the impact of the covid 19 lockdown on hiv care in 65 south african primary care clinics CORD-Papers-2022-06-02 (Version 1)

Title: The impact of the COVID-19 lockdown on HIV care in 65 South African primary care clinics: an interrupted time series analysis
Abstract: BACKGROUND: The effect of the COVID-19 pandemic on HIV outcomes in low-income and middle-income countries is poorly described. We aimed to measure the impact of the 2020 national COVID-19 lockdown on HIV testing and treatment in KwaZulu-Natal South Africa where 17 million people are living with HIV. METHODS: In this interrupted time series analysis we analysed anonymised programmatic data from 65 primary care clinics in KwaZulu-Natal province South Africa. We included data from people testing for HIV initiating antiretroviral therapy (ART) and collecting ART at participating clinics during the study period with no age restrictions. We used descriptive statistics to summarise demographic and clinical data and present crude summaries of the main outcomes of numbers of HIV tests per month ART initiations per week and ART collection visits per week before and after the national lockdown that began on March 27 2020. We used Poisson segmented regression models to estimate the immediate impact of the lockdown on these outcomes as well as post-lockdown trends. FINDINGS: Between Jan 1 2018 and July 31 2020 we recorded 1 315 439 HIV tests. Between Jan 1 2018 and June 15 2020 we recorded 71 142 ART initiations and 2 319 992 ART collection visits. We recorded a median of 41 926 HIV tests per month before lockdown (January 2018 to March 2020; IQR 37 83851 069) and a median of 38 911 HIV tests per month after lockdown (April 2020 to July 2020; IQR 32 69942 756). In the Poisson regression model taking into account long-term trends lockdown was associated with an estimated 476% decrease in HIV testing in April 2020 (incidence rate ratio [IRR] 0524 95% CI 04460615). ART initiations decreased from a median of 571 per week before lockdown (IQR 498678) to 375 per week after lockdown (331399) with an estimated 462% decrease in the Poisson regression model in the first week of lockdown (March 30 2020 to April 5 2020; IRR 0538 04590630). There was no marked change in the number of ART collection visits (median 18 519 visits per week before lockdown [IQR 17 07419 922] vs 17 863 visits per week after lockdown [17 50918 995]; estimated effect in the first week of lockdown IRR 0932 95% CI 07941093). As restrictions eased HIV testing and ART initiations gradually improved towards pre-lockdown levels (slope change 1183/month 95% CI 11131256 for HIV testing; 1156/month 10851230 for ART initiations). INTERPRETATION: ART provision was generally maintained during the 2020 COVID-19 lockdown but HIV testing and ART initiations were heavily impacted. Strategies to increase testing and treatment initiation should be implemented. FUNDING: Wellcome Trust Africa Oxford Initiative.
Published: 2021-02-04
Journal: Lancet HIV
DOI: 10.1016/s2352-3018(20)30359-3
DOI_URL: http://doi.org/10.1016/s2352-3018(20)30359-3
Author Name: Dorward Jienchi
Author link: https://covid19-data.nist.gov/pid/rest/local/author/dorward_jienchi
Author Name: Khubone Thokozani
Author link: https://covid19-data.nist.gov/pid/rest/local/author/khubone_thokozani
Author Name: Gate Kelly
Author link: https://covid19-data.nist.gov/pid/rest/local/author/gate_kelly
Author Name: Ngobese Hope
Author link: https://covid19-data.nist.gov/pid/rest/local/author/ngobese_hope
Author Name: Sookrajh Yukteshwar
Author link: https://covid19-data.nist.gov/pid/rest/local/author/sookrajh_yukteshwar
Author Name: Mkhize Siyabonga
Author link: https://covid19-data.nist.gov/pid/rest/local/author/mkhize_siyabonga
Author Name: Jeewa Aslam
Author link: https://covid19-data.nist.gov/pid/rest/local/author/jeewa_aslam
Author Name: Bottomley Christian
Author link: https://covid19-data.nist.gov/pid/rest/local/author/bottomley_christian
Author Name: Lewis Lara
Author link: https://covid19-data.nist.gov/pid/rest/local/author/lewis_lara
Author Name: Baisley Kathy
Author link: https://covid19-data.nist.gov/pid/rest/local/author/baisley_kathy
