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When pandemic meets epidemic

06 Dec 2021

  • How has Covid-19 affected those dealing with HIV?
BY Sumudu Chamara  According to the World Health Organisation (WHO), even though the world has made significant progress in the past few decades as far as combating human immunodeficiency virus (HIV) is concerned, important global targets for 2020 have not been met, and on top of that, Covid-19 is exacerbating inequities and disruptions to services, making the lives of people living with HIV (PLHIV) more challenging.  This year, the world commemorated the annual World AIDS (Acquired Immunodeficiency Syndrome) Day in a context where global health bodies including the WHO have expressed serious concerns about the way Covid-19 is affecting PLHIV and those living with AIDS.  Rising HIV cases among youth  Alarmingly, Sri Lanka has recorded an increase in the number of HIV infections among youth, which according to health service providers, had been observed during the past few years.  Speaking of Sri Lanka’s situation, the National Sexually Transmitted Diseases (STD) and AIDS Control Programme (NSACP) said last week that there is a significant increase in HIV infections among youths between the ages of 15 and 24 years over the past five years and, therefore, stressed the need for the provision of proper sex education. This was revealed by NSACP Director Dr. Rasanjalee Hettiarachchi, while speaking to TV Derana on World AIDS Day, where she spoke about the NSACP’s statistics during the past five years.  According to Dr. Hettiarachchi, at present, only 60% of the PLHIV in the country are referred for treatment, while the remaining 40% remain untreated. She opined that the reason some do not obtain treatment could perhaps be due to the lack of awareness about their HIV status. She expressed concerns that HIV-infected individuals have not been referred for treatments properly, which she said has now become a serious issue.  She further noted that out of the estimated 3,700 PLHIV in the country, the majority was male.  As per the statistics published on the NSACP website, 363 individuals have been diagnosed with HIV in 2020, out of which 36 had been identified as youths between the ages of 15 and 24 years. In the first two quarters of 2021, a total of 148 cases of HIV infections had been reported, and among them were 25 persons between the ages of 15 and 24 years. The number of AIDS-related deaths reported in 2020 and in the first two quarters of 2021, were 52 and 19, respectively.  Services made easier  Speaking to The Morning, know4sure (NSACP’s online platform for the promotion of testing and awareness raising), Media Co-ordinator Adhil Suraj Vimukthi said that HIV testing has been made a lot easier compared to the past, and that any person, irrespective of age, sexual orientation and/or gender identity, or area of residence, can obtain assistance from the NSACP/know4sure to find out their HIV status and get treatments.  He added that awareness-raising activities about HIV, HIV testing, and service providers, among other activities, has been accelerated, through digital media including social media platforms and physical awareness-raising programmes. One of the recent positive developments, according to Vimukthi, is the promotion of self-test strips (a test kit which can be used by individuals without any professional assistance, to perform a preliminary test in order to find out whether they are infected with HIV).  He added: “Self-test strips are being promoted and any person from any part of Sri Lanka can obtain such a test kit. Upon a request and the provision of details, which will remain confidential, a person can have test kits delivered to their house.” In addition, through the know4sure.lk website, it is also possible to conduct an anonymous risk assessment (risk of contracting HIV) and also make an appointment to have a HIV and/or sexually transmitted infections (STI) test done.  As pointed out by Dr. Hettiarachchi, Vimukthi stressed that people not being aware of their HIV status or not identifying the risk factors that make them vulnerable to HIV is an issue with regard to getting people, especially those identified as being from high-risk groups, to get tested and obtain treatments. He also said that the majority of those seeking assistance in this regard is youth.  He said: “Those who test positive for HIV should obtain treatments without any hesitance. One of the obstacles that affect this is myths about how treatments may affect their health or how getting treatments may affect their overall life or social life. They should not succumb to those myths. In addition, there are also concerns pertaining to social stigma. It is not getting treated but refraining from getting treated that affects a person’s life. It is also important to find a properly qualified medical service provider to obtain advice and treatments.”  HIV and Covid-19: A global situation After the Covid-19 pandemic broke out, especially this year, global health bodies have pointed out the importance of strengthening testing facilities and awareness-raising activities regarding the same for those at high risk of contracting HIV, and also the provision of free and easily accessible treatments for PLHIV, as there is a global discourse about the risks PLHIV may be facing owing to the Covid-19 pandemic. In addition to enhancing the existing services, they highly recommend promoting vaccination among PLHIV and those at high risk of getting HIV, in a context where the WHO has presented study results that suggest that PLHIV may actually be more prone to experiencing severe or fatal complications from Covid-19.  A 2021 WHO report – based on clinical surveillance data obtained from 37 countries with regard to the risk of poor Covid-19 outcomes in PLHIV admitted to hospital for Covid-19 – said that around 23.1% of PLHIV who were hospitalised with Covid-19 had died, and that HIV infection is a significant independent risk factor for both severe or fatal Covid-19 presentation upon hospital admission and in-hospital mortality.  The analysis, titled “Clinical features and prognostic factors of Covid-19 in PLHIV hospitalised with suspected or confirmed severe acute respiratory syndrome coronavirus two (SARS-CoV-2), which is the virus that causes the Covid-19 infection”, focused on describing the clinical characteristics and outcomes of PLHIV hospitalised for Covid-19, assessing whether PLHIV hospitalised with Covid-19 were at increased risk of presenting with severe or critical illness at admission and were at increased risk of in-hospital death compared to individuals not infected with HIV, and assessing risk factors associated with severe or critical illness at hospital admission and of in-hospital death among PLHIV hospitalised for Covid-19.  