Preventing HIV infections at the time of a new pandemic - A synthesis report on programme disruptions and adaptations during the COVID-19 pandemic ...
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Preventing HIV infections at the time of a new pandemic A synthesis report on programme disruptions and adaptations during the COVID-19 pandemic in 2020
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Table of contents Executive summary.................................................................................................................................................. 3 Background.............................................................................................................................................................. 6 Aim and objectives.................................................................................................................................................. 7 Data sources............................................................................................................................................................ 9 A devastating new pandemic.................................................................................................................................11 Effect on vulnerability to HIV infection..................................................................................................................12 Effect on the risk of acquiring HIV..........................................................................................................................14 Country-level adaptations and innovations............................................................................................................16 National actions to address the intersections of COVID-19 and AIDS..................................................................17 Communities at the centre of the emergency responses.................................................................................18 Protecting and promoting rights.......................................................................................................................19 Reconfiguring service delivery models............................................................................................................ 21 Modelling how COVID-19 affects the risk of HIV infection................................................................................... 26 HIV service delivery disruptions and effect on access and coverage................................................................... 29 Overview........................................................................................................................................................... 29 HIV testing services.......................................................................................................................................... 30 Key population programmes............................................................................................................................ 32 Programmes for adolescent girls and young women and their male partners............................................... 36 Services for children and for preventing mother-to-child transmission.......................................................... 37 Condom promotion and distribution............................................................................................................... 39 Voluntary male medical circumcision................................................................................................................41 Pre-exposure prophylaxis..................................................................................................................................41 Conclusions............................................................................................................................................................ 42 Propositions for the way forward........................................................................................................................... 44 References.............................................................................................................................................................. 46
This crisis is a wake-up call to
do things differently. We need
a recovery based on economic
and social justice since
response gaps in pandemics,
whether HIV or COVID-19,
lie along the fault lines of
inequality.
António Guterres
United Nations Secretary-General
2 Status of HIV prevention services in the time of COVID-19
Executive summary
Throughout 2020, the COVID-19 pandemic to continue the face-to-face health
swept around the world, threatening encounters that have long been the
decades of hard-won development and backbone of HIV prevention, testing and
public health gains. Global and country- treatment services.
level efforts to control the AIDS epidemic
are facing unprecedented threats. Hard- Inevitably, HIV prevention services have
won gains in HIV prevention, with the been disrupted, and supply chains for
number of people newly infected with key prevention commodities, including
HIV declining by 23% since 2010, are in condoms, lubricants and antiretroviral and Hard-won gains
danger of being reversed by the COVID-19 other medicines, have been stretched. in HIV prevention,
pandemic—and populations already left This is reflected in the early dips observed with the number
behind are at risk of falling further behind. in the monthly numbers of people served of people newly
by key prevention interventions, including infected with HIV
The pandemic, and the measures put into those at high risk of HIV (such as sex declining by
23%
place to contain its spread, have triggered workers) and priority groups such as
a sharp economic downturn, which is adolescents and pregnant women.
having pervasive and devastating effects since 2010, are
on national economies and people’s At the same time, while it has vividly in danger of
livelihoods. Millions are being driven exposed and widened stark inequalities being reversed
into extreme poverty and precarity, with and health inequities, COVID-19 has also by the COVID-19
sub-Saharan Africa and South Asia hit indicated ways of making health systems pandemic—and
the hardest. Evidence indicates that the and other public institutions fairer, more populations
convergence of COVID-19 and HIV is inclusive and better able to meet the already left
deepening inequalities and sharpening challenges of ending the AIDS epidemic behind are at risk
the vulnerabilities that have long been in the years to come. Health-service of falling further
recognized as the structural drivers of providers and community organizations behind
HIV transmission. Upturned livelihoods, have responded to the crisis by changing
interrupted access to education, worsening the ways they provide HIV prevention
of gender inequalities, increased violence services to minimize disruptions of the
against women and erosion of human most essential services.
rights, with a surge in punitive legal and
policy measures in many settings, is likely The response to the pandemic has drawn
to increase HIV risk in the coming years. on decades of experience in pushing
back AIDS, and HIV-concerned experts
The stresses on health systems have and communities have in many instances
been acute, as health facilities and health stepped up to the plate during the worst
personnel were mobilized to contribute of the crisis. Many countries around the
to the pandemic response and refocused world took early, decisive action to address
their energies on the urgent need to critical vulnerabilities, maintain health
attend to related COVID-19 prevention, services and build synergy between both
testing, tracing and care responsibilities. COVID-19 and AIDS control approaches.
The demands on health-care workers These underline how these measures can
and other containment and mitigation complement and support each other, in a
responses (including lockdowns and coherent and comprehensive approach to
physical distancing mandates) have confronting both the COVID-19 and HIV
made it difficult—or even impossible— threats.
