The risks and benefits of providing HIV services during the COVID-19 pandemic

  1. John Stover
  2. Sherrie L. Kelly
  3. Edinah Mudimu
  4. Dylan Green
  5. Tyler Smith
  6. Isaac Taramusi
  7. Loveleen Bansi-Matharu
  8. Rowan Martin-Hughes
  9. Andrew N. Phillips
  10. Anna Bershteyn

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Abstract

The COVID-19 pandemic has caused widespread disruptions including to health services. In the early response to the pandemic many countries restricted population movements and some health services were suspended or limited. In late 2020 and early 2021 some countries re-imposed restrictions. Health authorities need to balance the potential harms of additional SARS-CoV-2 transmission due to contacts associated with health services against the benefits of those services, including fewer new HIV infections and deaths. This paper examines these trade-offs for select HIV services.

Methods

We used four HIV simulation models (Goals, HIV Synthesis, Optima HIV and EMOD) to estimate the benefits of continuing HIV services in terms of fewer new HIV infections and deaths. We used three COVID-19 transmission models (Covasim, Cooper/Smith and a simple contact model) to estimate the additional deaths due to SARS-CoV-2 transmission among health workers and clients. We examined four HIV services: voluntary medical male circumcision, HIV diagnostic testing, viral load testing and programs to prevent mother-to-child transmission. We compared COVID-19 deaths in 2020 and 2021 with HIV deaths occurring now and over the next 50 years discounted to present value. The models were applied to countries with a range of HIV and COVID-19 epidemics.

Results

Maintaining these HIV services could lead to additional COVID-19 deaths of 0.002 to 0.15 per 10,000 clients. HIV-related deaths averted are estimated to be much larger, 19–146 discounted deaths per 10,000 clients.

Discussion

While there is some additional short-term risk of SARS-CoV-2 transmission associated with providing HIV services, the risk of additional COVID-19 deaths is at least 100 times less than the HIV deaths averted by those services. Ministries of Health need to take into account many factors in deciding when and how to offer essential health services during the COVID-19 pandemic. This work shows that the benefits of continuing key HIV services are far larger than the risks of additional SARS-CoV-2 transmission.

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  1. Version published to 10.1371/journal.pone.0260820
  2. ScreenIT

    SciScore for 10.1101/2021.03.01.21252663: (What is this?)

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

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variableThe HIV services we examined included: the provision of voluntary medical male circumcision (VMMC) which reduces susceptibility to HIV transmission, HIV diagnostic testing which provides an entryway into treatment, viral load testing which determines whether ART is successfully controlling HIV, and programs to prevent mother-to-child transmission (PMTCT) which provides HIV testing and antiretroviral therapy to prevent transmission of HIV from mother to newborn.

    Table 2: Resources

    No key resources detected.

    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:
    There are limitations to this analysis. COVID-19 is a new disease, so models are also new and relatively untested in projecting into the future. We have modelled HIV services in isolation but they are imbedded within a larger health system and effects of shortages of health personnel to deal with COVID-19 hospitalizations, testing and vaccination campaigns may also affect HIV services. Decision to continue a specific HIV service, such as testing, may be determined more by decisions about how to provide all types of health services rather than just those related to HIV. Disruptions to supply chains may also affect the delivery of health services. Most programs have taken steps to ensure that essential HIV services such as ART re-supply can continue. Often this involves multi-month scripting to reduce the number of visits required for patients doing well on ART. Countries have learned from past epidemics, such as Ebola, how to maintain essential services under extraordinary circumstances. [23] Many health systems are under great strain trying to cope with the surge of hospitalizations due to COVID-19 and meanwhile maintain other essential health services, but many are finding ways to continue these important services in spite of the obstacles. These efforts are important not only for averting new HIV infections but also for averting other infectious diseases through continued childhood immunization, avoiding unintended pregnancies by continuing family planning services, avoidin...

    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.

    About SciScore

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  3. Version published to 10.1101/2021.03.01.21252663v2 on medRxiv
  4. Version published to 10.1101/2021.03.01.21252663v1 on medRxiv