Reduction in initiations of HIV treatment in South Africa during the COVID pandemic

  1. Mariet Benade
  2. Lawrence Long
  3. Sydney Rosen
  4. Gesine Meyer-Rath
  5. Jeanne-Marie Tucker
  6. Jacqui Miot

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Abstract

Background

In response to the global pandemic of COVID-19, countries around the world began imposing stay-at-home orders, restrictions on transport, and closures of businesses in early 2020. South Africa implemented a strict lockdown in March 2020 before its first COVID-19 wave started, gradually lifted restrictions between May and September 2020, and then re-imposed restrictions in December 2020 in response to its second wave. There is concern that COVID-19-related morbidity and mortality, fear of transmission, and government responses may have led to a reduction in antiretroviral treatment (ART) initiations for HIV-infected individuals in countries like South Africa.

Methods

We analyzed national, public sector, facility-level data from South Africa’s District Health Information System (DHIS) from January 2019 to March 2021 to quantify changes in ART initiation rates stratified by province, setting, facility size and type and compared the timing of these changes to COVID-19 case numbers and government lockdown levels. We excluded facilities with missing data, mobile clinics, and correctional facilities. We estimated the total number of ART initiations per study month for each stratum and compared monthly totals, by year.

Results

At the 2471 facilities in the final data set (59% of all ART sites in the DHIS), 28% fewer initiations occurred in 2020 than in 2019. Numbers of ART initiations declined sharply in all provinces in April-June 2020, compared to the same months in 2019, and remained low for the rest of 2020, with some recovery between COVID-19 waves in October 2020 and possible improvement beginning in March 2021. Percentage reductions were largest in district hospitals, larger facilities, and urban areas. After the initial decline in April-June 2020, most provinces experienced a clear inverse relationship between COVID-19 cases and ART initiations but little relationship between ART initiations and lockdown level.

Conclusions

The COVID-19 pandemic and responses to it resulted in substantial declines in the number of HIV-infected individuals starting treatment in South Africa, with no recovery of numbers during 2020. These delays may lead to worse treatment outcomes for those with HIV and potentially higher HIV transmission. Exceptional effort will be needed to sustain gains in combatting HIV.

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  1. Version published to 10.1186/s12913-022-07714-y
  2. ScreenIT

    SciScore for 10.1101/2021.08.18.21262046: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Ethicsnot detected.
    Sex as a biological variablenot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.

    Table 2: Resources

    Experimental Models: Organisms/Strains
    SentencesResources
    Data: The District Health Information System (DHIS)[11] is used by the South African Government to collect aggregate (facility-level) data about service delivery at the more than 4,000 public sector facilities in the country, which provide HIV services for roughly 92% of South Africa’s population[12].
    DHIS

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    We were not able to assess differences by sex with our data set.) Our study had a number of limitations. First, as explained above, our analysis included only public sector health facilities in the DHIS that reported complete data (monthly observations) for the entire study period. The selection bias introduced by the exclusion of roughly 2/5 of the country’s facilities is unclear, but we speculate that it may have biased the sample in favor of better-resourced and/or better-performing sites. Second, we had no way to validate the data in the DHIS database, but as noted above, we know from others’ analyses that accuracy is variable. Third, our study period ended in March 2021, just after the end of South Africa’s second wave of COVID-19. We do not know if ART initiation numbers recovered over the course of April and May, prior to the start of the third wave in June 2021. It is possible that, given a longer study period, ART initiation may have recovered to pre-lockdown levels. Fourth, our comparison values, from 2019, may or may not be a valid counter-factual for 2020. In some areas, ART initiation rates were trending down prior to the pandemic, as the number of HIV-infected persons not on ART declined. On the other hand, efforts made to achieve the Government’s 2020/2021 goals for HIV treatment coverage may have led to a larger number of ART initiations in 2020, in the absence of the pandemic. Fifth, it is possible that some of the patients who would have initiated ART in the...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    Results from scite Reference Check: We found no unreliable references.

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  3. Version published to 10.1101/2021.08.18.21262046v1 on medRxiv