What are the challenges faced as a result of the COVID-19 outbreak and how are they tackled among frontline healthcare workers? What innovative approaches and practices introduced may be preserved for the long-term, into the future?
The International AIDS Society gathered pioneer work and feedback from frontline experts in response to COVID-19 and how it impacts PLWHIV. In a series of webinars, experts discussed and shared learnings from countries at different stages of the pandemic, including lower- and middle-income countries. Some of the steps taken may help reshape future practice, with more patient-centric care and with less of a burden on the healthcare system.
Univadis summarized this exchange:
Prof Monica Gandhi broke down the potential impact of HIV on COVID-19 outcomes:
The worst outcomes can be hypothesised due to:
- Distancing from clinics.
- Immunosuppression that can worsen the response to SARS-CoV-2.
- Other comorbidities in PLWHIV might worsen COVID-19-related outcomes.
Better outcomes are also speculated:
- As HIV modulates inflammatory responses, less inflammation may decrease cytokine storms and COVID-19 severity.
- Some HIV medication is protective against COVID-19: phosphorylated forms of TDF may have activity against RNA polymerase, which may make those with HIV on tenofovir therapy less susceptible to COVID-19. A clinical trial in Spain has been initiated on healthcare workers to explore this option (Emtricitabine/tenofovir disoproxil Randomized Clinical Trial for the Prevention of SARS-CoV-2 Infection (COVID-19) in Healthcare Personnel (EPICOS) https://clinicaltrials.gov/ct2/show/NCT04334928
- LPV/r may have activity against SARS-CoV-2. One clinical trial was unsuccessful; however, it was too small and the late administration of LPV/r makes it unclear whether it is protective.
For the first time, there is an unprecedented directive in keeping people away from the clinic, while people themselves are scared coming in. Multiple steps were taken to optimise care during distancing measures.
1. Protection and support to patients – both from infection and from fear
For HIV patients one of the main difficulties during the lockdown was finding a clinic, as most were dealing only with COVID-19 patients.
In Italy, outpatient clinics were not reachable and closed since the first day of the epidemic. A dedicated pharmacy also had to be closed. In cases where clinics were still open, some patients discontinued their therapy due to fear to come to the hospital/ambulance. Patients coming from other regions of the country could not come for drug supply refill, since the lockdown.
Chelsea and Westminster Hospital in London (a complex of 7 outpatient clinics all over London looking after 10,000 PLWHIV, also running in-patient services for North-West London, including day-care chemotherapy unit looking after HIV/oncology patients) completely reorganized over a week to a virtual clinic, with only phone calls after the lockdown, except 56 Dean Street where some doctors were left dedicated to HIV patients who needed to be seen. Most workers were re-deployed to a COVID-19 ward, thus performing two jobs at the same time. One of the clinics was completely transformed into a COVID-19 testing hub. HIV inpatients were moved to another clean area in the proximate building.
In the US, New York became the centre of the epidemic, and the most prominent risk factor for COVID-19 appears to be obesity. Homeless people have challenges in finding isolated shelters. In San Francisco, an outbreak was reported inside a shelter. Still, compared with New York, San Francisco has been interestingly spared (11,254 test cases, 1216 positive cases reported, and 20 deaths, as of 20 April 2020), despite being highly populated. When first community transmission was reported on March 5 all major tech companies closed before the official March 16 shelter guidelines. Publicly funded Ward 86 changed their guidance from in-person visits to phone consultations. The patients themselves did not want to come to the clinic. Some workers dealing with HIV patients have been pulled out for COVID-19 responses and transformed into COVID-19 ID teams. Each morning, a multidisciplinary team discusses patients, treatment, and trials. The rest of the day is spent ruling out COVID-19 suspected cases.
South Africa: Mitigating factors were early lockdown and a young population (5% of population >65 years old). Aggravating factors – high HIV prevalence (13%) with 7.7 million people positive with only 54% virally suppressed on ART and a high incidence of tuberculosis, high prevalence of obesity (28%), and type 2 diabetes (6%-12%) in adults. Distancing is difficult in overcrowded communities and public transport. Hospitals have been transformed into COVID-19 testing facilities and COVID-19 wards.
Kenya: Measures enforced by the government in response to COVID-19 were a ban on social gatherings, mandatory masks in public, quarantine centres across the country, 7 pm – 5 am curfew, and restricted access to “infected” surrounding counties. HIV prevalence of 4.9% and the total population of 47.5 million accounts for 1.3 million adults on ART.
