Mitigating the effects of COVID-19 on HIV treatment and care in Lusaka, Zambia: a before–after cohort study using mixed effects regression

Abstract

IntroductionThe Zambian Ministry of Health (MoH) issued COVID-19 mitigation guidance for HIV care immediately after the first COVID-19 case was confirmed in Zambia on 18 March 2020. The Centre for Infectious Disease Research in Zambia implemented MoH guidance by: 1) extending antiretroviral therapy (ART) refill duration to 6 multi-month dispensation (6MMD) and 2) task-shifting communication and mobilisation of those in HIV care to collect their next ART refill early. We assessed the impact of COVID-19 mitigation guidance on HIV care 3 months before and after guidance implementation.MethodsWe reviewed all ART pharmacy visit data in the national HIV medical record for PLHIV in care having ≥1 visit between 1 January—30 June 2020 at 59 HIV care facilities in Lusaka Province, Zambia. We undertook a before–after evaluation using mixed-effects Poisson regression to examine predictors and marginal probability of early clinic return (pharmacy visit >7 days before next appointment), proportion of late visit (>7 days late for next appointment) and probability of receiving a 6MMD ART refill.ResultsA total of 101 371 individuals (64% female, median age 39) with 130 486 pharmacy visits were included in the analysis. We observed a significant increase in the adjusted prevalence ratio (4.63; 95% CI 4.45 to 4.82) of early return before compared with after guidance implementation. Receipt of 6MMD increased from a weekly mean of 47.9% (95% CI 46.6% to 49.2%) before to 73.4% (95% CI 72.0% to 74.9%) after guidance implementation. The proportion of late visits (8–89 days late) was significantly higher before (18.8%, 95% CI17.2%to20.2%) compared with after (15.1%, 95% CI13.8%to16.4%) guidance implementation .ConclusionsTimely issuance and implementation of COVID-19 mitigation guidance involving task-shifted patient communication and mobilisation alongside 6MMD significantly increased early return to ART clinic, potentially reducing interruptions in HIV care during a global public health emergency.

The impacts of COVID-19 pandemic on service delivery and treatment outcomes in people living with HIV: a systematic review

“…Thus, it is obvious that a shortage of ART medications is of great danger for PLHIV in terms of physical, psychological, and social wellbeing. To address this issue many countries and HIV services worldwide took measures such as sending medications via mail delivery, extended ART stock refills [ 61 ], incorporating telemedicine for healthcare provision continuation and decreasing the risk of exposure [ 62 ], broadening access to ART multi-month dispensing (MMD) policy, concentrating on community-based case-finding, and immediate, initiating ART among newly-diagnosed cases [ 63 ], launching telephone consultations, expanding ART refill sites [ 60 ], and HIV-positive patients task-shifting for early ART refill collection [ 64 ]. Hopefully, these measures assisted HIV services substantially to mitigate COVID-19-related ART disruptions and eventually caused an early return to normal ART adherence.…”

Poor adherence to antiretroviral therapy among adult people living with HIV initiated during the COVID-19 epidemic waves – observations at the University Teaching Hospital in Lusaka, Zambia

“…However, we are also aware that the major event that happened on a large scale during the period data was collected, soon after the U=U campaign initiative was launched in Zambia, was the COVID-19 pandemic. The effects of the COVID-19 pandemic on HIV care are well documented ( 22 – 24 ) and we think more will continue to be documented. In our study, therefore, the increased likelihood of having a detectable viral load among adult PLWHIV who were initiated on ART during the pandemic period was most likely due to HIV program services-related disruptions brought about by the COVID-19 pandemic.…”

Provider perspectives on service delivery modifications to maintain access to HIV pre‐exposure prophylaxis during the COVID‐19 pandemic: qualitative results from a PrEP implementation project in Kenya

“…In addition, the World Health Organization and PEPFAR have recently recommended modifications to HIV service delivery in line with those employed in Kenya, including decentralized services, extended refills, and innovative recruitment and retention approaches to enable PrEP delivery despite pandemic‐related disruptions [ 20 , 21 , 22 ]. Limited data are available on the impact of such approaches, but two studies of modified ART delivery for persons living with HIV in Africa and Asia found that extending ART refill duration, task‐shifting, phone check‐ins with staff and community‐based ART delivery significantly increased retention and were acceptable for patients and staff [ 23 , 24 ].…”