Addressing Health Inequities Exacerbated by COVID-19 Among Youth With HIV: Expanding Our Toolkit

Emerging from the shadows: Trends in HIV ambulatory care, viral load testing, and viral suppression in a U.S. HIV cohort, 2019-2022: Impact of COVID-19 pandemic

This article aimed at analyzing the acute impact and the longer-term recovery of COVID-19 pandemic effects on clinical encounter types, HIV viral load (VL) testing, and suppression (HIV VL < 200 copies/mL). This study was a longitudinal cohort study of participants seen during 2019-2022 at nine HIV Outpatient Study (HOPS) sites. Generalized linear mixed models (GLMMs) estimated monthly rates of all encounters, office and telemedicine visits, and HIV VL tests using 2010-2022 data. We examined factors associated with nonsuppressed VL (VL ≥ 200 copies/mL) and not having ambulatory care visits during the pandemic using GLMM for logistic regression with 2017-2022 and 2019-2022 data, respectively. Of 2351 active participants, 76.0% were male, 57.6% aged ≥ 50 years, 40.7% non-Hispanic White, 38.2% non-Hispanic Black, 17.3% Hispanic/Latino, and 51.0% publicly insured. The monthly rates of in-person and telemedicine visits varied during 2020 through mid-year 2022. Multivariable logistic regression showed that persons with no encounters were more likely to be male or have VL ≥ 200 copies/mL. For participants with ≥1 VL test, the prevalence rate of HIV VL ≥ 200 copies/mL during 2020 was close to the rates from 2014 to 2019. The change in probability of viral suppression was not associated with participant's age, sex, race/ethnicity, or insurance type. In the HOPS, overall patient encounters declined over 2 years during the pandemic with variations in telemedicine and in-person events, with relative maintenance of viral suppression. Ongoing recovery from the impact of COVID-19 on ambulatory care will require continued efforts to improve retention and patient access to medical services.

Evaluating the impact of an educational intervention on the history of racism in America for teaching structural competency to medical academicians

BACKGROUND

A challenge facing many Academic Health Centers (AHCs) attempting to revise health professions education to include the impact of racism as a social and structural determinant of health (SSDoH) is a lack of broad faculty expertise to reinforce and avoid undermining learning modules addressing this topic. To encourage an institutional culture that is in line with new anti-racism instruction, we developed a six-part educational series on the history of racism in America and its impact on contemporary health inequities for teaching structural competency to health professions academicians.

METHODS

We developed a six-hour elective continuing education (CE) series for faculty and staff with the following objectives: (1) describe and discuss race as a social construct; (2) describe and discuss the decolonization of the health sciences and health care; (3) describe and discuss the history of systemic racism and structural violence from a socio-ecological perspective; and (4) describe and discuss reconciliation and repair in biomedicine. The series was spread over a six-month period and each monthly lecture was followed one week later by an open discussion debriefing session. Attendees were assessed on their understanding of each objective before and after each series segment.

RESULTS

We found significant increases in knowledge and understanding of each objective as the series progressed. Attendees reported that the series helped them grapple with their discomfort in a constructive manner. Self-selected attendees were overwhelmingly women (81.8%), indicating a greater willingness to engage with this material than men.

CONCLUSIONS

The series provides a model for AHCs looking to promote anti-racism and structural competency among their faculty and staff.

Projecting the Clinical and Economic Impacts of Changes to HIV Care Among Adolescents and Young Adults in the United States: Lessons From the COVID-19 Pandemic

BACKGROUND

During the COVID-19 pandemic, many US youth with HIV (YHIV) used telehealth services; others experienced disruptions in clinic and antiretroviral therapy (ART) access.

METHODS

Using the Cost-effectiveness of Preventing AIDS Complications (CEPAC)-Adolescent HIV microsimulation model, we evaluated 3 scenarios: 1) Clinic: in-person care; 2) Telehealth: virtual visits, without CD4 or viral load monitoring for 12 months, followed by return to usual care; and 3) Interruption: complete care interruption with no ART access or laboratory monitoring for 6 months (maximum clinic closure time), followed by return to usual care for 80%. We assigned higher 1-year retention (87% vs 80%) and lower cost/visit ($49 vs $56) for Telehealth vs Clinic. We modeled 2 YHIV cohorts with non-perinatal (YNPHIV) and perinatal (YPHIV) HIV, which differed by mean age (22 vs 16 years), sex at birth (85% vs 47% male), starting CD4 count (527/μL vs 635/μL), ART, mortality, and HIV-related costs. We projected life months (LMs) and costs/100 YHIV over 10 years.

RESULTS

Over 10 years, LMs in Clinic and Telehealth would be similar (YNPHIV: 11 350 vs 11 360 LMs; YPHIV: 11 680 LMs for both strategies); costs would be $0.3M (YNPHIV) and $0.4M (YPHIV) more for Telehealth than Clinic. Interruption would be less effective (YNPHIV: 11 230 LMs; YPHIV: 11 620 LMs) and less costly (YNPHIV: $1.3M less; YPHIV: $0.2M less) than Clinic. Higher retention in Telehealth led to increased ART use and thus higher costs.

