The worst predictions of modelling studies concerning the impact of the 2020 COVID-19 lockdown on HIV care appear not to have come true in South Africa. A study in The Lancet HIV shows that in the province of KwaZulu-Natal, antiretroviral therapy (ART) provision was maintained throughout. However, the lockdown negatively impacted HIV testing and the number of people starting ART.
COVID-19 and HIV in South Africa
To what extent have COVID-19 control measures impacted HIV services? One year into the pandemic, data on this issue are scarce. This gap is particularly worrying for sub-Saharan Africa, where HIV/AIDS remains a leading cause of death.
Last year, modelling studies of the COVID-19 pandemic’s impact on HIV estimated that interruptions in ART would have the largest effect on HIV-related mortality in Africa. For instance, a three-month interruption of ART supply to every person diagnosed with HIV in 13 African countries translated into a rise in annual mortality during 2021, ranging from 35 to 131%, depending on the model used. In another worst-case scenario, interruption of ART for six months for 50% of patients would result in 296,000 excess HIV-related deaths.
These concerns resonate loudly in South Africa. The country is the most heavily affected by both HIV and COVID-19 in Africa. Just in KwaZulu-Natal, an estimated 1.7 million people are living with HIV and 76,706 cases of COVID-19 were confirmed by the end of July 2020.
In March 2020, a national lockdown was implemented in South Africa, with measures gradually eased in subsequent months. While it was one of the most severe COVID-19 control steps globally, it allowed travel to receive health care.
The study was conducted by Dr Jienchi Dorward from the Centre for the AIDS Programme of Research in South Africa (CAPRISA) and colleagues from other institutions. The investigators quantified the lockdown impact on HIV care in 65 primary care clinics in KwaZulu-Natal. Of the 65 clinics, 56 were urban and nine were rural. Data were from people testing for HIV, starting ART and collecting their HIV medications regularly.
Dorward and colleagues proceeded with an interrupted time series analysis of the data. This method evaluates the effects of an intervention – in this case, lockdown – on previously observed population trends.
For HIV testing, data were captured from 2018 to 31 July 2020. The other two variables were captured to 15 June 2020.
Reported on a monthly basis, the median number of HIV tests performed were 41,926/month in the 27 months preceding lockdown (IQR 37,838-51,069) and 38,911/month between April and July 2020 (IQR 32,699-42,756).
In April 2020, HIV testing decreased deeply by 48%. After this first month of lockdown, it increased by some 18% per month, reaching 83% of its pre-lockdown levels in July 2020. The median proportions of tests that were positive were 6.1% and 4.3% before and after lockdown, respectively.
These findings were similar among women and men. The decrease in HIV testing was deeper at urban clinics. This may be due to more tightly enforced restrictions in cities and people working in cities having moved back to rural areas during the lockdown.
In the 117 weeks before lockdown, there was a median of 571 people starting ART per week (IQR 498-678). This compares with 375 per week (331-399) in the first eleven weeks of lockdown.
There was a 46% decrease in people starting ART in the first lockdown week. Thereafter, this outcome recovered gradually by 16% per month, reaching 75% of pre-lockdown levels by mid-June 2020.
The recovery for this outcome occurred mainly in women. Among men, starting ART remained low. The effect of lockdown on this outcome was similar across age groups, and in rural and urban clinics.
Patients attended a median of 18,519 scheduled visits to collect ART per week before lockdown (IQR 17,704-19,922). After lockdown, this number decreased to 17,863 per week (IQR 17,509-18995). Reported per month, ART collection levels remained constant after lockdown (IRR 0.974, 95% CI 0.900-1.053).
Interestingly, there was an increase in collection visits in the four weeks between the first SARS-CoV-2 case identification and lockdown. Also, there was an increase in visits occurring earlier than scheduled in this pre-lockdown period. This suggests that people may have been stocking up ART in preparation for potential disruptions.
The number of missed collection visits increased for a short period of time, before returning to pre-lockdown levels. The investigators also focused on potential difficulties in collecting ART from community pick-up points. Such hurdles would have led to an increase in collections at clinics. However, there was no evidence of this.
The investigators discuss a key issue in their paper. The study suggests that HIV services were generally maintained for people already on ART. However, engaging new people into care was impeded by the lockdown. So, why were HIV testing and starting ART most affected by the measure?
"Efforts to continue providing ART to people during the 2020 lockdown were successful."
One possible reason might be that 28,000 HIV community healthcare workers were diverted from HIV testing to COVID-19 symptom screening. This redeployment might have led to fewer referrals to clinics for HIV testing and to fewer people starting ART. At least, this is suggested by the broadly similar decrease in HIV testing, positive HIV tests and the number of people starting ART.
People not already engaged in care might be discouraged by challenges attending a clinic, especially during lockdown. These challenges include increased transport costs, travel permits and fear of catching SARS-CoV-2 at clinics. On the other hand, people already engaged in HIV care and aware of the importance of maintaining high treatment adherence might have prioritised ART collection.
Overall, the study shows that the worst modelled scenarios of the COVID-19 impact on HIV care are unlikely to play out in South Africa. Instead, efforts to continue providing ART to people during the 2020 lockdown were successful.
Nevertheless, Dorward and colleagues underline how important it is for these efforts to now focus on catching up with HIV testing and starting people on ART. They suggest the integration of HIV and SARS-CoV-2 testing programmes. They advocate for an increased focus on HIV self-testing and for people to be able to start ART in community and home settings.
“Strategies to increase HIV testing and treatment initiation should be implemented to address the current and future outbreaks”, they say.
Dorward J et al. The impact of the COVID-19 lockdown on HIV care in 65 South African primary care clinics: an interrupted time series analysis. The Lancet HIV, published online, February 2021 (open access).
Full image credit: Sister Nonkosi Mrwebo, a nurse at the Hamburg clinic, shows a well-stocked dispensary. PWRDF. Available at www.flickr.com/photos/45005153@N07/8201070686/ under Creative Commons licence CC BY 2.0.