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      The impact of the COVID-19 lockdown on HIV care in 65 South African primary care clinics: an interrupted time series analysis

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          Summary

          Background

          The effect of the COVID-19 pandemic on HIV outcomes in low-income and middle-income countries is poorly described. We aimed to measure the impact of the 2020 national COVID-19 lockdown on HIV testing and treatment in KwaZulu-Natal, South Africa, where 1·7 million people are living with HIV.

          Methods

          In this interrupted time series analysis, we analysed anonymised programmatic data from 65 primary care clinics in KwaZulu-Natal province, South Africa. We included data from people testing for HIV, initiating antiretroviral therapy (ART), and collecting ART at participating clinics during the study period, with no age restrictions. We used descriptive statistics to summarise demographic and clinical data, and present crude summaries of the main outcomes of numbers of HIV tests per month, ART initiations per week, and ART collection visits per week, before and after the national lockdown that began on March 27, 2020. We used Poisson segmented regression models to estimate the immediate impact of the lockdown on these outcomes, as well as post-lockdown trends.

          Findings

          Between Jan 1, 2018, and July 31, 2020, we recorded 1 315 439 HIV tests. Between Jan 1, 2018, and June 15, 2020, we recorded 71 142 ART initiations and 2 319 992 ART collection visits. We recorded a median of 41 926 HIV tests per month before lockdown (January, 2018, to March, 2020; IQR 37 838–51 069) and a median of 38 911 HIV tests per month after lockdown (April, 2020, to July, 2020; IQR 32 699–42 756). In the Poisson regression model, taking into account long-term trends, lockdown was associated with an estimated 47·6% decrease in HIV testing in April, 2020 (incidence rate ratio [IRR] 0·524, 95% CI 0·446–0·615). ART initiations decreased from a median of 571 per week before lockdown (IQR 498–678), to 375 per week after lockdown (331–399), with an estimated 46·2% decrease in the Poisson regression model in the first week of lockdown (March 30, 2020, to April 5, 2020; IRR 0·538, 0·459–0·630). There was no marked change in the number of ART collection visits (median 18 519 visits per week before lockdown [IQR 17 074–19 922] vs 17 863 visits per week after lockdown [17 509–18 995]; estimated effect in the first week of lockdown IRR 0·932, 95% CI 0·794–1·093). As restrictions eased, HIV testing and ART initiations gradually improved towards pre-lockdown levels (slope change 1·183/month, 95% CI 1·113–1·256 for HIV testing; 1·156/month, 1·085–1·230 for ART initiations).

          Interpretation

          ART provision was generally maintained during the 2020 COVID-19 lockdown, but HIV testing and ART initiations were heavily impacted. Strategies to increase testing and treatment initiation should be implemented.

          Funding

          Wellcome Trust, Africa Oxford Initiative.

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          Most cited references 27

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          Interrupted time series regression for the evaluation of public health interventions: a tutorial

          Abstract Interrupted time series (ITS) analysis is a valuable study design for evaluating the effectiveness of population-level health interventions that have been implemented at a clearly defined point in time. It is increasingly being used to evaluate the effectiveness of interventions ranging from clinical therapy to national public health legislation. Whereas the design shares many properties of regression-based approaches in other epidemiological studies, there are a range of unique features of time series data that require additional methodological considerations. In this tutorial we use a worked example to demonstrate a robust approach to ITS analysis using segmented regression. We begin by describing the design and considering when ITS is an appropriate design choice. We then discuss the essential, yet often omitted, step of proposing the impact model a priori. Subsequently, we demonstrate the approach to statistical analysis including the main segmented regression model. Finally we describe the main methodological issues associated with ITS analysis: over-dispersion of time series data, autocorrelation, adjusting for seasonal trends and controlling for time-varying confounders, and we also outline some of the more complex design adaptations that can be used to strengthen the basic ITS design.
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            Potential impact of the COVID-19 pandemic on HIV, tuberculosis, and malaria in low-income and middle-income countries: a modelling study

            Summary Background COVID-19 has the potential to cause substantial disruptions to health services, due to cases overburdening the health system or response measures limiting usual programmatic activities. We aimed to quantify the extent to which disruptions to services for HIV, tuberculosis, and malaria in low-income and middle-income countries with high burdens of these diseases could lead to additional loss of life over the next 5 years. Methods Assuming a basic reproduction number of 3·0, we constructed four scenarios for possible responses to the COVID-19 pandemic: no action, mitigation for 6 months, suppression for 2 months, or suppression for 1 year. We used established transmission models of HIV, tuberculosis, and malaria to estimate the additional impact on health that could be caused in selected settings, either due to COVID-19 interventions limiting activities, or due to the high demand on the health system due to the COVID-19 pandemic. Findings In high-burden settings, deaths due to HIV, tuberculosis, and malaria over 5 years could increase by up to 10%, 20%, and 36%, respectively, compared with if there was no COVID-19 pandemic. The greatest impact on HIV was estimated to be from interruption to antiretroviral therapy, which could occur during a period of high health system demand. For tuberculosis, the greatest impact would be from reductions in timely diagnosis and treatment of new cases, which could result from any prolonged period of COVID-19 suppression interventions. The greatest impact on malaria burden could be as a result of interruption of planned net campaigns. These disruptions could lead to a loss of life-years over 5 years that is of the same order of magnitude as the direct impact from COVID-19 in places with a high burden of malaria and large HIV and tuberculosis epidemics. Interpretation Maintaining the most critical prevention activities and health-care services for HIV, tuberculosis, and malaria could substantially reduce the overall impact of the COVID-19 pandemic. Funding Bill & Melinda Gates Foundation, Wellcome Trust, UK Department for International Development, and Medical Research Council.
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              Maintaining HIV care during the COVID-19 pandemic

