Yes, PLHIVs should worry.

Seventy-three countries warned that they are “at risk of stock-outs of antiretroviral (ARV) medicines as a result of the COVID-19 pandemic”. This is according to a new survey from the World Health Organization (WHO), which also found that 24 countries already reported having “either a critically low stock of ARVs or disruptions in the supply of these life-saving medicines.”

While there is still no cure for HIV, ARVs can control the virus and prevent onward sexual transmission to other people.

WHO did not name the affected countries in its survey.

According to Dr. Tedros Adhanom Ghebreyesus, WHO Director-General, this is “deeply concerning.” “Countries and their development partners must do all they can to ensure that people who need HIV treatment continue to access it. We cannot let the COVID-19 pandemic undo the hard-won gains in the global response to this disease.”

About 38 million people worldwide are currently infected with HIV.

Living with HIV at the time of Covid-19 lockdown

As FYI: Even prior to the release of the WHO statement, on July 2, Outrage Magazine already sent an email to the office of Department of Health (DOH) Sec. Francisco Duque III, with the National AIDS and STD Prevention and Control Program (NASPCP) and Philippine National AIDS Council (PNAC) Cc’d.

Four days later – and as of press time – no response/s has/have been received.

Various HIV-related services offered in the Philippines have been stalled – e.g. community-based HIV screening, with HIV service providers lamenting the lack of clear guidelines/protocols on how to do this coming from the DOH.

At what cost? HIV service disruptions at the time of Covid-19

But DOH itself already admitted the ill effects of Covid-19 to HIV-related services in the Philippines.

In June, a letter signed by Usec. Dr. Myrna Cabotaje from Department of Health (DOH) to Outrage Magazine noted the impact of Covid-19 on HIV program implementation. Specifically: Prevention services were reduced by 20% to 30%; HIV testing services reduced by 20% to 80%; viral load testing reduced by 42%; and ARV refill services reduced by 5%.

In the context of the COVID-19 pandemic, UNAIDS, APN+ and APCASO issue a joint statement to emphasize the key role that the HIV response can play in developing and implementing equitable systems for health, including sustainable HIV and COVID-19 programming.

Vulnerable and marginalized people are often the most affected by COVID-19, physically, economically and socially. They are the least able to protect themselves, often living in crowded conditions without sufficient hygiene facilities or on the street. In the context of lockdowns, women have faced increased rates of gender-based violence. Vulnerable and marginalized people are also the least likely to be able to access social protection measures designed to ensure access to basic food, hygiene and livelihood support.

At what cost? HIV service disruptions at the time of Covid-19

Winnie Byanyima, UNAIDS Executive Director in her remarks at the UNAIDS Programme Coordinating Board Meeting, held in Geneva, Switzerland, from 23 to 25 June 2020, recalled that the hard-learned lessons of the struggle against AIDS provide an invaluable practical guide as we confront Covid-19. Such lessons are the importance of empowering communities; that human rights do not hinder but enable pandemic response; that pandemic responses must go beyond health interventions, and address economic and social drivers and impacts, including providing social protection; that pandemic responses must tackle inequalities in rights and in access to services.

“The HIV response has demonstrated that where communities are able to fully participate in decision-making and service delivery, and human rights protections are strengthened, HIV outcomes and impacts have improved. UNAIDS will continue to work with regional community networks, to reach the people who are left the furthest behind and to tackle gender inequalities and human rights violations that place people at greater risk of both HIV and COVID-19,” says Eamonn Murphy, UNAIDS Regional Director for Asia and the Pacific.

Living with HIV at the time of Covid-19 lockdown

With the joint statement, UNAIDS, APN+ and APCASO emphasize that community-led responses must be a formally recognized element of any country’s responses to HIV and COVID-19. They also call on governments and donors to ensure sufficient funding and political and legal support to networks of people living with HIV and key populations, community-based health services, and community and civil society service and advocacy organizations.