Counter measures taken to support patients:
Italy: All patients diagnosed with HIV before the epidemic were followed-up by phone calls to discuss the results of the examinations, while continuous support was established by a WhatsApp connection with patients. A virtual ambulance is also under consideration.
UK: Apart from virtual clinic services, all clinics have implemented shipping services from pharmacies to patients. A home-shipping service existed before the epidemic, but only to distant areas. Home-tests for HIV are recommended.
In China, patients could refill ARVs at the nearest CDC. Also, doctors were delivering directly to patients and in rural areas or via an express post service.
US: Nurses and social workers are supporting patients on the phone. Patients without a phone received one by donation, so they could be reached. A virtual town-hall meeting was organised “COVID-19 and living with HIV”, providing information on how to get insurance, a 3-month ART refill, and what services are still open.
South Africa, Cape Town: To minimise contact with the healthcare sector, the Southern African HIV Clinical society advocates a 6-month supply of ART to clinically stable HIV+ individuals. Only patients with uncontrolled infection or a medical condition that needs monitoring are not be given 6-months of treatment.
South Africa, Khayelitsha: The adaptation from in-person support to telephone counselling, social media, and leaflets were introduced. Also longer refills for up to 6 months for ART and 4 months for PrEP (if the user is already on PrEP). A positive byproduct of social distancing is that primary care facilities are more available to patients needing necessary care and management. To make meetings as safe as possible, group meetings while mask-wearing were organised one at a time. Oral HIV self-tests are promoted. If the test is positive, the patient is initiated and managed in the community and followed-up with the same procedure, but with counselling by phone or remotely. Multiple ART service delivery models to patients were introduced.
Kenya: Secured 4-month drug supplies along with additional shipments oversees, spaced out daily appointments for HIV patients, multi-month dispensing of ART, PrEP, and other preventive tools, like condoms. Special attention is given to pregnant women to prevent vertical transmission, as they are scared coming into the clinic. Service delivery is organised by vans to the key population. Self-testing is promoted.
2. Specific challenges
In China, there have been reported cases of Pneumocystis pneumonia (PCP) in HIV patients being misdiagnosed as COVID-19. Patients did not declare their HIV status, and as PCR accuracy was low, CT scan was used for diagnosis and the patients were treated in the same in-patient room as COVID-19 patients. Thus, there is a need to screen patients for HIV as an additional exclusion factor.
In South Africa the high prevalence of HIV and substantial incidences of TB are challenging. Similar chest x-ray pathologies of HIV positive patients with TB co-infections (SARS-CoV-2 negative) and HIV negative but SARS-CoV-2 positive patients conditioned that all patients under investigation for COVID-19 are tested for HIV, while HIV+ patients are given a broader differential diagnosis for pulmonary pathology (PCP, pulmonary TB with lower zone infiltrates, pulmonary cryptococcosis are considered). Patients with a differential diagnosis are managed with person under investigation (PUI) side wards until results are available. If a patient is infected with both HIV and SARS-CoV-2, but not yet on ART, ART is planned to be initiated 2 weeks after COVID-19 diagnosis and clinical stabilization.
In Khayelitsha, South Africa, further steps and services to be added are family planning with long-acting reversible contraceptives, flu vaccines, and TB-preventive therapy. The adherence club model is already used, where groups of 15 stable and suppressed patients receive prepacked ART from a counsellor every 2 months and have 2 annual clinical visits.
In Kenya, the key population at risk are HIV positive patients not on treatment — immunocompromised and thus possibly more susceptible to COVID-19. This population experiences a disproportional burden of poverty, marginalisation, and stigmatisation. There is also a lack of PPE. Fundraising, WhatsApp platforms, and Zoom meetings are employed to address these challenges. Mobile services and MAT services for people who inject drugs are deployed.
3. Collaboration with societies and communities
EACS and BHIVA made statements on the risk of COVID-19 for PLWHIV, while the Liverpool drug-drug interaction site released detailed recommendations for PLWHIV. (https://www.covid19-druginteractions.org/)
https://prepster.info/covid/ deployed a dedicated section about COVID-19 and an ongoing Spain trial on PrEP activity on COVID-19.
4. Preparation for the next phase and steps to be taken
Only after carefully assessing the consequences of the lockdown period will it be possible to determine what could have been done differently. Some of the measures might also be implemented long-term after the lockdown, as they might optimise healthcare services and future savings.
Dr Marta Boffito raised some of the questions still to be answered:
- Are the clinics to remain virtual and delivery sufficient; how much can be saved from home-tests for HIV?
- Were the patients unwell without continuous in-person treatment, do they have to come to the clinic for liver tests, was there toxicity due to chronic treatment?