CONCLUSIONS

Telehealth could be as effective as in-person care for some YHIV, at slightly increased cost. Short interruptions to ART and laboratory monitoring may have negative long-term clinical implications.

Living through a pandemic: depression and anxiety experienced by youth living with HIV in South Africa

Youth living with HIV (YLHIV) face significant psychosocial challenges and are at increasedrisk of developing depression and anxiety. This study aims to invesBgate symptoms ofdepression, anxiety and associaBons with psychosocial factors in YLHIV during the first andthird waves of the COVID-19 pandemic. This longitudinal study enrolled 135 YLHIV (ages 12-21) in Cape Town, South Africa. Measures administered telephonically included theCoRonavIruS Health Impact Survey (CRISIS quesBonnaire), Center for Epidemiologic StudiesDepression Scale (CES-D), Beck Anxiety Inventory and Beck Youth Inventory. During the firstwave of COVID-19, 7.5% and 8.0% of YLHIV were depressed (<18 and ≥18 years,respecBvely), and 10% and 4% of parBcipants were anxious (<18 and ≥18 years). During thethird wave, 8.9% and 40.6% of YLHIV were depressed (<18 and ≥18 years), and 13.3% and12.5% (<18 and ≥18 years) were anxious. Depression and anxiety were measured using cutoffscores provided by clinical measures. Symptoms of depression and anxiety in YLHIVescalated over the course of the COVID-19 pandemic. Socio-economic factors, substanceuse, disrupted support and stability concerns were associated with depression and anxiety.These data highlight the increasing need of mental health support and social intervenBonsfor YLHIV in post-pandemic South Africa.

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.

Psychosocial impacts of the COVID-19 pandemic from a cross-sectional Survey of people living with HIV in Washington, DC

BACKGROUND

COVID-19 has not only taken a staggering toll in terms of cases and lives lost, but also in its psychosocial effects. We assessed the psychosocial impacts of the COVID-19 pandemic in a large cohort of people with HIV (PWH) in Washington DC and evaluated the association of various demographic and clinical characteristics with psychosocial impacts.

METHODS

From October 2020 to December 2021, DC Cohort participants were invited to complete a survey capturing psychosocial outcomes influenced by the COVID-19 pandemic. Some demographic variables were also collected in the survey, and survey results were matched to additional demographic data and laboratory data from the DC Cohort database. Data analyses included descriptive statistics and multivariable logistic regression models to evaluate the association between demographic and clinical characteristics and psychosocial impacts, assessed individually and in overarching categories (financial/employment, mental health, decreased social connection, and substance use).

RESULTS

Of 891 participants, the median age was 46 years old, 65% were male, and 76% were of non-Hispanic Black race/ethnicity. The most commonly reported psychosocial impact categories were mental health (78% of sample) and financial/employment (56% of sample). In our sample, older age was protective against all adverse psychosocial impacts. Additionally, those who were more educated reported fewer financial impacts but more mental health impacts, decreased social connection, and increased substance use. Males reported increased substance use compared with females.

CONCLUSIONS

The COVID-19 pandemic has had substantial psychosocial impacts on PWH, and resiliency may have helped shield older adults from some of these effects. As the pandemic continues, measures to aid groups vulnerable to these psychosocial impacts are critical to help ensure continued success towards healthy living with HIV.

Impact of COVID-19 pandemic and anti-pandemic measures on tuberculosis, viral hepatitis, HIV/AIDS and malaria-A systematic review

COVID-19 pandemic puts an enormous strain on health care systems worldwide and may have a detrimental effect on prevention, treatment and outcomes of tuberculosis (TB), viral hepatitis, HIV/AIDS and malaria, whose ending is part of the United Nations 2030 Agenda for Sustainable Development. We conducted a systematic review of scientific and grey literature in order to collect wide-ranging evidence with emphasis on quantification of the projected and actual indirect impacts of COVID-19 on the four infectious diseases with a global focus. We followed PRISMA guidelines and the protocol registered for malaria (CRD42021234974). We searched PubMed, Scopus, preView (last search: January 13, 2021) and websites of main (medical) societies and leading NGOs related to each of the four considered infectious diseases. From modelling studies, we identified the most impactful disruptions; from surveys and other quantitative studies (based e.g. on surveillance or program data), we assessed the actual size of the disruptions. The identified modelling studies warned about under-diagnosis (TB), anti-retroviral therapy interruption/decrease in viral load suppression (HIV), disruptions of insecticide-treated nets (ITN) distribution and access to effective treatment (malaria), and treatment delays and vaccination interruptions (viral hepatitis). The reported disruptions were very heterogeneous both between and within countries. If observed at several points in time, the initial drops (partly dramatic, e.g. TB notifications/cases, or HIV testing volumes decreased up to -80%) were followed by a gradual recovery. However, the often-missing assessment of the changes against the usual pre-pandemic fluctuations hampered the interpretation of less severe ones. Given the recurring waves of the pandemic and the unknown mid- to long-term effects of adaptation and normalisation, the real consequences for the fight against leading infectious diseases will only manifest over the coming years.

