Counting the cost of COVID-19 on HIV care in Africa
Lockdown in KwaZulu-Natal, South Africa saw HIV testing halve and the weekly number of people beginning antiretroviral treatment fall by 200.
An analysis of COVID-19’s impact in KwaZulu-Natal – where 27% of adults are living with HIV – finds that rates of HIV testing halved in April 2020, the first month of lockdown. The weekly number of people starting antiretroviral treatment (ART) also fell by around 200.
But, encouragingly, people already on ART maintained access to antiretrovirals (ARVs) throughout lockdown - which lasted from April through to July. The number of people testing for HIV and beginning treatment did recover each month throughout lockdown, although ART initiation among men remained lower than normal.
South Africa went into national lockdown on 27 March 2020. In May, restrictions changed to allow public transport, and they were lifted further in June to allow some businesses to open.
Research on how COVID-19 has affected HIV care is limited. Modelling studies suggest that ART interruptions could increase illness and death, with one study predicting that a six-month ART interruption for half of those on treatment could lead to nearly 300,000 excess AIDS-related deaths in Africa. Whether such high levels of ART disruption have happened remains unclear.
To help answer this question, researchers assessed data from people of all ages attending 65 urban and rural primary health clinics in KwaZulu-Natal between January 2018 and July 31 2020. All clinics remained open during lockdown.
The study is the first to take long-term trends and seasonal variations into consideration when analysing COVID-19’s impact on HIV testing and treatment.
In April 2020, the first month of lockdown, there was a 48% decrease in HIV testing. After April, HIV testing increased by 18% per month, reaching 83% of pre-lockdown levels by July 2020. This equates to a median of 41,926 monthly tests before lockdown and 38,911 monthly tests during lockdown (between April and July 2020).
In the first full week of lockdown (30 March to 5 April 2020) ART initiations dropped by 46%. After that, ART initiations rose by 16% each month, reaching 75% of pre-lockdown levels by mid-June 2020, with women more likely than men to benefit.
This equates to a median of 570 people beginning ART each week before lockdown, and 375 each week during lockdown.
There was a brief reduction in ART collection visits in the first month of lockdown. But this quickly returned to pre-lockdown levels, and most people who missed a visit attended in the next month. This finding suggests that the worst-case modelling in relation to HIV treatment disruption and excess deaths is unlikely to occur.
The study found lockdown affected rural clinics less than clinics in urban areas, where lockdown restrictions might have been more heavily enforced.
ART collections and early collections were higher in the four weeks before lockdown, suggesting people rushed to stock up on ARVs in case of shortages.
Catch-up strategies should now be considered in KwaZulu-Natal and similar settings. This could include a focus on HIV self-testing, and home- or community-based ART initiation.
The study’s authors said: “Efforts to continue providing treatment to people in the ART programme appear to have been largely successful. Although this evidence is reassuring, COVID-19-related disruptions to ART supply chains and future COVID-19 outbreaks and lockdowns still pose a threat to HIV programmes.”