Two sessions at the recent 18th European AIDS Conference (EACS 2021) concentrated on the way the COVID pandemic has impacted on HIV diagnosis, treatment and prevention, especially in Europe and central Asia.
Both keynote presenters said that the services most badly affected were HIV testing and HIV case surveillance.
Elena Vovc from the World Health Organization (WHO) said that HIV testing was so badly affected that it should not be assumed that the reductions in HIV diagnoses seen during the last year were entirely caused by people having less sex with new partners under lockdown. A large proportion of the reduction in diagnoses might be due to fewer tests having been done.
A backlog of undiagnosed cases, she added, may negatively impact the HIV treatment cascade, potentially raising transmissions, and also raising the number of late-diagnosed people.
The keynote presenter at the other session, Teymur Noori from the European Centre for Disease Prevention and Control (ECDC), said that a reduced capacity to respond to HIV during COVID was especially important in central and eastern Europe, the only part of the world where, in his words, “HIV incidence is still going straight up.”
He asked whether HIV services would ever return to pre-pandemic levels, but both he and Elena Vovc praised the role of community organisations in maintaining supplies of both antiretroviral therapy (ART) and, in some countries, PrEP.
Vovc commented: “The community response to maintain services in response to COVID, within civil society taking on its shoulders the burden of helping to provide ART, has been very important and has definitely improved the picture."
WHO and UNAIDS surveys: piecing together the data
Vovc said that only now has COVID been around for long enough to start to see the impact on new HIV diagnoses and the treatment cascade. Even so, she said, the data WHO had managed to amass was still fragmentary, especially in the case of prevention services. WHO was still collating data and planned to report more of its findings on December 1, World AIDS Day.
Data from the EuroTEST survey, which compared the number of HIV tests done in March to May and in June to August 2020 in the WHO European region, found a drastic fall-off in numbers of tests during the first time period. Representatives from 70% of countries in the EU/European Economic Area (EEA) answered the survey, including 55% of the mainly eastern non-EU/EEA countries.
Between March and May 2020, 92% of countries in the whole region reported a decrease in the number of HIV tests performed, compared to the same period in 2019, and 63% reported a drop of over 50%. Between June and August, 40% recorded that HIV tests had recovered and the number was now similar or higher than the previous year. However, the other 60% still reported lower levels of testing than in the previous year, and 18% still had performed less than half the number of tests than they had done a year previously.
Vovc presented more data from four eastern European countries (Armenia, Georgia, Kyrgyzstan and Tajikistan) that showed big surges in HIV testing in three of them immediately after the lifting of lockdowns, but sustained increases only in Kyrgyzstan. More data from this research will be presented on World AIDS Day, 1 December.
Fewer tests being performed was overwhelmingly due to lack of testing appointment slots in clinics, closure of community testing sites, and redeployment of health workers. One promising sign, therefore, is that out of 12 countries in the eastern European region, eleven now allow community-based HIV testing in their guidelines. The number allowing self-testing, and testing by trained volunteer lay providers, has also increased from zero in 2017 to eight and seven respectively in 2020.
One issue of concern is that nearly all new HIV diagnoses in eastern Europe and central Asia are occurring in key affected populations or in their sexual partners: there appears to be very little transmission between heterosexuals who do not belong to one or other of the most affected groups. In 2020 this proportion shrank to almost nothing.
Infections among female sex workers shrank from 13% to 8% of the total number of diagnoses. But there has been a resurgence of infections among people who inject drugs, up from 43% of the total to 48%. Infections as a proportion of the total have also risen among gay and bisexual men, from 16% to 22%, and has slightly increased among the heterosexual partners of people who inject drugs and the clients of sex workers, from 18% to 20%. Remarkably, the proportion of infections that happened neither in members of key populations nor their partners shrank from 8% of the total in 2019 to just 1% in 2020, though this may be partly due to lower testing rates in those seen as being less at risk.
The UNAIDS HIV Services Tracking tool, which collects routine HIV programme data monthly from countries, including 16 in Europe, found that HIV tests decreased significantly during the first wave of COVID-19 in most reporting countries, and were still below pre-COVID lives in all but one country in June 2020. The number of people starting ART after diagnosis had gone down in five out of the 16 countries, but the provision of ART to people already taking it was generally maintained.
In the WHO European region as a whole (it stretches from Iceland to Kazakhstan), the proportion of people with HIV (including the undiagnosed) who are virally suppressed appears to have increased between 2019 and 2020, with 53% of people virally suppressed throughout the region in 2019 and 61% in 2020. But this conceals a stark regional difference. The 90-90-90 target is just under 73%. Western Europe surpassed this target in 2019 with 75% of its people living with HIV virally suppressed, but in eastern Europe and central Asia, only 43% were virally suppressed.
