Impact of Covid on Critical Health Issues

As per the latest ‘Sankalak: Status of National AIDS Response’ (2020) report of the Government, around 5.56 lakh HIV/AIDS cases have been reported in last three years under HIV testing and counseling services of National AIDS Control Programme in country. Throughout the COVID-19 pandemic, the World Health Organization (WHO) Director General’s has emphasized that “All countries must strike a fine balance between protecting health, minimizing economic and social disruption, and respecting human rights”.

When health systems are overwhelmed, countries need to make difficult decisions to balance the demands of responding directly to COVID-19, while simultaneously engaging in strategic planning and coordinated action to maintain essential health service delivery. The provision of many services will become more challenging. Women’s choices and rights to sexual and reproductive health care, however, should be respected regardless of COVID-19 status. To guide national health systems in planning for the strategic shifts needed to sustain sexual and reproductive health services while also responding to the additional demands of the COVID-19 pandemic, WHO has published COVID-19 specific resources that complement and supplement existing resources in this field.

People living with HIV (PLHIV) who are not taking antiretroviral treatment (ART) and have a low CD4 cell count, particularly those with advanced HIV disease, are at increased risk of opportunistic infections and AIDS related complications. However, there is evolving and conflicting evidence whether people living with HIV have an increased risk of acquisition of SARS-CoV-2 infection and and/or COVID-19 clinical complications in PLHIV compared to the general population. PLHIV can have a greater prevalence of the known risk factors for COVID-19 acquisition and complications, such as heart disease, kidney disease, diabetes, chronic pulmonary disease, obesity, as well as, other comorbidities and co-infections, like tuberculosis.

Several case report series and small cohort studies among hospitalized PLHIV with COVID-19 have shown comparable clinical outcomes and similar risk of SARS CoV2 infection when compared with general population, particularly in those with well controlled HIV infection (on ART and with a CD4 count > 200 cells/mm3 and supressed viral load). These limited clinical data suggest the mortality risk in PLHIV is associated with known COVID-19 factors such as older age and presence of comorbidities including cardiovascular disease, diabetes, chronic respiratory disease and obesity [1-3]. There have been several systematic and non-systematic reviews that evaluated COVID-19 outcomes among PLHIV; most have found comparable outcomes of mortality and morbidity when compared with HIV negative patients [4-8]. Methods did not always include assessment of outcomes while controlling for known COVID-19 risk factors [4]. There is also limited data in patients with advanced HIV disease (i.e. low CD4 cell count).

One systematic review, notably published as a pre-print, found of 144,795 hospitalized COVID-19 patients in North America, Europe, and Asia the pooled prevalence of HIV in COVID-19 patients was 1.22% [95% (CI): 0.61%-2.43%)] translating to a 2-fold increase compared to the respective local-level pooled HIV prevalence in the general population of 0.65% (95% CI: 0.48%-0.89%) – which hinted at a potential susceptibility among PLHIV [9]. Additional data on this topic come from several cohort studies from South Africa, the USA and the UK [10-12] have reported a moderate increased risk of death directly attributed to HIV infection after adjustments for age, sex, ethnicity and presence of comorbidities; an unpublished meta-analysis including these studies found that the risk of death was almost double that of HIV-negative patients; however, confounding by comorbidities associated with increased risk of severe COVID-19 cannot be ruled out.

Protecting people living with HIV during the COVID-19 pandemic, and ensuring they can maintain treatment, is critical. Researchers are currently investigating whether people with HIV have an increased risk of poor outcomes with COVID-19.Preliminary evidence of moderate increased vulnerability of people with HIV makes it even more urgent that people with HIV have access to ARVs and treatments for co-morbidities – such as treatment for hypertension, cardiovascular disease, chronic pulmonary disease, diabetes, tuberculosis, and maintenance of a healthy body weight. A larger dataset from a broader geographical representation is required to expand understanding of how SARS-CoV-2 co-infection with HIV impacts the severity of illness, disease progression and outcomes from hospitalization with COVID-19. For this purpose, WHO has established a Global COVID-19 Clinical Platform. As of 4 November 2020, WHO has received clinical data from 79 000 patients hospitalised with confirmed or suspected COVID-19, including from 5 291 hospitalised patients living with HIV, from over 30 countries around the world. The platform is open to all Member States and health facilities to contribute data and inclusion will help inform future guidance on how best to ensure PLHIV are well protected during the COVID-19 pandemic.

PLHIV are advised to take the same COVID-19 precautions as recommended for the general population [14-15]: wash hands often; practice cough etiquette; ensure physical distancing; wear masks when appropriate and according to local regulations; seek medical care if symptomatic; self-isolate if one develops symptoms or has contact with a positive COVID-19 case; and other actions per the local and government response. It is important to ensure that PLHIV have access to antiretroviral drugs for longer periods (3-6 month supply); and that programmes practice multi-month dispensing (MMD) of ARVs, as well as, other necessary medications, such as, opiate substitution therapy (OST), TB preventative therapy (TPT) and treatments for comorbidities. It is also important to ensure that some vaccinations are up to date (influenza and pneumococcal vaccines) and there is access to adequate supplies of medicines to treat or prevent co-infections and comorbidities.