Systematic Review

Syndemic effect of COVID-19 outbreak on HIV care delivery around the globe: A systematic review using narrative synthesis

Introduction

The first documented case of COVID-19 infection was detected in China’s Wuhan province on December 2019, and it was proclaimed a worldwide pandemic by the World Health Organization (WHO) on March of 2020.¹ With the rapid spread across the globe, the successive waves of the pandemic have reversed the progress of various healthcare programs leaving serious short as well as long-term impacts on essential healthcare services. Many essential healthcare activities were paused temporarily and healthcare workers from different streams were diverted to COVID-19 care resulting in disruption of the services. HIV comprehensive care services being one of them were no exception. Like the general population, people living with HIV (PLHIV) were also forced to stay indoors with limited access to health facilities, loss to follow-up, and discontinuation of antiretroviral therapy.²

According to the UNAIDS Global AIDS Update 2022, in 2021 HIV-AIDS took a life each minute, leading to 650 000 AIDS-related deaths worldwide. In 2021, a new case of HIV infection occurred among adolescent girls or young women every two minutes. In the given situation, COVID-19 pandemic jeopardized the treatment and prevention services for HIV infection.³ According to WHO, 73 countries reported antiretroviral therapy (ART) disruptions during the pandemic in varying degrees.⁴ Although the lockdown was the need of the hour to break the transmission chain, it limited public mobility and access to various healthcare services. This study intends to address the evidenced threats faced by HIV care services during the pandemic; so that it helps in further research to combat such disruptions in care delivery during any public-health crisis.

Evidence before this study

A substantial number of primary studies have been conducted representing different low and middle-income countries to understand the pandemic’s effect on HIV care services at the regional level. These studies proved that COVID-19 has impacted all aspects of the HIV healthcare system specifically treatment and testing services. To the best of our knowledge, studies that are objectively similar to our latest review curating shreds of evidence from March 2020 could be found. However, majority of the studies have focussed only on the adverse effects of the pandemic on HIV care delivery services, none has reported a robust framework for recommendations.

Added value of this study

Despite of irreversible damage faced in the progress made in the fight against HIV; alternative, resilient approaches were adopted worldwide to combat the loss. In this review alongside assessing the aftermath of the pandemic on HIV care delivery services, we attempted to summarise what was successful in sustaining the services, innovative approaches that have evolved, and suggestions to accelerate the recovery.

Therefore, this systematic review has been planned with a novel approach to achieve a deeper insight into addressing the compensatory measures which were adopted as temporary alternatives to alleviate the burden of interruptions alongside the negative outcomes of the pandemic on HIV care services along with reasonable recommendations for the healthcare advocates to envisage at the policy level.

Implications of all available evidence

The available evidence will help in planning and in the implementation of the novel strategies which came up during the pandemic not only in HIV care delivery but also in routine healthcare programmes wherever applicable.

This review attempted to address the reverberations of the coronavirus pandemic on HIV care service delivery in a multi-dimensional, holistic approach. It will guide to win over the losses as well as to protect the HIV care delivery services in any future public health crisis.

Material and Methods

Protocol and registration

A detailed plan for this systematic review was registered with the Open Science Framework (DOI: 10.17605/OSF.IO/74GHM). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for systematically reviewing the available evidences. Any deviation from the protocol has been described accordingly.

Strategy for searching and procedure for selection

Strategy for searching

Search strategies were developed in collaboration with the research team. Databases namely PubMed, DOAJ, Science Direct were searched methodically to retrieve the eligible studies. The keywords “COVID-19”, “pandemic”, “HIV”, “HIV care continuum”, “impact”, “systematic review” were identified and then the key terms were customised to form the possible combination of search strings seeking to capture the most appropriate studies (Supplementary file 1) respectively for each database. The search strategy was restricted to papers in English language between December, 2019 to December,2022. Additionally, for other sources studies were searched in Google Scholar and using citation analysis of included studies from the three databases. NIH quality assessment tool and JBI Critical Appraisal Checklist (for qualitative studies) was used for assessing the quality of individual studies.

Inclusion and exclusion criteria

The inclusion and exclusion criteria were set based on PICOT (Population, Intervention, Comparison, Outcome and Time) criteria.⁵ We included original research, short communications, report and viewpoint articles in English language, relevant to the repercussions of COVID-19 pandemic on services for HIV care. Studies without an available free full text, published in languages other than English, irrelevant to the scope of our study objective were excluded. Review articles, case studies, programme reports, policy documents, commentary and scientific letters were excluded.