              Coronavirus disease 2019 (COVID-19) has spread rapidly around the world since the first reports from Wuhan in China in December, 2019, and the outbreak was characterised as a pandemic by WHO on March 12, 2020. 1 Approximately 37·9 million people living with HIV 2 are at risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19. Although some international institutions, in collaboration with governments and community partners, are working to sustain HIV service provision for people living with HIV, the COVID-19 pandemic presents several barriers and challenges to the HIV care continuum. 3 First, implementation of quarantine, social distancing, and community containment measures have reduced access to routine HIV testing, which challenges completion of UNAIDS' first 90-90-90 target globally, that 90% of all people living with HIV will know their HIV status. HIV testing is the vital first step towards initiation into the HIV care continuum. 3 Even with availability of HIV self-testing kits in some areas, 4 testing remains a big challenge in settings with scarce access to these kits. Therefore, increased efforts are needed to augment access and to facilitate testing. Second, timely linkage to HIV care could be hindered during the COVID-19 pandemic. People living with HIV who should have initiated antiretroviral therapy (ART) in hospital might be deterred or delayed because hospitals are busy treating patients with COVID-19. Furthermore, because many public health authorities globally are focused on COVID-19 control, allocation of resources for HIV care could be diminished, and circumstances surrounding the HIV care continuum could worsen. Third, the COVID-19 pandemic might also hinder ART continuation. Hospital visits could be restricted because of implementation of city lockdowns or traffic controls. UNAIDS and the BaiHuaLin alliance of people living with HIV, with support of the Chinese National Center for AIDS/STD Control and Prevention, did a survey among people living with HIV in China in February, 2020.5, 6 Among this population, 32·6% were at risk of ART discontinuation and about 48·6% did not know where to get antiviral drugs in the near future.5, 6 People living with HIV who are faced with ART discontinuation not only could undergo physical health deterioration but also might suffer great psychological pressure. In response to these challenges, WHO, UNAIDS, and the Global Network of People Living With HIV are working together to ensure continued provision of HIV prevention, testing, and treatment services.6, 7, 8 The Chinese National Center for AIDS/STD Control and Prevention issued a notice guaranteeing free antiviral drugs for selected treatment management agencies in China, and released a list of ART clinics. 6 People living with HIV can refill antiviral drugs either at the nearest local Center for Disease Control and Prevention or by post, to maintain enrolment in treatment programmes and to continue ART. 6 Hospitals in Thailand are to dispense antiviral drugs in 3–6-month doses to meet the needs of people living with HIV and reduce facility visits. 9 The US Department of Health and Human Services released interim guidance for COVID-19 and people living with HIV on March 20, 2020, 10 which emphasised that people living with HIV should maintain at least a 30-day supply and ideally a 90-day supply of ART and all other drugs, by mail-order delivery if possible. Community-based organisations have also played an important part in maintaining HIV services. UNAIDS is working with the BaiHuaLin alliance of people living with HIV and other community partners to reach and help those who will run out of antiviral drugs in the near future. 6 Since the lock down of Wuhan on Jan 23, 2020, a community-based organisation (Wuhan TongZhi Center) has dedicated resources to ensure the supply of antiviral drugs and opened a hotline to provide consultations. As of March 31, 2020, this organisation has had more than 5500 consultations with people living with HIV and has helped more than 2664 individuals obtain antiviral drugs. The Thai Red Cross AIDS Research Centre set up a visible platform outside their anonymous clinic with a screening system for every client, providing HIV testing and prevention supplies (eg, condoms, postexposure prophylaxis, and pre-exposure prophylaxis). 9 As COVID-19 continues to spread around the world, many locations are facing the risk of SARS-CoV-2 infection and barriers and challenges for maintaining the HIV care continuum. The situation could be worse in places with weak health-care systems. We recommend that governments, community-based organisations, and international partners should work together to maintain the HIV care continuum during the COVID-19 pandemic, with particular efforts made to ensure timely access to, and to avoid disruption of, routine HIV services.
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                Author and article information

                Contributors
                Journal
                Lancet HIV
                Lancet HIV
                The Lancet. HIV
                Elsevier B.V
                2405-4704
                2352-3018
                04 February 2021
                March 2021
                04 February 2021
                : 8
                : 3
                : e158-e165
                Affiliations
                [a ]Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
                [b ]Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
                [c ]Department of Family Medicine, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
                [d ]Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
                [e ]eThekwini Municipality Health Unit, eThekwini Municipality, Durban KwaZulu-Natal, South Africa
                [f ]Bethesda Hospital, uMkhanyakude District, KwaZulu-Natal, South Africa
                [g ]London School of Hygiene & Tropical Medicine, London, UK
                Author notes
                [* ]Correspondence to: Dr Jienchi Dorward, Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK jienchi.dorward@ 123456phc.ox.ac.uk
                Article
                S2352-3018(20)30359-3
                10.1016/S2352-3018(20)30359-3
                8011055
                33549166
                © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

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