A new analysis of the health outcomes of 12,987 people with COVID-19 in Western Cape, South Africa, indicates that people living with HIV and people with past or current tuberculosis infections have a two- to three-times greater risk of dying of COVID-19. These data, the first to come from a country with a high burden of HIV and tuberculosis, should serve as a wake up call to sub-Saharan African countries that are failing to prioritize HIV adult and pediatric treatment and prevention access as part of their COVID-19 responses. The fragile gains communities across sub-Saharan Africa have made in securing HIV treatment and prevention scale up are at risk of rapidly unraveling as an effect of COVID-19.
This observation of increased risk of death from COVID-19 among people with HIV comes at the same time activists have uncovered deteriorating HIV treatment and prevention access, triggered by flawed COVID-19 responses, in countries across sub-Saharan Africa—home to the majority of people living with HIV and HIV/TB co-infection.
Activists have made repeated demands to national governments, PEPFAR and the Global Fund to prevent a roll back of gains made in response to HIV and TB during the COVID-19 pandemic by ensuring multi-month refills of antiretrovirals for adults and children; promoting, protecting, and defending human rights amidst severe limits on people’s movement; equipping front-line healthcare workers with proper personal protective equipment (PPE); and increasing funding for treatment and prevention programs. But many countries have been unwilling to safeguard the needs of people with HIV and tuberculosis, with dire effects.
Reports from multiple countries with high burdens of HIV show a decrease in the collection of ARVs due to new barriers posed by COVID-19. A survey of people living with HIV in South Africa found that approximately one in four people received one month or less supply of antiretrovirals, forcing them to return to clinics just for refills, increasing their risk of exposure to COVID-19 and adding to the burden on healthcare systems as they treat people with COVID-19. While South Africa has been expanding COVID-19 testing, government hasn’t used the opportunity to expand HIV and TB testing at the same time, which is a sorely wasted opportunity. In Kenya, there has been a reversal of six-month dispensing of ARVs to three-months due to fears of medicine stockouts. In Uganda, 68% of PLHIV respondents to a recent survey had less than one month’s supply of ART and of those who had attempted a refill of ART in the preceding week, two thirds were unsuccessful. 23% of survey respondents had children taking ARVs but lacked the means to reach their clinic because the government had made no plan to exempt PLHIV from severe travel restrictions.
Severe restrictions on movement including transport bans and curfews in some countries have been violently enforced. Police violence during these so-called lockdowns is driving people – including LGBT people, sex workers, and other criminalized groups – from seeking HIV prevention and treatment services for themselves and their families.
As the COVID-19 pandemic gains momentum in sub-Saharan Africa, PLHIV are facing new challenges that put them at greater risk of sickness and death – directly from COVID-19 and from the political choices our leaders are making. The response to these combined pandemics must be even more aggressive. Doubling down on the HIV, TB, and COVID-19 responses with increased funding for HIV and TB treatment and prevention programs and COVID-19 responses structured with the needs of PLHIV in mind are critical in preventing waves of preventable suffering and death. The study investigators point out that the two- to three-fold increased risk of death from COVID-19 among people with HIV that they found is somewhat lower than what researchers have predicted. But these data provide no cause for comfort. Instead, these data, combined with the reports of reduced access to ARVs, should serve as a call to action by policymakers and public health officials working to prevent thousands of avoidable deaths.