Impact of COVID-19 pandemic in the care of people living with HIV and cancer at an oncologic center in Mexico

BACKGROUND

People living with HIV(PLWH) and cancer are among the most vulnerable patients and require constant access to medical services. We compared the characteristics of PLWH and cancer in Mexico, before and during the COVID-19 pandemic.

METHODS

Patients admitted 1 year before (pre-pandemic) and 1 year after the start of the pandemic (pandemic) were included. Clinical characteristics, HIV-related variables, and 90-day mortality were compared. Data are described a proportions (N,%) and central tendency measures. A multiple regression model for variables associated with 90-day mortality was performed.

RESULTS

Seventy-nine patients were seen in the pre-pandemic period; 92 during the pandemic. Main diagnoses were Kaposi Sarcoma and lymphoma. CD4⁺ cell count at diagnosis was lower during the pandemic: 81 cells/mm³ vs. 128 cells/mm³, p = .035. CD4+<100 cells/mm³ at first consultation increased from 41% to 58% during the pandemic (p = .041). Only BMI <20 kg/m² was associated to death (aOR 8.27, 95%CI 1.74-39.25) (p = .008). The pandemic period was not associated with a higher 90-day mortality.

CONCLUSIONS

PLWH and cancer presented to care with advanced disease overall. This was more pronounced during the pandemic period. Mortality was associated with AIDS-related variables regardless of study period. This underscores the need for strategies to maintain in-person access to health-care services for PLWH.

The impact of the COVID-19 pandemic on mental health, associated factors and coping strategies in people living with HIV: a scoping review

INTRODUCTION

The COVID-19 pandemic and associated measures implemented by authorities have created additional stressors and increased the risk of psychological illnesses among people living with HIV (PLWH). Yet, there is no collective evidence on the mental health status of this population during the global pandemic and associated factors. This scoping review aimed to synthesize the evidence in the current literature related to the mental health outcomes and challenges faced by PLWH during the COVID-19 pandemic, identify the associated factors with psychological distress and summarize various coping strategies to ease these psychological distresses used by this population.

METHODS

We conducted a scoping review following the PRISMA-ScR guideline and a literature search in four electronic databases in August 2022. Three reviewers independently screened all the search records and extracted the data from studies that met the inclusion criteria. Factors associated with worsened mental health outcomes were synthesized according to the socio-ecological framework.

RESULTS

Among 1100 research records, 45 articles met the eligibility criteria and were included in the final review and data extraction, most of which were quantitative analyses. PLWH reported high rates of mental health problems during the pandemic. Multi-level factors were associated with increased psychological distress, including substance use, antiretroviral adherence, social support, financial hardship and economic vulnerability during the pandemic. PLWH used social media as a coping strategy to foster social support to deal with growing mental distress. Increased mental health illnesses were associated with increased substance use, it was also found associated with suboptimal medication adherence and antiretroviral therapy (ART) care engagement.

DISCUSSION

PLWH experienced high rates of mental health illnesses, such as depression during the global COVID-19 pandemic. There is an urgent need to provide comprehensive HIV treatment and mental health services as the pandemic continues to evolve.

CONCLUSIONS

The review summarized how the mental health of PLWH was affected during the COVID-19 pandemic. Future work in the implementation of effective interventions to promote mental health in this population is needed, not only to ensure their quality of life but also to help them maintain ART adherence and healthcare during more unprecedented times.

Impact of COVID-19 on HIV service delivery in Miami-Dade County: a mixed methods study

BACKGROUND

Facilitating access to HIV prevention and treatment is imperative in Miami-Dade County (MDC), a U.S. HIV epicenter. With COVID-19, disruptions to these services have occurred, leading HIV organizations to innovate and demonstrate resilience. This study documented COVID-19 related disruptions and resilient innovations in HIV services within MDC.

METHODS

This mixed methods cross-sectional study included HIV test counselors in MDC. In the quantitative component (N=106), participants reported COVID-19 impacts on HIV service delivery. Data visualization examined patterns within organizations and throughout the study period. Generalized estimating equation modeling examined differences in service disruptions and innovations. In the qualitative component, participants (N=20) completed interviews regarding COVID-19 impacts on HIV services. Rapid qualitative analysis was employed to analyze interviews.

RESULTS

Quantitative data showed that innovations generally matched or outpaced disruptions, demonstrating resilience on HIV service delivery during COVID-19. HIV testing (36%, 95%CI[28%, 46%]) and STI testing (42%, 95%CI[33%, 52%]) were most likely to be disrupted. Sexual/reproductive health (45%, 95%CI[35%, 55%]), HIV testing (57%, 95%CI[47%,66%]), HIV case management (51%, 95%CI[41%, 60%]), PrEP initiation (47%, 95%CI[37%,57%]), and STI testing (47%, 95%CI[37%, 57%]) were most likely to be innovated. Qualitative analysis revealed three orthogonal themes related to 1) disruptions (with five sub-components), 2) resilient innovations (with four sub-components), and 3) emerging and ongoing health disparities.

CONCLUSIONS

HIV organizations faced service disruptions during COVID-19 while also meaningfully innovating. Our findings point to potential changes in policy and practice that could be maintained beyond the immediate impacts of COVID-19 to enhance the resilience of HIV services. Aligning with the US Ending the HIV Epidemic Plan and the National Strategy for HIV/AIDS, capitalizing on the observed innovations would facilitate improved HIV-related health services for people living in MDC and beyond.

