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The stories are coming from Malawi, South Africa, Uganda, Zambia, Zimbabwe and elsewhere—people struggling to get treatment for chronic illness, failed attempts to refill ARVs and key prevention commodities, high numbers reporting they can’t get to the clinic, informal groups coming together to find and deliver medication. These are pictures of communities in lockdown from COVID-19, facing the consequences to public health.
This troubling news from advocates in sub-Saharan Africa has grave implications. According to a May 2020 analysis of multiple mathematic models by the HIV Modelling Consortium, COVID-related barriers to HIV treatment, care and prevention could result in 500,000 additional deaths from AIDS-related illnesses. The world has made tremendous progress against HIV. If we allow COVID-19 to set us back, we could lose more than a decade of these gains. As AVAC’s Mitchell Warren said, “We cannot play global health whack-a-mole and ignore other devastating diseases while we turn attention to COVID-19. HIV treatment and prevention interruption cannot be an acceptable result of COVID-19: in that model, even if we succeed against COVID-19, we fail against everything else.”
The good news is we know how to preserve the progress made: we have to urgently expand models for differentiated service delivery (DSD), and we have to do it right now. DSD puts clients at the center and adapts—tailoring HIV programs and services to reflect the preferences and expectations of various groups who need HIV prevention or treatment.
In Zimbabwe, a DSD program of the Batanai HIV & AIDS Service Organisation (BHASO) has succeeded with allowing health care workers to bring needed care and medicine to clients, instead of requiring clinic visits. The program is expanding and is exactly the kind of initiative that others should model.
DSD can mean people get their medications, learn about prevention options, find the counseling they need, and stay connected to care. DSD can mean individuals at risk of diseases such HIV or TB are engaging with healthcare that works for them.
AVAC has been expanding its advocacy for DSD, even before COVID-19 gripped the world. Why? Because tenaciously high incidence rates, a heartbreaking number of people lost to follow-up, and the millions of people who don’t know their status or are not virally suppressed can all be addressed with DSD. This means developing programs and services that clients and communities have helped to design, programs that offer a range of approaches, programs that support diverse needs.
Now we need DSD more than ever, so people can access the care, treatment and prevention they need in the midst of COVID-19 lockdowns and disruptions to the healthcare systems in their communities. The results of this new modeling escalate the urgency for widespread adoption of DSD approaches.
The modeling is detailed and the findings are drastic: five teams contributed to models looking at disruptions of three and six months and their impact on AIDS mortality and incidence. According to the findings, if services are disrupted for six months then additional deaths will range from 471,000-673,000 in the following year, which could bring the death toll from AIDS in 2021 to more than 900,000. Those figures “set back the clock” on the HIV epidemic to 2008, a year when the WHO reports 950,000 people died from AIDS in the region. And the heightened rates of loss of life are expected to last for years. Other predictions include reversed gains in mother-to-child transmission with a “drastic” rise of infections among children, up by 37 percent in Mozambique, 78 percent in Zimbabwe and 104 percent in Uganda, and adverse impacts on prevention efforts as well.
As advocates, we cannot allow these scenarios to come true. As UNAIDS executive director Winnie Byanyima says, “The COVID-19 pandemic must not be an excuse to divert investment from HIV. There is a risk that the hard-earned gains of the AIDS response will be sacrificed to the fight against COVID-19, but the right to health means that no one disease should be fought at the expense of the other.”
WHO leader, Dr. Tedros Adhanom Ghebreyesus, is also raising the alarm, “We must read this as a wake-up call to countries to identify ways to sustain all vital health services.”
Watch-dogging country governments to adapt HIV service delivery is vital to sustain and advance three decades of progress in HIV prevention and treatment. Countries must develop the capacity to deliver DSD rapidly and safely, while also pursuing the strongest and wisest course of action against COVID-19.
To get the job done:
- Give people options to choose where and when to access their ART and prevention, and make it easy for them to do so. No one size fits all.
- Governments and donors must establish models that revolve around the clients, not the health system.
- Governments, donors and implementers must anticipate factors such as geography, HIV prevalence or individual barriers to care and address those factors in programs that are codesigned with clients and community. This creates models for service delivery that serve diverse populations. All this necessarily involves investment in both lay and professional health workers for quality clinical care that includes psychosocial support.
- Governments and donors should expand and invest in DSD models for treatment, which include: six monthly refills, community ART groups, nurse-led community ART distribution points, door-to-door ART delivery and there are many more!
- The field must also use these models to guide efforts to develop DSD for PrEP and HIV prevention. These include conducting online risk assessments and follow-up consultations, providing multi-month refills for continuing clients, peer drop-offs and courier delivery of PrEP refills, to name a few.
- It’s time to seize opportunities for integration with other essential services such as: sexual reproductive health and rights (as recently highlighted in a new report from UNAIDS and WHO), interventions for gender-based violence (GBV), and the response to COVID-19. This requires an enabling policy environment and robust program monitoring and evaluation.
- Human rights should never be compromised during the COVID-19 pandemic. Governments must find ways to deliver both COVID-19 and HIV programs within a human rights framework.
AVAC and our partners are leading the charge on DSD advocacy and on identifying where COVID-19 is impacting HIV service delivery. Along with other HIV advocates, we have recommended people living with HIV (PLHIV) receive three to six month refills of ARVs during lockdown. Georgetown University’s HIV Policy Lab has been writing about the need for these multi-month dispensing strategies and policies that support them. COMPASS advocacy partners in Malawi, Tanzania and Zimbabwe have engaged with their respective ministries of health and identified that staffing and supply shortages in ministries and among implementers are making it difficult or impossible to meet the recommendation. Advocates are continuing to follow up with ministries, implementers and funders to find ways to make DSD work during this time.
We are urgently working with TB, SRHR and other health advocates locally and globally to ensure that people receive the care, treatment and prevention they need for all aspects of their health. It isn’t an easy task. The effort requires collaborations and investment at a scale never before seen in global health. But there is no other choice. This is the only way.