key: cord-1030923-fg9bgbcy authors: Musuka, Godfrey; Dzinamarira, Tafadzwa; Madziva, Roda; Herrera, Helena; Sadr, Wafaa El title: Protecting HIV service delivery for key populations in Southern Africa in the context of the COVID-19 pandemic date: 2022-03-16 journal: IJID Regions DOI: 10.1016/j.ijregi.2022.03.008 sha: 3ea6ad4812b92c0f77cf8ffd5015362b7d50c744 doc_id: 1030923 cord_uid: fg9bgbcy The 2025 UNAIDS targets prioritize reaching all subpopulations living with HIV and those at risk for HIV as the only pathway to achieving control of the HIV epidemic. This brought to the fore the importance of addressing the needs of key marginalized groups and placing such communities at the centre of HIV response strategies. However, the COVID-19 pandemic has resulted in a setback in terms of confronting HIV. With this viewpoint, we offer recommendations not only to protect services within the HIV response amongst key populations but urge the expansion of such services to meet the UNAIDS 2025 targets. Without this, gains in controlling COVID–19 may be achieved at the expense of losses in controlling the spread of HIV, which had been achieved after sustained and resource-intensive actions. The 2025 UNAIDS targets prioritize reaching all subpopulations living with HIV and those at risk for HIV as the only effective pathway to achieving control of the HIV epidemic. This brought to the fore the importance of addressing the needs of key marginalized groups and placing such communities at the center of HIV response strategies (UNAIDS, 2021b) . The 2021 UNAIDS report estimated that in 2020, these key populations and their sexual partners accounted for 65% of HIV infections worldwide and 39% of infections in sub-Saharan Africa (UNAIDS, 2021c) . While still considered important targets, the advent of the COVID-19 pandemic has and continue to threaten progress in successfully achieving these crucial targets. The COVID-19 pandemic has resulted in a setback in terms of confronting HIV , as well as addressing other major health threats such as malaria and tuberculosis (Fund, 2021) . Two welldescribed models of HIV epidemics, published in the early days of the COVID-19 pandemic estimated that a 6-month interruption of supply of ART across the whole population of people living with HIV (PLWH) on treatment would be expected to lead to a 1.63 times increase in HIV-related deaths (Jewell et al., 2020 ) over a 1 year period or a 10% increase in HIV deaths over a 5 year period (Hogan et al., 2020) compared to the case with no disruption. Recent evidence has shown that progress in the HIV response has reversed, with one study finding that testing alone had dropped globally by 22% in 2020 (Brown, Spinelli, & Gandhi, 2021) . Another study involving 20 countries revealed that of 10,654 individuals surveyed, 30% had experienced interruptions to in-person HIV testing, with 55% reporting interruptions to HIV self-testing, a further 56% reporting interruptions to pre-exposure prophylaxis, and 10% interruption to condom access (Rao et al., 2021) . Less than half of HIV positive clients reported for ART collection appointments in the period March to April 2020 (Pierre, Uwineza, & Dzinamarira, 2020) . Many other reports revealed evidence of reduced access to ART during the COVID-19 pandemic due to various barriers such as lockdowns, fear of acquiring COVID-19, and unavailability of healthcare services for HIV, which should be addressed to ensure viral suppression -a critical element of the 2025 targets. Data from 46 countries in sub-Saharan Africa show a positive relationship between HIV prevalence and income disparity (UNAIDS, 2021a). COVID-19 was shown to have severe economic implications globally (Nicola et al., 2020) and the impact is expected to be much stronger in already disadvantaged regions such as sub-Saharan Africa. Moreover, the economic toll of the pandemic was suggested to be much greater for women (UNWomen, 2020), which might have contributed to the already established gender inequality in HIV services in Africa. Addressing these key gaps in HIV responses is required to propel countries toward HIV epidemic control, in the context of a new pandemic. Key populations which are also hard-to-reach groups include men who have sex with men (MSM), transgender women, people who inject drugs, and sex workers. These are recognized as being at