Coronavirus disease 2019 (COVID-19) and HIV: Key issues and actions

Prepared by The UNAIDS Cosponsors Regional Group (UCRG) for Latin America and the Caribbean.

March, 20, 2020- The HIV community and response have much to offer to the coronavirus disease 2019 (COVID-19) preparedness and resiliency. Having community-led organizations, such as people living with HIV (PLHIV) networks, engaged at the planning and response tables early on is key to build trust, ensure productive exchange of information, and lay the foundations for joint problem-solving measures. The following key actions addressing issues that may arise for the HIV response amid COVID-19 outbreak should be taken by governments, civil society organizations (CSOs) and networks, and PLWVIH to ensure that the response to COVID-19 is aligned with human rights principles.

Quick facts about COVID-19 and HIV

COVID-19 is the name scientists have given for the illness people develop after becoming infected with SARS-CoV-2, a new strain of coronavirus discovered in 2019.
There is currently no strong data to suggest that people living with HIV (PLHIV) are at a higher risk of acquiring SARS-CoV-2 or developing more severe COVID-19 if they do acquire it, especially if their immune system is not compromised, although people with underlying conditions and a weaker immune system may be most vulnerable to COVID-19 infection.
Therefore, all PLHIV should be put on antiretroviral treatment (“treat all”) no more than seven days after confirmation of diagnosis of HIV infection (“rapid initiation”), including same day initiation if willing and eligible. For PLHIV on ART, maintaining optimal adherence ensures viral suppression and immunological recovery (higher 2 CD4 count), reducing the risk of complications in case of infection with SARS-CoV-2 (the agent of COVID-19).
In addition, it is strongly recommended that PLHIV take the general preventive measures for COVID-19 recommended for all people according to PAHO/WHO guidance (see next section). As other populations at high risk for severe COVID-19, PLHIV who are 60 or older and/or with underlying chronic conditions (e.g. diabetes, cancer, respiratory and cardiovascular diseases) may be at higher risk or suffering more serious COVID-19-related illness. Note: information may change as COVID expands in countries with higher HIV prevalence and more data and evidence becomes available on COVID-19 in PLHIV.
Vaccinations (e.g. influenza, pneumococcal) should be offered to all PLHIV and be up to date. • There is currently no approved treatment for COVID-19, no immune therapeutics, and no vaccine. Treatment is symptomatic (e.g. rest, hydration, antipyretics) and transmission prevention measures should be adopted (see next section).
Experimental drugs (e.g. remdesivir), combination of LPV/r and interferon beta, other broad- spectrum antivirals, chloroquine and therapeutic monoclonal antibodies are being tested for the treatment of COVID-19 in the context of clinical research. There is no current evidence to recommend any specific anti-COVID-19 treatment for patients with confirmed COVID-19. WHO recommendation on clinical management of severe acute respiratory infection (SARI) when COVID-19 is suspected are available on this WHO web site:
Frequently asked questions on COVID-19, HIV and antiretrovirals are also available and regularly updated on this WHO web site.

Information on COVID-19 prevention for PLHIV

It is important to follow latest information about COVID-19 and always check the accuracy of the information by verifying the source and follow the advice of your healthcare provider. The Pan American Health Organization (PAHO), the World Health Organization (WHO) and UNAIDS have developed a set of public information messages and guidance for communicating on COVID-19:

The best way to prevent COVID-19 is to avoid being exposed to SARS-CoV-2. PLHIV should take the same prevention measures for COVID-19 recommended for all people according to PAHO/WHO guidance:

