The U.S. Congress is weighing legislation that would employ hundreds of thousands of Americans to conduct testing and contact tracing of people who’ve contracted or have potentially been exposed to COVID-19. By some estimates, the U.S. needs to ramp up from approximately 8,000 contact tracers now to 300,000. Some public health experts say that such a monumental effort to hire and train tracers could go even further, by addressing other infectious diseases and even identifying underlying health problems.
Just one year before the COVID-19 pandemic hit, officials at the various agencies at the federal Department of Health and Human Services (HHS) were beginning to implement a plan to end the HIV epidemic in the United States—a big part of which would require identifying people living with HIV who are not in care and/or don’t know they’re HIV positive, to connect them to care and support them in getting virally suppressed. But as the nation has turned its attention to a new infectious disease threat, where does that leave the work to end the HIV epidemic?
Agreeing with a quip sometimes attributed to Winston Churchill, “Never let a good crisis go to waste,” the authors of a new paper published in the journal Clinical Infectious Diseases suggest that COVID-19 tracing could be a platform for expanded HIV testing as well. The authors, Carlos del Rio, M.D., Wendy Armstrong, M.D., and Bohdan Nosyk, Ph.D., conclude, “Though it may feel like a distant priority, now more than ever, as the official language of the plan [to end the HIV epidemic by 2030] goes, we have an unprecedented opportunity to end the HIV epidemic in America. Accomplishing this and expanding the impact to other health conditions is an opportunity we must not let go to waste.”
Speaking with TheBodyPro, Nosyk, an associate professor of HIV/AIDS research at Simon Fraser University in Canada, admits that the paper is long on theory and short on details. Every person tested for COVID-19 would be given routine, opt-out HIV and hepatitis C tests.
“It could be drive-through testing, or on-the-street outreach,” Nosyk said. “And it could be accomplished by a workforce of lay people, not medical professionals. Some training would be required, but not much. The effort would require county, state, and federal coordination, and that’s asking a lot, I know.”
The authors say piggybacking HIV testing onto COVID-19 diagnostic tests would capture many people who would otherwise never come into a clinic or even think to request an HIV test. It’s estimated that more than a million people in the U.S. have HIV, and one out of seven don’t know they’re positive.
Armstrong, a professor at the Emory University School of Medicine, offered that HIV and hepatitis C testing could be part of a “health care package” in conjunction with COVID-19 tracing.
“The bigger picture is health promotion,” Armstrong said. “If you call it a ‘health care package’ rather than screening for HIV, this can reduce stigma and potentially find many people who wouldn’t ordinarily go for [an HIV] test.” People who are concerned about their risk for HIV could also be given access to pre-exposure prophylaxis (PrEP), she adds.
Armstrong emphasizes that such an effort would not include contact tracing for sexual partners. That would happen if someone tests positive for HIV and if such tracing is available from the county board of health.
The authors say that, if done right, such opt-out HIV and hep C testing could reduce some of the reasons for racial disparities in these diseases, including stigma over testing and medical mistrust.
“If we could reach most of the people undiagnosed with HIV [and bring them] into treatment, it could have a profound long-term benefit,” said del Rio, chair of the Hubert Department of Global Health at Emory University’s Rollins School of Public Health.
Del Rio also sees the possibility of a COVID-19 outreach team addressing more health issues than infectious diseases. “We see health disparities in COVID-19, and they are mostly the same as with HIV, diabetes, and hypertension. These are already big killers. If we have this opportunity to make contact [with people who have COVID-19], we should also address other health disparities.”
A program of multitasking community health outreach workers may be unique in the U.S., but it’s been done in many countries. Recent international research showed a community-based model led to 20% fewer HIV deaths, reduced the incidence of HIV and tuberculosis, and improved control of hypertension and diabetes. Even in the U.S., alternative ways to find people with HIV, such as the No Wrong Door plan to offer HIV testing in retail pharmacies, have succeeded in linking more vulnerable people to care.
Doing Testing Right
Assuming such a plan is doable, there are several hurdles to cross: The Centers for Disease Control and Prevention (CDC) would need to release funding, and state and county health departments would have to decide whether and how they want to do it. The authors don’t suggest HIV testing needs to be done everywhere; North Dakota, for example, might decide not to. A state with a very high rate of potentially undiagnosed HIV cases—Louisiana, say—might eagerly embrace it.
Jacob Schneider, a staff attorney at The Center for HIV Law and Policy (CHLP), says surveillance is important to limiting disease transmission, but only if employed in a thoughtful way. “If care is not taken, you risk harming public health by alienating people who are already wary of government,” Schneider told TheBodyPro.
“A lot of information can be derived from a blood sample or swab, and we must take care with how that is used,” he explained. “The law is not sufficiently protective. We are still figuring out what the implications of having COVID-19 will be. Will it be stigmatizing like HIV—criminal prosecutions, prevention from entering a store? There’s a danger in creating public health infrastructure before considering these questions.”
Amir Sadeghi, national community outreach coordinator for CHLP, says COVID-19 tracing and testing should be informed by the lessons that should have been learned from tracing—and criminalizing—HIV.
“We’re already seeing criminalization of social distance enforcement with COVID-19. We need to avoid stigmatizing identities of people, or treating them as disease vectors. With COVID-19 and with HIV, there should be a broad and diverse coalition of all stakeholders, a good faith collaboration of law enforcement and public health, guided by the community.”
Nosyk said that, ideally, testers and tracers for COVID-19 and HIV would come from the community, to counteract mistrust of medical personnel.
“There are 3 million people newly unemployed across the U.S., and many people in every community could be trained to do this,” Nosyk said.
It’s notable that the CDC considers “cultural competency appropriate to the local community,” to be a key skill for COVID-19 tracing.
Del Rio has shared this theory with officials at CDC and the with the Georgia Department of Public Health and has received “positive responses,” though no promises that such multifaceted public health outreach teams will materialize. “It will take money, and our public health infrastructure has been woefully underfunded for years,” he said. Even more than money, he says, a new way of thinking about public health is needed, and states, counties, doctors, lawmakers, and public health professionals need to take a broader look at preventing disease and reducing health disparities. “Everyone needs to start thinking outside their silos.”