When it comes to maintaining access to HIV treatment, the picture was much better than for testing. A WHO survey showed that Europe had fewer overall stockouts and drug interruptions than any other global region. Only one country reported significant ART treatment interruption for any month in 2020 (Romania, in June). This compares to Africa, for instance, where 15 countries recorded interruptions to drug supply at the same time and 7-8 are still doing so.
The number of newly diagnosed patients starting ART declined relative to 2019. Vovc presented incomplete data from Armenia, Kyrgyzstan, Tajikistan and Ukraine that showed that the numbers starting ART had been lower in all four countries in every month from March 2020 to the latest month measured, which in the case of Ukraine was June 2021. But this could be due to lower rates of testing.
When it comes to prevention services, the data is too fragmentary to draw many conclusions. A survey of ten eastern and south-eastern European countries showed condom supply had declined by about one-third on average between 2019 and 2020 in eight of them. Data was available for opiate substitution therapy (OST) in Armenia, Kazakhstan and Ukraine during the first wave of the COVID epidemic from February to at least June 2020. While supply had declined continually by between 2 and 4% month-on-month from February to June in Kazakhstan, it had declined but then rebounded to pre-epidemic levels in Armenia. In Ukraine, despite COVID, the number of people accessing OST had increased smoothly, month-on-month, between February and September 2020.
The supply of PrEP had similarly increased in Ukraine between 2019 to 2020, from 1750 PrEP starts in 2019 to 2500 in 2020.
Country health departments report on COVID and HIV services
Teymur Noori presented data from 40 countries that responded to an ECDC survey of the effect of COVID on HIV services. Survey responses were collected in the first three months of this year. The 15 countries that did not respond include Russia, Bulgaria, and Norway.
Noori emphasised that whereas the WHO data had been collected from a variety of sources including individual clinics and organisations, the ECDC survey had been answered by politicians or civil servants in charge of ministries of health and public health, so was ‘top-level’ data that countries had already collected and collated. The survey asked whether COVID had had an impact on specific HIV services at any time since the pandemic began, without breaking it down into specific time periods.
Prevention and testing services were those most severely reduced.
'Severe reduction' meant either complete closure of a service or a reduction of over 50% in provision. Thirty per cent of countries reported severe reduction in prevention outreach. One country, Malta, closed its prevention outreach service entirely for a while. A quarter of countries reported severe reduction in community HIV testing, 23% reported severe reduction in condom distribution, 20% in STI testing and treatment and 17% in HIV testing in clinics.
In contrast relatively few countries reported severe reductions in HIV treatment and care, NGO and community organisation support services, syringe exchange, OST for drug users, and PrEP distribution and testing for PrEP users (quite a lot of countries, however, lacked data on harm reduction and PrEP services).
Services where more than half of countries reported any reduction in services included HIV testing (in all settings), prevention outreach, STI testing and treatment, and NGO capacity. Just over half of countries also reported some reduction at some point to HIV treatment and care services.
The survey asked whether resources were diverted from responding to HIV to responding to COVID. Eighty-four per cent reported diversion of human resources from the monitoring and surveillance of HIV to that of COVID.
Noori commented: “We can’t measure the impact of COVID on HIV services if one of the impacts is to redeploy the staff that supply that data.” Seventy per cent of countries expected that COVID would give rise to significant delays in reporting HIV cases.
A similar proportion of countries reported significant redeployment of clinical resources, ranging from doctors and nurses to hospital bedspace; 69% reported reduction in laboratory capacity, such as HIV viral load testing being diverted to COVID PCR testing, and TB lung function tests diverted to COVID ones; 47% said personnel providing prevention services were also redeployed to COVID; and 25% said HIV funding had been diverted into paying for COVID.
Europe-wide experiences of HIV services under COVID
At the WHO-led symposium, a number of panellists were asked about their personal experiences of service reductions under COVID.
Aidsmap’s Susan Cole commented that while a lot of HIV services had been maintained by diverting in-person appointments into telemedicine, this created digital inequality, both in people who did not have good computer or phone access, and in people whose living situation made confidentiality hard. She gave an example of an asylum seeker living in a shared house with others who did not know he had HIV.
Dr Nikoloz Chkhartishvili, Deputy Director of the Georgian HIV Research Centre, said that HIV testing and diagnosis in Georgia had been a major challenge under COVID. There had been a 25% drop in new HIV diagnoses in 2020 compared to 2019, and he was not convinced it was entirely due to an actual reduction in incidence.
However, intensive efforts to keep HIV treatment supplies and monitoring going had actually resulted in a reduced time to ART initiation after diagnosis, and small improvements in retention and care and the proportion of people virally suppressed.
