European AIDS Treatment Group documents impact of COVID on HIV services across Europe
A series of rapid-response surveys conducted by the European AIDS Treatment Group (EATG) have revealed significant changes in access to HIV testing, PrEP and HIV treatment during the COVID epidemic. 19, the Glasgow 2020 HIV conference said last week.
Ian Hodgson of the EATG, presenting the results that the EATG published in three newsletters, said the results not only documented the impact of the COVID epidemic on HIV-related services, but also showed that a number of community organizations had organized innovative solutions to address this.
Hodgson told the conference that the challenge now is for HIV and other community organizations to move from an emergency to a strategic response to the COVID pandemic. Donor priorities could change permanently, he said, and organizations may need to change their goals and priorities to meet the needs of the post-COVID world.
The EATG conducted a series of rapid-response surveys of EATG members and affiliates almost at the onset of the COVID-19 emergency in Europe, with the first survey being carried out from March to early April, the second d April to May, and a third, the findings of which have not yet been fully analyzed, in August. A fourth is scheduled for the end of October.
In the first survey, 30 people from 22 different countries, mainly in Western and Central Europe, responded. In the second, 57 people from 26 countries, mainly from Central and Eastern Europe, including Russia and Central Asia, responded.
In the first survey, 23 people said they were involved in a national or local organization for people living with HIV and in the second, 50 people. Fourteen in the first survey identified as gay and bisexual men and 35 in the second; five and four identified as migrants respectively. In the first survey, only one person identified themselves as injecting drugs, but in the second, 19 did, reflecting the different populations of people at risk for HIV in the regions. Twenty people identified themselves as people living with HIV in the first survey but the question was not asked in the second. There were also three women in the first survey and in the second 16 were identified as sex workers and nine as trans people.
Impact on HIV prevention
People from almost every country said there had been disruption to testing services in their area. It should be noted, said Ian Hodgson, that testing appeared to be more disrupted in countries with more stringent anti-COVID measures. In many places, rapid HIV testing services have been completely suspended. More than a third of those surveyed said rapid testing services had remained relatively unchanged, but another third said HIV testing only became available in emergencies, while the remaining quarter said it was only available after delays, negating the value of rapid testing.
In many places there had been an increase, or at least continued availability, of the self-test. Fourteen respondents to the second survey (around 25%) said that the HIV self-test had never been available in their country or region and five others said that there were not enough kits. About 45% said HIV test kits were provided by local nongovernmental organizations, and the same proportion said they could be purchased online. About 30% said they were available at pharmacies on the main street and three said their country provided them at vending machines in some locations (these percentages are not exclusive).
In some countries, NGOs have organized campaigns to raise awareness of self-test options. One example was a community-based NGO that started a program offering online self-testing, counseling, a 24-hour hotline and a link to a care service.
A larger and less expected impact was screening for sexually transmitted infections (STIs). Half of those surveyed said STI testing in their area was only available for acute infections and emergencies, not routine testing. Only 25% said ITS services were kept at something like their old level. However, this had been offset to some extent by reduced demand, perhaps because the incidence of STIs had decreased, but also perhaps because people had difficulty traveling.
Regarding PrEP, some respondents from countries that had only recently introduced PrEP reported that their health service had stopped providing it. Others noted significant delays in access.
Twelve respondents to the first survey said that PrEP was still available in hospital pharmacies and seven in community pharmacies. Four people said it was provided to users either by the health system or by a community organization. But 15 said people access PrEP in “other” ways – either buying it online or getting it informally from friends.
A very similar trend has been observed with respect to the availability of opioid substitution therapy.
Impact on HIV care
Respondents from almost all countries reported an interruption in normal HIV appointments, which were either postponed, with additional antiretroviral therapy (ART) supplies sent, or appointments provided over the phone.
In a number of countries, the diversion of doctors to COVID care has left a severely inadequate service. A respondent from Greece commented: “The community ended up with hardly any doctors to follow us. “
Countries where HIV care was organized around infectious disease departments appeared to be more vulnerable to this loss of HIV doctors due to COVID than countries with specialized HIV clinics.
Thirty-nine respondents to the second survey said that ART was still provided by hospital pharmacies, but that there had been an increase in provision by community pharmacies. Home delivery, organized either by the health sector or by community organizations, was mentioned by 40 respondents. Not all countries have been able to deliver longer prescriptions, in part due to drug shortages caused by logistical difficulties in getting supplies during the lockdown. It had affected Kazakhstan, Russia and Switzerland.
Regarding co-infections, there was evidence that the link to care for those diagnosed or requiring treatment for hepatitis C was severely compromised. In a number of countries, tuberculosis tests were also compromised because x-ray machines and other diagnostic technologies were repurposed for the diagnosis and treatment of COVID.
Finally, many respondents were extremely concerned about the adequacy and sustainability of mental health services. People living with HIV, who already have higher psychological support needs than the general population, have further been affected by the general anxiety and uncertainty of the COVID pandemic. The inability to travel had a real impact on access to more intensive in-person support services.
The EATG surveys provided evidence that community and healthcare organizations were responding to the pandemic with innovative solutions. These ranged from extended prescriptions to community organizations offering more access points to services where the usual peripheral clinics had been closed and services centralized in a single hub. Healthcare workers took care of the delivery of medicines and brought their medicines to people in cars and, in a British example, on bicycles. Community pharmacies had been opened or authorized to dispense ART.
Funding, however, was also an issue on which community organizations needed to strategize. Funding models will likely never revert to the pre-COVID situation, and funders, especially with the need to save money, will change their preferred service delivery models. Organizations that support people infected with or exposed to HIV needed to start planning for the “new normal” now.
Hodgson I. Overview of services and impact on prevention and care and psychosocial implications for PLWHIV. HIV Glasgow 2020 virtual conference, oral presentation O241.
Greenhalgh F et al. Understand how HIV testing has been affected by the COVID-19 response. HIV Glasgow 2020, poster P138.
Greenhalgh F et al. How has the COVID-19 response changed drug deliveries for people living with or at risk of HIV? HIV Glasgow 2020, poster p144.