When the COVID-19 pandemic led to a blanket shelter-in-place order in California in March, it did more than shut down in-person visits at Ward 86, the HIV clinic for publicly insured patients at San Francisco General Hospital. It also led to a decrease in viral suppression among the clinic›s clients. By the end of June, the percentage of patients with an undetectable viral load had dropped by nearly one-third.
This is exactly what Monica Gandhi, MD, associate division chief of HIV, infectious diseases, and global medicine at the University of California, San Francisco, and medical director of the clinic, was afraid of.
“We’re profoundly worried about the impact of COVID-19 on actual treatment outcomes,” said Dr. Gandhi, cochair of the virtual International AIDS Conference (AIDS) 2020.
And it’s not just the clinic’s clients at risk. Of the 106 countries served by the Global Fund to Fight HIV, Tuberculosis, and Malaria, 85% saw disruptions in HIV programs, according to a report released last month.
These service disruptions are considerable and “life threatening,” affecting some of the people at greatest risk for HIV acquisition and poor outcomes – such as people engaged in transactional sex (40%), men who have sex with men (37%), and transgender people (31%) – the 2020 Global AIDS Update, released today by UNAIDS, reports.
“In sub-Saharan Africa alone, if there is a 6-month interruption in HIV treatment services, it will account for an additional 500,000 deaths. That doubles the number of deaths in sub-Saharan Africa alone and brings us back to 2008 mortality levels,” said Shannon Hader, MD, deputy executive director of UNAIDS. “We just can’t allow that to happen.”
In addition, 73 countries are at risk of running out of HIV medications, according to a World Health Organization report, also released today.
Quantifying the impact
The impact is not the same for all patients, said Anton Pozniak, MD, consulting physician in HIV medicine at the Chelsea and Westminster Hospital in London, and international cochair of AIDS 2020.
For some, COVID-19 has not changed much. Their viral loads remain undetectable and all they need is multimonth supplies of their antiretroviral therapy (ART) medications, he told Medscape Medical News. Still, he said he worries about the well-documented effects that social isolation is having on the mental health of these patients, and the increase in substance use associated with the pandemic.
Then there is a small group of patients with HIV who had put off starting ART before the pandemic, but now want to start, he reported.
And finally, there are the people for whom the fear of COVID-19 has crippled their ability to get care.
There are people who have decided they don’t want to come to the hospital or come to the clinic because they’re scared of getting COVID-19.
“It’s really very striking,” said Dr. Pozniak. “There are people who have decided they don’t want to come to the hospital or come to the clinic because they’re scared of getting COVID-19. We’ve offered to deliver treatment, but they don’t want the stigma of parcels of drugs arriving.”
In a study presented at the conference, four of 12 care and substance-use treatment facilities in Europe and North America – including Seattle and Philadelphia – reported patients taking longer to fill ART prescriptions. And four of the 12 also reported that clients who injected drugs and were at risk for or living with HIV were having trouble adhering to prescribed therapies. In addition, at 11 of the sites, HIV testing has either nearly or completely shut down.