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Seventy-three countries have warned that they are at risk of stock-outs of antiretroviral (ARV) medicines as a result of the COVID-19 pandemic, according to a new WHO survey conducted ahead of the International AIDS Society’s biannual conference. Twenty-four countries reported having either a critically low stock of ARVs or disruptions in the supply of these life-saving medicines.

The survey follows a modelling exercise convened by WHO and UNAIDS in May which forecasted that a six-month disruption in access to ARVs could lead to a doubling in AIDS-related deaths in sub-Saharan Africa in 2020 alone.

In 2019, an estimated 8.3 million people were benefiting from ARVs in the 24 countries now experiencing supply shortages. This represents about one third (33%) of all people taking HIV treatment globally.  While there is no cure for HIV, ARVs can control the virus and prevent onward sexual transmission to other people.

A failure of suppliers to deliver ARVs on time and a shut-down of land and air transport services, coupled with limited access to health services within countries as a result of the pandemic, were among the causes cited for the disruptions in the survey.

The findings of this survey are deeply concerning,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “Countries and their development partners must do all they can to ensure that people who need HIV treatment continue to access it. We cannot let the COVID-19 pandemic undo the hard-won gains in the global response to this disease.

Stalled progress

According to data released today from UNAIDS and WHO, new HIV infections fell by 39% between 2000 and 2019. HIV-related deaths fell by 51% over the same time period, and some 15 million lives were saved through the use of antiretroviral therapy.

However, progress towards global targets is stalling. Over the last two years, the annual number of new HIV infections has plateaued at 1.7 million and there was only a modest reduction in HIV-related death, from 730 000 in 2018 to 690 000 in 2019.  Despite steady advances in scaling up treatment coverage – with more than 25 million people in need of ARVs receiving them in 2019 – key 2020 global targets will be missed.

HIV prevention and testing services are not reaching the groups that need them most. Improved targeting of proven prevention and testing services will be critical to reinvigorating the global response to HIV.

WHO guidance and country action

COVID-19 risks exacerbating the situation. WHO recently developed guidance for countries on how to safely maintain access to essential health services during the pandemic, including for all people living with or affected by HIV. The guidance encourages countries to limit disruptions in access to HIV treatment through “multi-month dispensing,” a policy whereby medicines are prescribed for longer periods of time – up to six months. To date, 129 countries have adopted this policy.

Countries are also mitigating the impact of the disruptions by working to maintain flights and supply chains, engaging communities in the delivery of HIV medicines, and working with manufacturers to overcome logistics challenges.

New opportunities to treat HIV in young children

At the IAS conference, WHO will highlight how global progress in reducing HIV-related deaths can be accelerated by stepping up support and services for populations disproportionately impacted by the epidemic, including young children. In 2019, there were an estimated 95 000 HIV-related deaths and 150 000 new infections among children. Only about half (53%) of children in need of antiretroviral therapy were receiving it.  A lack of optimal medicines with suitable pediatric formulations has been a longstanding barrier to improving health outcomes for children living with HIV.

Last month, WHO welcomed a decision by the U.S. Food and Drug Administration to approve a new 5mg formulation of dolutegravir (DTG) for infants and children older than 4 weeks and weighing more than 3 kg. This decision will ensure that all children have rapid access to an optimal drug that, to date, has only been available for adults, adolescents and older children. WHO is committed to fast-tracking the prequalification of DTG as a generic drug so that it can be used as soon as possible by countries to save lives.

Through a collaboration of multiple partners, we are likely to see generic versions of dolutegravir for children by early 2021, allowing for a rapid reduction in the cost of this medicine,” said Dr Meg Doherty, Director of the Department of Global HIV, Hepatitis and STI Programmes at WHO. “This will give us another new tool to reach children living with HIV and keep them alive and healthy.”

Tackling opportunistic infections

Many HIV-related deaths result from infections that take advantage of an individual’s weakened immune system. These include bacterial infections, such as tuberculosis, viral infections like hepatitis and COVID-19, parasitic infections such as toxoplasmosis and fungal infections, including histoplasmosis.

Today, WHO is releasing new guidelines for the diagnosis and management of histoplasmosis, among people living with HIV. Histoplasmosis is highly prevalent in the WHO Region of the Americas, whereas many as 15 600 new cases and 4500 deaths are reported each year among people living with HIV. Many of these deaths could be prevented through timely diagnosis and treatment of the disease.