Status of HIV prevention services in the time of COVID-19
3
Many of the changes made have been early on by mathematical models. The
inspired by community-based service picture that emerges for HIV prevention
models pioneered over the years in services, however, is more mixed, with
the HIV response. These models are variable degrees of disruptions across
characterized by their strong client focus, services and over time. Reports from
their responsiveness and flexibility and countries convey a sense of programmes
their attention to the wider realities of the struggling to maintain coverage in the
communities in which they are embedded. face of difficult times. They also portray
Over the past year, the communities most countries recognizing and responding
affected by HIV have mobilized to defend quickly to the most acute challenges.
the gains in the AIDS response, to protect These changes are many faceted, being
people living with HIV and other key and devised and implemented across sectors,
vulnerable groups and to push back the by government programmes and as well
coronavirus. They have taken bold steps, by civil society. The level of disruption to
in the face of considerable adversity and services so far is less than many feared,
with limited financial assistance, to assure thus making it possible to avoid the worst
continued HIV prevention services to effects predicted by the mathematical
community members but also to support models.
measures to prevent COVID-19 and
The HIV and manage its consequences. To overcome More detailed and contextualized analysis
COVID-19 the constraints imposed by pandemic- would be required to assess how coverage
pandemics and related restrictions, they have campaigned with different types of HIV prevention
their responses for multi-month dispensing of medicines services has been affected and why. More
have exposed and supplies, organized their delivery analyses are also required to understand
the dangers and brokered financial support, food how vulnerabilities might translate now
of insufficient and shelter to marginalized groups at and into the future into changes in sexual
investment higher risk. They have innovated with the or other risk behaviour and the possible
in pandemic use of virtual platforms to continue to effect on the numbers of people acquiring
response capacity meet the multiple needs and concerns of HIV. Evidence of any changes in incidence
at the national beneficiaries. Country-level experiences in the time of COVID-19 is expected to
and global levels documented in this report demonstrate be available over the coming year, as
how COVID-19 has catalysed the countries estimate the numbers of new
accelerated implementation of innovations HIV infections in their populations, using
that predate the pandemic but that standard approaches. Additional data
have previously struggled to obtain may also become available from well
traction. In most settings, these measures characterized cohorts in settings with a
have managed to compensate for the high burden of HIV infection. A careful
breakdown of formal health services and review of observed trends will be required
enable rapid rebound in the delivery to assess to what extent they may be
of essential services to those in need. associated with increased COVID-19
In some cases, they have even led to vulnerabilities, changes in risk behaviour
increases in service coverage compared and/or HIV prevention or treatment service
with the pre-COVID situation. disruptions.
The ability of HIV programmes to adapt The HIV and COVID-19 pandemics and
to COVID-19 highlights their resilience their responses have exposed the dangers
and flexibility, especially in settings with of insufficient investment in pandemic
strong community systems and in which response capacity at the national and
robust links have been built with the formal global levels. They have also underscored
health system. An overview of currently the importance of increasing the resilience
available trend data about actual service of societies and health systems and the
delivery disruptions at the country level importance of addressing underlying
suggests that disruptions to HIV treatment inequalities. At the same time, they have
efforts may not be severe as feared stimulated the acceleration of people-
and that the impact on AIDS-related centred approaches to infectious disease
mortality may be less than that predicted prevention and control—approaches
4 Status of HIV prevention services in the time of COVID-19
long called for by people living with be directed to strengthen mechanisms
HIV and other civil society activists. such as social contracting to support and
Collective global efforts that give priority sustain community-led service delivery.
to people can transform the COVID-19
crisis into an opportunity to accelerate In the meantime, some reprogramming
both the HIV response and the efforts to of HIV prevention efforts needs to
achieve universal health coverage and continue as necessary to achieve
the Sustainable Development Goals. As improvements, increase coverage and
countries mobilize against COVID-19, the build efficiency. Existing strategies and
lessons learned from decades in pushing technologies should be taken forward,
back on AIDS must continue to inform the such as multi-month dispensing and
latest pandemic response, and the HIV differentiated service delivery and self-
control programmes must be bolstered testing approaches, as well as innovations,
to prevent the world from falling further such as the use of online platforms for
behind on its commitments to end AIDS reaching people at highest risk and
by 2030. young people who are frequently missed The COVID-19
by conventional programme delivery and the HIV
The COVID-19 and the HIV responses must methods. These changes need to be responses must
build synergy to ensure that they address scaled up, sustained and institutionalized. build synergy
and do not exacerbate the inequalities Attention must be placed on building to ensure that
and vulnerabilities that increase risk of capacity, strengthening links and ensuring they address
infection and disease, impede access to the safety of frontline workers (such as by and do not
services and curtail programme impact. providing personal protective equipment exacerbate the
Restrictions to protect public health and mobile technologies as required). inequalities and
must be context-relevant, time-limited, Procurement and supply systems need vulnerabilities
proportionate, necessary and evidence- urgent attention as well, to fix the faults that increase risk
informed. In particular, education systems thrown up in the COVID-19 crisis. Finally, of infection and
must be protected, in view of the huge strategic information platforms need to disease, impede
benefits, including health benefits, they be developed to monitor how COVID-19 access to services
bring to future generations, and the affects programmes and make data- and curtail
enduring effects of any disruptions, driven course corrections. Triangulation programme
especially for girls and women. It is and analysis of HIV and COVID-19 data is impact
also time to heed the previous calls of required as countries promptly respond
the HIV community for strengthening to both pandemics. Guidance has been
the social protection of those most in developed for taking forward key service
need, for combatting all forms of stigma delivery adaptations and innovations, of
and discrimination, for supporting and which examples are provided in the report.
protecting health-care workers, and for
ensuring free and affordable access to In the longer term, specific efforts will be
diagnostic, preventive and therapeutic needed to ensure that the move towards
tools, with particular attention to the needs universal health coverage reflects the key
of the most vulnerable and hardest to attributes of the HIV response (including
reach. In countries with a high HIV burden, community engagement, inclusive
it is recommended that social protection governance, accountability for results
schemes be made sensitive to the needs and a commitment to human rights and
of people living with HIV, those at higher gender equality), that all services provided
risk of HIV infection and others affected are free of stigma and discrimination and
by the epidemic. Adequate investments that service packages include essential
must finally be made into community HIV diagnostic, treatment and prevention
systems, which have been essential to services. No one should be left behind.
