AIDS fight suffers a blow

Coronavirus has dire impact on earlier epidemic

The coronavirus pandemic has hobbled progress in fighting HIV worldwide, including San Francisco’s efforts to quash new infections, with public health resources diverted toward COVID19 and millions of people struggling to access care, according to reports presented this week at the International AIDS Conference.

San Francisco’s “Getting to Zero” initiative, aimed at ending all new infections and deaths from HIV/AIDS, is dependent upon an aggressive public health response that has been dramatically derailed by COVID19, health care providers and patient advocates said.

Testing for HIV has dropped as much as 90% in some clinics over the past four

months, according to San Francisco officials. Simply determining how the new pandemic has affected trends in HIV infections will be complicated this year. The city has reported decreasing new HIV cases every year since 2012, achieving a new low of 197 infections in 2018, the most recent year for which data is available.

Worldwide, the urgent response to COVID19 — including border closures, manufacturing interruptions and public health resource diversions — has left many countries scrambling to maintain supplies of antiretroviral drugs for treatment and prevention of HIV. Shelterinplace orders have cut off people living with HIV from regular health care. Some countries have reported condom shortages.

“Much like the early years of HIV, the COVID19 pandemic has impacted our lives in so many ways,” said Dr. Tedros Adhanom Ghebreyesus, director general of the World Health Organization, in a news briefing Monday at the International AIDS Conference.

“While tackling COVID19 is a global priority, we must not turn our backs on the 38 million people living with HIV and the millions more at risk of infection,” he said. “Now is the time to redouble our efforts — build national unity and global solidarity to tackle both the COVID19 pandemic and diseases like HIV.”

The International AIDS Conference, the world’s largest and most important meeting on HIV/AIDS, had been set to return to San Francisco this week for the first time in 30 years, with 20,000 scientists, health care providers, public health officials and people living with HIV expected to descend on the Bay Area. Instead, it was forced online due to the coronavirus.

But public health and infectious disease experts worldwide fear the new pandemic has overshadowed the AIDS response in much more harmful ways than curtailing a single conference, and the details of those impacts may not be fully understood for months or even years. A report released in May by UNAIDS, the United Nations agency leading the global AIDS response, projected up to 500,000 additional HIV deaths in subSaharan Africa alone due to disruptions in care from COVID19.

For several years, AIDS response efforts worldwide have focused on ending the epidemic, using a combination of testing, treatment and prevention that is highly effective but requires intense public health investment and vigilance. The idea is to get atrisk individuals onto drugs that prevent infection, and quickly identify and treat new cases to stop further spread of disease.

The coronavirus pandemic already has hindered those efforts, globally and locally, public health leaders say. Plus, the resulting economic downturn has caused job losses that impact people’s access to health care, and likely is leading to increases in mental health and substance use problems that are known to increase the risk of HIV.

“There’s no doubt that the pillars of HIV are being affected by COVID19 worldwide,” said Dr. Monica Gandhi, medical director of San Francisco General Hospital’s HIV clinic and a UCSF professor of medicine, who is cochair of the International AIDS Conference. “And there’s no doubt it’s happening in our city.”

In San Francisco, widely considered a global leader in fighting AIDS, testing has decreased for HIV plus other sexually transmitted diseases that leave people vulnerable to HIV infection.

Viral suppression, an important HIV marker, has dropped precipitously in some communities. People with HIV are virally suppressed when they are taking appropriate medications and the virus is undetectable in their blood. In addition to protecting the individual who’s infected, it also means that person cannot spread the virus to others.

At San Francisco General’s HIV clinic, which treats many highrisk individuals, including people who are homeless or have serious mental health or substance use problems, 33% fewer patients are virally suppressed now compared to preCOVID19 days.

“I’m so not surprised, because part of being in HIV care is this touch, these social services. Just the connection to the clinic. And in an instant we told them to stay away from care,” Gandhi said.

A study in Boston, results of which were released during the AIDS conference Monday, found a decrease in people starting medication to prevent infection, known as preexposure prophylaxis, or PrEP, and an increase in people already on the drug who let their prescription lapse. Gandhi said San Francisco hasn’t yet done a similar study but she expects similar effects here.

The San Francisco AIDS Foundation has seen an increase in people requesting help accessing health care because they lost insurance due to the recent economic downturn, said Janessa Broussard, director of clinical services with the foundation. Meanwhile, visits to their Castro District clinic have fallen by more than 75%.

It’s possible that shelterinplace orders will reduce the spread of disease simply because people aren’t socializing, Broussard said. But she worries that potential drop will be offset by people becoming infected, not getting tested and quickly into care, and unwittingly infecting others.

She’s especially concerned about people of color who already are disproportionately affected by HIV and have also been hit hard by COVID19. The AIDS foundation and other groups have made progress toward reaching those communities to increase access to testing, prevention and care, but disruptions caused by the pandemic have certainly left them more at risk, she said.

“We haven’t made enough progress into supporting these communities,” Broussard said, “so I don’t think there’s any indication that things would improve over this time.”

If there’s a potential sign of hope, it’s that so far people with HIV do not seem especially vulnerable to the new coronavirus, said Dr. Brad Hare, chief of infectious diseases and HIV at Kaiser Permanente in San Francisco. They have not shown high rates of hospitalization and death from COVID19, he said.

Dr. Diane Havlir, chief of the HIV/AIDS division at UCSF and cofounder of the Getting to Zero campaign, said the San Francisco public health response that’s been activated to fight COVID19 was built in the battle against AIDS in the 1980s and 1990s.

“It’s alarming, and it’s disconcerting to think of how the progress that we’ve made in HIV could be undermined because of the virus,” Havlir said. “But we have the opportunity in the city to leverage some of the things that we learned in HIV. It makes sense to harness all the knowledge we have to respond to an epidemic when a new one comes along.”