When are in-person HIV services worth the risk of COVID-19 and other communicable illnesses? Optimizing choices when virtual services are less effective

ABSTRACT/SUMMARY Sub-Saharan Africa (SSA) is home to two-thirds of all people living with HIV (PLHIV). During the COVID-19 pandemic, HIV services in sub-Saharan Africa have been adapted to lower-contact alternatives that reduce exposure to SARS-CoV-2, which maintained the effectiveness of some services but reduced the effectiveness of others. For example, multi-month dispensing of antiretroviral therapy (ART) did not reduce retention or viral load suppression, whereas many services involving navigation, social support, and mental health became less effective when delivered in lower-contact manners. Three such services critical to achieving the HIV treatment and prevention targets are HIV testing, treatment of depression, and ART adherence support. In-person HIV counseling and testing was adapted into remote self-testing, with lower rates of linkage to care and commensurate declines in HIV treatment initiation. In-person psychotherapy for depression (a condition affecting 10-15% of PLHIV in SSA) was adapted into teletherapy, with reduced treatment completion and effectiveness. In-person peer support for ART adherence was adapted into telephone and telehealth adherence support, with lower rates of adherence and viral load suppression. As of mid-2021, SSA countries continue to implement these lower-contact alternatives and lack evidence regarding when, and for whom, higher-contact services should resume. We will partner with the Ministries of Health of Zambia and Kenya and local NGOs to identify services that have been adapted into lower-contact alternatives and estimate (Aim 1) incremental effectiveness at treating and preventing HIV, (Aim 2) incremental exposure to COVID-19, tuberculosis, and influenza, and (Aim 3) which patients should use lower-contact services at what times. To estimate incremental effectiveness, we will use program data to compare outcomes in terms of service-specific indicators such as HIV tests performed, changes in depression scores, and changes in ART retention and viral load suppression. Using an HIV transmission and progression model, we will translate these service-specific indicators into comparable estimates of disability-adjusted life-years. To estimate SARS-CoV-2, tuberculosis, and influenza exposure through different service alternatives, we will perform in-field visits to obtain parameters for a Wells-Riley model of respiratory disease transmission. We will combine these estimates with mathematical modeling to the risk of exposure under different pandemic conditions and the resulting risk to health in terms of disability-adjusted life years. Finally, we will compare HIV-related benefits and SARS-CoV-2- related risks for different COVID-19 pandemic conditions and patient sub-populations in order to determine thresholds when higher-contact services should resume. We will furthermore establish targets for how much the effectiveness of lower-contact services would need to improve in order to be widely recommended in the era of COVID-19.