assure the resilience and sustainability of
the health system in the context of the
spread of COVID-19 and will be necessary
to finish the job, through advocating for
and supporting the delivery of vaccines,
when available. Domestic funding must
Status of HIV prevention services in the time of COVID-19
5
Background
Throughout 2020, the COVID-19 pandemic the potential to add another 500 000
swept around the world, leading to spikes people dying from AIDS-related causes
in excess mortality and untold suffering in sub-Saharan Africa by the end of 2021
(1). As the spread of SARS-CoV-19 (3). Access to health and HIV services
disrupts health systems and lockdowns is not the only concern, however. Many
and other containment measures restrict key and priority populations also face
People living with movement, threaten livelihoods and strain increased vulnerability and risk because
HIV and people economies, AIDS control programmes face of upturned livelihoods, interrupted
at higher risk of unprecedented threats. access to education, increased levels
HIV infection are of gender-based violence and, in some
facing immediate, People living with HIV and people at cases, an upsurge in punitive legal and
life-threatening higher risk of HIV infection are facing policy measures. Hard-won gains in HIV
challenges to immediate, life-threatening challenges to prevention, with the number of people
access the health access the health and HIV services that acquiring HIV declining by 23% since 2010,
and HIV services they need. HIV testing and treatment, are in danger of being reversed by the
that they need voluntary medical male circumcision, COVID-19 pandemic—and populations
condom procurement and distribution, already left behind are at risk of falling
needle syringe and opioid substitution further behind.
therapy programmes, pre-exposure
prophylaxis and other programmes This report considers the status of HIV
have all been negatively affected (2). prevention programmes in the time of
Modelling conducted on behalf of UNAIDS COVID-19 and efforts at the country level
and the World Health Organization has to make the necessary service adaptations
shown that a six-month disruption to and build synergy with COVID-19
antiretroviral therapy services alone has responses.
Laboratory test, Kyrgyzstan. Photo: Alexei Sokolov, AIDSInfoshare, UNAIDS
6 Status of HIV prevention services in the time of COVID-19
Aim and objectives
The aim is to provide a synthesis of the programme improvements—even under
status of HIV prevention programming the circumstances required to prevent
in the time of COVID-19, identifying key the ongoing transmission of SARS-CoV-2
vulnerabilities and risks, major service and address its consequences. It is hoped
disruptions and documenting responses that the report will serve as a basis for
in a range of settings. A major focus decision-making in the next year or
was placed on gathering information two, as countries step up their efforts to
on programme innovations at the control both epidemics.
community level.
This synthesis focuses on how the This synthesis
Specific objectives include: unfolding of the COVID-19 pandemic focuses on how
has affected efforts for the primary the unfolding of
To analyse information on how prevention of HIV infection among adults, the COVID-19
COVID-19 affects new patterns of HIV infants and children. For this purpose, pandemic has
infection, taking into account changes primary prevention encompasses “a affected efforts
in vulnerabilities and risks. network of strategically and necessarily for the primary
combined strategies” to anticipate prevention of HIV
To summarize available information on and avert new HIV infections and to infection among
disruptions of HIV prevention service contain the AIDS epidemic (4). These adults, infants
delivery in health facilities and in strategies include social and structural and children
communities. changes, are not limited to biomedical
commodities and services and assume
To document HIV prevention that people have the resources they
responses, including innovations and need to anticipate and deal with critical
good practices but also critical gaps. challenges. This implies that countries will
take concrete steps to address key policy
Based on the findings, to develop and legal barriers and create an enabling
propositions for HIV prevention in the environment for successful prevention
new normal. programmes. With this important
principle in mind, the Global HIV
This report is primarily directed to key Prevention Coalition has recommended
partners and decision-makers in the that HIV prevention responses be
global HIV and COVID-19 response. organized around five pillars, depending
These include technical and funding on country context (5):
partners and country-level decision-
makers, programme planners and Programmes for key populations,
managers. Additional audiences are including sex workers, gay and
UNAIDS staff, consultants and technical other men who have sex with men,
experts and members of civil society prisoners, people who inject drugs and
and community organizations. The transgender people.
lessons from successful HIV responses in
countries and communities are identified Programmes for adolescent girls and
and shared with a view to promote young women and their male partners
and sustain resilience strategies and in settings with high HIV incidence.
Status of HIV prevention services in the time of COVID-19
7
Condom promotion and distribution. their role in comprehensive programmes
for key and other priority populations,
Voluntary male medical circumcision. including but not only with respect to entry
into voluntary male medical circumcision,
Pre-exposure prophylaxis (PrEP). PrEP and services for preventing mother-
to-child transmission.