Wash your hands frequently. Regularly and thoroughly wash your hands with soap and water for at least 20 seconds, especially after you have been in a public place, or after blowing your nose, coughing, or sneezing. If soap and water are not readily available, clean your hands using a hand sanitizer that contains at least 60% alcohol.
Frequently touched surfaces (like desks and table) and objects (telephones, keyboards, handles, toilets) should be wiped with disinfectant regularly. Most common household disinfectants will work.
Practice respiratory hygiene. Make sure you, and the people around you, follow good respiratory hygiene. This means covering your mouth and nose with your bent elbow or tissue when you cough or sneeze. Then dispose of the used tissue immediately in the trash.
Avoid touching your eyes, nose and mouth. Hands touch many surfaces and can pick up viruses. Once contaminated, hands can transfer the virus to your eyes, nose or mouth. From there the virus can enter your body and can make you sick.
Maintain social distancing. Avoid close contact with people who are sick. Maintain at least two meters (6 feet) distance between yourself and anyone who is coughing or sneezing.
If you are over the age of 60, or if you have an underlying chronic condition, take additional precautions and avoid crowds.
Stay home if you feel unwell. If you have a fever, cough and difficulty breathing, seek medical attention immediately, and call in advance your local doctor or health professional, if possible. Follow the directions of your local health authority.
Depending on the stage of the COVID-19 epidemic in your country follow the recommendation of self-isolation in your home when possible to minimize the risk of exposure to the virus.
When to use a face mask:
- Wear a mask if you are coughing or sneezing. o If you are healthy, you only need to wear a mask if taking care of a person with suspected COVID-19 infection.
- Masks are effective only when used in combination with frequent handcleaning with alcohol-based hand rub or soap and water. o If you wear a mask, then you must know how to use it and dispose it properly, for example, do not touch the inside of the mask. Check here for recommended instructions.
- Facemasks may be in short supply and should be saved for caregivers.

COVID-19 preparedness for continuity of HIV services

Overburden of health services may affect regular access to essential and necessary comprehensive medical care and treatment for people living with HIV.
Programs should assess the possibility of service interruption, especially care and treatment for PLHIV, HIV testing, antenatal care and other relevant services; and contingency plans should be developed in case COVID-19 responses affect the routine of these services. Measures should apply to all service delivery platforms including health facilities, community-based, mobile and outreach.
Less frequent clinic visits (e.g. every 6 months) are recommended for PLHIV stable on ART.
PLHIV should have ample antiretroviral (ARV) medication supply, thus HIV services are strongly recommended to adopt Multi-Month Prescriptions (MMP) and MultiMonth Dispensing (MMD) for 3-6 months, especially for PLHIV stable on ART, as recommended by WHO. Countries with HIV Pre-Exposure Prophylaxis (PrEP) programs should also ensure a minimum of 3-month supply for users.
MMD may increase treatment adherence, ensure uninterrupted ARV supply, and decongest services in preparation for a potential emergency due to COVID-19 pandemic. In addition, the benefit of MMD is that PLHIV do not have to go to saturated health services just to obtain their medications, thus avoiding possible exposure to SARS-CoV-2.
MMD requires an adequate supply chain management system for ARV (planning, procurement and distribution), as well as specific guidelines for services. Pharmacy and supply chain planning should be accelerated to facilitate sufficient stocks for full implementation of MMD.
The feasibility of utilizing non-health facility-based ARV dispensing modalities for stable persons on antiretroviral treatment (ART) should also be explored (e.g. pharmacy dispensing and home-delivery).
Plans should be established to ensure access to clinical care for PLHIV, including if isolated or quarantined (e.g. telemedicine options, on-line portals, virtual/telephone and messaging; etc.), with strong community systems, when available, to support adherence. PLHIV should have access to telephone or other virtual support (ex, WhatsApp) to minimize the need to access an overburdened health system during time of response and risk increased exposure to SARS-CoV-2 at health facilities.
While implementing MMP/MMD and more spaced clinical consultations for stable patients, health services should prioritize and ensure ongoing care for PLHIV with low CD4 counts who are particularly vulnerable and at higher risk of COVID-19, as well to PLHIV with other underlying chronic conditions, and TB patients.
As part of COVID-19 preparedness, countries should develop specific standard operating procedures with clear patient routes and specific infection prevention and control (IPC) measures in health facilities to ensure safety for personnel and patients.
Additionally, in the context of COVID-19 response, it is important not to interrupt HIV testing services to diagnose, as soon as possible, people infected with HIV who do not know their status. Community-based HIV testing should be managed with great caution, or temporarily put on hold, while national authorities’ recommendations for social distancing are in place. However, provider-initiated HIV rapid screening (RST) and HIV testing requested by users in clinic settings could be prioritized. Countries should quickly overcome local barriers for the adoption of HIV self-testing, following WHO recommendations, and quickly develop an implementation strategy and scale it up. http://onusidalac.org/1/images/key-messages-covid-hiv.pdf
https://www.who.int/docs/default-source/coronaviruse/covid19-stigma-guide.pdf

