COVID-19 disruption of ARV treatments could double HIV deaths

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A synthesis of five different studies that model the effect of a three- or six-month interruption of HIV services across sub-Saharan Africa finds that excess deaths due to HIV – in other words those in addition to the usual number of HIV deaths – may be in the order of 550,000, reports Aidsmap. As the current annual HIV-related death toll is around 470,000 (in 25m people living with HIV in the region), there may therefore be around 1m deaths, equating to a 2.2-fold rise in HIV mortality, during the COVID-19 pandemic.

The World Health Organisation (WHO) and UNAIDS, which convened the group of modelling experts issued a press release accompanying the modelling synthesis, which warned that people would continue to die from the disruption for at least another five years, with an average annual excess in deaths of 40% over that period.

Dr Tedros Adhanom Ghebreyesus, WHO director-general, said: “The terrible prospect of half a million more people in Africa dying of Aids-related illnesses is like stepping back into history”.

In addition to the five-model synthesis, in its press release, WHO and UNAIDS refer to a more sophisticated model, developed by Imperial College London, that models the impact COVID-19 itself, HIV, TB and malaria may have in the next year and the next five years. This models what would happen to deaths from all four infections under five different scenarios for the containment of COVID-19.

According to the report, this finds that disruption to the health services due both to planned reduction in services and unplanned increases in demand could give rise to several million excess deaths due to HIV and TB, in particular, over the next five years – but that doing nothing to contain COVID-19 would involve the deaths of even more people.

The five-model synthesis combines findings from five existing mathematical models of the impact of HIV diagnosis, prevention, care and treatment on the HIV epidemic in sub-Saharan Africa. It investigates what happens if a three- or six-month suspension of ART and of other HIV healthcare measures happens due to the COVID-19 epidemic.

The models are the Goals Model developed by Avenir Health for UNAIDS’ Fast Track strategy; the Optima Model developed by the Kirby Institute in Australia; a so-called HIV Synthesis model developed by University College London to measure the impact of various HIV interventions, most recently PrEP in South Africa; a model developed by Imperial College London, based on the South African epidemic, most recently to estimate the impact on the HIV epidemic of injectable contraceptives in women; and a model called EMOD developed by the US Institute for Disease Modelling, based initially on the HIV epidemic in South Africa, but that can be used to model any infectious disease.

The report says the lesson of these models taken together would appear to be then, that preventing as many cases of COVID-19 as possible would save more lives than failing to prevent it; but that if services for HIV, TB and malaria can be preserved, millions of extra deaths due to these diseases over the next five years can also be averted.

COVID-19 has the potential to cause disruptions to health services in different ways; through the health system becoming overwhelmed with COVID-19 patients, through the intervention used to slow transmission of COVID-19 inhibiting access to preventative interventions and services, and through supplies of medicine being interrupted. We aim to quantify the extent to which such disruptions in services for HIV, TB and malaria in high burden low- and middle-income countries could lead to additional loss of life. In high burden settings, HIV, TB and malaria related deaths over 5 years may be increased by up to 10%, 20% and 36%, respectively, compared to if there were no COVID-19 epidemic. We estimate the greatest impact on HIV to be from interruption to ART, which may occur during a period of high or extremely high health system demand; for TB, we estimate the greatest impact is from reductions in timely diagnosis and treatment of new cases, which may result from a long period of COVID-19 suppression interventions; for malaria, we estimate that the greatest impact could come from reduced prevention activities including interruption of planned net campaigns, through all phases of the COVID-19 epidemic. In high burden settings, the impact of each type of disruption could be significant and lead to a loss of life-years over five 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/TB epidemics. Maintaining the most critical prevention activities and healthcare services for HIV, TB and malaria could significantly reduce the overall impact of the COVID-19 epidemic.

WHO Collaborating Centre for Infectious Disease Modelling

Full Aidsmap report

University College London pre-print

WHO material MRC Centre for Global Infectious Disease Analysis abstract

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