Information was gathered and synthesized
therefore on how COVID-19 has affected Relevant and illustrative experiences from
programming related to all five pillars and all countries from the Global South served
Information was to secure an enabling environment for HIV by UNAIDS have been considered, as
gathered and prevention. A specific focus was placed available. The sourcing of information has
synthesized on community-led prevention efforts. been opportunistic since efforts to collect
therefore on Information was also collected on the data comprehensively and systematically
how COVID-19 status of programmes for preventing HIV on this topic have not yet been put
has affected among infants and young children through into place. An attempt has been made,
programming programmes for preventing mother-to- however, to include country experiences
related to all child transmission. Finally, consideration across all regions and all main types of HIV
five pillars was given to HIV testing services, given epidemics.
and to secure
an enabling
environment for
HIV prevention
Visit to sex workers, Cotonou, Bénin. Photo: Yanick Folly / UNAIDS | Bénin
8 Status of HIV prevention services in the time of COVID-19Data sources
To set the context, information from primarily by querying the UNAIDS/WHO/
authoritative sources about the social and UNICEF HIV Services Disruption Tracking
economic impact of COVID-19 and how Database and/or the UNAIDS COVID-19
it affects health systems and other key Portal. Specifically, trends in country-
sectors such as education was identified. level service statistics from 1 January to
The main thrust of the exercise, however, 30 September 2020 were examined to
was seeking and summarizing information detect key service disruptions and identify
on HIV prevention responses at the multi-country and individual country
country level. trends in key prevention services and
numbers of clients served over the first
The main sources of data were as follows: nine months of the year. Trend data were Two potential
somewhat limited, and the countries’ ways COVID-19
reporting varied by the indicator being affects HIV
Literature (including grey literature) reported: good multimonth trend data on prevention are of
found through a structured but not one aspect of a country’s HIV prevention concern: service
exhaustive search approach. efforts was not often accompanied by disruptions in
similar trend data for other aspects of HIV prevention
Country, organizational and thematic its programme. Further, any analysis of programmes and
reports, such as from the Global Fund these data is compromised by the lack of related activities
to Fight AIDS, Tuberculosis and Malaria, good ways to measure the disruption and at the country
the United States President’s Plan recovery of services. The sudden arrival level and how
for Emergency AIDS Relief (PEPFAR) of the pandemic precluded a systematic these service
and the UNAIDS Secretariat and approach to developing a comprehensive disruptions
Cosponsors, including UNICEF, UNFPA, monitoring system with standardized affect the risk
UNODC, UNDP and the World Bank. indicators. As a result, the data that do of acquiring
exist are often incomplete, lack important HIV in specific
The UNAIDS COVID-19 Portal and the context and do not reveal trends. subpopulations
UNAIDS/WHO/UNICEF HIV Services
Disruption Tracking Database. This first-level analysis was complicated by
different timing of the arrival of COVID-19,
Reports of surveys conducted by different timing of the responses to it
diverse interested organizations, and differences in the intensity of these
responses. Contextual information
The results of COVID-19 impact to enable a better understanding of
modelling exercises. emerging patterns was sought from the
qualitative reports that accompanied these
A variety of methods was used to analyse data. As with the quantitative data, the
the data assembled for this enquiry. existence of high-quality information was
Two potential ways COVID-19 affects not uniform or consistent.
HIV prevention are of concern: service
disruptions in HIV prevention programmes In addition to the Portal data, other
and related activities at the country sources were sought and used to provide
level and how these service disruptions context when possible. Data from online
affect the risk of acquiring HIV in specific surveys and from other organizations such
subpopulations. The first was assessed as the Global Fund and from published
Status of HIV prevention services in the time of COVID-19
9and grey literature were also sought for Additional material was obtained mainly
inclusion. Responses to the numerous from narrative reports and results of
surveys that have been conducted, mostly primary studies based on interviews, and
online data collection, were examined to analysis was therefore largely qualitative,
The report detect effects on reported behaviour that focusing on key emerging themes
considers how may suggest how COVID-19 is affecting and providing illustrative case study
the unfolding of the risk behaviour patterns of those at descriptions.
the COVID-19 highest risk.
pandemic led to The report first considers how the
increased HIV The second impact, how COVID-19 affects unfolding of the COVID-19 pandemic led
vulnerability and the risk of acquiring HIV, is more difficult to to increased HIV vulnerability and risk,
risk, through assess at this stage. Several mathematical through disruptions to health services, and
disruptions to models originally developed to track the the economic and social repercussions of
health services, AIDS epidemic have been used to assess pandemic containment responses. It then
and the economic the potential impact of COVID-19 on examines the magnitude and potential
and social the epidemic trajectory. Most of these effect of HIV service disruptions, as
repercussions models have focused on treatment and predicted by early modelling efforts and
of pandemic AIDS mortality but less on prevention documented at the country level. It follows
containment and numbers of people acquiring HIV. As with examples of country-level adaptations
responses a result, these models are more limited and innovations. Finally, the report
in addressing how COVID-19 affects HIV provides propositions for the way forward.
prevention.
Visit to Kalembelembe Paediatric HIV Unit by First Lady of DRC and other officials. photo: UNAIDS Photolibrary
10 Status of HIV prevention services in the time of COVID-19A devastating new pandemic
Disrupting billions of lives and livelihoods, In 2020, an estimated 168 million people
the COVID-19 pandemic threatens need humanitarian assistance and face
decades of hard-won development and a considerably worse situation because
public health gains. By late December of the COVID-19 pandemic (7). In a
2020, the global number of new cases wide range of settings, lockdowns and
reported was increasing, and all countries other containment measures have been
were affected in some way or another. adopted to curtail the spread of the virus
The pandemic is challenging the world’s (Figure 1). These measures can restrict
health systems and has triggered a deep livelihood options and access to a range
global economic downturn, with uncertain of social, educational and health services.
outcomes (6). The recession in advanced In some settings, concerns have been
economies is hitting low- and middle- raised about measures such as curfews,
income countries hard and exacting banning demonstrations, enforcement
a massive toll on poor and vulnerable via police or military violence, restricting
people. The World Bank warns that millions media and responses benefitting certain
of people will fall into extreme poverty, groups or regions at the expense of
and millions of existing poor people will others, which may be perceived to restrict
experience even deeper deprivation—the civil and political liberties and exacerbate
first increase in global poverty since 1998 existing or create new societal fault lines
(6). The pandemic is aggravating social (such as those based on identity, political
and economic inequalities in most affected allegiance or regional disparities) (8).
countries. In fragile and conflict-affected These threats require particular vigilance
situations, it is deepening existing sources to leave no one behind in responding to
of fragility and exacerbating instability. the COVID-19 pandemic.