By the end of April, 37 countries had provided clinical information on 268,412 persons who had been hospitalised with suspected or confirmed Covid-19, while 24 had provided clinical data about PLHIV. Among the countries that had provided the data were Argentina, Belarus, Brazil, Cameroon, Chile, China, Congo, the Dominican Republic, France, Germany, Guinea, India, Italy, Jordan, Nigeria, Panama, Romania, the Russian Federation, South Africa, Spain, the UK, the US, Zambia, and Zimbabwe. Of the sample, 9.2% cases hospitalised with suspected or confirmed Covid-19 were HIV positive, while 96.1% of PLHIV were from the WHO African region, with 94.6% cases being reported from South Africa alone.  “Among PLHIV, 37.1% were male, the mean age was 45.5 years, 91.8% were on antiretroviral therapy (ART), and 36.2% had severe or critical illness on hospital admission. Among the severe cases, 89.8% were 65 years of age or younger and 39.1% were male,” according to the analysis report. Per the analysis findings, the risk of developing severe or fatal Covid-19 (complications) was 30% greater in PLHIV, compared to people who are not infected with HIV.  “Underlying conditions such as diabetes and hypertension are common among PLHIV. Among male PLHIV over the age of 65 years, diabetes and hypertension were associated with an increased risk of more severe and fatal Covid-19. These conditions are known to put people at increased risk of severe disease and death,” the WHO said. The most common underlying conditions were hypertension (33.2%), diabetes (22.7%), and obesity (16.9%).  The WHO analysis, which involved assessing the relationship between the potential risk factors and severe or critical illness at hospital admission, had reached a conclusion after adjusting for age, sex, and underlying conditions such as diabetes and hypertension, that PLHIV who were older than 65 years of age and males with diabetes or hypertension had an increased risk of severe or critical illness at hospital admission after controlling for the other risk factors.  Meanwhile, an informal WHO poll had revealed that out of 100 countries that had provided information about PLHIV, 40 countries had prioritised PLHIV for Covid-19 vaccination.  Furthermore, the Joint United Nations Programme on HIV/AIDS (UNAIDS) also said that even though PLHIV are at higher risk of Covid-19 illness, they have lower access to Covid-19 vaccines.  In October of this year, the Joint United Nations Programme on HIV and AIDS (UNAIDS) said that data from the US had shown that PLHIV who have contracted the SARS-CoV-2 virus were much more likely to require hospitalisation and suffer severe illness than people who are not infected with HIV. In addition, it said that studies from England and South Africa have further found that the risk of dying from Covid-19 among people with HIV was double that of the general population.  Adding that advanced HIV disease and/or the presence of chronic comorbidities – which tend to be common in people living with HIV – appear to be strongly associated with poor Covid-19 outcomes in people living with HIV. The UNAIDS further said: “However, access to Covid-19 vaccines around the world remains exceedingly unequal and unjust. At the beginning of October 2021, there were still low levels of access to vaccines in the low-income and lower middle-income countries that are home to more than half (55%) of the people living with HIV globally.”  Measures  Several studies regarding the risk PLHIV are facing due to the spread of Covid-19 claimed that such conditions may affect a person’s ability (immune system) to fight Covid-19 and that it shows the need for increased attention to vaccinating PLHIV and at-risk groups more prone to contracting HIV. Therefore, they recommend identifying the risk the said groups are facing and prioritising them in national health policies and in programmes relating to Covid-19 prevention including vaccination.  With regard to the measures that can be taken to address this situation, the WHO said that the findings highlight the need for PLHIV to stay as healthy as possible, regularly access and take their ART medications, and prevent and manage underlying conditions. This, according to the WHO, also means that PLHIV, independent of their immune status, should be prioritised for vaccination in most settings.  The WHO analysis, however, said that additional evidence from larger data sets with a broader geographical representation is required in order to expand the understanding of the interplay between HIV and SARS-CoV-2 co-infection and also guide global discussion on optimal clinical care for PLHIV who are infected with SARS-CoV-2.   “The report will have important policy implications – providing data to confirm that HIV is a risk for poor outcomes from Covid-19 – and increasing the urgency to see all PLHIV on treatment and with access to Covid-19 vaccinations,” WHO Global HIV, Hepatitis, and STI Programmes Director Dr. Meg Doherty had said.  The International AIDS Society (IAS), meanwhile, noted that regardless of the HIV status, adhering to basic Covid-19 safety measures, and getting vaccinated after discussing the HIV status (when the HIV status is known) with health professionals, are recommended. At the same time, the IAS recommends PLHIV to commence HIV-related treatments without delay if they have not done so despite being aware of their HIV status.  The Covid-19 pandemic made everyone vulnerable, and some groups more vulnerable than they were before. But, it has become evident that with the right measures, it is possible to protect against Covid-19 to a great extent, and that vaccination is still the best precaution.  In this context, Sri Lanka needs to pay more attention to educate PLHIV to get vaccinated after discussing with medical professionals and commencing HIV-related treatments.  Those who wish to get a HIV test done and/or obtain professional medical advice or treatment, can contact the NSACP via 0112667163 and can get more information regarding HIV-related services via www.aidscontrol.gov.lk, and they can also do a self-risk assessment or make an appointment to obtain professional medical advice online via know4sure.lk or 0766447873. They can also visit the NSACP at No. 29, De Saram Place, Colombo 10.

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