Stakeholder efforts to mitigate antiretroviral therapy interruption among people living with HIV during the COVID‐19 pandemic in China: a qualitative study

Abstract

Introduction:The COVID-19 pandemic has affected antiretroviral therapy (ART) continuity among people living with HIV (PLHIV) worldwide. We conducted a qualitative study to explore barriers to ART maintenance and solutions to ART interruption when stringent COVID-19 control measures were implemented in China, from the perspective of PLHIV and relevant key stakeholders. Methods: Between 11 February and 15 February 2020, we interviewed PLHIV, community-based organization (CBO) workers, staff from centres for disease control and prevention (CDC) at various levels whose work is relevant to HIV care (CDC staff), HIV doctors and nurses and drug vendors from various regions in China. Semi-structured interviews were conducted using a messaging and social media app. Challenges and responses relevant to ART continuity during the COVID-19 pandemic were discussed. Themes were identified by transcript coding and mindmaps. Results: Sixty-four stakeholders were recruited, including 16 PLHIV, 17 CBO workers, 15 CDC staff, 14 HIV doctors and nurses and two drug vendors. Many CDC staff, HIV doctors and nurses responsible for ART delivery and HIV care were shifted to COVID-19 response efforts. Barriers to ART maintenance were (a) travel restrictions, (b) inadequate communication and bureaucratic obstacles, (c) shortage in personnel, (d) privacy concerns, and (e) insufficient ART reserve. CBO helped PLHIV maintain access to ART through five solutions identified from thematic analysis: (a) coordination to refill ART from local CDC clinics or hospitals, (b) delivery of ART by mail, (c) privacy protection measures, (d) mental health counselling, and (e) providing connections to alternative sources of ART. Drug vendors contributed to ART maintenance by selling out-of-pocket ART. Conclusions: Social and institutional disruption from COVID-19 contributed to increased risk of ART interruption among PLHIV in China. Collaboration among key stakeholders was needed to maintain access to ART, with CBO playing an important role. Other countries facing ART interruption during current or future public health emergencies may learn from the solutions employed in China.

The impact of COVID-19 non-pharmaceutical interventions on HIV care continuum in China: An interrupted time series analysis

“…Barriers to facility-based HIV care services during the COVID-19 pandemic, including the closure of health facilities, shortage of HIV specialists as many of them were shifted to do COVID work, cumbersome administrative procedures, COVID-related stigma and fear of being exposed to SARS-COV-2, complicated the management of HIV care services. 32 Many provinces, autonomous regions and municipalities across China instituted a series of NPI measures to contain COVID under which all non-essential shops were closed, public transportation suspended, and residents confined to their homes. 20 While deemed necessary to contain COVID-19, these measures profoundly affected the people at risk of HIV as well as PLHIV, 1 , 2 , 3 increasing the likelihood of HIV transmission, drug resistance, late ART initiation, and opportunistic infections, particularly because HIV care and antiretroviral therapy (ART) in China are nearly exclusively provided through government-designated clinics and hospitals of their household registration.…”

“…Collaborations among stakeholders, including people at high risk of HIV transmission, PLHIV, community based organisations (CBOs), HIV specialists and policy makers, were leveraged to mitigate these disruptions. 32 The Chinese Center for AIDS/STD Control and Prevention released a nationwide directive on 26 January 2020 under which PLHIV could obtain one month of ART from any local HIV care clinic or hospital. 33 This information was released to the public through official websites and social media official accounts.…”

“…At designated hospitals and clinics, doctors and nurses worked with CBO members to post ART medications to PLHIV in need. 32 These efforts put together alleviated ART interruption to the largest possible extent. However, services other than ART were affected to a greater extent for a longer period.…”

Challenges and Innovation in Community-Based Organization HIV/AIDS Services During COVID-19 in China

“…Barriers including patients' concerns for side effects and "pills burden," lack of effective communication between patients and health care providers, low patient self-e cacy of ART, competing priorities for patients, and depression and stigma associated with HIV [11][12]. Like many Community-Based Organizations (CBO) serving vulnerable populations globally, Chinese CBOs play critical roles in helping PLHIV to improve their access to HIV screening, treatment and care, and reduce stigma especially among men who have sex with men [13][14][15][16]. There are two main types of CBOs providing services to PLHIV: those independently registered with the state/provincial or local government of Civil Affairs as a non-pro t organization, and those a liated with health clinics and local public health o ces without an independent registry [17].…”

“…Although several studies in China highlighted the challenges to PLHIV [19,[27][28][29] and healthcare workers [30][31], few looked at the implications for Chinese CBOs during the lockdowns. Only one stakeholder study published in English included 17 CBO workers in the interviews and found that CBOs could assist HIV care among PLHIV in multiple ways during COVID-19 [13].…”