In recent years, the development of highly sensitive diagnostic tests has allowed for rapid and accurate confirmation of histoplasmosis and earlier initiation of treatment. However, innovative diagnostics and optimal treatments for this disease are not yet widely available in resource-limited settings.

Missed targets have resulted in 3.5 million more HIV infections and 820 000 more AIDS-related deaths since 2015 than if the world was on track to meet the 2020 targets. In addition, the response could be set back further, by ten years or more, if the COVID-19 pandemic results in severe disruptions to HIV services.

GENEVA, 7 July 2020 — A new report by UNAIDS shows remarkable, but highly unequal, progress, notably in expanding access to antiretroviral therapy. Because the achievements have not been shared equally within and between countries, the global HIV targets set for 2020 will not be reached. The report, Seizing the moment, warns that even the gains made could be lost and progress further stalled if we fail to act. It highlights just how urgent it is for countries to double down and act with greater urgency to reach the millions still left behind.

“Every day in the next decade decisive action is needed to get the world back on track to end the AIDS epidemic by 2030,” said Winnie Byanyima, the Executive Director of UNAIDS. “Millions of lives have been saved, particularly the lives of women in Africa. The progress made by many needs to be shared by all communities in all countries. Stigma and discrimination and widespread inequalities are major barriers to ending AIDS. Countries need to listen to the evidence and step up to their human rights responsibilities.”

Fourteen countries have achieved the 90–90–90 HIV treatment targets (90% of people living with HIV know their HIV status, of whom 90% are on antiretroviral treatment and of whom 90% are virally suppressed), including Eswatini, which has one of the highest HIV prevalence rates in the world, at 27% in 2019, and which has now surpassed the targets to achieve 95–95–95.

The scale-up of antiretroviral therapy has saved millions of lives and new infections. However, 690 000 people died of AIDS-related illnesses last year, and 12.6 million of the 38 million people living with HIV were not accessing the life-saving treatment.

“We cannot rest on our successes, nor be discouraged by setbacks. We must ensure that no one is left behind. We must close the gaps. We are aiming for 100–100–100,” said Ambrose Dlamini, the Prime Minister of Eswatini.

The world is far behind in preventing new HIV infections. Some 1.7 million people were newly infected with the virus, more than three times the global target. There has been progress in eastern and southern Africa, where new HIV infections have reduced by 38% since 2010. This is in stark contrast to eastern Europe and central Asia, which has seen a staggering 72% rise in new HIV infections since 2010. New HIV infections have also risen in the Middle East and North Africa, by 22%, and by 21% in Latin America.

Seizing the moment shows unequal progress, with too many vulnerable people and populations left behind. Around 62% of new HIV infections occurred among key populations and their sexual partners, including gay men and other men who have sex with men, sex workers, people who inject drugs and people in prison, despite them constituting a very small proportion of the general population.

Stigma and discrimination, together with other social inequalities and exclusion, are proving to be key barriers. Marginalised populations who fear judgement, violence or arrest struggle to access sexual and reproductive health services, especially those related to contraception and HIV prevention. Stigma against people living with HIV is still commonplace. At least 82 countries criminalise some form of HIV transmission, exposure or non-disclosure, sex work is criminalised in at least 103 countries, and at least 108 countries criminalise the consumption or possession of drugs for personal use.

Women and girls in sub-Saharan Africa continue to be the most affected and accounted for 59% of all new HIV infections in the region in 2019, with 4500 adolescent girls and young women between 15 and 24 years old becoming infected with HIV every week. Young women accounted for 24% of new HIV infections in 2019, despite making up only 10% of the population in sub-Saharan Africa.

However, where HIV services are comprehensively provided, HIV transmission levels are reduced significantly. In Eswatini, Lesotho and South Africa, high coverage of combination prevention options, including social and economic support for young women and high levels of treatment coverage and viral suppression for previously unreached populations, have narrowed inequality gaps and driven down the incidence of new HIV infections.

The COVID-19 pandemic has severely impacted the AIDS response and could disrupt it more. A six-month complete disruption in HIV treatment could cause more than 500 000 additional deaths in sub-Saharan Africa over the next year (2020–2021), bringing the region back to 2008 AIDS mortality levels. Even a 20% disruption could cause an additional 110 000 deaths.