“Beyond fighting the virus, we are also battling social inequities, injustices, and rights violations that make pandemics like COVID-19, and HIV, disproportionately impact and further marginalise key populations and vulnerable communities. We need strengthened communities and civil society working alongside governments, highlighting community, rights, and gender dimensions of issues, as a legitimate part of country health responses,” says RD Marte, APCASO Executive Director.

Communities are at the heart of any effective and equitable public health response. “A robust and enabled civil society was an essential element of the HIV response. As we face the challenges of COVID-19 in the short and longer term, communities and civil society must be resourced and enabled to play a legitimate role in delivering sustainable, gender-based, rights-based responses,” points out Shiba Phurailatpam, Director of the Asia Pacific Network of People Living with HIV/AIDS (APN+).

With the COVID-19 pandemic continuing to pose a challenge to the HIV programs in the Philippines, Project Red Ribbon – with the Joint United Nations Programme on HIV and AIDS (UNAIDS) – came up with a pilot program, the “Love on Wheels”, that eyes to continue delivering HIV services in the country. 

Via this program, health facilities in local government units (LGUs) will be provided with at least three electric motor bikes to allow HIV service providers to reach PLHIVs (like getting their antiretroviral medicines), those who want to get tested, or those requiring safer sex materials. The pilot is being done in the City of Manila.

With the end of the COVID-19 pandemic still nowhere in sight, said Ico Rodulfo Johnson, who helms Project Red Ribbon, “we took it upon ourselves to develop an ingenious way for HIV services to still be delivered. The fight against HIV despite COVID-19 must continue. The country needs to innovate to continue the years of successes of the HIV programs.”

The move is also much-needed, considering Department of Health’s (DOH) continuing focus on COVID-19 that seem to be relegating other health services, including those related to HIV.

At what cost? HIV service disruptions at the time of Covid-19

In a June 10 letter sent to Outrage Magazine by the DOH, the impact of Covid-19 on HIV program implementation has been noted. Specifically: Prevention services were reduced by 20% to 30%; HIV testing services reduced by 20% to 80%; viral load testing reduced by 42%; and ARV refill services reduced by 5%.

Over three months since COVID-19 lockdowns were imposed in the Philippines, the only existing protocol from DOH related to HIV only tackles ARV distribution; and service providers continue to lament the absence of clear-cut, B&W policies re testing, as well as link to treatment of those who may test HIV-positive.

“Love on Wheels” will be implemented by social hygiene clinics (SHCs) of LGUs, involving medical practitioners like nurses, case managers and medical technologists, among others. This way, confidentiality is ensured (e.g. when accessing HIV testing, or when PLHIVs get their medicines via “Love on Wheels”).

The longer-term plan is to expand this to other LGUs in Metro Manila by July, and eventually to provinces after July.

For those who may want to avail of the services of the “Love on Wheels” in the City of Manila, coordinate with the Manila Social Hygiene Clinic and Treatment Hub, located at 667 Earnshaw St., Sampaloc, via 5310-1326, 749-8273 or 09455102130.

Researchers have found that astrocytes, a type of brain cell can harbor HIV and then spread the virus to immune cells that traffic out of the brain and into other organs. HIV moved from the brain via this route even when the virus was suppressed by combination antiretroviral therapy (cART), a standard treatment for HIV.

The study, conducted by researchers at Rush University Medical Center in Chicago and published in PLOS Pathogens, was funded by the National Institutes of Health.

“This study demonstrates the critical role of the brain as a reservoir of HIV that is capable of re-infecting the peripheral organs with the virus,” said Jeymohan Joseph, Ph.D., chief of the HIV Neuropathogenesis, Genetics, and Therapeutics Branch at NIH’s National Institute of Mental Health, which co-funded the study. “The findings suggest that in order to eradicate HIV from the body, cure strategies must address the role of the central nervous system.”

