Leveraging the advances in HIV for COVID-19

The global HIV response at 40

It is helpful to divide the global HIV response into three phases: The first, from about 1980 to 2000, represents "Calamity". The second, from roughly 2000 to 2015 represents "Hope." The third, from 2015, is unfolding and may be termed "Choices" - and these choices may be severely constrained by COVID, so "Constrained Choices in an era of COVID" may prove more apt. As we take stock of HIV at 40, there are positive lessons for the wider health response - and challenging reflections for the wider impact of the global HIV response. The positive lessons include: (1) the importance of activism; (2) the role of scientific progress and innovation; (3) the impact of evidence in concentrating resources on proven approaches; (4) the importance of surveillance to understanding transmission dynamics; (5) the use of epidemic intelligence to guide precision implementation; (6) the focus on implementation cascades (diagnosis, linkage, adherence, disease suppression); and finally (7) an overarching execution and results focus.Given this remarkable legacy, it seems churlish to ask whether the HIV response could have achieved more. Yet, consider these approximate figures. Development assistance for HIV totals about 100 billion dollars, 70 billion from the USA matched by roughly 100 billion in domestic resources. For 200 billion dollars, should we not have achieved more than 23 million people initiating treatment (very crudely, 10 000 dollars per person on treatment)? Much of the hundred billion dollars of development assistance (roughly half) focused on about a dozen priority countries in eastern and southern African. The larger PEPFAR recipients, with populations of roughly 50 million, each received 5 billion dollars or more cumulatively. And there are further Global Fund contributions of an additional billion dollars in many of these countries. For 6 billion dollars per country, should we have expected more?The World Bank Human Capital Project posits that to maximize human capital formation, countries must ensure that their children survive, are well nourished and stimulated, learn skills and live long, productive lives. Using the Human Capital Index (a composite index based on these factors), South Africa - the largest HIV financing recipient - ranks 126th of 157 countries, below Haiti, Ghana, the Congo Republic, Senegal and Benin. Consider how many recipients of major HIV development finance fall into the bottom fifth: Namibia, Botswana, Eswatini (formerly Swaziland), Malawi, South Africa, Tanzania, Zambia, Uganda, Lesotho, Ethiopia, Mozambique, Cote D'Ivoire and Nigeria. Of course, causality is unresolved and there are several possible explanations: (1) low human capital formation may increase HIV transmission; (2) the HIV epidemic may have intergenerational impacts; (3) the all-consuming focus on HIV may have displaced other health, education and development priorities. Yet, it remains hard to see these data and to argue that successful HIV responses among the largest HIV financing recipients strengthened their wider health sector and human development outcomes.A plausible principle emerges. Narrowly targeted disease-specific emergency responses may lead to disease-specific gains but do not improve governance or national systems capacity or wider disease or development outcomes. This is not to undermine the emergency origins of the HIV response; 2021 is not 2000 and it is unlikely that we would have 23 million people initiating treatment without an emergency response. Yet, there are reasons (intensified by COVID), to suggest that we must pivot towards long-term, integrated, developmental, nationally owned and financed, systems-orientated responses - particularly when both development assistance and national budgets are likely to be constrained in an era of COVID.

Fighting COVID-19 and HIV through community mobilisation: lessons from an integrated approach to the Africa CDC Partnership to Accelerate COVID-19 Testing (PACT) initiative in seven countries

Recent literature has shown how the HIV architecture, including community systems, has been critical for fighting COVID-19 in many countries, while sustaining the HIV response. Innovative initiatives suggest that fostering the integration of health services would help address the colliding pandemics. However, there are few documented real-life examples of community mobilisation strategies responding to COVID-19 and HIV. The African Union and Africa Centres for Disease Control and Prevention (Africa CDC) launched the Partnership to Accelerate COVID-19 Testing (PACT) in June 2020 with the goal of training and deploying one million community health workers across the continent. UNAIDS partnered with Africa CDC to implement the PACT initiative in seven countries, i.e. Algeria, Côte d'Ivoire, Gabon, Ghana, Madagascar, Malawi and Namibia. The initiative engaged networks of people living with HIV and community-led organisations to support two of its pillars, test and trace, and the sensitisation to protective measures against COVID-19 for the most vulnerable populations. It later expanded to improve access to COVID-19 vaccines. Based on the assessment of country projects, this article explains how PACT activities implemented by communities contributed to mitigating COVID-19 and HIV among vulnerable and marginalised groups. This article contributes to a better understanding of the impact of a community-based approach in responding effectively to emerging health threats and provides lessons from integrated COVID-19 and HIV community-led responses.