Figure 1. National lockdown measures implemented because of COVID-19, global overview
Yes Unknown No
Sources: UNICEF Rapid Situation Tracking for COVID-19 Socioeconomic Impacts and Assessment Capacities Project (ACAPS).
Status of HIV prevention services in the time of COVID-19
11Effect on vulnerability to
HIV infection
The COVID-19 crisis is amplifying the girls and boys, and it is likely to hit
deep inequalities and vulnerabilities that marginalized girls the hardest (20). Girls’
structurally drive the HIV epidemic (9). education has long been recognized as a
In both cases, poor, marginalized and critical tool for advancing gender equality
criminalized people are the most exposed and enhancing the health and welfare of
to infection and death and the least families and communities (21).
able to cope with the broader epidemic
effects. In some contexts, efforts aimed All key populations, including sex
at controlling the spread of COVID-19 workers, gay men and other men who
penalize people already on the margins of have sex with men, transgender people
The COVID-19 society. and people who inject drugs, and also
crisis is amplifying migrants, refugees, internally displaced
the deep Although the available data suggest people and populations in humanitarian
inequalities and that men experience higher rates of settings, face higher risks of COVID-19
vulnerabilities COVID-19-related deaths (10), women and a range of adverse socioeconomic
that structurally and girls in all their diversity are bearing effects that increase their vulnerability
drive the HIV a disproportionate burden of the larger to and, in turn, risk of acquiring HIV (22).
epidemic. Poor, effects of the pandemic and of emergency This is of grave concern—although they
marginalized responses, given entrenched gender- are a small proportion of the general
and criminalized based social and economic disparities, population, key populations and their
people are the women’s roles in the informal economy sexual partners accounted for more than
most exposed and their unpaid care and domestic 60% of the adults acquiring HIV infection
to infection and workload (11–14). In particular, efforts to in 2019 (23). Stigma and discrimination,
death and the reduce COVID-19 transmission, including punitive laws and practices, lack of
least able to cope mobility restrictions, geographical infrastructure and medications and
with the broader lockdowns and curfews—compounded other health commodities and the lack
epidemic effects by pandemic-linked stresses—have led of tailored information and services
to sharp increases in reported violence pose recurrent, overlapping and often
against women and girls (15, 16). India entrenched challenges to meeting their
reported double the usual number of basic needs. These populations are hard
domestic abuse cases in the first week to reach through formal health facility
of nationwide movement restrictions, structures. They also tend to have limited
according to the country’s National livelihood options. Currently, more
Commission for Women (17), and South than half of the world’s population is
African police reported 87 000 gender- estimated to have no social protection
based violence calls in the first week of coverage (23). This applies to many
that country’s lockdown (18). populations most severely affected by
HIV and AIDS, who may also be excluded
At the end of March 2020, about 89% of from assistance packages in the face of
students worldwide were not attending the COVID-19 pandemic. In addition,
school because of COVID-19 closures. aggressive enforcement of restrictions
This represents 1.54 billion children and created for containing the pandemic
youth enrolled in school or university, have targeted marginalized communities
including nearly 743 million girls (19). in some countries, amplifying their
The impact of this period of disrupted vulnerability and undermining public
education will be far-reaching for both health objectives (24).
12 Status of HIV prevention services in the time of COVID-19Sex workers all over the world are facing because they are frequently detained in
increased discrimination and harassment, crowded, confined and poorly ventilated
with reports of punitive crackdowns against spaces and are exposed to high levels of
sex workers resulting in raids on homes, violence, including sexual violence (36, Some of the
compulsory COVID-19 testing, arrests 37). Prison populations already have a 272 million
and episodes of extortion and threatened weaker health profile than the broader international
deportation of migrant sex workers (25, community, and many prisons do not migrants and
26). Their livelihoods are under threat provide adequate health care, including refugees
(27). For example, when Thailand shut access to condoms, lubricants, PrEP worldwide
23 000 entertainment venues as part of and harm-reduction services (38). The have had their
its lockdown, tens of thousands of sex COVID-19 crisis exposes yet again and vulnerability
workers were instantly left unemployed compounds these stark inequities. exacerbated by
and without a source of income (28). A the COVID-19
rapid community-led assessment managed Some of the 272 million international pandemic
by Service Workers in Groups (SWING), migrants and refugees worldwide have because of a lack
an organization led by Thai sex workers, had their vulnerability exacerbated by the of appropriate
showed that many sex workers were COVID-19 pandemic because of a lack of health insurance,
unable to pay for daily expenses, housing appropriate health insurance, insufficient insufficient
and medicine (29). In settings in which income and stigmatization because of the income and
any aspect of sex work is criminalized, perception that migrants carry infection stigmatization
sex workers lack legal protection against and disease (39, 40). According to the because of the
violence, discrimination and abuse and International Organization for Migration, perception that
are excluded from the labour protections at least 2.75 million migrants have been migrants carry
and benefits that might be available to stranded globally by travel restrictions infection and
workers in the formal sector (30). Many imposed to contain the spread of the disease
similar examples exist. Demands for social COVID-19 pandemic and face even higher
distancing, curfews and restrictions on levels than ever of abuse, exploitation
movement have all contributed to reducing and neglect and amplifying underpinning
income from a livelihood that is increasingly vulnerability to HIV infection (40, 41).
difficult to pursue.