Author Name: Butler Christopher C
Author link: https://covid19-data.nist.gov/pid/rest/local/author/butler_christopher_c
Author Name: Gxagxisa Nomakhosi
Author link: https://covid19-data.nist.gov/pid/rest/local/author/gxagxisa_nomakhosi
Author Name: Garrett Nigel
Author link: https://covid19-data.nist.gov/pid/rest/local/author/garrett_nigel
sha: f6fabc0a55882ba6fcb609806a429682cf55003c
license: cc-by
license_url: https://creativecommons.org/licenses/by/4.0/
source_x: Medline; PMC
source_x_url: https://www.medline.com/https://www.ncbi.nlm.nih.gov/pubmed/
pubmed_id: 33549166
pubmed_id_url: https://www.ncbi.nlm.nih.gov/pubmed/33549166
pmcid: PMC8011055
pmcid_url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8011055
url: https://doi.org/10.1016/s2352-3018(20)30359-3 https://www.ncbi.nlm.nih.gov/pubmed/33549166/
has_full_text: TRUE
Keywords Extracted from Text Content: 1·113-1·256 lockdown people lockdown IRR 0·932 COVID-19 lockdown [17 509-18 995 pre-lockdown COVID-19 lockdown antiretroviral 1·085-1·230 Patients 0·823 SARS-CoV-2 Pre-lockdown people 3·4 5·4 7·5 CD4 cell Bethesda Hospital SM, AJ Oct 16 antiretroviral BE646/17 CB LL KB patients 0·973-1·391 People COVID-19 lockdowns collec 7·0 1·163 IRR 1·991 post-lockdown capturers implemen lockdown 4·0-4·8 coronavirus 2 KZ_201807_021 KG stay-at-home 1·113-1·366 women lockdown implemen patient pre-lockdown men COVID-19 lockdown 1·165, 1·042-1·303 1·584-2·503 YS 1·110-1·456 1·113-1·256 appendix Post-lockdown NGx 1·271 IRR 1·926 NGa COVID-19 lockdowns collateral appendix p 1 1·085-1·230 Bethesda Hospital primary Bethesda Hospital patients
Extracted Text Content in Record: First 5000 Characters:Background The effect of the COVID-19 pandemic on HIV outcomes in low-income and middle-income countries is poorly described. We aimed to measure the impact of the 2020 national COVID-19 lockdown on HIV testing and treatment in KwaZulu-Natal, South Africa, where 1·7 million people are living with HIV. Methods In this interrupted time series analysis, we analysed anonymised programmatic data from 65 primary care clinics in KwaZulu-Natal province, South Africa. We included data from people testing for HIV, initiating antiretroviral therapy (ART), and collecting ART at participating clinics during the study period, with no age restrictions. We used descriptive statistics to summarise demographic and clinical data, and present crude summaries of the main outcomes of numbers of HIV tests per month, ART initiations per week, and ART collection visits per week, before and after the national lockdown that began on March 27, 2020. We used Poisson segmented regression models to estimate the immediate impact of the lockdown on these outcomes, as well as post-lockdown trends. Findings Between Jan 1, 2018, and July 31, 2020, we recorded 1 315 439 HIV tests. Between Jan 1, 2018, and June 15, 2020, we recorded 71 142 ART initiations and 2 319 992 ART collection visits. We recorded a median of 41 926 HIV tests per month before lockdown (January, 2018, to March, 2020; IQR 37 838-51 069) and a median of 38 911 HIV tests per month after lockdown (April, 2020, to July, 2020; IQR 32 699-42 756). In the Poisson regression model, taking into account long-term trends, lockdown was associated with an estimated 47·6% decrease in HIV testing in April, 2020 (incidence rate ratio [IRR] 0·524, 95% CI 0·446-0·615). ART initiations decreased from a median of 571 per week before lockdown (IQR 498-678), to 375 per week after lockdown (331-399), with an estimated 46·2% decrease in the Poisson regression model in the first week of lockdown (March 30, 2020, to April 5, 2020; IRR 0·538, 0·459-0·630). There was no marked change in the number of ART collection visits (median 18 519 visits per week before lockdown [IQR 17 074-19 922] vs 17 863 visits per week after lockdown [17 509-18 995]; estimated effect in the first week of lockdown IRR 0·932, 95% CI 0·794-1·093). As restrictions eased, HIV testing and ART initiations gradually improved towards pre-lockdown levels (slope change 1·183/month, 95% CI 1·113-1·256 for HIV testing; 1·156/month, 1·085-1·230 