CATIE News

• A computer model suggests the COVID-19 pandemic could facilitate the spread of HIV
• Disruptions to healthcare services would drive a 9% increase in new HIV infections
• However, integrating HIV and COVID-19 testing could reduce new HIV infections 17%

The global COVID-19 pandemic has burdened health systems and disrupted routine medical care for many people. It is at least plausible that this disruption caused by the pandemic may create conditions that facilitate the spread of HIV, as people may be unable to access services such as PrEP (pre-exposure prophylaxis) prescriptions and testing for HIV and other sexually transmitted infections (STIs).

The pandemic along with its associated changes—self-isolation, physical distancing, psychological distress—has been reported to reduce access to syringe services programs, opioid substitution therapy and social services, among others. All of these changes could make it more difficult to reach vulnerable populations, thus facilitating the spread of HIV and other infections.

A team of scientists at leading universities in the United States, the Centers for Disease Control and Prevention (CDC) and the British Columbia Centre for Excellence in HIV/AIDS has developed a computer model to explore the impact of the disruption caused by the COVID-19 pandemic on the trajectory of the HIV epidemic. The computer simulation also allowed the scientists to learn about the effect of offering more widespread testing for SARS-CoV-2 (the virus that causes COVID-19) together with HIV testing. The latter would be offered on an opt-out basis; that is, such testing would automatically occur unless participants declined it. The simulation was designed for key U.S. cities. Increased HIV testing is needed because scientists estimate that about 14% of people with HIV in the U.S. are not aware of their infection status. Also, previous research has found that HIV testing is a cost-effective intervention that not only links newly diagnosed people to care and treatment but also helps to reduce future HIV infections.

The scientists explored different scenarios related to the impact of the COVID-19 pandemic and found that the computer simulation predicted varying increases in new HIV infections, depending on the degree of service disruption and behavioural changes. However, it also showed that intervening with a broad-based COVID-19 and HIV testing program could conceivably avert thousands of new cases of HIV. Such a campaign would have long-term effects, as newly diagnosed people would be offered HIV care and treatment, which would stabilize their health and prevent transmission. Over the long term, these effects would be cost effective.

Study details

The scientists focused on the following cities:

• Atlanta
• Baltimore
• Los Angeles
• Miami
• New York
• Seattle

They inputted data from high-quality studies to simulate the spread of HIV.

The scientists estimated pandemic-related disruptions and changes to healthcare services and risk behaviours from March 1, 2020 to February 28, 2021. They assumed that about 66% of adults offered HIV testing would accept it, based on results from a randomized clinical trial of opt-out HIV screening offered in the emergency room of a major hospital.

Results

The computer simulations produced three main results:

• In what the scientists called the “best case scenario,” they assumed that the disruption to health and other services was minimal and that there would be a 50% reduction in sexual and injection drug risk behaviour. Also, there would be no enhanced testing program for HIV and COVID-19. In this scenario, the simulation suggested that HIV infections would decline by about 16.5% over the next five years.
• In what the scientists called “the worse-case scenario,” there would be no reduction in HIV risk behaviour and a 50% reduction in service delivery. This resulted in a 9% increase in HIV infections.
• The simulation found that “implementing linked HIV testing alongside SARS-CoV-2 testing has the potential to reduce the number of HIV infections by up to 17% over five years if 90% [of people] are offered HIV testing [and about 60% accepted to undergo HIV testing].”

Although such a strategy initially would be costly, the simulation found that an investment in testing would be “cost-saving in the long-term across all cities.” Specifically, the scientists calculated that a scaled-up twin virus testing program would cost between US$20 to US$220 million.

Bear in mind

No study is perfect and there are assumptions that underpinned the simulation that could undergo refinement. For instance, the scientists stated that if the level of disruption in services is higher and lasts longer or if less people than expected agree to the “ambitious [HIV testing] levels we have proposed, then the estimated additional number of HIV cases that could occur would be even greater.”

It is also possible that if health systems and people adjust to the changes brought about by the pandemic, disruption to health services will resolve quickly.

The impact on hepatitis C

The disruption caused by the coronavirus pandemic is likely not only having an impact on the HIV epidemic. Anecdotal reports suggest that the hepatitis C virus epidemic is also being affected—fewer people are getting tested and initiating treatment than in the pre-pandemic era. This suggests that countries and regions may ultimately fall behind on their ability to eliminate HCV as a public health issue by 2030, as encouraged by the World Health Organization.

For the future

The bold proposal to combine testing for COVID-19 and HIV deserves further attention. It has the potential to help stop the spread of both SARS-CoV-2 and HIV and to improve the health of affected populations.

—Sean R. Hosein

Resources

Seizing the moment: Tackling entrenched inequalities to end epidemics – UNAIDS

Global health sector strategy on viral hepatitis, 2016–2021 ­– WHO

Blueprint to inform hepatitis C elimination efforts in Canada ­– Canadian Network on Hepatitis C (CanHepC)

REFERENCES:

1. Zang X, Krebs E, Chen S, et al. The potential epidemiological impact of COVID-19 on the HIV/AIDS epidemic and the cost-effectiveness of linked, opt-out HIV testing: A modelling study in six U.S. cities. Clinical Infectious Diseases. 2020; in press.
2. Walensky RP, Freedberg KA, Weinstein MC, Paltiel AD. Cost-effectiveness of HIV testing and treatment in the United States. Clinical Infectious Diseases. 2007 Dec 15;45 Supplement 4:S248-54.
3. Pfefferbaum B, North CS. Mental health and the COVID-19 pandemic. New England Journal of Medicine. 2020 Aug 6;383(6):510-512.
4. Gao J, Zheng P, Jia Y, et al. Mental health problems and social media exposure during COVID-19 outbreak. PLoS One. 2020 Apr 16;15(4):e0231924.
5. Lim LW, Yip LW, Tay HW, Ang XL, Lee LK, Chin CF, Yong V. Sustainable practice of ophthalmology during COVID-19: challenges and solutions. Graefe’s Archive for Clinical and Experimental Ophthalmology. 2020 Jul;258(7):1427-1436.
6. Palmer K, Monaco A, Kivipelto M, et al. The potential long-term impact of the COVID-19 outbreak on patients with non-communicable diseases in Europe: consequences for healthy ageing. Aging Clinical and Experimental Research. 2020 Jul;32(7):1189-1194.
7. Tapper EB, Asrani SK. The COVID-19 pandemic will have a long-lasting impact on the quality of cirrhosis care. Journal of Hepatology. 2020 Aug;73(2):441-445.
8. Yu EW, Tsourdi E, Clarke BL, et al. Osteoporosis management in the era of COVID-19. Journal of Bone Mineral Research. 2020 Jun;35(6):1009-1013.