WHO guidance to support HIV care models during the Covid-19 era

© The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society of America. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. WHO guidance to support HIV care models during the Covid-19 era

M a n u s c r i p t Dear editors -We read with interest the recent Viewpoint summarizing guidelines launched by key HIV/AIDS societies to support HIV management during the COVID-19 pandemic.
In the first 6 months of the pandemic the World Health Organization (WHO) published three guidelines with the objective of ensuring continuity of essential health services, including HIV/AIDS care. In March 2020 WHO published operational guidance for maintaining essential health services during an outbreak. This was followed by guidance published in May 2020 which outlined recommendations to ensure continuity of select community-level health services, including expansion of HIV self-testing. In June 2020 WHO published operational guidance aimed at maintaining essential health services during the COVID-19 outbreak. This guidance recognized that health systems around the world are being challenged by increasing demand for care of people with COVID-19, compounded by fear, stigma, misinformation and limitations on movement that disrupt the delivery of health care for all conditions. National surveys of 101 countries have revealed substantial disruption across all major health areas. HIV services have been disrupted in nearly half of countries, with 49% of countries reporting disruptions to HIV testing services and 43 (46%) countries reporting disruptions to HIV prevention services; 25% of countries reported disruptions to services to initiate new antiretroviral (ARV) treatment, and 17 (17%) reported disruptions to continuation of established ARV treatments. The Global Fund's results report 2021 confirms the devastating impact of COVID-19 on HIV services including a 16% decrease in TB treatment in PLHIV; 11% decline in prevention services and 22% reduction in HIV treatment initiation.
In September 2021 WHO released updated guidance on maintaining essential health services which provides direction on modifications and specific measures for safe delivery of HIV services, and considerations for transition towards restoration and recovery. Modelling suggests that in sub-Saharan African region a 6-month interruption of ART would result in an excess of over 500,000 adult HIV deaths and an up to two-fold increase in mother-to-child transmission of HIV. Additional modelling suggests that maintaining HIV services could lead to additional COVID-19 deaths; however the HIVrelated deaths averted by providing services is at 100 times greater than the COVID-19 deaths averted by closing services.
Poorer quality clinical care due to over-burdened health workers and facilities, interruptions of the supply of other drugs and suspension of HIV testing would also have significant population impacts. To limit the potential for disrupted supply of ART and other essential medications and limit client volumes in health facilities, WHO recommends drug dispensing for ART should be for longer periods of up to 6 months. Table 1 summarizes WHO guidance on measures for safe delivery of HIV treatment and monitoring.
M a n u s c r i p t Restriction in movements has limited community-based care provision, while care in health facilities has been limited as staff have been diverted to the COVID-19 response. Many countries have relaxed movement restrictions or are cycling between restrictions and relaxations. Where restrictions on movement and the epidemiological situation permits, catch-up campaigns should be implemented to improve coverage of testing, prevention, and treatment interventions. WHO recommends that national programmes develop guidance for providers on how best to successfully locate and re-enrol clients into care, especially if their treatment has been interrupted. This should include reducing existing operational, regulatory, legal, and structural barriers that impede the expansion of essential services for HIV and related infectious diseases such as viral hepatitis and sexually transmitted infections.
According to patient-level clinical data from 37 countries HIV infection is independently associated with a 30% increased risk of death among patients hospitalized with suspected or confirmed SARS-CoV-2 infection. WHO has encouraged all PLHIV to be vaccinated and recommend countries to consider including them as a priority group for early COVID-19 vaccination in their national plans, particularly those with advanced HIV disease and co-morbidities. WHO is also monitoring the safety and efficacy of COVID-19 vaccines in PLHIV in ongoing trials. A c c e p t e d M a n u s c r i p t M a n u s c r i p t Telemedicine.
Safe drop-in service for symptomatic patients.

Routine ART: adults and adolescents
Emphasize same day ART start, including out of facility ART start (eg outreach and mobile services) according to context. Extend to 6 monthly dispensing and promote community dispensing points.
Telemonitoring of recently started treatments. Online appointment scheduling.
Maintain emphasis in same day ART start, including out of facility ART start Continue and expand group adherence support (small group, virtual, mobile phone format).

Improve community-based
A c c e p t e d M a n u s c r i p t strategies to improve retention, adherence, and viral suppression in coordination with CBOs.