Managing HIV During COVID-19: Working to End One Epidemic While Confronting Another

As the COVID-19 outbreak continues to grow in the United States, it threatens efforts to address existing health challenges, including the HIV/AIDS epidemic. Last year, before the threat of COVID-19 was known, the Trump Administration began implementing Ending the HIV Epidemic: A Plan for America (EHE) to significantly reduce new HIV infections through a combination of diagnostic, treatment, and preventive efforts. The question now is can efforts to end one epidemic be sustained while confronting another, particularly as the very systems and workforce needed to address HIV are being stretched thin to confront this new crisis?

Through our Greater Than AIDS initiative, KFF produces public health information campaigns with funding from health departments and others on HIV, STIs and related issues. These unique public-private partnerships extend the reach of limited resources in high need areas. Based on recent conversations with our partners in some areas most affected by both diseases, here are some of the issues and concerns we are hearing about looking ahead.

Maintaining access to care and medications: Antiretrovirals (ARVs), the medications used to treat HIV, work to keep the immune system of those with HIV functioning as it is supposed to. Advancements in these treatments have been so successful that today, when taken daily as prescribed, it is possible to reduce HIV viral load (the amount of HIV in the body) to very low – often undetectable — levels. This means better health outcomes for people living with HIV, and that HIV cannot be passed to sexual partners. Maintaining access to these medications can help fight both epidemics.

Before the COVID-19 outbreak, only about half of the 1.1 million people living with HIV in America had their virus suppressed with treatment .  Given that people living with HIV are undoubtedly among the record number of Americans losing jobs and employer-based coverage, the share of those sustained in HIV care could decrease, putting more at risk for serious illness from COVID-19. According to the CDC, people who are immunocompromised, including those with poorly controlled HIV or AIDS diagnoses, are among those who need to take extra precautions against COVID-19.

Medicaid will be an important safety net to retaining care, but much less so in the 14 states that have not expanded eligibility under the Affordable Care Act (ACA). For others, the ACA offers a marketplace to purchase health coverage where individuals with HIV and other chronic conditions cannot be turned away – but even with subsidies this will be out of reach for some.

The Ryan White HIV/AIDS Program funds grants to states, cities/counties, and local community-based organizations across the country to provide HIV related care and medications for people with HIV without health coverage or with coverage limitations. In response to COVID-19, some grantees are making eligibility procedures more flexible to allow for physical distancing among clients and staff, among other adaptations. The program could be stretched thin as more people join its rolls in the face of coverage loss or lapses, despite program efforts to shore up access and services.

Recognizing increased need for those living with HIV, Congress included $155 million for HIV programs in the Coronavirus Aid, Relief, and Economic Security Act, or the CARES Act, which was signed into law by the President on March 27, 2020. The CARES Act authorized $90 million for the Ryan White HIV/AIDS Program response to COVID-19 and $65 million for the Housing for People with AIDS (HOPWA) Program, the federal program dedicated to housing needs for this population.

Addressing increased risk of illness. Other factors compounding the risk of serious illness from COVID-19 among people with HIV, even those with controlled HIV through treatment, are higher rates of certain comorbidities — cardiovascular disease, pulmonary disease, hypertension, diabetes, renal failure, and liver disease – than in the population overall.  Also, disproportionate numbers of people living with HIV are in the South where COVID-19 death rates are trending higher and health systems are strained to provide even basic care. If indicators from New York City extend to the rest of the country, poverty will likely correlate with greater COVID-19 prevalence, as it also does with HIV.

Adjusting practices and protocols to address HIV and COVID-19. Health departments, clinics, and organizations that provide HIV services report that they are working hard to ensure access to HIV treatment and care is maintained during COVID-19. Even in the best of times, this work is difficult.

Supported by guidance from HRSA , programs that are able to are pivoting to telemedicine, extending monthly prescriptions fills to 60 or 90 days, and reaching out to HIV clients to check on other needs like food and housing. Drawing on HIV outreach experience, programs in some areas are now testing for coronavirus and assigning staff to trace contacts for those who are infected – familiar work they have done for years with HIV. But the rapid changes brought on from shifting to telehealth, retraining staff for new roles, redirecting HIV program staff to focus on COVID-19, and adopting new technologies to coordinate internal processes take time and bring their own challenges.

Keeping HIV prevention efforts moving forward.  HIV educational and testing events, fundamentals of prevention, are no longer viable with group gatherings not allowed in most areas.  Some agencies are moving to social media and other online activities and virtual counseling sessions with at-home testing to maintain services in their communities. Programs to support PrEP, the HIV prevention pill, require a confirmatory HIV negative test to initiate a prescription, as well as ongoing lab work (typically every three months). Depending on the capacity of the healthcare workforce, these programs may also be limited in the months to come. Already, we have seen that while some clinics report they are providing PrEP-related services via telehealth, others report suspending services.

State and local health departments as well as providers, including HIV providers, are on the front lines of both the HIV and COVID-19 response. They have the expertise needed but are stretched thin and, while essential, addressing both epidemics simultaneously creates new challenges.

Follow @GreaterThanAIDS for KFF’s ongoing HIV updates and visit Staying Healthy: HIV & Coronavirus for more information for people living with HIV.