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.

'We are not going anywhere': a qualitative study of Kenyan healthcare worker perspectives on adolescent HIV care engagement during the COVID-19 pandemic

INTRODUCTION

Adolescents living with HIV (ALHIV) may be vulnerable to widescale impacts of the COVID-19 pandemic and to health system responses which impact HIV care. We assessed healthcare worker (HCW) perspectives on impacts of the COVID-19 pandemic on adolescent HIV care delivery and engagement in western Kenya.

METHODS

We performed in-depth qualitative interviews with HCW at 10 clinical sites in the Academic Model Providing Access to Healthcare in Kenya, from January to March, 2021. Semistructured interviews ascertained pandemic-related impacts on adolescent HIV care delivery and retention.

RESULTS

Interviews were conducted with 22 HCWs from 10 clinics. HCWs observed adolescent financial hardships, unmet basic needs and school dropouts during the pandemic, with some adolescents relocating to rural homes, to partners or to the street. Marked increases in adolescent pregnancies and pregnancy complications were described, as well as barriers to family planning and antenatal care. Transportation challenges and restrictions limited access to care and prompted provision of multi-month refills, refills at local dispensaries or transfer to local facilities. Adolescent-friendly services were compromised, resulting in care challenges and disengagement from care. Clinic capacities to respond to adolescent needs were limited by funding cuts to multidisciplinary staff and resources. HCW and youth peer mentors (YPMs) demonstrated resilience, by adapting services, taking on expanded roles and leveraging available resources to support adolescent retention and access to care.

CONCLUSIONS

ALHIV are uniquely vulnerable, and adolescent-friendly services are essential to their treatment. The combined effects of the pandemic, health system changes and funding cuts compromised adolescent-friendly care and limited capacity to respond to adolescent needs. There is a need to reinforce adolescent-friendly services within programmes and funding structures. Support for expanded YPM roles may facilitate dedicated, scalable and effective adolescent-friendly services, which are resilient and sustainable in times of crisis.

Telemedicine and Health Equity During COVID-19 in Pediatric Gastroenterology

INTRODUCTION

Telehealth (TH) services rapidly expanded during the COVID-19 pandemic. This rapid deployment precluded the opportunity for initial planning of implementation strategies. The purpose of the quality improvement project was to understand the needs of nurse practitioners and examine TH procedures and interventions designed to promote high-quality, equitable health care for pediatric patients with gastrointestinal concerns.

METHOD

The Plan-Do-Study-Act model was used. Survey data from providers and families were collected and analyzed. They were further illuminated through iterative dialog across the research team to determine the quality and efficiency of TH.

RESULTS

A toolkit of strategies for promoting the quality and efficiency of TH was created according to the three domains of health equity: availability, accessibility, and acceptability.

DISCUSSION

TH will be used in the postpandemic era. Institutions need to implement evidence-based strategies that ensure health equity across TH platforms to ensure excellent patient care.

Health and development-related priorities and challenges of adolescents and young people: findings from South Africa and Kenya prior to and during COVID-19 pandemic

Growing evidence documents the effects of the COVID-19 pandemic on adolescents in East and Southern Africa. We present and explore the longitudinal health and development-related priorities and challenges of adolescent advisors in South Africa and Kenya, including prior to, and during the COVID-19 pandemic. Findings were co-generated with adolescent advisors in the Eastern Cape Province of South Africa (n=15, ages 18-22 in 2019) and Kisumu, Kenya (n=16, ages 10-14 in 2020). Prior to COVID-19, adolescent advisors engaged in a participatory exercise to share and explore their health and development-related priorities and challenges in 2019 and 2020. During the COVID-19 pandemic in 2020 and 2021, members of the same groups shared their experiences, challenges and coping strategies in semi-structured telephone interviews (Eastern Cape: n=14, aged 19-23; Kisumu n=12, aged 11-16) and group-based remote participatory social media activities (n=27 activities with n=12 advisors, Eastern Cape). We thematically analysed COVID-19 activities, considering them alongside pre-pandemic priorities and challenges. Many of the health and development-related priorities and challenges identified prior to COVID-19 remained issues of concern during COVID-19. These included education; victimization and violence; teenage pregnancy; substance use; household tension, conflict and inadequate family and caregiver support; health and medication concerns (South Africa) and water and food shortages (Kenya). Other issues such as financial insecurity, mental health, and crime were strong themes that emerged during COVID-19, which were not directly reported as priorities prior. Although almost all of adolescent advisors' most pressing pandemic-related challenges were also priorities for them prior to COVID-19, these issues were often discussed as new, and caused by the onset of COVID-19. While demonstrating how COVID-19 has exacerbated pre-existing vulnerabilities, we also suggest that the pandemic may have brought about a new way for adolescents to make sense of, and articulate pre-existing challenges.

Determining factors that influence parents' perceptions of telehealth provided in a pediatric gastroenterological practice: A quality improvement project

BACKGROUND

In response to the COVID-19 pandemic, local and institutional guidelines restricted non-emergent, in-person visits in outpatient specialty clinics. Nurse practitioners (NPs) in pediatric gastroenterology clinics immediately shifted their practice to telehealth (TH).

