Sustaining the response to HIV in a world shaped by COVID-19

Although global attention is dominated by COVID-19, the HIV / AIDS pandemic, entering its fifth decade, is far from over. Since the early 1980s, 75.7 million people have been infected with HIV. 32 · 7 million people have died from AIDS-related illnesses. HIV / AIDS remains a major public health crisis and only a few countries will reach the 90–90–90 treatment target by 2020. Much has been made of how information systems and service models in the response to HIV have helped the response to COVID-19. But the COVID-19 pandemic could have knock-on effects on the HIV response and be devastating for communities. How could the COVID-19 pandemic shape the future response to HIV / AIDS to achieve the goal of ending HIV / AIDS by 2030?

The COVID-19 pandemic has affected health systems and exposed gaps in public health almost everywhere. From the highest levels of national leadership to community health facilities, human, financial and research resources have been diverted from HIV-related efforts. Most health systems in regions with a high burden of HIV are fragile, and several studies suggest that interruptions in HIV services could have negative effects on health outcomes in the medium and long term. Modeling of data published in The Lancet Global Health show that severe treatment interruptions in high burden settings could increase HIV mortality by 10% in 5 years. The HIV Modeling Consortium has shown that severe treatment interruptions in sub-Saharan Africa (for example, prevention of HIV treatment for 50% of patients for 6 months) could result in an excess of 296,000 HIV deaths in one year . UNAIDS models suggest that interruptions of mother-to-child transmission of HIV services for six months could increase new infections among children by between 40% and 80% in high-burden countries.

While in many countries, HIV prevention, testing and care have been disrupted due to strict lockdown policies and disruptions in drug supply chains, UNAIDS says the effects of COVID-19 on maintenance of treatment services so far have been less severe than originally feared. Thanks to novel approaches, such as home delivery of medicines and digital platforms for virtual patient support, HIV prevention services have recovered in many communities.

A chilling pattern of inequity shapes the burden of COVID-19 and HIV. The adverse effects of each disease are compounded by social and economic disparities and disproportionately affect poor and marginalized people, particularly young women and girls. The socioeconomic impacts of the COVID-19 pandemic will be far-reaching and long-lasting. The World Bank warns that 115 million people fell into extreme poverty in 2020. COVID-19 is also destined to increase inequality, as pandemic-related job losses and deprivations affect people most acutely poor and vulnerable. Poverty could create more barriers to participation in the HIV care system.

December 1, 2020 is World AIDS Day. In the context of an extraordinary health crisis, this year’s campaign calls for global solidarity and shared responsibility. For healthcare leaders facing many competing priorities, what might this mean in practice? In 2018, the Lancet Commission of the International AIDS Society envisioned a new era of global solidarity, in which the response to HIV would be integrated with the broader field of global health. Built on the AIDS movement’s commitment to human rights, gender equality, and health equity, this new era could focus on developing strong, flexible and people-centered health systems, achieving universal health coverage, and addressing the social and structural determinants of health. The Global Fund to Fight AIDS, Tuberculosis and Malaria took a systems strengthening approach in 2016. For other institutions that have been instrumental in the AIDS response, this perspective should mean that fragmented and isolated approaches are replaced by broader strengthening and preparedness of the health system than integrating HIV with other health priorities.