HIV attacks the immune system by infecting CD4 positive (CD4+) T cells, a type of white blood cell that is vital to fighting off infection. Without treatment, HIV can destroy CD4+ T cells, reducing the body’s ability to mount an immune response – eventually resulting in AIDS.

cART, which effectively suppresses HIV infections, has helped many people with HIV live longer, healthier lives. But some studies have shown that many patients receiving antiretroviral drugs also show signs of HIV-associated neurocognitive disorders, such as thinking and memory problems. Researchers know that HIV enters the brain within eight days of infection, but less is known about whether HIV-infected brain cells can release virus that can migrate from the brain back into the body to infect other tissues.

The brain contains billions of astrocytes, which perform a variety of tasks — from supporting communication between brain cells to maintaining the blood-brain barrier. To understand whether HIV can move from the brain to peripheral organs, Lena Al-Harthi, Ph.D., and her research team at Rush University Medical Center transplanted HIV-infected or noninfected human astrocytes into the brains of immunodeficient mice.

The researchers found that the transplanted HIV-infected astrocytes were able to spread the virus to CD4+ T cells in the brain. These CD4+ T cells then migrated out of the brain and into the rest of the body, spreading the infection to peripheral organs such as the spleen and lymph nodes. They also found that HIV egress from the brain occurred, albeit at lower levels, when animals were given cART. When cART treatment was interrupted, HIV DNA/RNA became detectable in the spleen — indicating a rebound of the viral infection.

“Our study demonstrates that HIV in the brain is not trapped in the brain — it can and does move back into peripheral organs through leukocyte trafficking,” said Dr. Al-Harthi. “It also shed light on the role of astrocytes in supporting HIV replication in the brain — even under cART therapy.”

This information has significant implications for HIV cure strategies, as such strategies need to be able to effectively target and eliminate reservoirs of HIV replication and reinfection, Dr. Al-Harthi added.

“HIV remains a major global public health concern, affecting 30 to 40 million people across the globe. To help patients, we need to fully understand how HIV affects the brain and other tissue-based reservoirs,” said May Wong, Ph.D., program director for the NeuroAIDS and Infectious Diseases in the Neuroenvironment at the NIH’s National Institute of Neurological Disorders and Stroke, which co-funded the study. “Though additional studies that replicate these findings are needed, this study brings us another step closer towards that understanding.”

Ashley Galvinez, board member of the Sta. Catalina Active LGBT Organization in Zamboanga in Mindanao, used to get screened for HIV every month (to every three months). “I’ve been doing this since I became sexually active,” she said to Outrage Magazine via video interview.

But then the world was struck by Covid-19, and the country was placed under lockdown. And this already-regular part of her health monitoring was stopped.

“Kaya sa bahay na lang muna; tiis-ganda,” she said, adding that she was still scared she could get infected with HIV or get sexually-transmitted infections.

The fear of Galvinez isn’t unfounded.

This May, UNAIDS noted with the World Health Organization (WHO) “the need for urgent efforts to ensure the continuity of HIV prevention and treatment services in order to avert excess HIV-related deaths and to prevent increases in HIV incidence during the COVID-19 pandemic. It will be important for countries to prioritize shoring up supply chains and ensuring that people already on treatment are able to stay on treatment, including by adopting or reinforcing policies such as multimonth dispensing of antiretroviral therapy in order to reduce requirements to access health-care facilities for routine maintenance, reducing the burden on overwhelmed health-care systems.”

“Every death is a tragedy,” said Winifred Byanyima, executive director of UNAIDS. “We cannot sit by and allow hundreds of thousands of people, many of them young, to die needless deaths.”

This is in no way limited to the Philippines, too.

UNAIDS similarly noted that “if efforts are not made to mitigate and overcome interruptions in health services and supplies during the COVID-19 pandemic, a six-month disruption of antiretroviral therapy could lead to more than 500,000 extra deaths from AIDS-related illnesses, including from tuberculosis, in sub-Saharan Africa in 2020–2021.”

In 2018, approximately 470,000 people died of AIDS-related deaths in that region.