LOCAL PROBLEM

The shift to TH necessitated a change in practice. This quality improvement project was designed to define factors influencing family's perceptions of TH and secure feedback on the TH experience. TH is remaining an option for accessing care even as restrictions are being lifted. Feedback is necessary to ensure that quality of care and high patient satisfaction are maintained in a virtual environment.

METHODS

The Unified Theory of Acceptance and Use of Technology was used to frame the project. Surveys were collected from NPs related to services provided and complexities of each encounter. Post-visit surveys were conducted with families to assess their perceptions of the visit. Findings were discussed to identify and address gaps in service.

RESULTS

Parent/family surveys were consistent with NP feedback. Results indicated that parents were satisfied with care provided via TH, but that these visits were limited by incomplete assessments, lacked the intimacy of in-person encounters and were often difficult to access due to technological issues.

CONCLUSIONS

It is anticipated that TH will be used in the post pandemic era to provide routine and non-emergent acute care. Institutions and providers need to consider factors influencing the patient experience learned during the pandemic and implement evidenced-based strategies that ensure quality care that meets patients' needs.

HIV Care Access During the COVID-19 Pandemic as Perceived by Racial/Ethnic Minority Groups Served by the Ryan White Program, Miami-Dade County, Florida

The Ryan White Program (RWP) in Miami-Dade County, Florida made several modifications to keep HIV care accessible during the COVID-19 Pandemic, including expanding telehealth services, increasing access to HIV medications, and waiving required lab tests for service recertification. We assessed ease of access to medical providers, medical case managers, and antiretroviral medications during the COVID-19 Pandemic among 298 Non-Hispanic Black, Hispanic, and Haitian people with HIV (PWH) served by the RWP Part A, Miami-Dade County, Florida using a telephone-administered survey between October 2020 and January 2021. Overall, most clients reported similar or better access compared to before the Pandemic. Use of videocalls to communicate with HIV medical providers varied by race/ethnicity: Hispanics (49.6%), Non-Hispanic Blacks (37.7%), and Haitian clients (16.0%). Results suggest the modifications helped maintain access to care during an unprecedented health crisis. Permanently adopting many of these modifications should be considered to continue to facilitate access to care.

Changes in the time of COVID-19: a quality improvement initiative to maintain services at a youth sexual health clinic

OBJECTIVES

Adolescents and young adults (AYAs) face difficulties accessing sexual and reproductive health services. These difficulties were exacerbated for a variety of reasons by the COVID-19 pandemic. We document strategies and outcomes implemented at an urban youth sexual health clinic in Florida that allowed uninterrupted provision of services while protecting against spread of COVID-19.

METHODS

The plan-do-study-act (PDSA) model was used to implement COVID-19 interventions designed to allow continued service delivery while protecting the health and safety of staff and patients. This method was applied to clinic operations, community referral systems and community outreach to assess and refine interventions within a quick-paced feedback loop.

RESULTS

During the COVID-19 pandemic, changes made via PDSA cycles to clinical/navigation services, health communications and youth outreach/engagement effectively responded to AYA needs. Although overall numbers of youth served decreased, all youth contacting the clinic for services were able to be accommodated. Case finding rates for chlamydia, gonorrhoea, syphilis and HIV were similar to pre-pandemic levels.

CONCLUSIONS

Quality improvement PDSA initiatives at AYA sexual health clinics, particularly those for underserved youth, can be used to adapt service delivery when normal operating models are disrupted. The ability for youth sexual health clinics to adapt to a changing healthcare landscape will be crucial in ensuring that under-resourced youth are able to receive needed services and ambitious Ending the HIV Epidemic goals are achieved.

Brief Report: Supporting Access to HIV Care for Children and Youth During the COVID-19 Pandemic With Telemedicine and Rideshare

BACKGROUND

In response to the COVID-19 pandemic, we scaled up telemedicine and rideshare services for clinic and laboratory visits for pediatric and adolescent patients with HIV.

SETTING

HIV subspecialty program for patients aged 0-24 years at Children's National Hospital, Washington, DC.

METHODS

Using the χ2 and Wilcoxon rank sum tests, we compared demographics, visit and laboratory data, and rideshare usage among patients who scheduled telemedicine at least once (telemedicine) versus those who never scheduled telemedicine (no-telemedicine) during the pandemic (April-September 2020). We compared the number and proportion of scheduled and completed clinic visits before the pandemic (April-September 2019) with those during the pandemic.

RESULTS

We analyzed 178 pediatric and adolescent patients with HIV (median age 17.9 years, 89.3% Black, 48.9% male patients, 78.7% perinatally infected), of whom 70.2% and 28.6% used telemedicine and rideshare, respectively. Telemedicine patients scheduled more visits (236 vs 179, P < 0.0001) and completed a similar proportion of visits (81.8% vs 86.0%, P = 0.3805) compared with no-telemedicine patients. Laboratory testing rates (81.3% versus 98.5%, P = 0.0005) were lower in telemedicine patients compared with no-telemedicine patients. Rideshare usage (12.4% versus 26.5%, P = 0.0068) was lower in telemedicine versus no-telemedicine patients. During the pandemic, most of the patients (81.0%) had HIV RNA <200 copies/mL. The total number of completed visits and the proportion of visits completed were similar before and during the pandemic.

