Innovations, adaptations, and accelerations in the delivery of HIV services during COVID-19 – The Lancet

Summary

Introduction

UNAIDS convened a virtual consultation on Feb 1–2, 2022, to assess the effect of COVID-19 on HIV services; review innovations, adaptations, and accelerations in practice; suggest which novel approaches to sustain; and propose further implementation research. The meeting was co-sponsored by WHO, the International AIDS Society (IAS), The Global Fund, Columbia University’s ICAP programme, and the President’s Emergency Plan for AIDS Relief. Representatives from networks of people living with or disproportionately affected by HIV shared their experiences, and group discussions focused on adaptations and knowledge gaps. Approximately 60 people attended the meeting from Europe, the Americas, Asia, and Africa.

Challenges to service delivery

How HIV services adapted

Regarding services providing antiretrovirals for adults, adolescents, and children, essential adaptations were multimonth dispensing, community-based treatment initiation and maintenance, and PrEP initiation after HIV self-testing. Community organisations led by peers were essential in providing psychosocial support and collecting data, and most importantly ensuring that the most disproportionately affected groups, such as key populations, could receive uninterrupted access to services. Use of information technology was essential for outreach and generating demand for HIV services. Community services were able to integrate services for comorbidities. Knowledge gaps included how to deal with advanced HIV disease, how to address needs of key populations, optimum monitoring of people who use PrEP, generating tailored approaches to HIV prevention supplies, clarification of ideal intervals between ART refills, and how to integrate with and assure COVID-19 services.

Essentials for vertical transmission prevention focused on decentralisation and task sharing and shifting (ie, redistributing tasks from highly trained clinical health-care providers to providers with less training). Multimonth dispensing of drugs was tied to antenatal care and child vaccination schedules. PrEP for members of key populations and the use of navigators to guide clients through the health-care system were emphasised during the meeting discussions. Point-of-care diagnostics, such as those used for early infant diagnosis, were needed for increased community-based services. Use of virtual platforms and communications was essential. Some requirements highlighted by the pandemic were longstanding, such as need for addressing HIV breastfeeding transmission, low HIV testing rates among infants and children, point-of-care early infant diagnosis, defining the role of long-acting ART preparations, and elimination of user fees in west and central Africa that impede access to services.

Direct service delivery that was community-led addressed not only ART, but also food, hygiene packs, and other essentials. Community-led newsletters conveyed important information, including about COVID-19 prevention. Virtual platforms provided social support and helped address mental health requirements. For people who use drugs, rapid decarceration was shown to be feasible as a COVID-19 risk-reduction strategy relevant to this population that is over-represented in detention facilities. Adaptations also included simplified prescribing, take-home opioid agonist therapy, increased access to naloxone, and the provision of food and PPE.

Conclusions

Implementation science should address acceptability, sustainability, and cost of such adaptations in the long term. Several adaptations could be implemented in high-income settings. Overall, these adaptations emphasise client autonomy, self-care, and decentralisation of health-care provision to the community level. Increased use of electronic communications, virtual platforms, and mass and social media for health education, staff supervision, and client monitoring can lessen direct interaction with health facilities. Further differentiated service delivery approaches are emerging, such as same day PrEP after self-testing for HIV, and in community settings. Efficiencies could be gained by further integration of health service delivery. Continued investment in the strengthening of health systems will be important to sustain the scale up of multimonth dispensing in resource-limited settings.

This collective experience has reiterated the centrality of communities in the HIV response, the importance of maintaining standards of human rights, service access, and addressing HIV-related stigma and discrimination, the need to address unmet requirements of key populations, children, adolescents, and men, and the crucial role of community-led organisations. The effect of the COVID-19 pandemic on HIV service delivery has provided important lessons for further upscaling of HIV services, as well as preparedness for future health shocks.

Acknowledgments

We thank all participants and presenters who contributed to the UNAIDS virtual consultation on HIV service innovations in COVID times on Feb 1–2, 2022, the Ministry of Health of Germany for their support, and Cleiton de Lima and Elani Nassif for their invaluable contributions to the planning and moderation of key meeting sessions.