for ART initiations). Interpretation ART provision was generally maintained during the 2020 COVID-19 lockdown, but HIV testing and ART initiations were heavily impacted. Strategies to increase testing and treatment initiation should be implemented. Funding Wellcome Trust, Africa Oxford Initiative. The number of deaths from COVID-19 continues to rise globally, but data quantifying the effect of the pandemic on other health conditions are scarce, especially in low-income and middle-income countries. Interruption of supply chains, diversion of resources, and overwhelmed health systems could have severe collateral effects on existing public health programmes. [1] [2] [3] [4] Furthermore, COVID-19 control measures, such as stay-at-home orders, or lockdowns, might limit access to health-care services, further jeopardising broader public health goals. 3, 5, 6 In Africa, the impact on HIV services is of particular concern. Despite improvement in HIV prevention, testing, and treatment, HIV/AIDS remains one of the leading causes of mortality, with more than 400 000 deaths on the continent in 2019. 7 Of the estimated 25·8 million people in Africa living with HIV in 2019, 4·3 million were not diagnosed, and a further 3·4 million were not receiving antiretroviral therapy (ART). 7 Modelling studies of disruptions to HIV programmes by the COVID-19 pandemic estimate that interruptions in ART would have the largest effect on HIV-related mortality. 8, 9 In a worst case scenario, interruption of ART for 6 months for 50% of patients would result in 296 000 excess HIV-related deaths. 8 Such scenarios are of particular concern in the province of KwaZulu-Natal, in South Africa, which is the country most heavily affected by both COVID- 19 and HIV in Africa. 493 183 cases of COVID-19 had been confirmed in South Africa by July 31, 2020, 10 and in 2019 an estimated 7·5 million people were living with HIV in the country. An estimated 1·7 million people are living with HIV in KwaZulu-Natal, a prevalence of 27% in adults aged 15-49 years. 11 76 706 cases of COVID-19 had been confirmed in KwaZulu-Natal by July 31, 2020, making it the third most COVID-19 affected province in South Africa. 10 The largest urban area in KwaZulu-Natal is the eThekwini Metropolitan Municipality, which has a population of approximately 3·7 million and includes the city of Durban. 12 South Africa announced a national lockdown on March 23, 2020, which was implemented on March 27. 6 Starting at level 5, the lockdown was one of the most severe globally, w
Keywords Extracted from PMC Text: 1·991 7·5 1·163 allowed,6 People sites14 people 1·165, 1·042–1·303 498–678 stay-at-home 2020.14 15–49 years.11 76 706 IRR 1·926 COVID-19 BE646/17 patient capturers Bethesda Hospital Oct 16 post-lockdown lockdown sites15 IRR −0·630 Africa.10 lockdowns women patients collateral Patients study22 Pre-lockdown allowed.6 lockdown,26 appendix p 1 15–30 studyWe COVID-19 lockdown 16–30 SARS-CoV-2 coronavirus 2 Uganda,24 appendix 1·271 errors19 Kenya14 1·584–2·503 KwaZulu-Natal,13 COVID-19 lockdowns treatment.26 pre-lockdown HIV.16 91·8–96·7 activities.14 3·4 KZ_201807_021 men CD4 cell antiretroviral
Extracted PMC Text Content in Record: First 5000 Characters:The number of deaths from COVID-19 continues to rise globally, but data quantifying the effect of the pandemic on other health conditions are scarce, especially in low-income and middle-income countries. Interruption of supply chains, diversion of resources, and overwhelmed health systems could have severe collateral effects on existing public health programmes.1, 2, 3, 4 Furthermore, COVID-19 control measures, such as stay-at-home orders, or lockdowns, might limit access to health-care services, further jeopardising broader public health goals.3, 5, 6 In Africa, the impact on HIV services is of particular concern. Despite improvement in HIV prevention, testing, and treatment, HIV/AIDS remains one of the leading causes of mortality, with more than 400 000 deaths on the continent in 2019.7 Of the estimated 25·8 million people in Africa living with HIV in 2019, 4·3 million were not diagnosed, and a further 3·4 million were not receiving antiretroviral therapy (ART).7 Modelling studies of disruptions to HIV programmes by the COVID-19 pandemic estimate that interruptions in ART would have the largest effect on HIV-related mortality.8, 9 In a worst case scenario, interruption of ART for 6 months for 50% of patients would result in 296 000 excess HIV-related deaths.8 Such scenarios are of particular concern in the province of KwaZulu-Natal, in South Africa, which is the country most heavily affected by both COVID-19 and HIV in Africa. 