“The terrible prospect of half a million more people in Africa dying of AIDS-related illnesses is like stepping back into history,” Dr. Tedros Adhanom Ghebreyesus, WHO Director General was quoted as saying. “We must read this as a wake-up call to countries to identify ways to sustain all vital health services.”

To be specific, disrupted HIV-related services could include:

• Difficulty in accessing antiretroviral medicines
• Reduced quality clinical care owing to health facilities becoming overstretched
• Suspension of viral load testing
• Reduced adherence counseling and drug regimen switches
• Interruption of condom availability
• Suspension of HIV testing

ALSO IN NEED OF FOCUS

According to Ms Jaya L. Jaud, community HIV outreach worker for the Zamboanga City-based Mujer LGBTQ+ Org., HIV is also a pandemic, and this is something “na dapat ding tutukan.”

Jaud added that there is a need to face reality that HIV cases are increasing in the Philippines.

From October to December 2019, there were 3,029 newly confirmed HIV-positive individuals reported to the HIV/ AIDS & ART Registry of the Philippines (HARP). Sixteen percent (474) had clinical manifestations of advanced HIV infection at the time of testing.

By end-2019, the country was registering 35 new HIV infections per day, up from only one case per day in 2008, seven in 2011, and 16 in 2014.

EMPHASIS ON COVID-19

In Antipolo at the outskirts of Metro Manila, Darwin Tenoria, case manager at Antipolo Social Hygiene Clinic, said that they are already trying to return their HIV-related services to how they were before Covid-19.

“It doesn’t mean that our (HIV-related) services stopped,” he said, but these services were instead only modified. For instance, the actual HIV testing is the same (e.g. blood extraction, et cetera); but the pre- and post-test counseling were amended (via installation of dividers, practice of social distancing, as well as use of face shields and/or masks) so that the counselor and the client are protected.

But at least, Tenoria said, “we have some foot traffic.”

HALTED COMMUNITY-BASED SCREENING

Tenoria, at least, works in a health facility.

But – as far as HIV testing and/or screening is concerned – it is the community-based screening (CBS) that has been greatly affected, many actually stalled.

CBS is the HIV screening process done by the likes of Jaud, wherein a volunteer/screener goes to communities to offer HIV testing and screening. This is particularly beneficial to those who live far from a testing facility or those who may not have the time to visit a testing facility.

In idea, this seems like a good idea particularly at the time of Covid-19 because the lockdowns meant people have no means to access health facilities.

But according to Gregory Rugay from the CBS team of Northern Sanctuary MCC in Baguio City, “screening itself has totally stopped at the moment.”

Instead, the focus has been to link to treatment, care and support those who have tested reactive or positive before Covid-19 lockdowns.

“It is kind of tricky,” Rugay said, “because those who have been calling us, wanting to be tested right away, are people who have symptoms (akin to Covid-19) like fever, colds… and difficulty of breathing. With the pandemic going on, you are at a loss on how to treat this kind of issue because their symptoms can also point to (having) Covid-19.”

WANTED: COMMUNITY-BASED SERVICE PROVIDERS

Rugay’s fear has merit… even if, obviously, the services he used to be able to freely offer is still needed.

On May 18, UNAIDS stated that “the role of community-led organizations must be appropriately recognized and supported in the context of COVID-19. They must be factored into all aspects of planning, design and implementation of interventions to combat both COVID-19 and the efforts required to mitigate the impact of COVID-19 on other health areas, including HIV and tuberculosis.”

And so UNAIDS recommended, among others:

• Including community-led health care service providers into lists of essential service providers
• Policies allowing community-led services to continue operating safely
• Ensure that community-led organizations are provided with personal protective equipment and training to protect them and their clients in service delivery

LACK OF CLARITY?

In terms of CBS, “they do not have specific guidelines,” Tenoria said. “There’s no clear guideline on how to mobilize CBS.”

This is even if three months have passed since the Covid-19 lockdown has started.