Upholding human rights

It is possible to implement an effective COVID-19 epidemic response, including restrictions on people’s movements, while also upholding human rights. Lack of trust between affected communities and government or public health experts may get in the way of effective epidemic responses. As well-known from the HIV response, one way to establish trust and engagement is to include community leaders in preparedness, planning, and response. This also means giving them a seat at the governance and planning tables of the COVID-19 response.
Some basic principles: restrictions to limit movements or for isolation should be of limited duration and based on scientific evidence. They should not be implemented in an arbitrary or discriminatory manner. Generally large-scale quarantines or restrictions on movement, especially without community engagement, can drive the outbreak underground, having the opposite effect of than intended.
While travel restrictions across the world are increasing it is important to clarify that WHO advises against the application of travel or trade restrictions on affected countries. Evidence shows that restricting the movement of people and goods during public health emergencies is ineffective in most situations and may divert resources from the response and other interventions.
This is a time where xenophobia, racism, stigma and discrimination can rear up against groups “considered” to be affected. Countries should apply experiences learnt in the HIV epidemic that cautions against such stigma and discrimination and its negative impact in the response, particularly in health care settings.
Ensure maintenance of up-to-date and reliable information flow on social media, as well as through qualified governmental authorities or experts assigned as spoke persons to provide information to the general public. People can best protect their health and engage in the response when fully informed.
It is important that people living with and affected by HIV have the most accurate and up-to-date information about COVID-19 and HIV and how to protect themselves from COVID-19, as well as on where and how accessing HIV prevention, care and treatment services, and further information.

PLHIV and platforms for communication

CSOs and PLHIV networks play an important role in monitoring the needs of PLHIV for information, preventive support and non-interruption of treatment.
Community representatives (PLHIV networks, CSOs or others) should be included in COVID-19 preparedness and response committees. An inclusive response builds transparency and public trust.
Community representatives should monitor if PLHIV have enough medicines, and advocate for MMP and MMD.
As part of COVID-19 preparedness, a rapid survey could be undertaken through networks of PLHIV to assess information needs, availability of medications, ability for people to access services and support through telephone or at community level, etc. This information should be used to ensure that community engagement and communication practices are tailored to identified local needs and challenges. Community support is a fundamental element of preparation for the COVID-19 epidemic.
Furthermore, coordinated work by CSOs and PLHIV networks will be necessary to guarantee care and support, especially for the most vulnerable, including PLHIV on the move (refugees and migrants), and those with TB. Special safety measures and standard operating procedures, as recommended by local health authorities, will need to be implemented in the context of COVID-19 epidemic.

Availability of emergency funds

If your country receives support from the Global Fund (GF), find out if the MCP has started planning for the GF COVID-19 emergency funds in its programming, and if these additional resources will be used effectively.
Find out about the World Bank COVID-19 emergency funds and the country’s plans to secure these funds.
Help to disseminate WHO COVID-19 Solidarity Response Fund. For more information access: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/donate

Resources

As the COVID-19 outbreak evolves and new evidence emerges, recommendations and guidance documents will be regularly updated. It is important to always consult official and reliable sources for the most up to date information and orientation on the COVID-19 response.