"We've been set back by COVID, but we've seen remarkable resilience, a lot of innovation and creativity," Siobhan Crowley MD, head of HIV at the Global Fund, says.
"If you consider that 21.9 million people are getting (HIV drugs) at this point through the Global Fund, I think that needs to be appreciated. Ten years ago, that wouldn't have been the case; all of those people would have disappeared into the ethers."
Through close partnerships with the U.S. Agency for International Development, the U.S. Emergency Plan for AIDS Relief, and other Western countries and organizations, the Global Fund has invested $22.7 billion in programs to prevent and treat HIV and AIDS, and $3.8 billion in tuberculosis /HIV programs, according to the organization's 2021 annual report.
But the report also underscores the significant effect the COVID-19 pandemic has had on progress that Global Fund beneficiary countries have made toward targets for HIV testing/diagnosis, treatment, and viral suppression by 2030.
The setbacks have been challenging and have touched nearly every service from prevention to treatment. According to the report, between 2019 and 2020:
- Voluntary male circumcision declined by 27%.
- Numbers reached by HIV prevention programs fell by 11%.
- 4.5% fewer mothers received medications to prevent HIV transmission to their babies.
- HIV testing services, including initiation, decreased by 22%.
The numbers only tell a part of the story, Crowley says.
"We put in place an emergency mechanism to make funds available for countries to do everything except vaccines in support of COVID," Crowley explained. (As of August 2021, these funds had been sent to 107 countries and 16 multicountry programs.)
Countries were advised that they could use the emergency funds three ways: for COVID-specific purposes (eg, diagnostics, oxygen, personal protective equipment; to support existing HIV, tuberculosis, and malaria programs, or for getting them back on track; and for so-called "health system fixes," such as investing in data systems to track COVID, HIV, and other core diseases, as well as the community workforce.
Countries were also asked to adapt HIV testing procedures by, for example, moving organized testing out of the facilities and into neighborhoods to meet people where they are. Rapid diagnostic testing and triage care using technologies such as WhatsApp were the result, as were opportunities for home testing which, Crowley says, remains a critical component of the overall strategy.
"The self-test is important for two reasons, not just because you are trying to find people with HIV, but also, when people know that they're negative, they know what they can or should do to stay negative," she said. "It's quite a powerful motivator."
The Imperfect Storm Globally and in the US
"One of the things that was striking in the report was the decline in the number of people reached with testing and prevention services," Chris Beyrer, MD, professor of Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health in Baltimore, says. Beyrer was not involved in the report's development.
"You know, a 10% decline in 1 year to reach people in need is substantial," he said. "Let's say it continues; many people are predicting that we won't have reasonable coverage for low income countries with COVID until 2023. That adds up to a substantial decline in people reached with these services."
Beyrer says he is also concerned about the convergence of HIV and tuberculosis in already overburdened, fragile health care systems. "Globally, the number-one cause of death for people living with HIV is TB, and of course, it's highly transmissible. So, in many high-burden countries, children are exposed, typically from household members early on, and so the number of people with latent TB infection is just enormous."
But it's not time for U.S. providers to rest on their laurels either. Beyrer says that the 22% decline in HIV testing reported by the Global Fund is similar to what has been happening in the United States with elective procedures such as HIV testing and even preventive procedures like medical male circumcision.
"It's very clear here in the Global Fund data that the majority of new infections worldwide are in key populations [that] include gay and bisexual men, men who have sex with men, transgender women who have sex with men, people who inject drugs, sex workers of all genders. Those are people who already faced barriers to health care access and were made worse by COVID."
Beyrer says that, according to the Centers for Disease Control and Prevention, in 2019 in the United States 68% of new HIV infections occurred in gay and bisexual men, and the effect that COVID will have is still unknown.
"It's also where we are seeing the worst of COVID, low immunization coverage, and high rates of hospitalization and death,” he says. "It's a dark, dark time for many," Crowley said. "And there has also been some amazing resilience and adaptation." "The weird thing is, the HIV platform is a natural platform; I mean, if we can keep 21.9 million people on treatment, we can probably deliver them a COVID test and a vaccine."