493 183 cases of COVID-19 had been confirmed in South Africa by July 31, 2020,10 and in 2019 an estimated 7·5 million people were living with HIV in the country. An estimated 1·7 million people are living with HIV in KwaZulu-Natal, a prevalence of 27% in adults aged 15–49 years.11 76 706 cases of COVID-19 had been confirmed in KwaZulu-Natal by July 31, 2020, making it the third most COVID-19 affected province in South Africa.10 The largest urban area in KwaZulu-Natal is the eThekwini Metropolitan Municipality, which has a population of approximately 3·7 million and includes the city of Durban.12 South Africa announced a national lockdown on March 23, 2020, which was implemented on March 27.6 Starting at level 5, the lockdown was one of the most severe globally, with restrictions on movement and cancellation of public transport, although travel to receive health care was allowed.6 The lockdown was eased to level 4 on May 1, 2020, when public transport was allowed,6 and to level 3 on June 1, 2020, which allowed some economic activity to resume. Research in contextEvidence before this studyThe COVID-19 pandemic could greatly affect HIV programmes in low-income and middle-income countries. Modelling studies have suggested that disruptions to antiretroviral therapy (ART) provision would have the worst consequences, with a 6-month interruption in treatment for half of people who receive ART, leading to nearly 300 000 excess HIV deaths in sub-Saharan Africa. However, whether such high levels of disruption have occurred is not clear. We searched PubMed for the terms (COVID-19 OR SARS-CoV-2) AND (HIV OR AIDS) AND (LMIC OR low income country OR middle income country OR Asia OR Africa OR Latin America) AND (lockdown OR lock-down OR curfew OR impact OR shelter OR restriction) from inception until Oct 16, 2020. We found four small studies that provided quantitative data comparing HIV care outcomes before and after COVID-19 lockdowns. A single site cohort study of pre-exposure prophylaxis in 455 pregnant women in South Africa found an increase in missed visits after lockdown. An interrupted time series analysis from 11 clinics in rural South Africa found a 20% increase in HIV-related primary care visits after lockdown implementation, and two studies from Kenya described a decrease in numbers of HIV tests in the first month of lockdown, compared with the previous 3 months.Added value of this studyWe contribute new evidence of the impact of the COVID-19 lockdown on HIV care in KwaZulu-Natal, South Africa, which has the largest ART programme in the world, and had one of the strictest lockdowns in Africa. We analysed a large dataset from urban and rural primary care clinics between Jan 1, 2018, and July 31, 2020, and used interrupted time series analysis to account for longer-term trends. HIV testing and ART initiations decreased substantially when lockdown was implemented, but ART collection visits decreased only slightly.Implications of all the available evidenceART provision was largely maintained during the South African lockdown, while HIV testing and ART initiations were more heavily affected. After lockdown, and in any future COVID-19 restrictions, strategies to catch up with HIV testing and increase ART initiation should be implemented, alongside efforts to maintain treatment provision. The impact of lockdown measures in South Africa and other African countries on HIV programmes is not clear. An interrupted time series analysis13 of data from 11 rural clinics in South Africa found a 20% incre
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