Health

As we refocus our efforts on tackling HIV, what can we learn from resilience in the face of COVID-19?

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We highlight in this blog post how COVID-19 has impacted HIV programming, research and practice.
COVID-19 brought severe disruptions to the status quo over the last two years. All countries and spheres of life have been affected. The SARS-CoV-2 virus spread swiftly with 559,469,605 confirmed COVID-19 cases and 6,361,157 deaths, reported as of July 18, 2022, according to the World Health Organization (WHO). Countries and health systems were ill prepared, and the response was fraught with a lot of fear, confusion, uncertainty and sometimes, knee jerk reactions. In many countries, the best equipped health facilities were completely closed to persons with non-COVID 19 related illnesses, leading to loss of lives from other illnesses.

As we head into the 24th International AIDS Conference, we highlight in this blog post how COVID-19 has impacted HIV programming, research and practice with a focus on selected elements directly relevant to programs.

The disruptions caused by COVID-19 significantly impacted HIV research and evidence generation. As we elaborate below, research funding was more likely to be secured if it was related to COVID-19. Additionally, in some resource-rich countries, COVID-19 engendered a race for vaccine development and rapid research into development of therapeutics. Hence, journals and publishing houses rightly prioritized manuscripts addressing COVID-19. All of these led to rapid advancements in COVID-19 science and practice, but other items on the research and evaluation agenda such as HIV had to give.

Research practice

COVID-19 ushered in new research interests in three areas: basic, clinical and implementation science.
In the immediate period after the onset of COVID-19, community activities and research labs had to be closed as movement restrictions were enforced. In some instances, specimen had to be discarded or were frozen for future resumption of studies and research teams were downsized to skeleton teams, the barest minimum that can keep a study running. Meanwhile, behavioral research mostly had to be halted due to human movement restrictions. Many studies had to device remote data collection approaches. Some would say, as time stood still in 2020, study timelines were totally disrupted. Yet, as we saw with many spheres of life where COVID-19 disruptions happened, researchers dug-in deep and developed, adapted or took to scale methods which helped research continue despite the challenges.

Despite the challenges above, COVID-19 ushered in new research interests in three areas: basic, clinical and implementation science.

In basic science, the similarities and differences of COVID-19 and HIV prompted many questions. Researchers wanted to know if persons living with HIV were at a higher risk of severe COVID-19 or if there could be some protective factors including from the antiretroviral medications being used. In clinical science, the course of illness in persons living with HIV was a subject of keen interest. Starting out with limited data and limited populations to draw inferences from, clinical scientists published case studies which later became cohort studies as the population of persons living with HIV who became infected with COVID-19 grew. We were at an HIV-focused conference earlier this year when a researcher was proudly introduced as a coronavirologist – not a new sub-discipline but certainly one which has found new identity. COVID-19 also impacted implementation science. Where HIV is concerned, programs sought to introduce ways to ensure uninterrupted services to persons living with HIV despite COVID-19 disruptions. Implementation scientists then focused on examining which approaches were more efficient in achieving higher impact in HIV control despite COVID-19 challenges.

It is thus fitting that sessions at the AIDS 2022 conference will be devoted to presenting some implementation science around COIVD-19 and HIV. The session – Resilience: The new normal? (Friday 29 July) – is one such session. Other sessions such as Pandemics: Living with HIV during COVID-19 (Sunday 31 July) present findings from behavioral science studies of how COVID-19 impacted people living with HIV. AIDS 2022 will not feature a lot of basic science at the intersection of HIV and COVID-19 but there is no doubt the COVID-19 has had its impact on HIV science.

Evidence sharing

It is reported that as high as 40 percent of COVID-19 publications were first published as preprints.
Another key area where the impact of COVID-19 was strongly felt was in peer-reviewed evidence sharing. The volume of COVID-19 evidence waiting at different stages of the publication pipeline from writing through reviews to publishing was enormous. Although preprints had been available since 1991, they became increasingly commonplace following the emergence of COVID-19. Indeed, many authors became acquainted with preprint publications as a result of mounting pressure on publishing houses occasioned by the immense flow of manuscripts covering COVID-19.

As the pressure to quickly publish grew, preprint publications became a thing. It is reported that as high as 40 percent of COVID-19 publications were first published as preprints. Peer review processes were affected as journal reviewers got overwhelmed during the lockdown, further weakening the rigor with which manuscripts were evaluated and the quality of the resulting evidence. Whether as preprints or peer-reviewed journal articles, retractions of shared evidence also rose with COVID-19.

Vaccine research

If nothing else is positive about COVID-19, the success of these HIV vaccine efforts would be the silver lining.
Despite the disruptions that came with COVID-19, the speed with which vaccines were developed, approved, and deployed was unprecedented. The speed itself was a double-edged sword. While it made vaccines rapidly available, it also led to doubts about safety and fueled vaccine hesitancy. But on a more positive side, the momentum in vaccine development has also rekindled efforts to fast-track HIV vaccine development with a number of promising candidates that were developed using the same mRNA technology currently under development and at trial stage.

If nothing else is positive about COVID-19, the success of these HIV vaccine efforts would be the silver lining. COVID-19 vaccination efforts have also helped ministries and donors rethink adult vaccination and the infrastructure used to rollout COVID-19 vaccination in resource-limited settings could be used to rollout vaccines and treatments for emerging or re-emerging infections such as monkeypox.

HIV, COVID and development financing

The long-term impact of COVID-19 on development assistance for health is still uncertain.
COVID-19 quickly became the priority agenda for countries, local governments, private sector, donors, media houses and all. Other items paled in significance. Such was the setting for HIV funding. Very rapidly, funding shifted away from HIV and experts quickly started sounding notes of caution. A joint Kaiser Family Foundation and UNAIDS report also highlighted decreasing bilateral funding for HIV and the pressure that COVID-19 places on this funding. The majority of HIV funding, however, comes from the US government and is thankfully ring-fenced through Congress, which provided a major stabilising force. A significant portion of HIV funding also comes from multiple donors to The Global Fund and the world could not afford a cut back on this funding.

The pandemic hit at the time of seventh replenishment for The Global Fund. Failure to meet the funding targets risked non-achievement of the UNAIDS 95-95-95 goals and ending TB, Malaria and HIV by 2030. Nonetheless, the long-term impact of COVID-19 on development assistance for health is still uncertain but there seems to be general agreement that the impact of COVID-19 will affect funding in ways beyond what we can immediately see.  A review of development assistance, government, out-of-pocket, and other private spending on health for 204 countries and territories, 1990–2050, paints an optimistic picture overall but poor countries and the most vulnerable could fare worse from the widening disparity in access to vaccines and therapeutics and now being worsened by global increase in prices.

Conclusion

The COVID-19 epidemic brought significant disruptions to HIV service delivery, underlying supply chains, access to HIV services and funding of the HIV response. However, HIV programming responded with resilience and innovation on many fronts. The gathering this year at AIDS 2022, presents an opportunity to share and to learn, how this resilience has played out in different corners of the globe.

Photo credit: Rapeepat/Adobe Stock

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