Study population and setting
Using three potential scenarios of disruption to HIV services in South Africa due to the COVID-19 pandemic, authors modeled the number of excess HIV-attributable deaths that could occur between 2020 and 2024 as a result of such interruptions. These scenarios were “managed pause” (least severe; expansion of services paused, but current services maintained), “managed disruption” (disruptions, such as reductions to viral load testing, occur but are managed to mitigate worst impacts), and “interruption of supply” (most severe; supply of key medicines interrupted and a proportion of persons living with HIV [PLWH] are forced off antiretroviral treatment [ART]). Scenarios were cumulative, and as they increased in severity, also incorporated all components from less severe scenarios. Authors compared modeled excess deaths to a baseline model in which no interruptions occurred and coverage would have been maintained as otherwise anticipated. In the first simulation, authors assumed disruptions would begin in mid-April 2020 and last for three months. Authors also compared the effect of interruptions to HIV programs to the estimated direct effects of COVID-19 epidemic in South Africa. Different mortality risks for PLWH who are forced off ART, the proportion of PLWH forced off ART, and duration of interruptions (i.e., months) were used for sensitivity analyses and estimate excess mortality in differing scenarios.
Summary of Main Findings
Model results suggest that excess HIV-related deaths in the “managed pause” and “managed disruption” scenarios are less than 1% in the first year. Conversely, in the “interruption of supply” scenario, the model estimates an excess of 23,000 HIV-related deaths in the first year, which represents more than a 30% increase compared to the 71,000 estimated HIV-related deaths in 2018. Over the five-year period, assuming a three-month interruption, results estimated that total HIV-related deaths will be 38,000, which is less than the number of estimated COVID-19 deaths. Assuming the lowest (0.26%) mortality risk per month for PLWH who are forced to drop off ART, in some situations, the excess number of deaths was estimated to exceed the number of COVID-19 deaths prevented through mitigation efforts such as social distancing. Compared to direct effects of COVID-19, excess deaths from HIV are distributed throughout the 2020-2024 time period (whereas COVID-19 deaths all occur in 2020-2021).
Authors repeated multiple model iterations using different combinations of scenarios and parameters in order to minimize uncertainty. Given the high HIV burden in South Africa, baseline estimates used for HIV-related deaths are likely robust.
Authors did not model interactions between COVID-19 and HIV, and assume that PLWH have the same risk of acquiring or dying from COVID-19 than persons without HIV. Risks for PLWH is currently unknown, and this may have important implications for the model results. Interruptions to services and epidemic mitigation strategies may have important implications for transmission risk. Potential increases in mother-to-child transmission, new partner acquisition, and drug resistance to ART regimens may contribute to excess HIV deaths in the long-term, but were not included in the model. Finally, authors note that the risk of death is likely to increase with accrued time off of ART, but do not include this increase in the model. Limitations in the results also arise from uncertainties regarding the scale of the COVID-19 epidemic in South Africa and the extent to which HIV programs will actually be interrupted.
The maintenance of primary healthcare programs during an acute healthcare crisis is critical to mitigating overall burden. This study estimates, under varying levels of intensity, how interruptions to primary healthcare services (HIV) can worsen the overall impact of the COVID-19 pandemic, and may be useful for planners and decision-makers regarding mitigation efforts and strategies to minimize interruptions to non-COVID-19 healthcare.