Gay and other men who have sex with men
and gender-diverse people seeking health
care, escape from violent situations or work
to survive can get caught up in criminal
law enforcement for violating movement
restrictions. Reports of harassment have
emerged from numerous countries in
the wake of restrictions linked to the
COVID-19 response (31–33). In some
settings, transgender people cannot leave
their homes without facing harassment or
punishment under the gender-segregated
quarantine measures that have been
enforced in a few countries. For example, a
transgender woman health outreach worker
in Panama was detained by police for being Homeless and unemployed people queue to receive food during the nationwide
out on the “wrong day” (34). People who lockdown as a preventive measure against the COVID-19 coronavirus, Mumbai/India.
use drugs have similarly reported increased Photo: Shutterstock
risks of police harassment and violence
during COVID-19 (35).
People in prisons and other closed
settings confront especially high risks of
acquiring infections, including COVID-19,
HIV, hepatitis C and tuberculosis,
Status of HIV prevention services in the time of COVID-19
13Effect on the risk of
acquiring HIV
The COVID-19 pandemic has clearly sexual abuse by peers and older men and
exacerbated the pre-existing vulnerability transactional sex to cover basic needs
of most key and priority populations (11). All these factors are associated with
through multiple mechanisms. increased risk of acquiring HIV. School
Nevertheless, how this vulnerability closures may be especially devastating
might translate now and into the future for girls with greater vulnerability, such
into changes in high-risk sexual or other as refugees, internally displaced people,
behaviour and how this might affect the returnees and girls with disabilities (48),
number of people acquiring HIV are not who face high risks of acquiring HIV
The impact of understood. through sexual violence in many settings.
COVID-19 on
women’s access Increased levels of violence, and the fear of Further, women and girls in many settings
to modern violence, associated with COVID-19 create have faced major barriers to accessing
contraceptives special difficulty for women in deciding services, including necessary sexual and
could result whether they will have sex (and with whom) reproductive health services—key points for
in a decline of and in negotiating safer sex (42). Violence, delivering critical HIV services for women
6 percentage or the potential for it, discourages many and girls, including HIV testing, prevention
points (from 77% women living with HIV from disclosing counselling and programmes for preventing
to 71%) in the their HIV-positive status to their partners, mother-to-child transmission (49). The
proportion of families and health-care providers, impact of COVID-19 on women’s access
women in 2020 creating difficulty for women and girls to to modern contraceptives could result in a
having their stay on HIV treatment (43). This can lead decline of 6 percentage points (from 77%
need for family to serious health problems for them but to 71%) in the proportion of women in
planning met, also curtails the prevention benefits of HIV 2020 having their need for family planning
resulting in about testing and treatment. met, resulting in about 60 million fewer
60 million fewer users of modern contraception worldwide
users of modern Education for girls, especially secondary in one year (50). In regions that rely less
contraception education, protects against acquiring HIV on long-acting contraceptive methods,
worldwide in one (44–46). This protection will be a huge such as sub-Saharan Africa, the potential
year and enduring loss in the aftermath of impact may be even greater. Increased
school interruptions because of COVID-19. unplanned pregnancies may substantially
Lessons learned from the Ebola crisis show affect the potential need for services to
that school closures can lead to increases prevent the mother-to-child transmission
in gender-based violence, teenage of HIV, services that have been affected
pregnancies, child marriage, exploitation themselves, especially if disruptions
and other forms of abuse against continue over a long period of time. Even
adolescent girls (including online sexual when countries have identified sexual and
exploitation and grooming) (47). reproductive health care as being essential,
barriers such as the increased burden of
Past crises have shown that adolescent care and transport and mobility bans have
girls are more likely to drop out after hampered health-seeking behaviour.
school closures, which further entrenches
gender gaps in education and leads Experiences from Kenya suggest that
to increased rates of early and forced the changes in the patterns of sex work
marriage, early pregnancy, unplanned or resulting from COVID-19 may lead to
forced sexual activity, risk of physical and situations and behaviour that increase
14 Status of HIV prevention services in the time of COVID-19the risk of HIV transmission (51). One efforts to reduce sexual transmission in sex
longstanding programme delivering sexual work settings.