Study selection

Out of the 1556 records identified from the three electronic databases searching, 129 studies were found to be duplicate records. After removing the duplicate records, 1427 studies were title screened, out of which 292 were sought for retrieval. From here, 142 studies had to be excluded after abstract screening. After eligibility assessment, finally 25 studies met the methodological criteria and were found to be appropriate for the final inclusion in this review. Parallelly with regard to other sources, studies were retrieved from Google Scholar using customized search strings and some more studies were fetched using forward and backward citation analysis of the already selected studies (Figure 1). Finally, 31 studies were retained to be included in this review.

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Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram for selection of studies.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram for selection of studies.

The screening procedures were carried out independently by three authors (RC, DA and RT). Any disagreements among the authors were settled through discussion to reach a consensus, if needed. In scenarios where agreement could not be reached, disagreements were resolved by a senior author (MB).

Data collection

Data extraction and analysis

Three authors (RC, DA, RT) independently extracted data from the included studies and any disagreement was resolved after discussing with a senior author (MB). We extracted data on study location, design, objective, target population, interventions or newer strategies adopted (if any) during pandemic period, primary and secondary outcomes using Microsoft Excel spreadsheet.

Quality assessment

The quality of included studies were assessed using NIH quality assessment tools and JBI Critical Appraisal Checklist (for qualitative studies).⁶ Detailed coverage of the quality evaluation has been provided in Figures 2, 3 and 4. Three authors (RC, DA and RT) performed a collaborative quality assessment, and any differences were addressed by involving a senior author (MB). All 31 studies have been considered in this review. However, studies with fewer items checked in the quality assessment checklist (Supplementary file 1) received limited attention. The summary score of each study was calculated and expressed as percentage for both NIH and JBI quality assessment tools. The studies were categorized into four categories: poor (0–25%), fair (25–50%), good (50–75%) or excellent (75–100%).⁷

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Figure 2.

NIH Quality Assessment tool for observational cohort & cross-sectional studies. Yes (Y)- Green; No (N)-Red; Not Reported (NR)- Blue; Not Applicable (NA)- Yellow; Cannot Determine (CD)- White.

Figure 2.

NIH Quality Assessment tool for observational cohort & cross-sectional studies. Yes (Y)- Green; No (N)-Red; Not Reported (NR)- Blue; Not Applicable (NA)- Yellow; Cannot Determine (CD)- White.

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Figure 3.

NIH Quality Assessment tool for Pre-Post studies without Control Group

Figure 3.

NIH Quality Assessment tool for Pre-Post studies without Control Group

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Figure 4.

JBI Critical Appraisal Checklist for Qualitative Studies

Figure 4.

JBI Critical Appraisal Checklist for Qualitative Studies

Results

Characteristics of included studies

The 31 included studies across the globe consists of high, low and middle-income countries namely USA, India, Kenya, Ethiopia, Italy, China, Haiti, South Africa, Netherlands, Vietnam, Guatemala, Belgium, Indonesia, Zimbabwe, Malawi and Uganda etc.

Findings

We found, 39% of the included studies (12/31 studies) collected data from online repositories such as electronic health records of the healthcare facilities, available program data and 48% (15/31) studies used traditional offline mode of data collection from hospital settings and telephonic surveys. Qualitative research included (n = 6) in this review, primarily utilized methods such as in-depth interviews and focus-group discussion for gathering data.

Based on the key highlights (Table 1), we have condensed the consequences of the pandemic on the HIV comprehensive care services under six major themes namely: (1) Lab services (2) Treatment and allied services, (3) Counselling services, (4) Outreach services, (5) Psycho-social impact, (6) Implementation of sustainable strategies.

1. Lab services

One of the most studied topic among the literatures included in this review is the access to the laboratory services under the HIV comprehensive care services during the pandemic. Despite of considerable heterogeneity of settings and services, 14 out of the 31 included studies (45%) reported decreased testing or reduced lab monitoring during the COVID-19 pandemic resulting in delay in diagnosis.^{15,22,25,26,28,29,33,35}