increased risk of HIV infection while at the same time facing challenges in garnering the benefits from access to antiretroviral therapy. In one study conducted among key populations in Zimbabwe, viral load suppression was 48.7% among persons newly diagnosed, and 61.5% among all living with HIV (regardless of self-reported HIV status) (ICAP, 2020). Common barriers to accessing health services during the COVID-19 pandemic in these groups are further compounded by the social and legal issues affecting them which increase their vulnerability . Some studies have shown that HIV positive individuals, particularly with advanced disease and not on ART, are at increased risk of severe COVID-19 (Karmen-Tuohy et al., 2020) . In addition, evidence suggests that persons living with HIV, particularly those with advanced disease, face the potential risk of prolonged SARS-CoV-2 infection and contribute to evolution of viral variants that are more transmissible, may cause more severe illness or may undermine protection provided by current COVID-19 vaccines (Tafadzwa Dzinamarira et al., 2021) . The COVID-19 pandemic, in this manner, has exacerbated existing inequalities in these key and vulnerable populations (Eghtessadi, Mukandavire, Mutenherwa, Cuadros, & Musuka, 2020) , while affecting more severely people living with HIV in general. For these reasons, it becomes crucial to ensure that access to HIV services is not only maintained, but rather protected and expanded, during the COVID-19 pandemic . A study conducted at specialized HIV clinics for MSM has shown that, during the March to August 2020 lockdown in Kenya, these were not classified as providing essential services, experienced disruption and closures (Macharia et al., 2021) , with similar circumstances having been reported in Zimbabwe (Mukwenha, Dzinamarira, Mugurungi, & Musuka, 2020) and Uganda (Kawala, Kirui, & Cumber, 2020) . Additionally, COVID-19 restrictions such as curfew and lockdowns had a considerable effect on the mental well-being among these populations. Reports from several countries indicate an increase in prevalence of depression, substance misuse and loss in income in these groups, (Santos et al., 2021) with findings from several studies in African countries showing that lockdown measures have disrupted the livelihoods of sex workers, resulting in breach of the lockdown regulations in a bid to make ends meet (Wheeler, 2020) thereby further exposing themselves and others and contributing to transmission not only of COVID-19, but also HIV. These findings underscore the need to identify strategies to prevent interruptions in HIV-related services particularly for key populations in the region, where impact is particularly marked. With this viewpoint, we offer recommendations not only to protect services within the HIV response amongst key populations but urge the expansion of such services in order to meet the UNAIDS 2025 targets. Without this, gains in controlling COVID-19 may be achieved at the expense of losses controlling the spread of HIV, which had been achieved after sustained and resource intensive actions. Firstly, it is critically important to obtain accurate data on the impact of COVID-19 on the HIV response among key populations in order to refine mitigation actions. Secondly, countries must work towards addressing criminalization and stigmatization of key population groups. This could influence behavior in terms of compliance with COVID-19 risk minimization measures. Thirdly, there is a need to strengthen prevention and treatment approaches, particularly engaging with trusted civil society groups serving these populations. Fourthly, there is a need to expand innovative methods of ensuring continue ART access during COVID-19. These include intensified focus on community-based, rather than facility-based, ART refilling; immediate initiation of the newly diagnosed PLHIV on 3-month ART starter packs; and broadened access to multi-month dispensing among PLHIV established in care (Boyd et al., 2021; Grimsrud & Wilkinson, 2021) . HIV service delivery methods used during the pandemic such as tele-medicine (Rogers et al., 2020) , mobile delivery of ART (Wilkinson & Grimsrud, 2020) , mobile testing units (Middleton, Somerset, Evans, & Blake, 2020) and self-testing (Mhango, Chitungo, & Dzinamarira, 2020) could also be leveraged to reach key