Jaud agrees, saying that “there’s no protocol – e.g. in using personal protective equipment (PPE).” What happens now is – at least in her case – they rely on the practices of the city health office, as well as the practices of NGOs.

Still waxing positive, Jaud said that the Department of Health (DOH) may have not focused on this because – obviously – Covid-19 was the focus for a while, and because there may have been this assumption that because there are a lot of NGOs/CBOs in this field already, they may already know what to do.

In Baguio, Rugay himself was told by someone offering CBS that CBS is actually stalled.

He admitted, though, that he can’t imagine himself offering CBS now particularly if doing so would mean he would be exposing himself to Covid-19, and thereby exposing his loved ones to the same when he returns home.

Tenoria said that “perhaps we need (something written in black and white), on what will be the direction (under) the ‘new normal’.”

He admitted that there were shortcomings particularly when the country – and the world – was initially responding to Covid-19. “Medyo napag-iwanan talaga yung HIV program.”

But now, there ought to be guidelines (beyond the initial one developed by DOH, though that one only focused on accessing antiretroviral medicines). For Tenoria, clearer guidelines will also provide clarity to both service providers and those accessing the services particularly as these may align protocols.

PLHIVs battle access to meds during quarantine

HIV BOOM ABOUT TO HAPPEN?

As it is, all lung-related cases in Antipolo are now considered as suspected Covid-19 cases, said Tenoria.

This is worth noting because tuberculosis (TB), for instance, is an opportunistic infection (OI); and it occurs more often/more severe in people with weakened immune systems (like someone with HIV).

So even if a person with HIV who may not have Covid-19 may have lung-related issues, he/she is required to be isolated. This, then, leads to another (and related) issue: The limited capacity of health facilities in the Philippines.

Tenoria admitted as much, saying that looking for facilities for PLHIVs is harder because isolation rooms are being dedicated to Covid-19 patients.

Of course: Those who test reactive but who have no OIs are luckier, as they are automatically enrolled into the system so they can immediately access ARVs.

For Rugay, “at this moment, there’s nothing we can do for (PLHIVs whose detection is late).” But for him, what the HIV arm of DOH should do is “step up in preparing itself for (a possibility of a) barrage of late detections once they figure out how we do screenings again. Are they prepared/equipped to have all those patients come in?”

Living with HIV at the time of Covid-19 lockdown

FROM THE D.O.H.

A June 10 letter signed by Usec. Dr. Myrna Cabotaje from Department of Health (DOH) to Outrage Magazine noted the impact of Covid-19 on HIV program implementation. Specifically: Prevention services were reduced by 20% to 30%; HIV testing services reduced by 20% to 80%; viral load testing reduced by 42%; and ARV refill services reduced by 5%.

These impacts were due to: geographic concerns, transportation issues and strict checkpoints.

As Tenoria already noted, a guideline was actually developed by DOH. But its main focus was on PLHIVs (particularly, access to ARVs by those already diagnosed to have HIV), and not on those who have yet to be tested.

But Cabotaje’s letter stated that data from HARP for January-March 2020 shows 552 new HIV cases. Meaning, according to HARP, “HIV testing, mostly facility-based, were still provided.”

For January-March 2020, 682 PLHIVs were also initiated on ART.

Asked about protocols re HIV testing, DOH stated that “at this point, HIV testing protocol based on current capacity of both the government and CBOs is centered on ether facility-based testing or community-based HIV screening. Our current HIV projects, e.g. Global Fund HIV grant, thru Save the Children, provided essential PPE to our field workers for them to continue performing their prevention and testing work.”

The likes of Jaud in Zamboanga and Rugay in Baguio are, obviously, not recipients of the aforementioned PPEs.

Moving forward, DOH is also looking at self-screening as an approach to HIV testing, although “the country is still currently testing this approach in a limited manner.”

No timelines were mentioned in the letter.

GOOD PRACTICES

Exactly because HIV-related efforts seemed to have relied on localized practices, some good practices have emerged.

In Naga City, for instance, Tenoria noted that HIV testing is offered with Covid-19 testing.