2. Treatment and allied services

The pandemic has significantly impacted the provision of HIV-related treatment and related services. This study has arrived to a pooled opinions on the consequences of the coronavirus pandemic on the HIV-related treatment and other allied services. The most common observation was regarding anti-retroviral therapy. Shortage of medicines,²⁴ delay in ART initiation,^11,33 delay in receiving medications or ART refills,^9,18,29,31resulting in sub-optimal or decreased ART adherence^1,36 were reported. Other focal points derived were decreased screening of opportunistic infections,^1,9,36 disruption in follow up services,^1,31 decreased allied services like Voluntary Male Medical Circumcision ³⁴ and preventive services.²⁵

3. Counselling services

In most of the countries HIV care comes in a comprehensive package. Along with treatment and reduction of viral load, screening of opportunistic infections, laboratory services, it is also equally dependent on the counselling services for risk reduction, safe practices, ensuring patients’ adherence to the care process in an integrated manner. Among the 31 included studies, only 2 studies covered the aspect of counselling services for HIV care. Both the studies reported that counselling services were ensured for the high-risk group amid the worldwide lockdown caused by the pandemic.^18,28

4. Outreach activities

The principal purpose of outreach activities in HIV comprehensive care services is case finding so that they become aware of their sero-status, and may get enrolled in care and treatment services.³⁸ The provision of outreach services was negatively impacted by the diversion and strikes of health care personnel,^11,20,22 cuts in funding for HIV care services,¹³ and decreased access to HIV care resources.¹⁰ Home delivery of ART medications and nutritional supplements was one of the strategies used to enhance outreach efforts.²⁹

5. Psycho-social impact

Social stigma and discrimination are known to be already prevalent among the high-risk groups for contracting HIV. The COVID-19 added to it and made it worse. 12 out of the included 31 studies has highlighted the various psycho-social factors faced by the high-risk groups during the COVID-19 pandemic worldwide. Financial burden^{10,12,19,21,30}and fear of COVID-19^12,18,19,24 has been the most common psycho-social impact in our findings, followed by increased stigma,^12,30,31 mental distress or psychological stress,^17,21,28 barriers due to lockdown like food insecurity^19,36 and transport disruption^10,30 leading to missed ART appointment.

6. Implementation of sustainable strategies

During the COVID-19 pandemic, though the global scenario was depicting interruptions in accessibility of HIV facility based-care, but it has also accelerated the growth of alternative options with increased flexibility. The decrease in traditional facility-based clinic appointments were compensated by virtual telemedicine platforms.^{9,12,15,18,22,23,25,26,28,37} Sustainable strategies like home delivery of ART medications,^15,30multi-month dispensing of ART for stable PLHIVs,^13,22 provision of HIV self-testing to know one’s sero-status^14,20,33has been reported. A study conducted by Parikh et al in Indian setting, reported nutritional supplementation and door-to-door ration delivery along with ART.²⁹

Discussion

Multiple waves of COVID-19 outbreak prompted a huge public health response on a global scale, making it an unparalleled public health emergency. The pandemic forced HIV clinics to alter their approach from efforts to link and keep patients in care reducing in-person clinical appointments for PLHIVs, which severely weakened the HIV healthcare delivery system.³⁹ This review has tried to examine the pandemic’s effect on the various facets of HIV care and listed suitable recommendations (Table 2) that were adopted to alleviate the burden of interruptions caused by the novel coronavirus pandemic.

To examine the noteworthy influence of the COVID-19 pandemic on HIV care services, this analysis of 31 studies from various nations discovered consistent proof of substantial declines in the usage of comprehensive HIV care services during the subsequent pandemic waves.

Although a meta-analysis was not possible due to a lack of quantitative summary from the available literature, this review has tried to summarize the repercussions of the coronavirus pandemic on HIV comprehensive care services under six major themes and has been discussed using a framework (Figure 5). Results revealed that the majority of the studies reported decreased testing or reduced lab monitoring,^{15,22,25,26,28,29,33,35} ultimately leading to a delay in diagnosis and hence interrupting the treatment cascade.^{9,11,18,29,31,33}

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Figure 5.

Framework showing impact of COVID-19 on the HIV Care cascade

Figure 5.

Framework showing impact of COVID-19 on the HIV Care cascade

It has been found that few countries have adopted multi-month dispensing of drugs ^8,13,22,32while most of the countries could not, due to a shortage of drugs. Such a buffer to health systems against external shocks is advisable. An interrupted supply of drugs under any unforeseen situations will hinder the progress of removing HIV/AIDS as a public health threat by 2030. Moving forward, countries should maintain a steady supply of ART drugs, especially keeping in mind of such public health crisis.

HIV comprehensive care components are highly interdependent. One such component is the counselling services. From the findings, it can be inferred that ensuring the counselling service was compromised during the COVID-19 pandemic.