Dr Cristiana Oprea, head of HIV services at Romania’s largest infectious disease hospital, said that her country currently has the largest number of people hospitalised with COVID per head of population in the world, and it had been difficult to maintain HIV services because of the need for mass redeployment of staff and beds.
Services for the majority of patients with less complex needs had been relocated to purpose-built off-site outpatient clinics. So had the provision of psychological support, the need for which had become critical, owing to larger numbers of people developing mental health issues due to COVID isolation.
But Romania has a high proportion of HIV patients with complex needs because of its high numbers of people who inject drugs and who were infected at birth. Hospital wards had had to be divided into those for COVID and keeping some available for conditions like TB.
However, she praised the willingness of medical staff at all levels to ‘act up’ and volunteer to cover COVID shifts in whatever capacity they could, as well as the extra efforts put in by NGOs and community organisations to secure home delivery of ART.
Dr Miłosz Parczewski, who runs the main HIV clinic in Szczecin, Poland, said that the first doctors whose skills were needed for COVID patients were often infectious disease specialists such as HIV doctors. “We are shuffling care,” he said, and they had switched to telemedicine and remote consultations for stable HIV patients. Most patients have in fact welcomed this, especially the younger ones, who felt that online consultation was less stigmatising. However the older and long-term diagnosed patients have found it unsettling.
There was some evidence that HIV viral load stability under COVID was not quite as good as it had been: the number of patients who were getting viral load ‘blips’, i.e. temporary rises to low levels of detectable viral load, had risen from 10% to 10-20%. This had not resulted in significantly higher rates of sustained virological failure so far but in people who did become virally unsuppressed on treatment, getting a resistance test was difficult, as those labs had been requisitioned for COVID PCR testing.
He said he had noticed a rise in the proportion of people diagnosed very late and of difficulty in finding beds for people who did present with AIDS-related infections.
In terms of diagnoses among the gay and bisexual population, he commented that during Poland’s first lockdown, gay men reduced their number of sexual partners but that during the second lockdown there was evidence of a rise of chemsex and home sex parties, often using potentially dangerous home-made drugs. The signal of this was a rebound in STI cases.
In terms of gay men resorting to underground activity, Susan Cole noted that in some countries, especially some in Africa, COVID public health measures had been used as a way to persecute gay men who gathered together. Miłosz Parczewski pointed to the increasing atmosphere of intolerance towards the LGBT community in Poland, but mentioned that sustained supply of, and demand for, PrEP was a sign of the resilience of the gay community.
Dr Marta Vasylyev of the Lviv Regional Public Health Centre in Ukraine commented that one reason the country had been able to continue to roll out its PrEP programme was because they had split assessment, prescription and monitoring between NGOs and health care: in many cases NGOs were doing the assessment and referring to clinics for monitoring. PrEP was being delivered postally, allowing clinics the space to provide HIV and monitoring tests.
Does COVID present opportunities for HIV care?
Finally, several of the panel members wondered if the COVID epidemic was pushing medical establishments to adopt measures they should have done earlier – or whether it should do.
Elena Vovc mentioned multi-month ART dispensing, in other words dispensing ART once every three to six months in countries that had previously assumed patients did best with monthly visits – or which were not funded to provide 3-4 months of drugs at a time. Evidence suggests that patients do better with multi-month dispensing and that the COVID epidemic has accelerated progress towards it. However, Cristiana Oprea said they had tried to implement it in Bucharest but resource constraints had made it difficult.
Dr Anton Pozniak, former International AIDS Society president and panel chair, wondered if an opportunity had been missed not to automatically test all appropriate COVID admissions for HIV, and Cristiana Oprea said that this is what they had actually been doing in Bucharest. They had found a number of new cases.
Elena Vovc added that testing people admitted to hospital not only had a better ‘yield rate’ than community testing, but also ensured patients were in a position to receive ART as soon as possible.
However, the real key to improving rates of HIV testing was to move it out to the community and develop home-based, community and self-testing. Except for very recent exposures, three oral HIV tests conducted a week apart were probably as reliable as a standard blood test for HIV, she said.
Milosz Parczewski agreed. He commented: “We were able to develop and roll out a widely used home test for COVID within three months. We have had home HIV tests for ten years and are still struggling with the concept. They could be done in any European country. Let’s start recommending them now.”
Vovc E. How is the Covid-19 pandemic impacting the cascade of care in resource limited regions? 18th European AIDS Conference, Covid-19 & HIV - Impacts on HIV care parallel session, London, 2021.
Noori T. Impact of COVID-19 on HIV policy and programmes in Europe. 18th European AIDS Conference, Standard of Care: convened by BHIVA, ECDC & EACS special session, London, 2021.