“Those of us who survived HIV and fought for life and access to treatment and care cannot afford to lose the gains that took so much effort to win. In some Latin American countries we are seeing how HIV resources, medicines, medical staff and equipment are being moved to the fight against COVID-19,” said Gracia Violeta Ross, President of the Bolivian Network of People Living with HIV. “Some good lessons and practices of the HIV response, such as meaningful participation and accountability, are being ignored. We will not allow HIV to be left behind.”

To fight the colliding epidemics of HIV and COVID-19, UNAIDS and partners are leading a global call for a People’s Vaccine for COVID-19, which has been signed by more than 150 world leaders and experts demanding that all vaccines, treatments and tests be patent-free, mass produced and distributed fairly and free for all.

UNAIDS is also urging countries to increase investments in both diseases. In 2019, funding for HIV fell by 7% from 2017 to US$ 18.6 billion. This setback means that funding is 30% short of the US$ 26.2 billion needed to effectively respond to HIV in 2020.

“We cannot have poor countries at the back of the queue. It should not depend on the money in your pocket or the colour of your skin to be protected against these deadly viruses,” said Ms Byanyima. “We cannot take money from one disease to treat another. Both HIV and COVID-19 must be fully funded if we are to avoid massive loss of life.”

• UNAIDS 2020 Databook

https://www.unaids.org/en/resources/documents/2020/unaids-data 

• Core Epidemiology Slides

• Fact sheet

Washington, D.C., June 9, 2020 (PAHO)—The Director of the Pan American Health Organization (PAHO), Dr Carissa F. Etienne, said preparing for winter and hurricanes is critical to mitigate the spread of COVID-19 in the Americas.

With more than 3.3 million cases of COVID-19 in the region and many areas reporting exponential rises in cases and deaths, “We are concerned by data showing the virus surging in new places that had previously seen a limited number of cases,” Etienne said in a press briefing today.

The PAHO Director noted, “In South America, our response to the pandemic will be impacted by the arrival of winter, while hurricane season will complicate our efforts in North and Central America, and especially in the Caribbean.” 

Preparing for respiratory infections during winter

Winter, now starting in South America, “fuels respiratory infections—like seasonal influenza and pneumonia—that can rapidly spread in colder climates and as more people gather indoors to stay warm,” she said. 

“This is a problem for patients because respiratory illnesses leave them at greater risk of severe COVID-19 infection. It’s also a challenge for strained health systems that will have to cope with the dual burden of a coronavirus pandemic and a spike in other respiratory illnesses. It does not help that the similar symptoms will make diagnosing COVID-19 even harder,” Dr. Etienne told journalists at the briefing.

Influenza vaccination “to prevent severe cases of flu is more critical than ever—particularly for high-risk groups like health workers, the elderly and people with chronic conditions. These same groups are also at high-risk of coronavirus infection,” she noted.

Seasonal influenza vaccination is ongoing in 14 countries, and more than 90 million people are being targeted. PAHO is helping countries buy vaccines through its Revolving Fund. “The Fund helped secure 24 million flu vaccine doses, despite the added logistical hurdles that we’re all facing in transporting essential supplies during the pandemic,” the PAHO Director explained.

Preparing for hurricane season

With hurricane season starting, PAHO’s director suggested that officials in the Caribbean, Central America, and the East coast of the USA “review national hurricane response plans and conduct simulation exercises to ensure your disaster and COVID-19 responses are aligned. We should also plan for potential disruptions to the care of critically ill patients and refine evacuation plans.”

She said PAHO is working to provide emergency response supplies throughout the region, and “to secure critical facilities like laboratories, and quarantine and isolation centers so diagnosis and treatment for COVID-19 can continue even under difficult circumstances.” 

“We must take action today to safeguard our progress and mitigate the spread of the virus during this time. That means redoubling our efforts to control the spread of COVID-19, so that we reduce the dual burden the approaching winter and hurricane seasons might bring,” Etienne added. 

Strengthening health infrastructure by hiring surge staff and expanding reserves of essential supplies and protective equipment is also important and “will help ensure the work done to prepare for COVID-19 is reinforced to address these seasonal threats, she said. 

The COVID-19 pandemic has pushed our region to the limit. Our communities and health systems are under duress, and our collective efforts are laser-focused on containing the virus, Dr. Etienne said.

“Preparing for winter and hurricane season is a critical part of this fight. We must take action today to safeguard our progress and mitigate the spread of the virus during this time. And that means redoubling our efforts to control the spread of COVID-19 so that we reduce the dual burden the approaching winter and hurricane seasons might bring.” 

