HIV Testing, ART Initiation in South Africa Falls Nearly 50% in COVID-19 Lockdown

In South Africa, a national lockdown during the coronavirus diseases 2019 (COVID-19) pandemic led to a reduction in HIV testing and antiretroviral therapy (ART) initiation, while ART was maintained for those already established as patients.

The study, published in The Lancet HIV, included data on people testing for HIV, initiating ART and continuing treatment at 65 clinics in KwaZulu-Natal, South Africa, which is home to 1.7 million people living with HIV.

“On the whole, people who were already receiving ART were able to continue collecting ART through the South African lockdown. In contrast, engaging people in care, through HIV testing and starting people living with HIV on ART, was heavily impacted by the lockdown,” first author Jienchi Dorward, BSc, MBChB, MRCGP, MSc, with the Center for the AIDS Program of Research in South Africa (CAPRISA) and Nuffield Department of Primary Care Health Sciences at the University of Oxford, told Contagion®.

The median monthly number of HIV tests before the pandemic (January 2018 to March 2020) was 41926, compared with 38911 after the lockdown. Using the Poisson regression model to factor in long-term trends, investigators estimated a 47.6% decrease in HIV testing associated with the lockdown in April 2020.

ART initiations fell from a weekly average of 571 to 375, with Poisson regression modeling showing an estimated 46.2% drop in the first week of the lockdown. ART collection visits were not significantly affected by the lockdown, dropping from an average of 18519 to 17863 visits per week after lockdown.

“We were surprised that ongoing ART provision was not more heavily impacted,” Dorward said. “Modelling studies (Jewell et al Lancet HIV 2020, see reference list of our article) had suggested that decreases in ART provision related to COVID-19 would have the largest impact on HIV related mortality in Africa. So it is good news that ART provision was not so heavily impacted.”

Rates of HIV testing and ART initiation gradually improved as the pandemic restrictions were eased from the implementation of the national lockdown, which began at Level 5 on March 27 and was eased to Level 4 on May 1 and Level 3 on June 1. There were 76,706 cases of COVID-19 confirmed in KwaZulu-Natal province by July 31, 2020.

“It is crucial to ensure access to all aspects of HIV care through the COVID-19 pandemic,” Dorward said. “This will require innovation to ensure that people can continue to test, start treatment and continue receiving uninterrupted ART.”

About 25.8 million people are living with HIV/AIDS in Africa, and the disease caused more than 400,000 deaths on the continent in 2019.

A report from the Joint United Nations Program on HIV/AIDS (UNAIDS) in July estimated that the COVID-19 pandemic could set the international AIDS response back by a decade or more. Another study estimated that deaths due to HIV could increase by 10% over the next five years because of the pandemic.

Further research is needed to better understand the effects of the pandemic on HIV treatment.

“We want to look at how the HIV program has adapted to enable provision of ART through the COVID-19 pandemic,” Dorward said. “Measures to increase flexibility and allow people to collect ART outside of clinics and in the community were introduced, and we want to assess how they were implemented and, if possible, whether this affected outcomes at all.”