health services to sex workers in Kenya has
been collecting information on the effects Very little information is available on
of the disruptions through online virtual risk behaviour in other key and priority
discussions (11). The disruptions have forced populations. A survey conducted in
sex workers to adapt in oftentimes risky the United Kingdom, where COVID-19
ways. Some sex workers have attempted restrictions discourage sexual intercourse
to bring clients to their homes to avoid with a casual partner, showed that most of
curfews but have encountered problems of the 1386 gay and bisexual men surveyed
privacy and the surveillance of neighbours between 17 April and 8 May reported
who have chastised them for breaking abstaining from casual sex during the
physical distancing rules and placing their lockdown, with 57% anticipating that
communities at further risk for COVID-19. their avoidance of casual sex would last
Sex workers have also tried going to the at least six months (55). This report may
clients’ homes, but this is risky, since they indicate the potential for lower rates of HIV The Global
have less control over their environment transmission in 2020. However, evidence Network of Sex
and do not benefit from the usual also indicates that people engage in Work Projects
protection of other sex workers, bartenders high-risk sexual behaviour as they seek to surveyed its
and bouncers, which leaves them more relieve loneliness and stress during the members in
vulnerable to physical and sexual violence pandemic. Among the men surveyed, 24% 55 countries
and not being paid as agreed. Some male reported having had casual sex during the and found
clients have kept them past curfew hours, lockdown, with 5% reporting having had that COVID-19
effectively forcing them to stay overnight, more than five casual partners. Similarly, a restrictions led to
then deducting a fee for lodging and food global online survey among more than 200 many challenges,
from the agreed cost of sex. Disagreements people who use drugs from 50 countries exposing sex
and violence are not uncommon or, if conducted in May 2020 highlighted severe workers to
sex workers break curfew to avoid this COVID-related disruptions to their lives severe loss of
situation, encounters with police and and many barriers to accessing services income, increased
potential harassment and confinement in (35). Anecdotal reports of multiple drug discrimination
quarantine centres. In the latter case, some use to manage drug shortages and deaths and harassment,
sex workers have reported securing their associated with overdose suggest that hunger and
freedom through unprotected sex with law COVID-19 is likely to have severe health reduced access
enforcement agents. In addition to these effects on people who use drugs. The to condoms
and many other indignities and risks they impact on whether they acquire or transmit and lubricants
face, sex workers have also experienced HIV, however, remains unclear. and other HIV
major losses in income. Because sex services, such as
work in Kenya is both criminalized and To obtain a clearer picture of how the HIV testing and
highly stigmatized, accessing social and pandemic affects high-risk sexual and harm reduction
financial support through government other behaviour, further studies are
social protection schemes is difficult if not needed in settings with both high and low
impossible. All these factors suggest that HIV prevalence. Evidence of any changes
sex work may have become much riskier in in incidence in the time of COVID-19 is
the time of COVID-19. expected to be available over the coming
year, as countries estimate the numbers of
The Global Network of Sex Work Projects people acquiring HIV in their populations,
surveyed its members in 55 countries and using standard approaches. Additional
found that COVID-19 restrictions led to data may also become available from well-
many challenges, exposing sex workers characterized cohorts in settings with a
to severe loss of income, increased high burden of HIV infection. Any changes
discrimination and harassment, hunger and need to be carefully analysed to assess to
reduced access to condoms and lubricants what extent they may be associated with
and other HIV services, such as HIV testing increased COVID-19 vulnerability, changes
and harm reduction (50, 52–54). These in high-risk behaviour and/or disruptions to
situations are evidence of considerable HIV prevention or treatment services.
setbacks, which do not portend well for
Status of HIV prevention services in the time of COVID-19
15Country-level adaptations
and innovations
Countries and communities have responded to how the spread of COVID-19 threatens
HIV prevention efforts in various ways, as described below and summarized in Table 1.
The country-level examples show how these measures can complement and support
each other, in a coherent and comprehensive approach to confronting both the
COVID-19 and HIV threats.
Table 1. Adaptations and innovations to bolster HIV prevention efforts in the time of COVID-19
Measures taken
Strengthen national and • Support the convergence of COVID-19 and HIV prevention efforts
subnational planning and • Strengthen coordination and build links between COVID-19 and AIDS control strategies
policy measures • Develop HIV contingency plans, reprogramme HIV activities as required and secure funding
• Consider temporary delay or repurposing of certain interventions (such as voluntary male medical
circumcision)
• Strengthen civil society engagement in both COVID-19 and AIDS control planning and
implementation
• Allow exemptions to COVID-19-related restrictions to enable continued HIV service delivery
• Remove or temporarily suspend health-care-related user fees
• Provide technical and financial support and supplies to community-based organizations to enable
continued HIV service delivery at the community level
• Strengthen social protection measures for vulnerable groups
• Minimize school closures and disruptions
Protect and promote rights • Monitor and report cases of violence and other human rights violations among key populations
and people living with HIV during the pandemic
• Extend services to prevent violence against women and support survivors
• Promote and protect sexual and reproductive rights and services
• Strengthen judicial systems to give priority to cases of violence against women and other
vulnerable groups
• Minimize pre-trial detention and incarceration for non-violent crimes in accordance with
international guidance
• Reduce inequities in the provision of health services to incarcerated populations
• Ensure the delivery of health, education and social services to mobile and migrant populations
Reconfigure service • Conduct rapid assessments to identify evolving needs and opportunities
delivery models • Safeguard the COVID-19 health and safety of implementers and beneficiaries
• Facilitate access to essential services, goods and commodities
• Decentralize services to the access points preferred by key and priority populations
• Bundle services at the point of service delivery
• Maximize distance-supported and online service delivery options
• Support supply chain continuity
• Strengthen systems to track the services delivered and population coverage
16 Status of HIV prevention services in the time of COVID-19National actions to address the
intersections of COVID-19 and AIDS
Many countries around the world took system disruptions. Several countries took
early, decisive action to address critical advantage of Global Fund support to
vulnerabilities, maintain health services protect the continuity of disease control
and build synergy between COVID-19 programmes, strengthen critical systems
and AIDS control approaches. In some for health and fight COVID-19. In early
countries, national HIV leaders were March 2020, the Global Fund enabled
mobilized to drive national COVID-19 countries to use up to US$ 500 million in
responses (56). For example, in South grant flexibility to rapidly adapt existing
Africa, a global leader in HIV prevention programmes and to purchase protective
research was appointed to head the equipment, diagnostics and medical
medical advisory committee for the supplies (57). In April, the Global Fund
COVID-19 response, and the director took a further step by launching the
of the national AIDS coordinating body COVID-19 Response Mechanism with an
helped to coordinate a multisectoral initial capacity of an additional US$ 500
advisory forum for the response. National million. As an example, Senegal took
AIDS directors in countries such as Angola, advantage of grant flexibility to support
Brazil, China, the Democratic Republic health-care workers providing critical Support from
of the Congo, Guatemala, Guinea, the services to key populations such as people health authorities
Islamic Republic of Iran, Kenya, Malawi, who inject drugs by equipping staff at has been critical
Mexico, Nigeria and Zambia are serving methadone clinics with personal protective to lift barriers to
as members of national planning and equipment and adapting services to community-based
decision-making bodies for national enable temperature checks, handwashing service delivery
COVID-19 responses. In other countries, and masks for all clients (57). Other
such as the Democratic Republic of the positive changes during the pandemic
Congo, Eswatini, Ghana, Indonesia, have included removing or suspending
Malawi, the United Republic of Tanzania health care–related user fees in at least
and Zambia, UNAIDS data show that four countries in sub-Saharan Africa (58).
