The COVID pandemic forced clinicians to come up with innovative workarounds to disruptions in care for people with HIV, but ultimately proved that there’s no substitute for in-person visits for this population.
The first year of the pandemic was plagued with numerous interruptions to HIV care, including healthcare providers canceling visits and patients missing visits, having difficulty accessing medical care, and overall lower confidence that they actually could manage their HIV care, according to a systematic review in AIDS and Behavior.
A report in the Morbidity and Mortality Weekly Report also noted a decline in HIV testing and diagnoses, as well as prescriptions for pre-exposure prophylaxis (PrEP) in the second quarter of 2020. However, the authors said that PrEP prescriptions rebounded in the third quarter and continued their pre-pandemic trend in 2021.
Prescriptions for antiretroviral therapy (ART) remained “stable,” the team said, suggesting that “prescriptions were provided without recommended viral load testing” per pandemic-era guidelines.
The most recent pandemic-era guidelines on HIV.gov were updated in February 2022. These guidelines recommended that providers and patients weigh the “risks and benefits” of in-person clinic visits, including community COVID transmission, as well as the amount of time since the patient’s last lab work and general overall health. Virtual or telephone visits were listed as options to in-person visits for “routine or non-urgent care and adherence counseling.”
But this was not true for all populations, said Monica Gandhi, MD, MPH, of the University of California San Francisco, who examined data from a safety net population in San Francisco, including people who were homeless, and found that rates of viral suppression improved from earlier in the pandemic once patients were allowed to return to in-person care.
“HIV care often needs to be in person in order to establish and strengthen bonds between the provider and the patient, have social work and other services delivered on site, assess sensitive topics such as substance use, and discuss barriers to pill-taking,” Gandhi said. “For medically and socially vulnerable populations, we felt that pandemic-related measures to separate the patient from clinical settings were not effective.”
Samir Gupta, MD, MS, of Indiana University School of Medicine in Indianapolis, noted that while many patients opted to return to the clinic once they were able to, some patients like having a virtual option.
“We now have the infrastructure to continue to use this modality for [people living with HIV] who may have difficulty attending in-person visits due to transportation difficulties or work conflicts. Hopefully, engagement in care will improve by our patients having this option,” Gupta said.
Not surprisingly, Gandhi and colleagues found that telemedicine was less palatable to people with HIV who were especially resource-challenged. A pragmatic randomized trial found that patients were less likely to be reached via a pre-visit call for their telemedicine visit if they were virally unsuppressed or homeless.
Gupta also cited some of the downstream effects on patients not having access to the clinic, namely that they “could not come for procedures requiring in-person visits, like vaccinations, exams, lab and STI [sexually transmitted infection] testing.”
However, as Gandhi pointed out, people living with HIV are resilient, having lived through their own epidemic. Gandhi and colleagues performed a small qualitative study that found that prior to COVID, these patients had already learned to cope with depression and anxiety, as well as change their health behaviors in the name of protecting themselves.
“We found that patients with HIV, having lived through a prior epidemic, actually have ‘pandemic resilience’ and adapt to public health recommendations more readily,” Gandhi said.
The pandemic also forced public health agencies across the globe to innovate, and find more creative ways to keep people in care. In March 2021, the World Health Organization amended its guidelines for HIV treatment and prevention, which advocated for “supporting HIV treatment start in the community, ensuring that children are diagnosed and treated early, and that viral load treatment monitoring is more accessible, focused, and triggers clinical action.”
Gandhi noted that parts of Africa adopted varying models of “differentiated service delivery.” Indeed, an October 2021 study in the Journal of the International AIDS Society characterized these models as “silver linings” within the context of the pandemic.
Key components of these differentiated service delivery models included longer refills of ART, virtual models of care, and community-based (rather than clinic-based) models of care, she said.
In fact, Gandhi noted that in addition to telemedicine, she has seen “spacing out laboratory monitoring and dispensing longer durations of ART (so that the patient does not need to come in as often)” as a pandemic-era innovation that remains in HIV care to this day.
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