basic income and universal Child Development Accounts-are likely to be productive.

COVID-19 Infection among People with HIV/AIDS in Africa: Knowledge Gaps, Public Health Preparedness and Research Priorities

The emergence of novel virus SARS-CoV-2 that causes COVID-19 has complicated Africa's public health challenges, especially with the pre-existing epidemics such as HIV/AIDS. We highlight the known evidence related to COVID-19 infections among people with HIV (PWH) with specific reference to Africa. The knowledge gaps, level of public health preparedness and the potential research priorities are also outlined. Although the epidemiology and clinical course of COVID-19 in HIV patients are evolving, existing evidence indicate that the disease outcomes are comparable to that of the general population. However, PWH with low CD4 cell counts may have worse outcomes than individuals with restored immunity, whereas old age and co-morbidities such as obesity, hypertension and diabetes can further increase their overall risk. While there may be slight disruption of HIV service delivery in selected African countries, the resilience and resourcefulness of others have helped to sustain HIV service delivery and enhanced the level of public health preparedness and fight against the pandemic. The paucity of data and research studies on HIV-COVID-19 coinfection in Africa, call for concerted efforts to address these limitations.

Potential effects of disruption to HIV programmes in sub-Saharan Africa caused by COVID-19: results from multiple mathematical models

Background

The COVID-19 pandemic could lead to disruptions to provision of HIV services for people living with HIV and those at risk of acquiring HIV in sub-Saharan Africa, where UNAIDS estimated that more than two-thirds of the approximately 38 million people living with HIV resided in 2018. We aimed to predict the potential effects of such disruptions on HIV-related deaths and new infections in sub-Saharan Africa.

Methods

In this modelling study, we used five well described models of HIV epidemics (Goals, Optima HIV, HIV Synthesis, an Imperial College London model, and Epidemiological MODeling software [EMOD]) to estimate the effect of various potential disruptions to HIV prevention, testing, and treatment services on HIV-related deaths and new infections in sub-Saharan Africa lasting 6 months over 1 year from April 1, 2020. We considered scenarios in which disruptions affected 20%, 50%, and 100% of the population.

Findings

A 6-month interruption of supply of antiretroviral therapy (ART) drugs across 50% of the population of people living with HIV who are on treatment would be expected to lead to a 1·63 times (median across models; range 1·39–1·87) increase in HIV-related deaths over a 1-year period compared with no disruption. In sub-Saharan Africa, this increase amounts to a median excess of HIV deaths, across all model estimates, of 296 000 (range 229 023–420 000) if such a high level of disruption occurred. Interruption of ART would increase mother-to-child transmission of HIV by approximately 1·6 times. Although an interruption in the supply of ART drugs would have the largest impact of any potential disruptions, effects of poorer clinical care due to overstretched health facilities, interruptions of supply of other drugs such as co-trimoxazole, and suspension of HIV testing would all have a substantial effect on population-level mortality (up to a 1·06 times increase in HIV-related deaths over a 1-year period due to disruptions affecting 50% of the population compared with no disruption). Interruption to condom supplies and peer education would make populations more susceptible to increases in HIV incidence, although physical distancing measures could lead to reductions in risky sexual behaviour (up to 1·19 times increase in new HIV infections over a 1-year period if 50% of people are affected).

Interpretation

During the COVID-19 pandemic, the primary priority for governments, donors, suppliers, and communities should focus on maintaining uninterrupted supply of ART drugs for people with HIV to avoid additional HIV-related deaths. The provision of other HIV prevention measures is also important to prevent any increase in HIV incidence.

Funding

Bill & Melinda Gates Foundation.

Continuity of health service delivery during the COVID-19 pandemic: the role of digital health technologies in Uganda

In response to coronavirus disease-2019 pandemic (COVID-19), the government of Uganda instituted movement restrictions to curb disease spread. However, this affected accessibility to medical services in a setting where the healthcare system is not equipped to handle most healthcare needs of the populace outside hospital premises. This gap led to the prominence and unprecedented rise in the use of digital health technologies to deliver health information and services at a distance (telehealth) during the COVID-19 outbreak. The use of telehealth modalities including tele-consultation, tele-psychiatry, call centers and mobile phone health information dissemination increased. The COVID-19 pandemic augmented the rising role of digital health technologies as a much needed aspect of medical service delivery in our times. However, the efficacy and impact on clinical outcomes across various healthcare thematic areas need to be explored further and more evidence generated.