Preventing HIV infections at the time of a new pandemic - A synthesis report on programme disruptions and adaptations during the COVID-19 pandemic ...

 
Preventing HIV infections at the time of a new pandemic - A synthesis report on programme disruptions and adaptations during the COVID-19 pandemic ...
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
Preventing HIV infections at the time of a new pandemic - A synthesis report on programme disruptions and adaptations during the COVID-19 pandemic ...
Cover graphic: Shutterstock
Preventing HIV infections at the time of a new pandemic - A synthesis report on programme disruptions and adaptations during the COVID-19 pandemic ...
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
Preventing HIV infections at the time of a new pandemic - A synthesis report on programme disruptions and adaptations during the COVID-19 pandemic ...
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
Preventing HIV infections at the time of a new pandemic - A synthesis report on programme disruptions and adaptations during the COVID-19 pandemic ...
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
Preventing HIV infections at the time of a new pandemic - A synthesis report on programme disruptions and adaptations during the COVID-19 pandemic ...
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
Preventing HIV infections at the time of a new pandemic - A synthesis report on programme disruptions and adaptations during the COVID-19 pandemic ...
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
Preventing HIV infections at the time of a new pandemic - A synthesis report on programme disruptions and adaptations during the COVID-19 pandemic ...
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
Preventing HIV infections at the time of a new pandemic - A synthesis report on programme disruptions and adaptations during the COVID-19 pandemic ...
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
ƒ 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
ƒ 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
ƒ 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
ƒ 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             ƒ 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   ƒ 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
Preventing HIV infections at the time of a new pandemic - A synthesis report on programme disruptions and adaptations during the COVID-19 pandemic ...
ƒ Condom promotion and distribution.                        their role in comprehensive programmes
                                                                                        for key and other priority populations,
                            ƒ Voluntary male medical circumcision.                      including but not only with respect to entry
                                                                                        into voluntary male medical circumcision,
                            ƒ 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-19
Data 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
ƒ 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
ƒ 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
ƒ 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,
ƒ 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
ƒ 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
                                                                                                                                9
and 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-19
A 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
                                                                                                                                                                 11
Effect 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-19
Sex 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
                                                                                                                                      13
Effect 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-19
the 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
                                                                                                                                 15
Country-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-19
National 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
                                                                                                                               17
HIV 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

18      Status of HIV prevention services in the time of COVID-19
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