LINKS

• Remarks from the Director: https://www.paho.org/en/media/weekly-press-briefing-covid-19-situation-americas
• Recording of the media briefing (original audio): https://youtu.be/apd6Fz9cYI8
• Recording of the media briefing (English): https://youtu.be/80A7B-3Z8M4
• Information about COVID-19 in the Americas: www.paho.org/coronavirus

Written by Oluatoyin Alleyne

“I am kind of scared and everybody like me, you know they scared. This is something new and, you know, we already have a compromised immune system so we all just frighten,” said a mother who has been living with HIV for a number of years.

“I want to talk about it and let people out there understand that this thing is real. People like me with HIV, we have to take extra care, we cannot take chances.”

Since being diagnosed with HIV and placed on treatment, she has been supporting mainly HIV-positive women as she believes they feel better speaking with someone who has walked their path or is walking their path.

“You see when the corona come to Guyana, I started cleaning, trying to get rid of the old stuff. I was scared to go out and the one good thing, I had my daughter, and if I want anything she would go and get it,” she said.

“And then the calls start coming, persons start calling and asking for aid and they were also afraid to go out and get their treatment. It was really frightening, and you know I had to direct them on how to go and get treatment, calling the health centres to help them.

“And then, you know, we see the news with them talking about HIV persons and how our immune systems was compromised and advising people who not on treatment to get on treatment because their immune system could weaken, that was frightening.

“So now I had to call up people and tell them to keep up their immune systems, tell them to drink a lot of vitamins and take their medication and not to miss taking it. It was then some of them started finding out about hampers and I decided to call NAPS [National AIDS Programme Secretariat] and I was told that you had to reach certain criteria to get a hamper.

“So if you not sick and you not working, you cannot get the hamper and I felt really bad because here we telling people stay home be safe, some of them would get a one day work here and there but now they frighten to go out. They frighten to go out, but they can’t get a hamper. We not asking for every month but at least one time. They felt really bad when I told them about the criteria, and I had to turn to my church and ask for help and some of them would get hampers.

“People always talking about criteria. It is like you have to be really sick to get a hamper. You have to carry yourself really down. Your immune system have to very low for you to get a hamper.

“They are people who not working and can’t support their children. They have HIV. Why can’t they get a hamper?” she questioned.

“I think also they need to train people with HIV about the corona so that we can really talk to others, because persons living with HIV will more listen to other positive persons and they need to get the information.

“Some of them call and even come looking for me because they want information and help. They would not want to talk to the people at the treatment centres they would prefer to talk to someone who understand what they are going through. It is a really frightening situation, especially for people who are working. And even those who are not working, they are afraid to go out,” the woman said.

“You know I am very brave but even I don’t want to go out. I don’t go out nowhere. Them children frighten for me more than I afraid [for] myself.

“It is sad to know that people living with HIV and they are in need and they have to go out there and compromise themselves and could get themselves and their children sick. It is a sad thing for single parents, especially. I stand a chance because I have me children and they would make sure I eat and that I alright.

“Depression is now getting a lot them. Even me I does feel so bored because before I am always out and about, and it can get difficult for me. It is something really sad. They don’t have nobody to talk to. The group we had ain’t really functioning right now. Because of the COVID, we can’t even meet. But some would call.

“A lady call me from the East Coast. Somebody give she my name for help. I submit she name, and I hope to get help from my church. She have six grandchildren and they mother die from HIV and she does have to work and mind them. She must be try all over and somebody must be just give her the number and she call. Is a good thing I does say give them me number and if I could help I would help.

“Persons are saying they want them doing a shutdown of the country but what will happen to persons who are working? They are not putting anything in place. I am scared but I don’t think we could afford a lockdown. Too much poor people will suffer,” she continued.

In a direct appeal to HIV-positive persons, the woman urged that they stay on treatment.

“If you on treatment, stay on the treatment, adhere to it. Keep your surroundings sanitized, keep it clean. And if you not on medication contact your nearest health centre. It is serious, don’t make joke, you already living with a compromised immune system and it is important that you adhere to the Ministry of Health guidelines,” she warned.

If there are HIV positive sisters out there who need support, please call 693-2817 and the positive sister who answers will do her best to assist or at least direct you where you can get some assistance.

