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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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              Has COVID-19 subverted global health?

              For the first time in the post-war history of epidemics, there is a reversal of which countries are most heavily affected by a disease pandemic. By early May, 2020, more than 90% of all reported deaths from coronavirus disease 2019 (COVID-19) have been in the world's richest countries; if China, Brazil, and Iran are included in this group, then that number rises to 96%. The rest of the world—historically far more used to being depicted as the reservoir of pestilence and disease that wealthy countries sought to protect themselves from, and the recipient of generous amounts of advice and modest amounts of aid from rich governments and foundations—looks on warily as COVID-19 moves into these regions. Despite this reversal, however, the usual formula of dispensing guidance continues to be played out, with policies deemed necessary for the hardest-hit wealthy countries becoming a one-size-fits-all message for all countries. Two centrepieces of this approach are the use of widespread lockdowns to enforce physical distancing—although, it is notable that a few wealthy countries like Sweden and South Korea have not adopted this strategy—and a focus on sophisticated tertiary hospital care and technological solutions. We question the appropriateness of these particular strategies for less-resourced countries with distinct population structures, vastly different public health needs, immensely fewer health-care resources, less participatory governance, massive within-country inequities, and fragile economies. We argue that these strategies might subvert two core principles of global health: that context matters and that social justice and equity are paramount. Context is central to the control of any epidemic, a truism we've known for centuries but that we seem to have overlooked in this pandemic. Perhaps this is unsurprising given the colonial history of medicine, in which the illnesses that affected Europeans were assumed to have universal significance whereas those that affected the non-European populations who were colonised were relegated to “tropical medicine”. That context matters is obvious in the case of COVID-19. Low-income and lower-middle-income countries, clustered in sub-Saharan Africa and south and southeast Asia, have a different demographic profile from wealthy countries of the OECD and east Asia. Their populations are much younger and most older people live at home, not in care homes, where up to half of all deaths in wealthy countries have occurred. Just these variations in age structure and social arrangements account for lower risk of COVID-19 mortality in these populations. Yet lockdowns have been imposed in these countries. The number of deaths from COVID-19 since the epidemic began is a tiny fraction of all deaths that have occurred due to any cause since the start of 2020. Thus, people continue to die in the millions of other diseases, and lockdowns have made accessing essential health care much more difficult in some places. In India, for example, public transport, the main way for the poor and many health-care workers to reach a health facility, has been barred since late March, although a limited restoration was announced on May 4, 2020. Not surprisingly, there have been dramatic reductions in essential public health and clinical interventions; data from India's National Health Mission indicate that there was a 69% reduction in measles, mumps, and rubella vaccination in children, a 21% reduction in institutional deliveries, a 50% reduction in clinic attendance for acute cardiac events and, surprisingly, a 32% fall in inpatient care for pulmonary conditions in March, 2020, compared with March, 2019. Similar reports are emerging from other countries, including disruptions to insecticide-treated net campaigns, access to antimalarial medicines, and suspension of polio vaccination. Twinned with lockdowns to achieve physical distancing is the promotion of widescale COVID-19 testing that relies on expensive kits and an emphasis on intensive-care units and ventilator capacity. These strategies, which have dominated much of the health-system response in rich countries, are a remote possibility in many low-resource contexts where access to intensive care or anything beyond basic diagnostics is far from universal. If COVID-19 vaccines are developed, history suggests they are likely to be available first in the countries that can afford to purchase them and only then will they trickle down to low-income countries, where they will reach the wealthy first. By contrast, there is barely any mention of the role of syndromic diagnosis (clinical diagnosis based on the constellation of symptoms and signs which are a hallmark of infection); the role of community health workers, primary care nurses, and doctors; and the role of community engagement. Constrained health-care systems already short of money, beds, equipment, and staff, are unlikely to be able to provide treatment for COVID-19 patients unless they reallocate scarce resources. And so, the combined effect of the reduced access to, and availability of, essential health care might lead to increases in deaths unrelated to COVID-19. © 2020 Reuters/Danish Siddiqui 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. A second key principle