key: cord-297612-swc2pitd
authors: Nosyk, Bohdan; Armstrong, Wendy S; del Rio, Carlos
title: Contact tracing for COVID-19: An opportunity to reduce health disparities and End the HIV/AIDS Epidemic in the US
date: 2020-04-27
journal: Clin Infect Dis
DOI: 10.1093/cid/ciaa501
sha: 
doc_id: 297612
cord_uid: swc2pitd

SARS-CoV2 testing and contact tracing have been proposed as critical components of a safe and effective COVID-19 public health strategy. We argue that COVID-19 contact tracing may provide a unique opportunity to also conduct widespread HIV testing, among other health promotion activities.

M a n u s c r i p t Massive SARS-CoV2 testing and contact tracing at a scale and speed never before seen have been proposed as critical components of a COVID-19 public health strategy that could, in theory, safely allow us to relax social distancing measures and begin to bring back the world we left behind before a cure or effective vaccine is delivered. One of a number of challenges this strategy faces is that contact tracing is extremely labor intensive. Deployed in sexuallytransmitted infections such as HIV, a recent study from New York reported costs of over $500 per contact interviewed with 85% of state-level costs attributable to personnel [1] . For Coronavirus these efforts are simpler but the volume of contacts-an average of 36 per positive case [2] pose substantial logistic challenges. Digital applications and other technological supports may help, though it appears inevitable that a large labor force will be needed. Already, Massachusetts has begun hiring to fill their state's projected need for 1,000 contact tracing workers [3] . Health Canada has an open call for a volunteer workforce to do contact tracing and other related tasks [4] . South Korea employed a massive workforce of public health workers at the peak of the epidemic [5] .

The value of a such a public health workforce extends beyond contact tracing for COVID-19 and could lead to progress fighting many other health conditions. Programs in African communities have combined HIV testing with screening for infectious diseases like tuberculosis and malaria as well as non-communicable diseases like hypertension and diabetes [6] . Using this model, we can take this opportunity to scale-up testing for infectious diseases as well as noncommunicable diseases and by doing so improve community health. As SARS-CoV-2 testing is evolving with, not only serological but saliva testing, similar approaches could be taken for optout HIV, HCV and hemoglobin A1C testing for which finger stick methods are already available.

This will allow us to begin to address the unacceptable health disparities that have existed for many of these conditions and, not surprisingly, also occur in COVID-19 [7, 8] . Aside from the potentially profound health benefits of a combination implementation approach, pairing COVID-19 contact tracing with testing for HIV may serve to offset the immense costs of such an approach. It is well-established that HIV testing provides outstanding value and can even be cost-saving in the long-term in high-prevalence populations and settings [9] . Simply learning of a new HIV infection is known to change behavior, with meta-analyses estimating an 80% reduction in sexual activity with partners of negative or unknown HIV status [10] , and starting ARVs with subsequent viral suppression stops HIV transmission [11] .

Testing focused on the geographic regions with the highest rates of new diagnoses and further targeted using phylogenetics to identify the largest and fastest-growing clusters of infection, has A c c e p t e d M a n u s c r i p t been positioned as a key pillar of the United States' 'Ending the HIV Epidemic' strategy [12] .

These efforts will be familiar to public health leaders in the US -Anthony Fauci was an architect of the strategy [13] , which was motivated by the profound successes in the African continent, engineered in part by the President's Emergency Plan for AIDS Relief (PEPFAR) and headed by Deborah Birx [14] . Yet testing remains one weak link in our efforts to End the HIV Epidemic, in part because of persistent stigma and because the communities at greatest risk often have limited access to healthcare and/or are young and without established healthcare.

We [BN, CDR] have recently written that for six of the largest US cities comprising nearly 1 in 4 people living with HIV/AIDS in the US, implementing a wide range of interventions to diagnose, treat and protect against infection at even near-ideal levels would fall short of the EHE targets [15] . We excluded contact tracing because of the relatively limited experimental evidence supporting its effectiveness in HIV and the uncertainty regarding the potential scale this type of effort could actually reach. Contact tracing for HIV is difficult to implement and may be profoundly threatening to already marginalized individuals. COVID-19 contact tracing may provide a unique opportunity to also conduct widespread HIV testing with modified contact tracing that could be acceptable and important for Ending the HIV Epidemic.