This review has not only highlighted the detrimental points that the world has seen regarding HIV care services during the pandemic but also highlighted the potential alternatives or compensatory measures that have been adopted to bypass the threat. Despite the diversion and strikes of health care personnel,^11,20,22 cuts in funding for HIV care services¹³ and decreased access to care resources,¹⁰ our findings revealed some best possible alternatives like door-to-door distribution of ART medications and nutritional supplements that were adopted to combat the issue.²⁹

As HIV mostly deals with a marginalized section, there is already a stigma and discrimination prevalent amongst the population. COVID-19 being another infectious infection, added fear,^12,18,19,24 psychological stress,^17,21,28 barriers due to lockdown like transport disruption,^10,30 food,^19,36and financial insecurity^10,19,21,30 to it and magnified the condition.

In high-resource settings, interruptions in the accessibility of HIV comprehensive care services were compensated by the accelerated provision of alternative options with increased flexibility. For example, teleconsultation or virtual platforms,^{9,12,18,22,23,25,26,28,37} was adopted for the smooth functioning of routine HIV care services. In some countries, home delivery³⁰ of ART medications, multi-month dispensing of ART,^6,8,13,32 provision of self-testing^14,20,33 and nutritional support²⁹ were adopted.

For improving service provision “Differentiated service delivery” (DSD) model, a people-centric approach to HIV service delivery have been successfully implemented in countries like Malawi, South Africa, and Zambia.⁴² This kind of model can change the “when, where, who, and what” of HIV service delivery to a diverse group of PLHIVs while maintaining the principles of public health approach.

Strengths & Limitations

This study has incorporated the most recent data from primary studies since the inception of the COVID-19 pandemic till December 2022, which covers the peak of the pandemic in most countries. Secondly, it has consolidated the consequences of the pandemic and related changes on the utilization of HIV care services. Thirdly, the risk of bias in the selection of studies has been minimized using standard quality assessment tools. Citations from retrieved publications were checked and necessary studies have been included. A clear explanation of the PRISMA flow diagram, formulation of search strategy, data curation, and analysis methods to eliminate any potential confusion has been provided. The results have been interpreted with a special focus on the pandemic scenario, hence broad generalization of inference may be restricted to situations related to any public health crisis only. Also, some potential primary studies with significant results might have been missed out due to limited access to multiple databases. Excluding literature in non-English language is a limitation of this study. Meta-analysis could not be done due to the lack of a quantitative summary of available literature. The effectiveness of all the compensatory measures that has been addressed from various literatures may not be uniform and has the potential to vary across different settings, here leaves scope for future research.

Recommendations

Same-day start of ART or rapid ART initiation, provision of ART initiation outside-the-clinic, reducing the frequency of clinical visits for stable patients via virtual platforms, and provision for ART refills from external pick-up points or community drug distribution points⁴⁰ will help in fast-tracking HIV care services. This study recommends measuring adherence using novel strategies like ‘pill count’⁴⁰; tracing and re-engagement of drop-out cases in care; psychosocial support for people living with HIV; task sharing for diagnostic services and integration of HIV service deliveries. These recommendations may help the programme managers and policy-makers in developing countries to design models and strategies that will help in the smooth functioning of the HIV care continuum and the standard of care for PLHIVs to mitigate any further public health crisis.

Conclusion

This study has tried to consolidate the evidence available from a global perspective. Though the COVID-19 containment measures like quarantine and lockdown measures have put the HIV care continuum in many parts of the world into a challenging situation, the transition with new innovative, sustainable care paradigms, and resilient interventions calibrated to combat such vulnerabilities are vital to ensure continuity of care and may prove to be the building blocks in removing HIV-AIDS as a public health threat. Strong organizational preparedness, inter-sectoral coordination, enhanced and improved service delivery techniques, need based timely and effective support to the community are required to combat this public health crisis.

Acknowledgements

The authors express their heartfelt gratitude to the staffs at the ICMR-National Institute of Cholera and Enteric Diseases in Kolkata, India, for their assistance and backing.

Competing Interests

The authors state that there are no possible conflicts of interest regarding the research, authorship and/or publication of this article.

Data Availability Statement

All data produced or examined for this article are incorporated within it. Further explanations can be provided by the corresponding author upon request.

Ethical Approval

Already published data in various literatures have been used, so ethics approval and consent were not required for this study.

Supplementary Files

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