01 Dec World AIDS Day: Drawing lessons from HIV to tackle COVID
For World AIDS day 2020, AIGHD takes you back nearly 20 years to 2001, when Heineken was one of the first multinational companies to provide free HIV treatment to employees and their relatives in several African countries. This private initiative was a result of Dr. Joep Lange’s mission to provide HIV treatment to people who need it most. Heineken, being the first to engage, set up a workplace treatment program at its breweries in Africa, starting in Rwanda and Burundi, moving to DRC, Congo-Brazza, Nigeria, Ghana, Namibia.
On World AIDS Day, we highlight once more what we have achieved over the past two decades since the launch of one of the earliest HIV treatment programs in Africa. Access to affordable HIV treatment coverage has increased and HIV treatment in developing countries now amounts to 45 US dollars/person1. We must continue in this path of evidence-based action, international collaboration, and global solidarity to end the AIDS epidemic. At AIGHD, we have many collaborative and interdisciplinary projects that contribute to HIV/AIDS research. Last week’s NCHIV conference and the annual INTEREST conference, for example, bring together multiple sectors, disciplines, and countries to exchange, learn, and network to fulfil their quest to end the AIDS epidemic by 2030.
Prof. Tobias Rinke de Wit, who took part in setting up the Heineken Workplace Program mentions that “It is crucial to draw lessons learnt from HIV to deal with COVID-19. Let’s not reinvent the wheel.” In a special interview for World AIDS Day, he highlights several points that put HIV in parallel with COVID-19.
Firstly, both HIV and COVID-19 are zoonoses; diseases that jump from animals to human beings. “Zoonosis is increasing as a result of human exploitation of the planet, putting planetary health at stake. With deforestation and cultural habits to eat wild meat, human-animal contact is becoming increasingly common. We now know that HIV came from Chimpanzees in South-East Cameroon around 1925 and spread through Kinshasa to Haiti-USA and Europe. COVID-19 came from bats, probably via the pangolin to the wet market in Wuhan, China in 2019 and since has spread through international travel.”
However, HIV and COVID differ in their treatment focus. HIV relies on drug therapy, whereas COVID relies on prevention. “There is still no HIV vaccine because the virus mutates extremely fast, but very specific and effective drugs are available (the antiretrovirals). The opposite is the case for COVID; there are no specific COVID drugs available, but there are promising vaccines in the pipeline (Moderna, Pfizer and now also Oxford-AstraZeneca).”
Additionally, both pandemics face access problems in poor countries that contribute to widening inequality. For HIV it is about access to (modern) drugs, for COVID it is about access to diagnostics and vaccines. According to Prof. Rinke de Wit, we must learn from HIV and how in terms of increasing access it gradually was de-medicalized over the past 20 years and apply the lessons to COVID. “Nowadays most HIV-infected patients in Africa are stably on antiretroviral therapy. They receive services through so-called ‘differentiated care models’, such as treatment clubs, home-based care. Stable HIV-infected patients only visit a doctor once a year. This should happen for COVID-19 too. There is too much pressure on the medical sector through COVID-19. This medial overload dominates the international policy decisions that have enormous social and economic consequences. I think citizens should be empowered to test themselves at home using rapid tests. Even when rapid tests are less sensitive, it is better to regularly test yourself with a ‘sloppy test’, than to do this only rarely with a hypersensitive PCR. COVID-19 has a long ‘tail’: the virus can be detected through PCR for many more days than it remains infective to other people. One should wonder whether this is necessary. One should not overemphasize clinical medical precision. It is not about who is infected, it is more about who is infectious.” Tobias advocates for rapid testing in Africa to increase access to COVID diagnostics. “There is far too little capacity on the continent for PCR. Rapid testing will relieve the medical sector, reduce the impact of stigma, empower citizens to get engaged again and eventually leads to a larger testing coverage.”
Thirdly, it is important to note that both HIV and COVID are viruses governed by stigma and fear. “This is especially the case in Africa. HIV-infected patients and COVID patients both fear to visit healthcare facilities. There is also a fast spread of misinformation and fake news. Stigma around HIV and COVID is similar but has different connotations. Individuals tend to associate HIV to sexual behavior. With COVID, one points fingers at the Chinese, referring to COVID as the China virus”. Both viral pandemics are source for the spread of fake news, which reinforces fear and stigma.
The abundance of attention paid to HIV and COVID pandemics generated a public sector response. During the HIV pandemic, private HIV initiatives by large employers in Africa, such as Heineken were often crowded out by the local public sector, through Global Fund and PEPFAR. “No true public-private partnerships were built. The private money streams were simply replaced by public funds, instead of complemented. I see similar developments for COVID. It is again a public sector dominated response. I see no attempts for example to integrate privately funded COVID vaccination into health insurance packages in Africa to help building sustainability.”
Another similarity must be noted: the pandemics both directly and indirectly impact mental health. Indirectly, through fear, stigma, discrimination, social exclusion, loneliness, and disruption of relations, both COVID and HIV impact mental health. This also happens directly by pure biology. “In the case of HIV, Glia cells in the brain get infected and this can lead to neural dementia. In the case of COVID, it is the olfactory nerves that get infected, through the nose to the brain. Through this “back door” route, the virus interferes with the olfactory functions of the brain leading to scent and taste loss. Considering that senses biologically indicate danger, this interruption may induce unrest and can lead to signs of depression.”
As a final remark, Tobias mentions that HIV care is at risk due to COVID. “Many clinics have closed during the COVID measures or lost staff due to reluctance to show up or due to sickness and quarantine”. The WHO reports that 36 low and middle-income countries worldwide experienced disruptions in the provision of HIV treatment. COVID brought about a fierce supply-chain issue, endangering the treatment pathways of many patients with HIV. “Disruption of HIV treatment can quickly lead to drug resistance: when drugs work less well or even become inadequate. Also, the community-level treatment clubs and the outreach programs suffer from COVID-19 since people are not allowed to gather.” Next to HIV care being at risk, COVID is also more dangerous for people with HIV. “People who are infected with HIV are more likely to get COVID due to weaker immune systems and they also have a higher probability of developing complications and even dying from COVID. COVID creates a new barrier for HIV-infected patients and for tuberculosis patients. A presentation during the AIGHD-Joep Lange Chair event indicated that in Eswatini there is a 75% reduction in TB diagnosis, leading to a 30% reduction of patients starting TB treatment.”
In the end, we can learn a lot from the HIV pandemic. Worldwide, HIV has infected roughly 70 million people. The COVID pandemic has already affected over 60 million people. In order to tackle the current pandemic, we must continue to draw similarities, explore solutions and learn from our past as a global health community. However, we must also not forget that while COVID is on the forefront of our minds, HIV still exists and requires our attention and research for adequate and affordable care for all infected.