of global health is social justice and equity: the concerns of the poor who already bear a disproportionate burden of risk factors and disease must be at the centre of all decisions. Yet a one-size-fits-all approach to COVID-19 has not only been inequitable in its impact, but is also likely to increase inequalities in the long term. A stark example is the inequitable economic impact of lockdowns on people who barely survive on precarious livelihoods. About 2 billion people make their living in the informal economy, and over 90% of them live in low-income and low-middle-income countries. Hunger is an immediate threat to these people and their families, both due to the loss of daily wages and the disruption of the food supply chains. The UN has estimated that over 300 million children who rely on school meals for most of their nutritional needs might now be at risk of acute hunger, which could reverse the progress made in the past 2–3 years in reducing infant mortality within a year. Then there is the practical challenge of physical distancing and quarantining in urban slums and rural households where multiple people share a room and where toilets cater for many families. Lockdowns have been enforced with an increase in authoritarian behaviour of the police with the poor experiencing brutality and humiliation in countries such as India, Nigeria, Kenya, and South Africa. In sharp contrast, lockdowns are little more than an inconvenience for affluent people, who typically look to high-income countries as the model to shape their view of how society should respond to the pandemic. What then should these countries do, especially as some of them begin to ease lockdown restrictions? Realistically, a community-based approach is needed that emphasises active case finding (through syndromic diagnosis where laboratory-confirmed diagnosis is not available) by community health workers and primary care providers, with contact tracing and home quarantining, especially early in an epidemic, engaging and enabling community resources with due attention to avoiding stigmatisation, and banning mass gatherings. District-level facilities for appropriate respiratory support that can be managed by locally available human resources, equipped with adequate personal protection, need to be developed as long-term assets for the health-care system. Lockdowns, if humanely planned and with the participation of the community affected, could be used sparingly to contain clusters of cases. Wearing masks at home for the ill person and caregiver, washing hands when possible, practising coughing etiquette, and physically distancing older people and those with comorbidities are a few of the non-intrusive interventions that are possible without disrupting the intrinsic fabric of society. Central to our proposals are the engagement and participation of all sections of the community, especially the poor and marginalised, as a mature and responsible citizenry, invoking their solidarity to be part of a shared endeavour, rather than seeing the goal of containing COVID-19 as a purely technocratic or law-and-order problem. Similar community-based strategies of social mobilisation and engagement were effective in reducing transmission of Ebola virus disease in west Africa. Concurrently, we suggest that countries must let people get on with their lives—to work, earn money, and put food on the table. Let shop keepers open and sell their wares and provide services. Let construction workers return to building sites. Allow farmers to harvest their crops and to transport them to be sold on the open market. Allow health workers to do their daily work as before, with sensible precautions such as use of gloves and masks to minimise the risk of exposure to the virus. And allow the average citizen to travel freely with restrictions only applied to clusters where lockdowns are necessary. Livelihoods are an imperative for saving lives. Some will say such an approach, which runs the risk of spreading disease, implies that the lives of poor people are not as valuable as those in wealthy countries. Nothing could be further from the truth. The policies of widespread lockdowns and a focus on high-technology health care might unintentionally lead to even more sickness and death, disproportionately affecting the poor. And, if such policies are mandated by global consensus, then global financial institutions must write off outstanding debts from low-income countries and finance the needed resources to underwrite the economic recovery of these countries. Key principles of global health are context and equity. We urge less-resourced countries to devise policies that speak to their unique demographics, diverse social conditions and cultures, precarious livelihoods, and constrained infrastructure and resources. A focus is needed on what is possible, acceptable, just, and sustainable. Given that substantial financial support from wealthy countries—in contrast to technical guidance—is unlikely, low-resource countries need to rely on their own home-grown expertise, grassroots experience, and community resources to chart a way through this crisis. In addition to being aligned with the founding principles of global health, such policies would adhere to a principle of the Hippocratic Oath “primum non nocere”—”first do no harm”.
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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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