We are appropriately concerned about the possible transmission of Covid-19 into high HIV prevalence communities. South Africa has the highest number of people living with HIV (PLHIV) in the world at 7.7 million. According to UNAIDS, this includes approximately 3.5 million PLHIV who are not virally suppressed, of which 2.9 million are not on antiretroviral treatment (ART) and 700,000 who do not know their HIV status.
On 17 March 2020, the World Health Organisation (WHO) published a document called “Questions and Answers on Covid-19, HIV and antiretrovirals”. There is so far no reported case of a Covid-19 infection in anyone living with HIV, so no evidence of an increased risk of infection or increased severity of Covid-19 among PLHIV. However, this could change rapidly as Covid-19 cases increase in high HIV prevalence communities.
The WHO warns that PLHIV not on ART or who do not have a suppressed viral load are likely to have a compromised immune system and may be more susceptible to opportunistic infections and disease progression. They report that there were only a few SARS and MERS cases reported among PLHIV and these individuals experienced mild disease.
We know from clinical data that the mortality risk from Covid-19 increases with older age and with co-morbidities, including cardiovascular or chronic respiratory disease, diabetes and hypertension.
The WHO advises that PLHIV not on ART should start ART immediately. Interactions with health facilities should be kept to a minimum and PLHIV should have a minimum of 30 days of ART with them, but preferably a supply for three to six months.
PLHIV are also advised, similarly to the general public, to diligently practice precautions of frequent hand washing (with soap and water or using alcohol-based hand rub), good cough hygiene, avoiding touching faces and social distancing (at least one metre apart).
At a time when we do not know the clinical outcomes of PLHIV co-infected with Covid-19, and in the context of a resource-constrained public health system where millions of PLHIV are not on treatment or virally suppressed, we need to take every precaution possible to avoid Covid-19 co-infection.
But, practically, how can we support people living with chronic conditions including HIV in South Africa during the Covid-19 pandemic?
South Africa has policies in place that can help.
For PLHIV not on ART – we need to encourage and support PLHIV who know their status and haven’t started treatment to start while limiting the number of times they need to attend the health facility to start treatment.
South African policy already supports PLHIV starting ART on the day of diagnosis. So, unnecessary returns to health facilities should be limited and, where possible, PLHIV should be initiated into ART in their communities using existing outreach and mobile clinics.
To support “social distancing” – all PLHIV already on ART with a suppressed viral load need to be offered and encouraged to urgently enrol in one of South Africa’s three repeat prescription collection strategies (RPCs). These strategies limit the number of times PLHIV need to visit a health facility by extending the duration of their ART refills. South Africa’s RPCs include facility pick-up points, adherence clubs and external pick up points.
The first allows patients to pick up their ART refill through a fast lane approach at the clinic with no need to sit in queues at registry, clinician consulting rooms or pharmacy.
The second involves groups of 10 to 30 PLHIV who meet either at their facility or in their community to pick up their ART refills at their group meeting.
The third allows patients to collect their ART refills from external pick-up points. These include private pharmacies and other community venues. All RPCs allow for multi-month dispensing and a maximum of two clinical consultations per year at the health facility for assessment and rescript.
Despite 2016 WHO guidance supporting ART refills of 3-6 months, South Africa’s public sector is still providing a maximum of two-month ART refills at a time. There has been a recent commitment to provide three-month ART refills and pilot six-month ART refills.
If ever there was a time to provide longer refills, thereby reducing the number and length of interactions getting to and attending health facilities, it is now.
There are also practical changes to the RPCs that should be considered in light of Covid-19.
First, out of facility models are preferable and should be prioritised. As the pandemic continues, acutely sick people will increasingly report to health facilities and require clinical staff to support them.
Second, where PLHIV are still collecting treatment refills from facility-based models, these should be relocated to outside health facility buildings.
Third, PLHIV in all RPCs models should be advised to keep at least a meter apart while waiting, collect their treatment individually, and no group interactions should be facilitated with the focus being on leaving the facility or community venue in the shortest possible time.
Finally, handwashing should be facilitated on entry and exit.
Importantly, people living with hypertension or diabetes considered clinically stable on their treatment are also entitled to collect their treatment refills through these same RPCs models with longer treatment refills and infrequent clinical consultations. PLHIV with co-morbidities (diabetes or hypertension) can also collect all their treatment through the same mechanism.
While longer treatment refills and limiting interactions with health facilities are obviously essential, implementation is highly dependent on drug supply chains which may be currently under threat.
In South Africa, we have a saving grace – Dolutegravir-based ART — a new first-line regimen for people initiating and on ART introduced in November 2019. Roll out has been slow, meaning South Africa has more stock of its one pill a day ART regimen with Dolutegravir (TLD) while stock of its one pill a day ART regimen with Efavirenz (TLE) is threatened. In public sector clinics, we need to urgently explain, offer and where the PLHIV decides he/she wants to switch to Dolutegravir, support switching while not increasing the frequency of visits to the clinic.
During South Africa’s national Covid-19 emergency response, we should consider moving beyond existing policy to further reduce contact with health facilities over the period of the outbreak. If TLE drug stock is insufficient, PLHIV starting treatment should be informed of this risk and encouraged to start TLD unless contra-indicated. PLHIV clinically stable on ART should also be informed of drug stock concerns, benefits and risks of TLD, assessed for and offered immediate switch to TLD. For all people living with chronic conditions, including those starting ART, there should be immediate provision of a minimum of three months of treatment with education to return to the facility earlier if unwell or experiencing side effects.
All clinically stable people living with chronic conditions not yet enrolled in RPCs models should immediately be enrolled in out of facility RPCs models and those newly enrolled and already enrolled should receive a refill for the full six months prescription.
Today, “social distancing” is a vital component of the response to the Covid-19 pandemic. In South Africa, people living with HIV and other chronic conditions should be urgently supported to reduce contact with health facilities both for social distancing purposes as well as saving healthcare worker capacity for those with the greatest immediate need. DM
Lynne Wilkinson is from the University of Cape Town’s Centre of Infectious Disease Epidemiology and Research. Anna Grimsrud is lead technical adviser at the International AIDS Society.
"I didn’t like having to explain to them so I just shut up smoked a cigarette and looked at the sea." ~ Albert Camus