Just as in the early HIV epidemic, the current COVID-19 pandemic demands that science be separated from politics, Salim Abdool Karim, M.D., Ph.D., of the Centre for the AIDS Program of Research in South Africa, emphasized at the 23rd International AIDS Conference (AIDS 2020), which was held virtually due to the novel coronavirus pandemic. “You can’t debate with a politician whether masks are a good idea or not,” he noted—science says they help contain the spread of SARS-CoV-2, the virus that causes COVID-19.
Masks have another benefit, Timur Abdullaev of TB People Uzbekistan explained at the virtual TB conference prior to AIDS 2020. In many parts of the world, only people who have tuberculosis used to wear masks, which made them easy targets. Now that everyone is wearing one, those with TB can no longer be picked out of the crowd. However, people living with SARS-CoV-2 are now facing some of the same attitudes that those affected by HIV or TB have had to confront. Stigmatizing language we may have overcome for HIV and TB is rearing its head again—this time often directed against China and used at the highest levels of U.S. government.
Fear of contracting the novel respiratory virus can even lead to threats of violence, reported Nataliya Nesvat of TB People Ukraine. She is a person living with HIV and survived both TB and COVID-19. Someone published online a list of people in her neighborhood who had tested positive for SARS-CoV-2. Neighbors then threatened those on the list, including herself.
Even health care workers may be afraid of contracting SARS-CoV-2, if they handle samples or attend to people who are coughing, noted Lloyd Mulenga, MBCHB, Ph.D., MMED, of the Zambian HIV Program. Such fears were exacerbated by an initial shortage of personal protective equipment. Like many countries, Zambia has implemented multi-month dispensing for HIV and TB medications and a reduced clinic visit schedule to minimize in-person contact between patients and providers.
Providing a longer supply of regular medications requires sufficient stocks of these drugs within the country, as supply chains have been interrupted by travel restrictions and other issues. Five to 10% of countries supported by the Global Fund to Fight AIDS, Tuberculosis, and Malaria are experiencing national stock-outs of some medications, reported Eliud Wandwalo, M.D., M.Phil., of that organization. Laboratory services have also been disrupted in some locations. The Global Fund estimates that there may be 500,000 excess deaths from HIV and TB as a result of COVID-19–related disruptions.
The pandemic requires new ways of delivering health care, Kwame Shanaube, M.D., Ph.D., of Zambart in Zambia said. People with TB are at great risk of severe COVID-19 if they contract the novel virus. Since symptoms for TB and COVID-19 are quite similar, SARS-CoV-2 needs to be ruled out before people enter a TB or HIV clinic. One way to separate patients is a clinical truck where those with COVID-19 symptoms are screened. Zambart just expanded its ongoing study of TB in people living with HIV to include COVID-19. “The TREATS-COVID study is an example of how the TB/HIV infrastructure is supporting the COVID response,” Shanaube said. Similarly, the existing systems for TB contact tracing and HIV partner notification can be used to find people who may have been exposed to SARS-CoV-2, and machines that process samples for HIV viral load testing can also process SARS-CoV-2 swabs.
While these synergies may be useful, they must not come at the expense of HIV and TB services, demanded Meg Doherty, M.D., Ph.D., M.P.H., of the World Health Organization (WHO). “Maintaining essential TB and HIV services is crucial” during the pandemic, she said. However, isolation wards originally set up for people with TB are used instead for COVID-19 patients. Other health care resources have also been shifted to COVID-19, reported Dr. Syed Karam Shah of the Pakistani Ministry of Health. Lockdowns that curtail transportation to clinics and fear of COVID stigma when presenting with a cough have also contributed to the plummeting TB case finding and HIV testing rates.
Screening people living with HIV for both TB and COVID-19 via telehealth, as well as self-monitoring of symptoms, could help to combine services and reduce in-person visits to HIV clinics, reported Andrea Howard, M.D., M.S., of ICAP, who is involved in trials of HIV-TB service integration in sub-Saharan Africa. When there are in-person visits, people living with HIV could be screened for TB at each such visit. However, people who require less intensive antiretroviral therapy management may not come to the clinic very often and hence would only be evaluated for TB—and potentially COVID-19—infrequently.
Ultimately, rapid molecular testing for multiple diseases could help to diagnose various issues all at once, Dr. Soumya Swaminathan of the WHO noted. Beyond the technology, an infrastructure that allows for quick turnaround of samples and results delivery is also needed, as is access to health care. Universal health care is not only a human right, but a prerequisite to conquering the COVID-19 pandemic. However, do not divorce the pandemic response from the public health response to other diseases, such as HIV, TB, or malaria, she warned.
TB is a disease of poverty, and lockdowns to contain the spread of SARS-CoV-2 hit those at the bottom of the socioeconomic scale hardest, noted Tereza Kasaeva, M.D., Ph.D., of the WHO’s Global TB Program. Winnie Byanyima, M.Sc., executive director of UNAIDS, echoed this statement: “COVID-19 reminds us that pandemics cannot be tackled by health systems alone,” demanding, “people must come before profits.” This means not only health care access, but also addressing inequalities in food security, crowded living conditions, and other issues that may preclude an effective response to global pandemics.
We need to use the lessons from COVID-19 to prepare for future pandemics, Safarali Naimov of Stop TB Partnership in Tajikistan said. Affected communities must become equal partners in responses to health crises, and people need to know about health issues and about their rights in order to advocate effectively in situations where human and civil rights may take a backseat to health concerns. Communities must monitor and report issues to generate data that can feed advocacy. Organizations need to come together to jointly address this and other health crises, he proposed.
“This pandemic is a wake-up call, laying bare inequities,” said Amina J. Mohammed, of the United Nations. As a global pandemic, COVID-19 cannot be conquered in isolation. “We need to show solidarity in this crisis, which is not just a health crisis, but a socioeconomic crisis,” she said. “No country can overcome this crisis alone.”