Adeeba Kamarulzaman: Innovations in HIV care for continuity and expansion

Adeeba Kamarulzaman: Innovations in HIV care for continuity and expansion

IAS President Adeeba Kamarulzaman's presentation at the World Health Organization World AIDS Day 2020 event.

World AIDS Day this year falls at the close of an unprecedented year for the planet. The spread of COVID-19 has affected communities across the world – disrupting and threatening lives and livelihoods.

This new pandemic also threatens to undo decades of progress in efforts to end HIV. At IAS - the International AIDS Society - many of us who usually work on the frontlines of HIV, now find ourselves on the frontlines of COVID-19. Others in our ranks are struggling to keep HIV programmes running smoothly as attention, expertise and resources are diverted.

While this focus is necessary to save lives and stop the spread of COVID-19, it also interrupts access to vital HIV treatment and prevention services. A recent survey of programmes in 106 countries found that COVID-19 disruptions have affected 85% of HIV programmes.

Modelling data have highlighted the impact that these disruptions could potentially have. These include an increase in HIV mortality by 10% within 5 years and an increase in new infections among children by 40–80% in high-burden countries.

In the early months of the pandemic, some predicted that COVID-19 would be a great leveler. Instead, we are learning that just like HIV, it is a great divider. We have seen those living in cities are better able to access prevention and treatment information and services online, further exacerbating an urban/rural divide.

COVID-19 has also exposed the challenges that have long excluded those most vulnerable to HIV from accessing care. These include men who have sex with men, people who inject drugs, sex workers and transgender people. Over the past year, these groups have experienced renewed stigma, persecution and economic hardship.

The recently released 2020 Global HIV Policy Report showed that every country in the world has at least one law criminalizing same-sex relationships, sex work, personal drug use, or HIV exposure/transmission - often all four. This is despite evidence that criminalization is counterproductive.

However, this year has also highlighted the power and ingenuity of frontline healthcare workers in adapting and innovating to ensure continuity of services. This year is the International Year of the Nurse and Midwife, a moment to reflect on the contributions of the professionals who have helped to put people at the centre of care even in these most trying of times.

One example is Loon Gangte, founder of the Delhi Network of Positive People or DNP+. Loon successfully lobbied for distribution of multi-month supplies of treatment at local ARV centres before lockdown restrictions went into effect in India and mobilized volunteers on motorbikes to distribute medication to 700 people in Delhi and surrounding states as far away as Agra.

The Princess PrEP programme in Thailand, which provides men who have sex with men and transgender people with same-day access to PrEP dispensed by community providers, has had to improvise by making their own plastic shields at community health centres, offering self-sampling for STIs to reduce time clients spend inside clinics, and rapidly setting up telehealth and PrEP home delivery services.

Our colleagues in Africa have equally embraced innovation to prevent HIV treatment disruption. A number of countries, including Cote d’Ivoire, Ethiopia, and Zimbabwe among many others, have changed policies allowing those initiating ART to receive at least a three-month supply of drugs.

These stories illustrate the immense dedication of HIV community service providers around the world and the innovations that are possible when people-centred approaches are prioritized. All of these innovative efforts to make care more accessible to more people are efforts that can easily stay in place and be expanded post-COVID.

While global attention has understandably been on the COVID-19 pandemic this year, continued advances in HIV cure research and innovations in HIV treatment and prevention give much reason for optimism.

Recent trial results showing the effectiveness of long-acting injectable cabotegravir as HIV prevention in women, men who have sex with men and transgender women is one example. While safety issues and implementation considerations of an 8-weekly injection need to be addressed, these findings expand prevention choices and may help overcome barriers to adherence to daily PrEP for those most vulnerable to HIV.

The COVID-19 pandemic has amplified and magnified existing health vulnerabilities and inequities. Research has shown how the response to COVID-19 has impacted other diseases and will roll back decades of efforts and successes to control HIV, TB and malaria. Minimising the negative impact of COVID-19 on these diseases will require countries and programmes to not only innovate, but also move towards integrating programmes that often exist in silos.

COVID-19 and HIV have both forced us to acknowledge and address social determinants of health. Redesigning health systems in the post COVID world must include strengthened communities. Adequate funding must be secured to ensure continuity of much needed community-led programmes that focus on vulnerable populations.

For both HIV and COVID-19, lasting progress will require addressing deep-seated structural inequalities to protect the most marginalized. This is no easy task and will require trust and collaboration uniting scientists, policy makers, frontline healthcare workers and affected populations.

On World AIDS Day, the IAS calls on the global community to address these challenges head on. Innovation must include equity, science must inform policy, and community must be meaningfully engaged every step of the way.