CONCLUSION

Most of the pediatric and adolescent patients with HIV used telemedicine and maintained HIV RNA <200 copies/mL during the pandemic. Despite rideshare usage, laboratory testing rates were lower with telemedicine compared with in-person visits.

Accessing needed sexual health services during the COVID-19 pandemic in British Columbia, Canada: a survey of sexual health service clients

Objectives

We assessed COVID-19 pandemic impacts on accessing needed sexual health services, and acceptability of alternative service delivery models, among sexual health service clients in British Columbia (BC), Canada.

Methods

We administered an online survey on 21 July–4 August 2020 to clients using a provincial STI clinic or internet-based testing service, GetCheckedOnline, in the year prior to March 2020. We used logistic regression to identify factors associated with having unmet sexual health needs (ie, not accessing needed services) during March–July 2020 and the likelihood of using various alternative service models, if available.

Results

Of 1198 survey respondents, 706 (59%) reported needing any sexual health service since March 2020; of these 706, 365 (52%) did not access needed services and 458 (66%) had avoided or delayed accessing services. GetCheckedOnline users (univariate OR (uOR)=0.62; 95% CI 0.43 to 0.88) or clients with more urgent needs (eg, treatment for new STI, uOR 0.40 (95% CI 0.21 to 0.7)) had lower odds of unmet sexual health needs. The most common factors reported for avoiding or delaying access were public messaging against seeking non-urgent healthcare (234/662, 35%), concern about getting COVID-19 while at (214/662, 32%) or travelling to (147/662, 22%) a clinic or lab and closure of usual place of accessing services (178/662, 27%). All factors were positively associated with having unmet sexual health needs, with public messaging showing the strongest effect (adjusted OR=4.27 (95% CI 2.88 to 6.42)). Likelihood of using alternative sexual health service models was high overall, with the most appealing options being home self-collection kits (634/706, 90%), receiving test kits or antibiotics at home (592/700, 85%) and express testing (565/706, 80%).

Conclusions

Of BC sexual health service clients needing services during March–July 2020, many had unmet needs. Offering alternative service delivery methods may help to improve access during and beyond the COVID-19 pandemic.

Social, economic, and health effects of the COVID-19 pandemic on adolescents retained in or recently disengaged from HIV care in Kenya

INTRODUCTION

Adolescents living with HIV (ALHIV, ages 10-19) experience complex challenges to adhere to antiretroviral therapy (ART) and remain in care, and may be vulnerable to wide-scale disruptions during the COVID-19 pandemic. We assessed for a range of effects of the pandemic on ALHIV in western Kenya, and whether effects were greater for ALHIV with recent histories of being lost to program (LTP).

METHODS

ALHIV were recruited from an ongoing prospective study at 3 sites in western Kenya. The parent study enrolled participants from February 2019-September 2020, into groups of ALHIV either 1) retained in care or 2) LTP and traced in the community. Phone interviews from July 2020-January 2021 assessed effects of the pandemic on financial and food security, healthcare access and behaviors, and mental health. Responses were compared among the parent study groups.

RESULTS

Phone surveys were completed with 334 ALHIV or their caregivers, including 275/308 (89.3%) in the retained group and 59/70 (84.3%) among those LTP at initial enrollment. During the pandemic, a greater proportion of LTP adolescents were no longer engaged in school (45.8% vs. 36.4%, p = 0.017). Over a third (120, 35.9%) of adolescents reported lost income for someone they relied on. In total, 135 (40.4%) did not have enough food either some (121, 36.2%) or most (14, 4.2%) of the time. More LTP adolescents (4/59, 6.8% vs. 2/275, 0.7%, p = 0.010) reported increased difficulties refilling ART. Adolescent PHQ-2 and GAD-2 scores were ≥3 for 5.6% and 5.2%, respectively.

CONCLUSIONS

The COVID-19 pandemic has had devastating socioeconomic effects for Kenyan ALHIV and their households. ALHIV with recent care disengagement may be especially vulnerable. Meanwhile, sustained ART access and adherence potentially signal resilience and strengths of ALHIV and their care programs. Findings from this survey indicate the critical need for support to ALHIV during this crisis.

HIV and COVID-19: review of clinical course and outcomes

Background:Understanding the relationship between HIV and SARS-CoV-2 has important public health implications.Objective:To summarize current research on COVID-19 among people with HIV (PWH) as published through 15 July 2021.Methods: We conducted a search of PubMed, Scopus, preprint databases (medRxiv, bioRxiv), and the references of publications found using key terms relevant to COVID-19 ('COVID-19' OR 'SARS-CoV-2' OR 'coronavirus') AND to HIV ('HIV' OR 'Human Immunodeficiency Virus' OR 'AIDS' OR 'Acquired Immunodeficiency Syndrome'). We summarized all articles that reported data or opinions on SARS-CoV-2 and HIV coinfection.Conclusions: Although many initial case series and cohort studies found no increased risk for SARS-CoV-2 infection or severe COVID-19 outcomes among PWH, recent studies have signaled an increased risk for severe COVID-19 disease progression even in the setting of well-controlled HIV. Whether this is due to the increased prevalence of comorbidities in PWH and other social determinants of health is unknown. These conflicting findings highlight the continued need for COVID-19 related research among PWH that addresses COVID-19 disease course as well as exacerbation of existing comorbidities already disproportionately represented among PWH.

