The Covid-19 Pandemic and Lockdowns
In December 2019, China reported the emergence of a pneumonia of unknown cause in
Wuhan [1]. By 7 January 2020, the etiology of the pneumonia was attributed to a virus
of the coronavirus family, and later on the disease was named coronavirus disease
(COVID-19) on 11 February 2020 by the WHO [2, 3]. The symptoms of COVID-19 appear
after an average incubation period of 5.2 days [1]. The median period from the onset
of the disease to death is 14 days (range 6 to 41) [3]. Transmission of the virus
is human to human through direct contact, or air droplets from infected persons spread
by coughing or sneezing. The infection droplets can also contaminate surfaces, and
the virus can remain infectious for several days in the environment, providing a reservoir
for the infection [4]. The majority of infections go into remission without intervention,
while approximately 15% will require hospitalization, with approximately 5% of these
requiring intensive care [3, 4]. Unmitigated spread of COVID-19 creates pressure on
health systems, and diverts resources that could have otherwise been better utilized
for other health conditions. Sub-Saharan Africa health systems are already strained
and are characterized by poor health outcomes with high mortality rates linked to
the triple burden of disease (HIV, tuberculosis, and non-communicable diseases) and
out of pocket healthcare.
In response to the epidemic China imposed restriction such as quarantine (lockdown)
of the whole city of Wuhan. This model proved efficacious, resulting in some Sub-Saharan
Africa countries implementing the same. The lockdown measures are in no way aimed
at ending the pandemic but seek to protect the health systems of countries from being
overwhelmed by flood of infected and sick patients needing medical care. However,
the restrictions come with unintended consequences, such as widening inequalities,
mental health problems, and exacerbating poor medical outcomes that are not COVID-19-related.
Of particular interest to this paper, The Joint United Nations Programme on HIV and
AIDS (UNAIDS) and the World Health Organization (WHO) have announced that the number
of AIDS-related deaths in Sub-Saharan Africa could double if access to healthcare
for people living with HIV (PLWH) is interrupted during the COVID-19 pandemic. While
interruption to the supply of ARV drugs would have by far the largest impact of any
potential disruptions [5], suspension of HIV testing would also have significant population
impact.
Current State of the HIV Epidemic in Sub-Saharan Africa
Sub-Saharan Africa (SSA) is home to over one billion people, with a current growth
rate of 2.3% [6]. By the end of 2020, it is estimated that the SSA region will have
an approximate population of 1.1 billion and it will account for most of the world’s
population growth in the coming decades, whilst other regions’ populations will be
declining [6]. However, with this growing population, the region has persisted as
the epicenter of the HIV epidemic [7]. There are over 26 million PLWH in Sub-Saharan
Africa [7, 8]. It was estimated that 1.7 million new HIV infections occurred globally
during the year 2018, which translates to 5000 new infections per day. Overall, 61%
of these new infections occurred in SSA [7]. Key populations and their sexual partners
contributed approximately 25% of the new infections in the Eastern and Southern regions
of Africa, whilst contributing 64% of the new infections in the Western and Central
African regions [8]. In the Eastern and Southern region of Africa, 85% of PLWH knew
their status, whilst 67% of those were on treatment and 58% of those on treatment
had viral suppression [8]. In the Western and Central African region, 64% of PLWH
knew their status, 79% were accessing treatment, and 76% had viral suppression [8].
Approximately 310,000 people died due to HIV/AIDS in 2018 in East and Southern Africa,
whilst 280,000 died in West and Central Africa [8]. Given the HIV disease burden in
SSA, it is critical that the region continues to implement control efforts, even in
the context of the COVID-19 pandemic [9]. Interventions that reach and test people
earlier and retest persons with ongoing HIV risk have benefits not only for reducing
HIV morbidity and mortality, but in interrupting and preventing HIV transmission [10–12].
The Case for Scaling Up Home-Based HIV Testing Interventions
HIV testing remains the primary entry point to care and treatment services. UNAIDS
is targeting viral suppression in at least 73% of PLWH by the end of 2020 in an effort
to end AIDS by 2030 [13]. This goal can only be achieved if at least 90% of the HIV
infected population is diagnosed and linked to care. Historically, community-based
testing has targeted volunteers, who were mostly women, to get tested. Men and youth
are not as forthcoming with regards to testing, and are disproportionately contributing
to testing gaps [14–16]. While interventions have been in place to improve testing
rates among these priority populations, confinement due to natural disasters in the
Unites States [17] and violence in Kenya [18, 19] have been shown to hinder uptake
of HIV testing services. The current COVID-19 crisis is even more complicated, as
there are multifaceted barriers to facility-based HIV testing, including but not limited
to a lack of access due to the closure of facilities, shortage of staff due to illness,
and reluctance by individuals to attend clinics due to fear of being exposed to SARS-COV
2 at health facilities [20].
The lockdown measures are in no way a panacea to the pandemic [9], but are aimed at
ameliorating shocks to the health systems of countries due to flood of infected and
sick patients needing medical care. The restrictive measures are, therefore, intended
to manage COVID 19 spread and the number of cases requiring treatment at any given
time—referred to as flattening the curve—so as to not overstretch health systems.
However, the restrictions come with unintended consequences in terms of HIV testing
and care [21]. Healthcare workers are focused on COVID 19 treatment and care, while
the general public are quarantined or scared to seek medical attention for other illnesses
due to the threat of acquiring the virus. The restrictive measures and threat of disease
have curtailed access to provider-initiated and community testing. SSA has to consider
the scaling up of home based HIV testing [22].
The WHO has recommended HIV self-testing (HIVST) as an additional method to increase
HIV testing rates. HIVST affords individuals privacy, convenience, and empowering
options for care [14, 15]. HIVST offers a means to fast track pre-screening and triaging
out of those who self-test negative. HIVST can close the testing gap, as it can increase
testing coverage and frequency. This allows the health system to focus only on those
who require further assistance with respect to counselling, confirmation testing,
and ART initiation. HIVST has the added benefit of reducing the number of health center
visits during the period of quarantine and social distancing, in order to curb viral
transmission. The COVID-19 pandemic has already placed a strain on the health system,
and expansion of the HIVST approach will ease the strain and help to prevent overwhelming
of facilities with HIV testing. Multiple studies conducted in the Sub-Saharan Africa
region have already revealed high acceptance across individuals of various demographics
[14, 23]. HIVST can be made available on online drug stores, so that those requiring
these services can order and have them delivered and use them in the comfort of their
homes. Population Services International has already reported success with HIVST in
Kenya [22]. In Eswatini, there has been a growing demand for HIV testing services
during the COVID-19 pandemic, as people are interested in knowing their underlying
conditions [24]. Scaling up of a home-based option to HIV testing such as HIVST could
prove beneficial and improve health outcomes with little strain to the health system.
The COVID-19 pandemic and associated restrictive measures to curb its spread have
stifled HIV testing. This not only threatens attainment of the UNAIDS goal to end
AIDS by 2030, but may result in increased AIDS-related mortality. Scaling up of HIVST
has the potential to improve awareness of HIV status and increase Sub-Saharan Africa
population’s ability to address and control the HIV epidemic, and save lives.