HIV-focused civil society organizations
are participating in national COVID-19 Support from health authorities has been
response planning and HIV contingency critical to lift barriers to community-based
planning efforts. In Kenya, according to service delivery. For example, in Kenya, the
UNAIDS data, the government is also Ministry of Health offered early guidance
strengthening structures for community and policy support to community-based
engagement in the COVID-19 response organizations for continued service
and mitigating its impact on HIV delivery in the context of strict measures
programming at the subnational level. to prevent the spread of SARS-CoV-2
These connections are important to ensure (including a dusk-to-dawn curfew and
that the lessons learned in tackling HIV mobility restrictions) (33). According to
are being applied to COVID-19 action, UNAIDS data, in Myanmar, the government
to support links between COVID-19 and has provided special permission to allow
other disease control programmes and unhindered movement of peers and
to mobilize additional funds to address community members who serve as health
common challenges. volunteers. Using COVID-19 personal
protective equipment and risk-reduction
The health authorities in many countries measures, they are able to continue to
took swift action to anticipate health deliver HIV prevention services, including
Status of HIV prevention services in the time of COVID-19
17HIV testing and commodities. Engagement households not receiving other monetary
with community service organizations support. Single mothers receive a double
and capacity-building efforts have also benefit. Several other countries have also
been reported in other countries, such introduced fiscal and economic measures
as Angola and Botswana. Virtual civil to support women in the economy (61).
society organization and community-based
organization platforms have been set up Overall, however, an insufficient number
to facilitate collaboration and programme of countries have sufficiently strengthened
integration in Botswana and Cameroon. and extended social protection systems
and other critical policy measures to
Some countries have reconsidered relieve the social and economic impact
priorities and consequently arranged of COVID-19. And even fewer countries
a temporary delay and repurposing of have implemented gender-sensitive
some HIV prevention interventions for measures in response to COVID-19,
which a programme hiatus would not considering the disproportionate impact
result in immediate increases in risk. of the pandemic on women, in terms
For example, voluntary medical male of the surge in violence against women
circumcision programmes were paused and girls, the unprecedented increase
in several countries during the first half of in unpaid care work and the large-scale
Other countries 2020 to enable health-care providers to loss of livelihoods, especially in the
have taken be reassigned to fight COVID-19 and to informal sector, in which women are
bold steps to reduce the transmission risks associated overrepresented (61).
strengthen with congregations of young people.
social protection In Botswana, Lesotho, South Africa and
measures to limit Zimbabwe, for example, the number of
Communities at the centre
the human and procedures plummeted––in Zimbabwe’s
economic impact case from about 24 000 in February 2020 of the emergency responses
of the COVID-19 to a few hundred a month after April
pandemic, with 2020. Kenya also experienced a decline, Efforts to maintain health services during
a special focus although services resumed rapidly after COVID-19 lockdowns have underscored
on vulnerable May 2020 (among men and boys older yet again the critical role played by
populations than 15 years) (Figure 16) (58). community-led organizations, which
are responsive to the needs, priorities
Other countries have taken bold steps to and rights of vulnerable populations.
strengthen social protection measures to Organizations that are at the centre of the
limit the human and economic impact of HIV response have stepped forward to
the COVID-19 pandemic, with a special lead local actions to fight both COVID-19
focus on vulnerable populations. For and HIV, challenging misinformation
example, the Ministry of Social Affairs of and stigmatization, delivering essential
Indonesia has introduced social safety supplies to those in need and organizing
net support for low-income households local support systems. According to a
such as food aid and conditional cash survey of 160 civil society organizations
transfers, and civil society organizations by the Civil Society Institute for HIV
working on HIV have worked actively and Health in West and Central Africa
to help key population beneficiaries conducted in May 2020, most (72%)
access this support in their localities HIV-focused organizations were already
(59). The Government of Thailand will working to raise COVID-19 awareness in
pay unemployed workers up to 50% of their communities (56). Although some
their wages for up to six months and community organizations were successful
has earmarked 45 billion baht for cash in mobilizing financial resources for
handouts to support informal workers COVID-19-related work, others said they
who are not covered by social security were struggling to handle the additional
(59, 60). Brazil established an emergency responsibilities. Many also reported
cash transfer of US$ 115 per month (or difficulties in obtaining sufficient personal
60% of the minimum wage) for adults who protective equipment for their staff.
do not have a formal job and live in poor
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