The pandemic had an immediate effect on patient care, and in pivoting to adapt to the quarantine, some changes may have created potentially permanent ways to deliver health care.
HIV patient care was greatly impacted by COVID-19 in 2020—whether on a large scale as observed in South Africa, or a smaller one as seen in San Francisco, aspects of clinical care like HIV testing, ART and PrEP initiation were affected especially during the early months of the pandemic.
South Africa has the largest HIV/AIDS population in the world with 7.5 million people, according to the CIA World Fact Book’s latest estimate done in 2019. In addition, it has the fourth largest prevalence with 17.3% and the highest mortality with 72,000 deaths estimated that same year.
Imagine these rates in a country that had a total population of 58.8 million in 2019.
In KwaZulu-Natal province, South Africa, there are 1.7 million people living with HIV (PWH). A study that was recently published in The Lancet HIV, included data looking at people in that region who were getting tested for HIV, initiated antiretroviral therapy (ART) and continued ART treatment at health care centers.The investigators found that both HIV testing and ART initiation dropped down nearly 50% during the first month of the country’s COVID-19 lockdown last year.
“We think the 2 are linked,” lead author Jienchi Dorward, BSc, MBChB, MRCGP, MSc, with the Center for the AIDS Program of Research in South Africa (CAPRISA) and Nuffield Department of Primary Care Health Sciences at the University of Oxford,said. “Because people couldn’t test, they couldn’t start treatment.”
Before the pandemic, a median of nearly 42,000 HIV tests per month were administered prior to the pandemic lockdown in South Africa, and nearly 39,000 after the lockdown. Dorward and the other investigators used the Poisson regression model to consider long-term trends, and they estimated a 47.6% decrease in HIV testing.
Within the first week of the lockdown, there was an estimated 46% decrease in ART initiations also using Poisson modeling.
For the purposes of the study, they focused on the period from the end of March 2020—when the lockdown began in South Africa—to June 2020 looking at ART initiation. And for HIV testing it began at the same time and ended in July of last year, explained Dorward.
Dorward said the country was very strict in their lockdown measures, including a curfew for citizens, businesses were closed, and travel was limited between provinces.
However, there was a silver lining to the aforementioned disturbing trend. “People who were already on [ART] treatment, in general, they managed to come in and collect treatment,” Dorward said. “We only saw a very small drop in treatment.”
ART collection visits dropped from an average of 18,519 weekly, to 17,863 after lockdown.
This is significant, as the country has the largest ART programin the world. According to one 2015 statistic, there are over 3 million people on ART. South Africa spent more than $1.54 billion in 2017 to run its HIV programs, according to UNAIDS.
Dorward pointed to modeling studies done that if there was a disruption in services and the ability to get ART treatment for 6 months this could have a catastrophic outcome. “That would lead to 300,00 excess deaths,” Dorward said of an elongated disruption. “We were pleased to see that is not what has played out.”
The Transient Trend
While there was a severe disruption in HIV clinical care last year due to COVID-19, Dorward pointed out that it was mostly a temporary, transient trend.
“The testing and treatment got better,” Dorward said. “As the lockdown measures eased they quickly came back.”
He does offer this with a caveat. During his study, the country had not fully emerged from its lockdown but went from a level 5 (strictest) to level 3 (easing of restrictions). So, testing and ART initiation was not fully back to pre-COVID-19 levels but was headed in that direction.
“It has definitely been a very different year,” Dorward said of 2020. “There’s been a big impact, although we showed people still came to collect their treatment, I think we can safely say there has been a lot of disruption.”
He pointed to the 2 surges of COVID-19 affecting health care workers, creating limited staffing in many of the clinics and this presented challenges for patients.
“While [patients] may have been able to collect treatment, they might not have had time for other things to discuss—[like] in-depth care and treatment,” Dorward said.
