Abstract
Background: South Africa bears the greatest burden of HIV in the world, with key populations (KP) such as men who have sex with men (MSM) being the most affected. Yet the latter have the least access to HIV services due to stigma, discrimination, criminalisation, and violence. The delivery of HIV services may have decreased further during the Covid-19 pandemic. The optimal delivery of HIV services is critical to achieve epidemic control. It is therefore important to conduct a retrospective look at HIV prevention and treatment outcomes during the Covid-19 pandemic, as well as assess the nature and quantify the impacts thereof for future preparedness.
Aim: To assess the impacts of Covid-19 on the HIV treatment continuum among MSM through understanding their current status, the nature and quantity thereof towards strengthening HIV treatment outcomes in selected Provinces of South Africa.
Methodology: This study followed a mixed-method design to assess the impacts of Covid-19 on the HIV treatment continuum among MSM. Systematic review: A systematic review was conducted to assess the current status of Covid-19 impacts in Sub-Saharan Africa (SSA) (Objective 1). It was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42022341813). The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines (PRISMA). Qualitative: In-depth interviews were conducted with a purposive sample of 26 key informants who were part of the MSM HIV programme in Capricorn district, Limpopo Province during the Covid-19 lockdown (Objective 2). The Consolidated Framework for Implementation Research (CFIR) domains and associated constructs were used to develop the interview guide. The interviews were audio-recorded and transcribed verbatim. Atlas.ti version 24 was used to capture the transcribed qualitative data. Quantitative: An interrupted time series analysis of programme data (January 1, 2018 to December 31, 2022) was conducted to measure the trends and patterns in HIV treatment outcomes among MSM in Gauteng, Mpumalanga, and KwaZulu Natal i.e., HIV tests, positive HIV results, linkage to HIV care, antiretroviral therapy (ART) initiation, ART collection, and viral load testing. The R software version 4.4.1 was used to analyse the data (Objectives 3 and 4).
Results: Systematic review: The systematic review included 17 eligible articles, three of which implemented KP-specific interventions to lessen the effect of Covid-19 on HIV treatment services. This indicates limited KP-specific interventions/services. In the three identified studies, differentiated service delivery (DSD) interventions were implemented across physical
v
and virtual locations such as drop-in centres; websites; and within communities. These interventions demonstrated improvements in HIV treatment linkage, initiation, and viral suppression. Qualitative: The in-depth interviews with service providers revealed fear of Covid-19 transmission, movement restrictions during the initial phase of the lockdown period, target-driven performance pressure, lack of mobile clinics, and understaffing as some of the barriers to HIV treatment services during the Covid-19 lockdown. The programme was tailored, and a door-to-door approach was used to provide HIV services, while healthcare facilities were provided with resources to assist MSM in accessing ART and other similar services. Teamwork in the programme, partnerships and connections with the Department of Health and other relevant organisations were among the facilitators identified in the MSM programme during the lockdown. Qualitative interviews with the MSM showed that tailoring of the programme services was helpful and enabled their continued access to HIV treatment services despite the elongated response time. Quantitative: The interrupted time series analysis indicated a decrease at the onset of the Covid-19 lockdown (March 2020), followed by an upward trend, as shown by the segmented regression models. Positive HIV tests (estimate=0.001572; p<0.001), viral load tests (estimate=0.001109; p<0.001), linkage to HIV care (estimate=0.001486; p<0.001), ART initiations (estimate=0.001003; p=0.004), and ART collection (estimate=0.001748; p<0.001) all increased significantly following the DSD model's implementation.
Conclusions: The KP-specific studies that implemented evidence-based interventions to mitigate the Covid-19 impact on HIV treatment services led to improved HIV treatment outcomes, i.e., HIV treatment initiation and viral load suppression. Incorporating tailored interventions can significantly enhance the effectiveness of health services, particularly during pandemic times. Teamwork, collaboration, and optimal use of available resources were instrumental in the tailoring of HIV services to ensure service continuity among MSM during the Covid-19 lockdown. Fostering the above can be applied widely to ensure continued service provision and utilisation during public health crises. The implementation of DSD models during the Covid-19 lockdown ensured the continuity of HIV services, leading to improved HIV treatment outcomes. The constant implementation of DSD models needs to be investigated and implemented on a larger scale in both private and public health facilities to facilitate reaching the 95-95-95 Joint United Nations Programme on HIV/AIDS (UNAIDS) goals