Though the task is indeed monumental, the necessary temporary labor force is readily available. were implemented [16, 17] . Some project the unprecedented stimulus packages and protections for workers may not return the hardest-hit industries to pre-COVID levels, and high unemployment may linger. Job loss is a major life stressor and is associated with declines in psychological and physical well-being along with a host of other negative social effects [18] .

Creating jobs, even if only for a limited term, is a necessary government intervention to not only kickstart the economy but also to mitigate further growth in the concurrent epidemic of loss and despair [19, 20] .

Mobilizing this labor force in the COVID-19 response will allow communities to take meaningful action to protect themselves, an act which in itself may have transformative benefits over the long-term. HIV is known to disproportionately impact urban African American and Hispanic/Latinx communities [21, 22] as do other chronic health conditions such as diabetes and hypertension. Now COVID-19 shows the all too familiar progression into vulnerable populations.

Early cases were seen primarily in international travellers, but currently African American and A c c e p t e d M a n u s c r i p t Latinx populations are disproportionately impacted. A public health workforce with point of care screening for these conditions as well could make meaningful strides to reduce the widespread disparities inherent in health. Furthermore testing to promote health allows for stigma-free messaging and broad acceptance. Testing and contact tracing for COVID-19 will provide an entry into social networks in communities where risk factors for conditions like HIV or noncommunicable diseases may be shared. It is imperative however that contact tracing does not increase stigma and discrimination of minority populations and thus the development of a workforce dedicated to culturally competent contact tracing, point of care testing and overall health promotion [23] has to be a priority in order to seize this opportunity.

The speed with which COVID-19 contact tracing must be conducted is on a different scale, though more intensive efforts can be triaged to specialized staff. The greatest effort howeverand valueis in testing. Of course, these potential benefits hinge on the rapid development of antibody testing technology, not to mention sufficient availability of personal protective equipment, and the public health system's ability to rapidly train and deploy the massive influx of temporary workers that would be needed.

Aside from the devastating death toll, the potential long-term effects of COVID-19 on the global economy are severe and may ultimately prove to be greater than any other period in living memory. Difficult decisions regarding how and when to restart the economy lie ahead, but the balance sheet can include the long-term benefits of widespread HIV testing, screening for chronic diseases and potentially narrowing health disparities. Though it may feel like a distant priority, now more than ever, as the official language of the plan goes, we have unprecedented opportunity to end the HIV epidemic in America. Accomplishing this and expanding the impact to other health conditions is an opportunity we must not let go to waste.

Notes: This study was funded by the National Institutes of Health/National Institute on Drug Abuse Grant No. R01-DA-041747 to Emory Center for AIDS research and Emory VTEU. The authors have no conflicts of interest to declare.

Cost Analysis and Performance Assessment of Partner Services for Human Immunodeficiency Virus and Sexually Transmitted Diseases

The efficacy of contact tracing for the containment of the 2019 novel coronavirus (COVID19)

Coronavirus Disease-19: Summary of 2,370 Contact Investigations of the First 30 Cases in the Republic of Korea. Osong Public Health Res Perspect

HIV testing and treatment with the use of a community health approach in rural Africa

COVID-19 and African Americans

Failing Another National Stress Test on Health Disparities

Localized Economic Modeling Study Group. The impact of localized implementation: determining the cost-effectiveness of HIV prevention and care interventions across six United States cities

Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States-Implications for HIV prevention programs

HPTN 052 Study Team. Prevention of HIV-1 infection with early antiretroviral therapy

Ending the HIV Epidemic: A Plan for the United States

at 15 years. Lancet

Localized HIV Modeling Study Group. Ending the HIV the USA: an economic modelling study in six cities

Mortality and morbidity in the 21 st century

The Epidemic of Despair Among White Americans: Trends in the Leading Causes of Premature Death

Trends in racial/ethnic disparities of new AIDS diagnoses in the United States

What lessons it might teach us? Community engagement in HIV research

Addressing HIV criminalization: science confronts ignorance and bias

A c c e p t e d M a n u s c r i p t