populations. Fifthy, as COVID-19 vaccine access continues to improve in low-resource countries, efforts must be made to ensure that key populations, including those living with HIV, have facilitated access to vaccines through convenient and trusted providers and service points. Vaccines are the mainstay of ending the COVID pandemic and equal access to vaccines is a crucial part of the response to the epidemic and the way forward to achieving the UNAIDS targets for HIV. However, Africa has been disproportionately affected by the inequity in COVID-19 vaccine distribution with less than 9% of people on the continent being full vaccinated by the end of 2021 (T. Dzinamarira et al., 2022; Loembé & Nkengasong, 2021) . Ensuring COVID-19 vaccine access in Africa will provide gains not only for COVID-19 control, but also for other endemic infectious diseases such as HIV. In conclusion, while key populations have been prioritized by UNAIDS in its new strategic plan, they continue to face substantial challenges in accessing HIV-related services and have been disproportionately impacted by the COVID-19 pandemic. This situation compels National HIV Control Programs to focus on these and other vulnerable groups. This requires addressing fundamental structural barriers described such as stigma and discrimination, which combined with COVID-19 restrictions put these populations at enormous risk and lead them to defer accessing critical services. Additionally, providing access to COVID-19 vaccines and other protective measures is also a critical priority. Expanding access to HIV services during the COVID-19 pandemic-Nigeria, 2020 The interplay between HIV and COVID-19: summary of the data and responses to date Insights from Zimbabwe's SARS-CoV-2 genomic surveillance. The Lancet. Global Health Unpacking the Implications of SARS-CoV-2 Vaccination Programs. Vaccines (Basel) Safeguarding gains in the sexual and reproductive health and AIDS response amidst COVID-19: The role of African civil society Acceleration of differentiated service delivery for HIV treatment in sub-Saharan Africa during COVID-19 Potential impact of the COVID-19 pandemic on HIV, tuberculosis, and malaria in lowincome and middle-income countries: a modelling study HIV and STI Biobehavioral Survey among Men Who Have Sex with Men, Transgender Women, and Genderqueer Individuals in Zimbabwe -Final Report Potential effects of disruption to HIV programmes in sub-Saharan Africa caused by COVID-19: results from multiple mathematical models Outcomes among HIV-positive patients hospitalized with COVID-19 Why policy action should focus on the vulnerable commercial sex workers in Uganda during COVID-19 fight COVID-19 vaccine access in Africa: Global distribution, vaccine platforms, and challenges ahead Sexual health among Kenyan male sex workers in a time of COVID-19 COVID-19 lockdowns: impact on facility-based HIV testing and the case for the scaling up of home-based testing services in sub-Saharan Africa Test@ work texts: Mobile phone messaging to increase awareness of HIV and HIV testing in UK construction employees during the COVID-19 pandemic Maintaining robust HIV and tuberculosis services in the COVID-19 era: A public health dilemma in Zimbabwe Targeting those left behind in Zimbabwe's HIV response: A call for decriminalisation of key populations to rapidly achieve 95-95-95 targets The socioeconomic implications of the coronavirus pandemic (COVID-19): A review Attendance to HIV Antiretroviral Collection Clinic Appointments During COVID-19 Lockdown Perceived interruptions to HIV prevention and treatment services associated with COVID-19 for gay, bisexual, and other men who have sex with men in 20 countries Development of telemedicine infrastructure at an LGBTQ+ clinic to support HIV prevention and care in response to COVID-19 Economic, mental health, HIV prevention and HIV treatment impacts of COVID-19 and the COVID-19 response on a global sample of cisgender gay men and other men who have sex with men Addressing inequalities can decrease HIV prevalence Global AIDS Strategy 2021-2026 -End Inequalities. End AIDS Global AIDS Update 2021 COVID-19 and its economic toll on women: The story behind the numbers Sex Workers Struggle to Survive Covid-19 Pandemic The time is now: expedited HIV differentiated service delivery during the COVID-19 pandemic Acknowledgments: None declared.