The impact of COVID-19 has been far-reaching and complex. Sub-Saharan Africa has been spotlighted as a region of particular concern for increased HIV transmission and mortality in the midst of the coronavirus pandemic. With interruptions to medication supply and a lack of prevention or testing facilities, we are in danger of swapping one pandemic for another as cases of HIV are set to rise dramatically.
What to Know:
· HIV – human immunodeficiency virus – HIV is a virus which suppresses your immune system through attacking your own immune defence cells (CD4 T Cells); this leaves you vulnerable to more dangerous infections and diseases. HIV is spread through exchanging bodily fluids with an infected individual who is not virally suppressed through ARV, e.g. blood, breast milk, semen, vaginal secretions.
· AIDS – acquired immune deficiency syndrome – AIDS refers to the set of illnesses you may acquire once your immune system has been damaged by HIV; these conditions can be fatal if untreated.
· ARV drugs – antiretroviral medication – ARV is a group of drugs used to treat HIV; they work by preventing the virus from replicating inside your human body cells. With long-term ARV, a person can live a long and healthy life with HIV.
Sixty-eight percent of people living with HIV are in sub-Saharan Africa, according to estimates from The Joint United Nations Programme on HIV/AIDS (UNAIDS); this equates to approximately 25.7 million people. The number of people dying from AIDS-related illnesses worldwide has reduced by more than 55% since 2004, from 1.7 million to 770,000.[1] This reduction in mortality is due primarily to improvements in treatment options and an increase in the availability of ARV medication. However, a significant concern is now that the COVID-19 pandemic will lead to disruptions in treatment for HIV and a subsequent rise in HIV-related deaths.
Across most countries in sub-Saharan Africa, individuals living with HIV attend health clinics to collect their medication. Throughout 2020 so far, there has been both a reduction in the availability of medication at these clinics, and a decrease in patients collecting their ARV drugs. In July the World Health Organization (WHO) conducted a survey, which found that seventy-three countries warned they were in danger of running out of ARV medication due to the COVID-19 pandemic. Furthermore, twenty-four of these countries had a "critically low stock" or "disruptions in the supply" of ARV. [2]
As HIV weakens your immune system, leaving you more vulnerable to opportunistic infections, there is evidence to suggest that individuals living with HIV who are not taking their appropriate medication are more likely to die of COVID-19. Two studies based in the UK recently found between a 63-130% increase in COVID-19 deaths among HIV-positive individuals. [3] [4] At this time when ARV medication is scarce, there may be a rise not only in HIV-related deaths, but also a disproportionately high number of deaths from COVID-19 in individuals living with HIV. However, the situation is changing daily and, as always, more data is required before extrapolating these results to another region of the world such as sub-Saharan Africa.
Stigma surrounding HIV and AIDS has been an issue for decades, predominantly because certain groups are at increased risk of transmission, including men who have sex with men and intravenous drug users. One country recently highlighting the problems that stigma still causes is Kenya: many patients living with HIV in Kenya register at clinics far from home to avoid seeing people they know
when collecting ARV treatment. Now, when they are forced to stay at home or nearby due to measures to control coronavirus, these patients are unable to collect their medication. Unless myths and stigma surrounding HIV are quashed, through improvements in education, the numbers of people collecting medication for HIV will remain low even in countries where ARV supply is unaffected, leading to rises in HIV-related mortality and transmission.
Several groups have attempted to estimate the possible extent of the disruption that COVID-19 will have on HIV in sub-Saharan Africa, using mathematical modelling to map the disease spread. Discrepancies in their findings largely stem from different assumptions in the percentage of the population that would be affected, and the duration of disruption.
The first model, published in the Lancet in September, assumed that the provision of ARV drugs would be disrupted for 50% of patients receiving treatment from HIV, lasting six months over a one year period. Under these conditions, they estimated that the number of HIV-related deaths would increase by 1.63 times (as a median across all mathematical models) compared to one year with no disruption to treatment provision. This estimate equates to 296,000 excess HIV-related deaths in sub-Saharan Africa.[5] They cited three primary reasons for these excess deaths:
1. Disruption of prevention: reduction in condom supplies; lack of education, particularly between peers
2. Disruption of HIV testing: due to social distancing and quarantine measures
3. Disruption of ARV treatment: both due to a lack of supply, and a reduction in patients collecting medication from clinics.
The second model was conducted by the WHO and UNAIDS. Based on their modelling, they estimated that a six-month disruption of ARV could lead to between 471,000 and 673,000 excess AIDS-related deaths in sub-Saharan Africa. [6]
Regardless of which model you accept, the conclusions are clear:
· The COVID-19 pandemic is threatening the supply of ARV medication globally
· COVID-19 could lead to hundreds of thousands of excess deaths related to HIV and AIDS in sub-Saharan Africa
Take-away message
This example of HIV and COVID-19 serves as an important reminder for epidemiological data generally: whilst the numbers of COVID-19 deaths are vital to understand the spread of the disease, the impact that this pandemic will have cannot be fully understood without also looking to its indirect effects. Excess deaths from other conditions, indirectly caused by disruption from the coronavirus pandemic, are also key to quantifying the detrimental effects of this virus now and for the years to come.
Author; Deborah Allen, MSc Global Health Science and Epidemiology, St Anne's College.
References
[1] UNAIDS. AIDSinfo, 2019. [Online] Available from: http://aidsinfo.unaids.org/ [Accessed 02 Oct 2020].
[3] K Bhaskaran et al. HIV infection and COVID-19 death: population-based cohort analysis of UK primary care data and linked national death registrations within the OpenSAFELY platform. [Pre-print] medRxiv, 2020 [Online] Available from: https://doi.org/10.1101/2020.08.07.20169490 [Accessed 02 Oct 2020].
[4] A.M. Geretti et al. Outcomes of COVID-19 related hospitalisation among people with HIV in the ISARIC WHO Clinical Characterisation Protocol UK Protocol: prospective observational study. [Pre-print] medRxiv, 2020 [Online] Available from: https://doi.org/10.1101/2020.08.07.20170449 [Accessed 02 Oct 2020].
[5] B.L. Jewell et al. Potential effects of disruption to HIV programmes in sub-Saharan Africa caused by COVID-19: results from multiple mathematical models. The Lancet, 2020, 7 (9), E629-E640. [Online] Available from: https://doi.org/10.1016/S2352-3018(20)30211-3 [Accessed 02 Oct 2020].
[6] World Health Organization. The cost of inaction: COVID-19-related service disruptions could cause hundreds of thousands of extra deaths from HIV, 11 May 2020. [Online] Available from: https://www.who.int/news-room/detail/11-05-2020-the-cost-of-inaction-covid-19-related-service-disruptions-could-cause-hundreds-of-thousands-of-extra-deaths-from-hiv [Accessed 02 Oct 2020].