On World AIDS Day, we must heed the lessons from COVID

A year ago today, the commemoration of World AIDS Day saw a time of unprecedented promise in HIV prevention, treatment, research and outcomes. Four decades of perseverance — by scientists, activists, people living with HIV, health care providers and policymakers — had led to a once almost uniformly fatal virus becoming a chronic and manageable condition, and an ambitious initiative to end HIV as an epidemic in America was being launched.

As an infectious diseases physician with a focus on caring for people with HIV and conducting HIV research, I have seen first-hand how following science and a patient-centered approach have made such an ambitious goal conceivable. Our gains against the impact of HIV are demonstrated in numbers of lives saved: recent data from the Centers for Disease Control and Prevention show that overall HIV-related death rates dropped by half from 2010 to 2017 in the United States, while access to testing and care brought down incidence in countries with some of the highest rates on earth.

In the midst of those gains, and the immense possibilities ahead, however, the coronavirus pandemic provided a stark reminder of how fragile our progress in HIV has been and how important it is to heed the lessons of the last 40 years of HIV care and research in confronting a new pandemic. 

Despite our success in science and care delivery, the sad truths HIV has shown about the impacts of inequities across our health systems have not led to critical change. Amid the progress chronicled in the recent CDC data were numbers showing that HIV-related deaths remained highest among Black/African American persons and among people with HIV in the South. There, death rates are nearly twice those in the Northeast. 

Now, disparities illustrated by those gaps challenge control of both HIV and COVID-19, with the current crisis widening existing health inequities and putting the end of HIV as an epidemic further from our reach.

Since March, my work, like that of most of my infectious diseases colleagues, has concentrated on responding to the coronavirus pandemic. I have seen the incredible stress of the pandemic on our underfunded public health systems and the harmful socioeconomic impacts on too many Americans, who have lost their jobs and their health insurance or experienced loss of income and housing. Case studies from across the country indicate that these and likely other factors affect the ability of people with HIV or those at risk for HIV to access the testing, treatment and prevention measures that have driven our progress — pillars of the Ending the HIV Epidemic initiative. 

While early HIV diagnosis is important to starting treatment to protect the immune system and prevent transmission, clinic closures and service reductions have added barriers to getting tested for HIV and other sexually transmitted diseases. One hospital in Chicago documented significant increases in acute HIV infection — early-stage infection with symptoms similar to COVID-19 — during the first eight months of 2020.

Fenway Health, the largest provider in New England of pre-exposure prophylaxis services (PrEP), which is the use of antiretroviral drugs to protect uninfected people from getting infected, has reported significant disruptions. In the first quarter of 2020, the number of people starting PrEP decreased by 72 percent. The clinic also reported an 85 percent drop in HIV and STI testing and a 191 percent increase in people unable to fill their prescriptions, with lapses occurring more frequently for younger, Latinx and multi-racial individuals.   Ref 

Researchers at the University of California, San Francisco reported that their rate of patients who were virally suppressed by HIV treatment at one clinic dropped by 30 percent after pandemic restrictions took effect. Patients who were homeless, under 35 years of age or Black were least likely to be virally suppressed.

And at my own institution, the vast majority of patients with HIV and COVID-19 are racial and ethnic minorities, highlighting once again the disproportionate impact of both COVID-19 and HIV — “twin pandemics” — on the most vulnerable in our society. 

Clearly, the ongoing COVID-19 pandemic threatens the hard-won successes in HIV responses worldwide, while inequitable access to healthcare, housing, income and employment threaten control of both pandemics. HIV showed us the importance of addressing these disparities. COVID-19 makes action more urgent than ever. Key to this effort will be investing in a strong public health infrastructure and health care workforce to respond to current public health crises and prevent future ones. 

Every year World AIDS Day gives us a chance to measure the gains we have made against our longest pandemic. This year a new pandemic has shown that although our gains are great, until the basic human right to health care is recognized and realized for all people, they will remain fragile.

Rajesh T. Gandhi, M.D., FIDSA, is chair of the HIV Medicine Association, a professor of medicine at Harvard Medical School and the director of HIV Clinical Services and Education in the Division of Infectious Diseases at Massachusetts General Hospital in Boston, Massachusetts.