COVID-19's impact on primary care and related mitigation strategies: A scoping review

Background

The COVID-19 pandemic has had a substantial impact on primary care throughout Europe and globally.

Objectives

This review aims to ascertain how the pandemic has impacted primary care service provision/patients and to examine strategies to mitigate these impacts.

Methods

The scoping review framework comprised a six-stage process developed by Arksey and O'Malley. The search process was guided by the Joanna Briggs Institute three-step search strategy and involved searching the PubMed, Embase, Scopus, CINAHL Plus, and Cochrane Library databases. The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. A thematic analysis approach by Braun and Clarke was used to interpret the findings.

Results

Thirty-two studies from 18 countries and six continents were included, 13 reported original research, three were reviews, and 16 were case reports reporting healthcare systems’ experiences of dealing with the pandemic. Emerging themes concerned the COVID-19 pandemic’s impact on primary care service provision and patients, the impact of the rapid transition to telemedicine due to COVID-19 on primary care, and strategies to mitigate the impact of COVID-19 on primary care (i.e. infection prevention and control measures, alternatives/modifications to traditional service delivery or workflow, government policy responses, and education).

Conclusion

The COVID-19 pandemic has considerably impacted on primary care at both service and patient levels, and various strategies to mitigate these impacts have been described. Future research examining the pandemic’s ongoing impacts on primary care, as well as strategies to mitigate these impacts, is a priority.

Interventions to Support Mental Health among Those with Health Conditions That Present Risk for Severe Infection from Coronavirus Disease 2019 (COVID-19): A Scoping Review of English and Chinese-Language Literature

This study aimed to address knowledge gaps related to the prevention and management of mental health responses among those with a condition that presents risk of severe COVID-19 infection. A scoping review that mapped English and Chinese-language studies (2019-2020) located in MEDLINE (Ovid), Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo, Sociological Abstracts, Embase, China National Knowledge Infrastructure (CNKI), Wanfang Data, and Airiti Library was undertaken. Search terms related to COVID-19, mental health, and physical health were used and articles that included all three of these factors were extracted (n = 77). With the exception of one hospital-based pilot study, there were no intervention studies targeting mental health in those at risk of severe COVID-19 infection. Promising practices such as integrated care models that appropriately screen for mental health issues, address health determinants, and include use of digital resources were highlighted. Patient navigator programs, group online medical visits, peer support, and social prescribing may also support those with complex needs. Future policies need to address digital health access inequities and the implementation of multi-integrated health and social care. Furthermore, research is needed to comprehensively assess multi-integrated interventions that are resilient to public health crises.

Global health disparities in vulnerable populations of psychiatric patients during the COVID-19 pandemic

The coronavirus disease 2019 pandemic affects psychiatric patients disproportionately compared to the general population. In this narrative review, we examine the impact of the pandemic on significant global health disparities affecting vulnerable populations of psychiatric patients: People of diverse ethnic background and color, children with disabilities, sexual and gender minorities, pregnant women, mature adults, and those patients living in urban and rural communities. The identified disparities cause worsened mental health outcomes placing psychiatric patients at higher risk for depression, anxiety and posttraumatic stress disorder symptoms. Those psychiatric patients who are ethnic minorities display barriers to care, including collective trauma and structural racism. Sexual and gender minorities with mental illness face discrimination and limited access to treatment. Pregnant women with psychiatric diagnoses show higher exposure to domestic violence. Children with disabilities face a higher risk of worsening behavior. Mature adults with psychiatric problems show depression due to social isolation. Psychiatric patients who live in urban communities face pollutants and overcrowding compared to those living in rural communities, which face limited access to telehealth services. We suggest that social programs that decrease discrimination, enhance communal resilience, and help overcome systemic barriers of care should be developed to decrease global health disparities in vulnerable population.

Potential and demonstrated impacts of the COVID-19 pandemic on sexually transmissible infections: Republication

PURPOSE OF REVIEW

This review considers the potential and demonstrated impacts of SARS-CoV-2 on the sexually transmissible infection (STI)/HIV transmission.

RECENT FINDINGS

COVID-19 increases the vulnerability of those at highest risk of acquiring STI/HIV. Altered health-seeking behaviour, reductions in STI/HIV clinic capacity, service disruptions and redeployment of human resources to assist COVID-19 control efforts have impacted on STI/HIV control programmes. Reports of reduced STI incidence are emerging, but it is hard to determine whether this is real or due to decreased testing during COVID-19 lockdown periods. Fear of COVID-19 and implemented control measures have altered STI/HIV transmission dynamics. Sexual health services adapted to the pandemic by reducing face-to-face patient encounters in favour of telehealth and mail-based initiatives as well as more stringent triage practice. Many sexual health and HIV treatment services now operate at reduced capacity and experience ongoing service disruptions, which necessarily translates into poorer outcomes for patients and their communities.