Dorward said there was a concerted effort by the government to make services available outside the clinic so as to make them less congested and to protect against COVID-19. He mentioned the Central Chronic Medicine Dispensing and Distribution (CCMDD) program as one example. Patients can register for this program to have their medication delivered to a convenient collection place.
For people with HIV who are stable, they can have their providers refer them into the program and it alleviates the concerns associated with exposure to COVID-19. “Rather than go to the clinic, you can go to the pick-up point. It’s meant to be much easier and much more efficient for patients.”
In addition, Dorward said the South African department of health really encouraged people to enroll in the program and they made it more flexible by relaxing the eligibility criteria and extending the amount of time people could remain in the program.
“A lot of those changes are general improvements of that program anyway, but they happened because of COVID. Hopefully, and this is something we hope to look at with our future research, those changes are beneficial to patients and are maintained beyond COVID,” Dorward said.
Another innovation being done there are medication-dispensing machines that Dorward likens to ATMs. This can be found in a variety of areas including shopping malls and outside clinics. People can register and use these machines to get their ART. And if people have a question, they can have a video conversation with a pharmacist.
A Move to Virtual Care
The US health care system also suffered from the pandemic. In California, at the Kaiser Permanente San Francisco Medical Center, Brad Hare, MD, chief of Infectious Diseases and HIV, at Kaiser, says that their patients with HIV are very engaged in their care. As an indicator, they have between a 96%-98% virologic suppression rate among their HIV patients.
However, when the COVID-19 pandemic hit, Kaiser saw a significant drop in patient visits both for those on pre-exposure prophylaxis (PrEP) therapy and those with HIV. “We saw dips in the range of a 50% to 70% decrease in the number of visits in March and April compared to the prior year,” Hare said.
Rather than remain in the same, traditional care paradigm, and wait for patients to return to the medical centers, Kaiser changed the way they delivered health care.They quickly moved to virtual care.
“One of the things the pandemic has done is that it has forced us to rethink how we do medicine,” Hare said.
They had already been using secured email with patients and Kaiser started using video for virtual visits. These features were already integrated into their electronic medical records (EMR) system, so it made the transition easier.
They are also planning to use their EMR for a more in-depth HIV prediction model to identify patients earlier in the care cycle who could benefit from PrEP therapy.
Hare said virtual care was successful for many of their patient population as they were able to stay home during the pandemic’s ramp-up in the spring.
While the drop of in-person visits was precipitous in March and April, Hare says patients began returning quickly in June and July to the point where they were just below 2019 levels. He said in this patient population that was used to getting tests done every 3-6 months, many of them were ready to return.
For its part, Kaiser developed protocols, workflows, and screening guidelines to make people feel safe for in-clinic care. Hare said once they had these elements in place, they invited people back.
However, not everyone has returned to the clinic, and Hare is concerned for those who still do not feel safe enough to come back. These patients have not had an in-person visit to check vital signs or have routine blood work or other testing in over a year in some cases.
One of the consequences of the pandemic has been the emergence of a potential hybrid model of care where some patients may come into the clinic for lab tests, a check on vitals, or prostate cancer screenings, but can supplement care with video visits when these things are not needed.
“The virtual pivot that we did was for some a sustainable tool and for others it was stop-gap measure, but whatever it is…we are going to be forever changed,” Hare said. “We are going to be doing a lot more virtual care. We found it very successful for a lot of people and patients really liked it.”
And while there is an electronic delivery to care, Hare is quick to point out that, with a multidisciplinary team of pharmacists, primary care providers, PrEP providers, and others at Kaiser, there are many people involved in care so there are many human touchpoints for patients.
A Temporary Trend Leads to Care Innovations
In both South Africa and San Francisco, there was a considerable drop-off in patient care with HIV testing and ART and PrEP initiation during the beginning of the pandemic. However, it appears it was a transient trend, and PWH or patients-at-risk began to seek care compliance after a few months in both areas.
Whether it be the addition of video visits or ATMs that dispense medicine, some innovations are here to stay, and will have a lasting effect on HIV patient care.