Only recently a call was made for persons living with HIV in Guyana to take extra measures to protect themselves from contracting COVID-19.

NAPS Director Dr Rhonda Moore pointed out that persons living with HIV are at an increased risk of developing the most severe form of the virus or even dying if they are to contract the virus. She noted that this may be the case for persons who are not on treatment or those who are not virally suppressed.

Moore had explained that the HIV attacks the immune system, making it difficult for those living with it to fight off any infection which includes COVID-19 and, therefore, contracting the virus may lead to persons needing hospital care and in most cases intensive care. She also mentioned that persons who are virally suppressed are those persons who have been using their treatment and as a result the virus is under control, which means that their immune systems can fight other infections.

Dr Moore urged persons living with HIV to stay at home unless it is absolutely necessary for them to venture outside, to practice COVID-19 precautionary measures put in place by the health authorities and to ensure they eat as healthy as possible. She had also informed that the NAPS food bank is prepared to work with the treatment facilities to provide those who need additional support with hampers.

Persons who are not using any treatment for HIV are urged to call NAPS hotline (Guyana) at 227-8683 extension 215 to be directed to treatment sites in their areas.

Photo by NEOSiAM 2020

Submitted by Enrique Romero, Executive Director, National AIDS Commission (NAC) – Belize and Anellie Paredes, Communications and Programs Officer, NAC – Belize

As part of its “Continuity of HIV Services during COVID-19 Action Plan”, the National AIDS Commission (NAC) – Belize conducted a Needs Assessment of People Living with HIV (PLHIV). The exercise was conducted through the various existing layers of support to PLHIV including social workers and adherence counsellors from the Ministry of Health (Belize), Peer Navigators, NAC District Committees and Civil Society Organizations (CSOs).

The assessment revealed that many PLHIV are desperately in need of food items to remain adherent to their medication. The NAC provided the Ministry of Human Development, Social Transformation and Poverty Alleviation (Belize) with a list of 100 persons to facilitate and expedite assistance to these individuals through the Government of Belize’s “Food Assistance Programme”. The NAC is currently in discussions with two private companies and other agencies to facilitate the donation of food items to PLHIV.

To further contribute to Belize’s COVID-19 response, the NAC has utilised its Facebook page to empower persons by promoting healthy lifestyles, social distancing and good hygiene. The NAC’s public education and awareness messages continue to focus on respect for Human Rights, condemnation of acts of violence and abuse against vulnerable groups, including persons from the LGBT community, women and children. The NAC also issued a call to action urging persons to refrain from cyberbullying, stigma and discrimination which have increased during COVID-19.

The NAC continues to work with its social partners and communities to provide care, treatment and support services to persons living with and affected by HIV and AIDS.

Contributor: Valerie Wilson, Director, Caribbean Med Labs Foundation (CMLF)

COVID-19 has undoubtedly changed the world; laboratories are not immune to this change.

The COVID-19 (Coronavirus) pandemic has laid bare the critical importance of accurate, reliable and timely laboratory testing for diagnosis, patient care and management.

It took COVID-19 to teach us, perhaps, one of the most striking lessons of the pandemic: the urgent need for scaling up testing to identify those infected, to prevent further spread and reduce harm.

Through online training, the Caribbean Med Labs Foundation (CMLF) assisted countries in ensuring quality management systems for accurate and reliable COVID-19 results.

As early as March, CMLF had pinpointed the crucial role of laboratories (article here).  As it has done for more than a decade of its work on strengthening laboratory services in the Caribbean, the Foundation provided vital information for Ministries of Health, laboratories and health care providers to help guide their decisions.  This guidance addressed options for, and benefits of COVID-19 testing to identify persons infected who require treatment and for surveillance of those who may have been infected and recovered.

CMLF also emphasised that COVID-19 illustrated the urgent need for regional governments to adopt national laboratory policies, enact legislation to improve quality and resourcing of public laboratories and monitor the quality of private laboratories to ensure readiness to address public health threats.

CMLF has assisted the Organisation of Eastern Caribbean States (OECS) to identify COVID-19 laboratory tests and supplies.  To ensure that other critical regional health interventions continue in light of severe supply chain disruptions globally, CMLF continues to collect and share data with partners on regional HIV and Sexually transmitted infections (STIs) reagent stocks.  The goal is to ensure that HIV and STI diagnostic, treatment and care services continue during the COVID-19 pandemic.