SUMMARY

In the short-term, COVID-19 related sexual behaviour change is driving STI/HIV transmission downwards. However, the impacts of the global COVID-19 response on sexual health-seeking behaviour and STI/HIV services threaten to drive STI/HIV transmission upwards. Ultimately, the expected rebound in STI/HIV incidence will require an appropriate and timely public health response.

VIDEO ABSTRACT

http://links.lww.com/COID/A31.

Innovations in Human Immunodeficiency Virus (HIV) Care Delivery During the Coronavirus Disease 2019 (COVID-19) Pandemic: Policies to Strengthen the Ending the Epidemic Initiative-A Policy Paper of the Infectious Diseases Society of America and the HIV Medicine Association

The goal of the Ending the HIV Epidemic Initiative is to reduce new infections in the US by 90% by 2030. Success will require fundamentally changing HIV prevention and care delivery to engage more persons with HIV and at-risk of HIV in treatment. While the COVID-19 pandemic reduced in-person visits to care facilities and led to concern about interruptions in care, it also accelerated growth of alternative options, bolstered by additional funding support. These included the use of telehealth, medication delivery to the home and increased flexibility facilitating access to Ryan White HIV/AIDS Program services. While the outcomes of these programs must be studied, many have improved accessibility during the pandemic. As the pandemic wanes, long term policy changes are needed to preserve these options for those who benefit from them. These new care paradigms may provide a roadmap for progress for those with other chronic health issues as well.

Potential and demonstrated impacts of the COVID-19 pandemic on sexually transmissible infections

PURPOSE OF REVIEW

This review considers the potential and demonstrated impacts of SARS-CoV-2 on the sexually transmissible infection (STI)/HIV transmission.

RECENT FINDINGS

COVID-19 increases the vulnerability of those at highest risk of acquiring STI/HIV. Altered health-seeking behaviour, reductions in STI/HIV clinic capacity, service disruptions and redeployment of human resources to assist COVID-19 control efforts have impacted on STI/HIV control programmes. Reports of reduced STI incidence are emerging, but it is hard to determine whether this is real or due to decreased testing during COVID-19 lockdown periods. Fear of COVID-19 and implemented control measures have altered STI/HIV transmission dynamics. Sexual health services adapted to the pandemic by reducing face-to-face patient encounters in favour of telehealth and mail-based initiatives as well as more stringent triage practice. Many sexual health and HIV treatment services now operate at reduced capacity and experience ongoing service disruptions, which necessarily translates into poorer outcomes for patients and their communities.

SUMMARY

In the short-term, COVID-19 related sexual behaviour change is driving STI/HIV transmission downwards. However, the impacts of the global COVID-19 response on sexual health-seeking behaviour and STI/HIV services threaten to drive STI/HIV transmission upwards. Ultimately, the expected rebound in STI/HIV incidence will require an appropriate and timely public health response.

VIDEO ABSTRACT

http://links.lww.com/COID/A31.

Disparity in HIV Service Interruption in the Outbreak of COVID-19 in South Carolina

To examine HIV service interruptions during the COIVD-19 outbreak in South Carolina (SC) and identify geospatial and socioeconomic correlates of such interruptions, we collected qualitative, geospatial, and quantitative data from 27 Ryan White HIV clinics in SC in March, 2020. HIV service interruptions were categorized (none, minimal, partial, and complete interruption) and analyzed for geospatial heterogeneity. Nearly 56% of the HIV clinics were partially interrupted and 26% were completely closed. Geospatial heterogeneity of service interruption existed but did not exactly overlap with the geospatial pattern of COVID-19 outbreak. The percentage of uninsured in the service catchment areas was significantly correlated with HIV service interruption (F = 3.987, P = .02). This mixed-method study demonstrated the disparity of HIV service interruptions in the COVID-19 in SC and suggested a contribution of existing socioeconomic gaps to this disparity. These findings may inform the resources allocation and future strategies to respond to public health emergencies.

The Impact of COVID-19 on Pediatric Adherence and Self-Management

The COVID-19 pandemic has presented unique circumstances that have the potential to both positively and negatively affect pediatric adherence and self-management in youth with chronic medical conditions. The following paper discusses how these circumstances (e.g., stay-at-home orders, school closures, changes in pediatric healthcare delivery) impact disease management at the individual, family, community, and healthcare system levels. We also discuss how barriers to pediatric adherence and self-management exacerbated by the pandemic may disproportionately affect underserved and vulnerable populations, potentially resulting in greater health disparities. Given the potential for widespread challenges to pediatric disease management during the pandemic, ongoing monitoring and promotion of adherence and self-management is critical. Technology offers several opportunities for this via telemedicine, electronic monitoring, and mobile apps. Moreover, pediatric psychologists are uniquely equipped to develop and implement adherence-promotion efforts to support youth and their families in achieving and sustaining optimal disease management as the current public health situation continues to evolve. Research efforts addressing the short- and long-term impact of the pandemic on pediatric adherence and self-management are needed to identify both risk and resilience factors affecting disease management and subsequent health outcomes during this unprecedented time.