Public health implications of adapting HIV pre-exposure prophylaxis programs for virtual service delivery in the context of the COVID-19 pandemic: a systematic review

Background

The novel coronavirus disease COVID-19 caused by SARS-CoV-2 threatens to disrupt global progress toward HIV epidemic control. Opportunities exist to leverage ongoing public health responses to mitigate the impacts of COVID-19 on HIV services, and novel approaches to care provision might help address both epidemics.

Objective

As the COVID-19 pandemic continues, novel approaches to maintain comprehensive HIV prevention service delivery are needed. The aim of this study was to summarize the related literature to highlight adaptations that could address potential COVID-19–related service interruptions.

Methods

We performed a systematic review and searched six databases, OVID/Medline, Scopus, Cochrane Library, CINAHL, PsycINFO, and Embase, for studies published between January 1, 2010, and October 26, 2021, related to recent technology-based interventions for virtual service delivery. Search terms included “telemedicine,” “telehealth,” “mobile health,” “eHealth,” “mHealth,” “telecommunication,” “social media,” “mobile device,” and “internet,” among others. Of the 6685 abstracts identified, 1259 focused on HIV virtual service delivery, 120 of which were relevant for HIV prevention efforts; 48 pertained to pre-exposure prophylaxis (PrEP) and 19 of these focused on evaluations of interventions for the virtual service delivery of PrEP. Of the 16 systematic reviews identified, three were specific to PrEP. All 35 papers were reviewed for outcomes of efficacy, feasibility, and/or acceptability. Limitations included heterogeneity of the studies’ methodological approaches and outcomes; thus, a meta-analysis was not performed. We considered the evidence-based interventions found in our review and developed a virtual service delivery model for HIV prevention interventions. We also considered how this platform could be leveraged for COVID-19 prevention and care.

Results

We summarize 19 studies of virtual service delivery of PrEP and 16 relevant reviews. Examples of technology-based interventions that were effective, feasible, and/or acceptable for PrEP service delivery include: use of SMS, internet, and smartphone apps such as iText (50% [95% CI 16%-71%] reduction in discontinuation of PrEP) and PrEPmate (OR 2.62, 95% CI 1.24-5.5.4); telehealth and eHealth platforms for virtual visits such as PrEPTECH and IowaTelePrEP; and platforms for training of health care workers such as Extension for Community Healthcare Outcomes (ECHO). We suggest a virtual service delivery model for PrEP that can be leveraged for COVID-19 using the internet and social media for demand creation, community-based self-testing, telehealth platforms for risk assessment and follow-up, applications for support groups and adherence/appointment reminders, and applications for monitoring.

Conclusions

Innovations in the virtual service provision of PrEP occurred before COVID-19 but have new relevance during the COVID-19 pandemic. The innovations we describe might strengthen HIV prevention service delivery during the COVID-19 pandemic and in the long run by engaging traditionally hard-to-reach populations, reducing stigma, and creating a more accessible health care platform. These virtual service delivery platforms can mitigate the impacts of the COVID-19 pandemic on HIV services, which can be leveraged to facilitate COVID-19 pandemic control now and for future responses.

Ending AIDS in the Asia-Pacific region by 2030: are we on track? Policy, epidemiological and intervention insights

The Asia-Pacific region is home to nearly 6 million people living with HIV. Across the region, key populations - men who have sex with men, transgender women, people who inject drugs, sex workers, prisoners - and their sexual partners make up the majority of those living with HIV. While significant progress has been made in the past 5 years towards UNAIDS's 90-90-90 goals (90% of people with HIV diagnosed, 90% on antiretroviral therapy, 90% virologically suppressed), significant gaps remain. The papers in this Special Issue address important questions: are we on track to end the AIDS epidemic in the Asia-Pacific region? And can countries in this region reach the new UNAIDS targets for 2030?