Still in Zamboanga, when goods are distributed, safer sex kits are included.

And still in Zamboanga, Jaud started tapping clients online; and this is even if this effort remains limiting because not everyone is active online.

“It’s difficult because gatherings of a big number of people are not allowed,” said Jaud. Her target population – i.e. transgender women in Zamboanga – frequently avail of HIV screening when they have gatherings. But now, “tapping social media has been helpful.”

Worth noting is how this immediately limits Jaud’s service delivery – i.e. because she know of the risks related to Covid-19, the clients she now serves are limited to people she knows/are friends with.

PROGRAMS STILL NEED TO CONTINUE

In the end, Tenoria said that people in power hopefully realize that there are still programs that need to be run. “Just as we say in HIV (advocacy), ‘No one should be left behind’.”

This is because sans the needed support, Rugay said people involved in CBS are limited. And so he urges those who want to get tested to, instead, go to health facilities, particularly if they may also have symptoms linked with Covid-19.

“Konting pasensya lang sana,” he said, until “we have clear protocols and figure it out how to make it safe for everyone concerned.”

“We (still) encourage everyone to get tested for HIV,” Tenoria said. But those who want to get tested will have to coordinate first with health facilities to schedule testing. Still, this “should not be a hindrance for you to access services (even during this pandemic).”

For Jaud, “we have to capacitate outreach workers (like myself)”. This may be via supplying with gears (e.g. PPE), training, and – yet again – laying down of protocols to use.

Back in Zamboanga, Galvinez said that government offices should give attention to community-based health workers like Jaud, who’s also “a frontliner. They’re ready to help, and serve the community.”

UNAIDS is urging governments to ensure that HIV service providers from community-led organizations be recognized as essential service providers at the time of Covid-19.

For UNAIDS, as a “cornerstone of the response to HIV, community-led health service delivery has become even more critical in the context of COVID-19, as the needs of marginalized community members and the burden on the health sector are increasing, making it vital that continued provision of HIV, tuberculosis and other health services is secured.” 

These community-led organizations are “providing a lifeline to underserved, marginalized and hard-to-reach populations around the world.”

UNAIDS acknowledged that physical distancing restrictions created challenges for those needing to access essential services, which created an increased burden on community organizations, which are at the center of service delivery.

But “community-led networks and organizations have… developed important working relationships and roles within health and community systems, including in coordination and task-shifting functions. As evidenced in many countries, these capacities can, with proper support, be deployed to facilitate the provision of Covid-19 information, prevention, testing and linkages to care.”

And yet “without formal recognition of the essential nature of their work, they face significant barriers to continuing to provide services.”

UNAIDS urged Covid-19 crisis committees at the national and district levels to:

• Include the workforce of community-led health care services into the lists of essential service providers and treat them as equivalent to health-care providers.
• Design physical distancing restrictions and policies in ways that allow community-led services to continue operating safely. Essential services include, but are not limited to, the physical provision of HIV, tuberculosis and Covid-19 and other health services that include prevention commodities, including condoms, lubricants, clean needles and opioid substitution therapy, contraceptives, hygiene kits, test kits, medication, triage and linkage to care, adherence support, packages of food and other essentials, the provision of legal services and protection for survivors of gender-based violence and other forms of violence and discrimination. Particular attention needs to be paid to people with physical disabilities.
• Provide special authorization to relevant community-led service providers to move freely, with appropriate personal protective equipment, to deliver the services when and where needed.
• Ensure that community-led organizations, networks and groups be provided with personal protective equipment and training in order to protect themselves and their clients in the course of service delivery.
• Take urgent measures to ensure the security, and expansion, of existing funding for community-led organizations, so that those organizations can continue to provide services.
• Ensure inclusive and transparent governance of Covid-19 responses, with decision-making bodies that include representatives of community-led organizations, including those focused on gender, equity and human rights, to ensure that Covid-19 policies are designed to support the range of service providers and activities necessary for an effective and equitable response.