This study describes the epidemiological and clinical behavior of patients at the Hospital University of Caracas and estimates the self-perceived impact of the COVID-19 pandemic on disruptions in care, ART, and vaccine hesitancy. The majority of patients were young, employed men, consistent with previous reports [21–23]. Nearly half had a tertiary level of education, yet three-quarters earned less than US$100 per month, insufficient for access to basic food necessities [24]. Most patients were in heterosexual relationships [21, 22], with almost half reporting a stable partner. Nearly half of these partnerships were HIV serodiscordant, similar to other studies [25, 26]. Some studies reported substantial interruptions in pre-exposure prophylaxis (27.8–56%) during COVID-19 restrictions [27–30]; however, Venezuela does not have a pre-exposure prophylaxis program.
The impact of the COVID-19 pandemic on the diagnosis, care, and treatment of HIV infection has been extensively explored in other countries [31–34]. In general, new HIV diagnoses decreased by 12–45% [35–41]. In this study, a quarter of patients were recently diagnosed (< 1 year), emphasizing the importance of maintaining diagnostic and care activities during the pandemic. Adherence to ART and undetectability rates were similar to those reported in other Latin American countries such as Peru [42], Brazil [30, 43], Argentina [44], and globally during the COVID-19 pandemic [43, 45, 46]. Despite WHO recommendations for continuity of HIV services during the pandemic [47], care and treatment have faced challenges worldwide. Unlike other countries [46, 48–50], we did not use telemedicine due to barriers such as lack of equipment and inconsistent internet access. Instead, we maintained face-to-face consultations with strict biosecurity measures and provided ART refills for longer periods, as documented in other countries [51].
The COVID-19 pandemic has variably impacted clinical appointments for PLHIV. Many patients have missed HIV clinical visits, support meetings, follow-up tests, and counseling services [52–57]. In a multi-country survey, 55.8% of PLHIV were unable to meet their HIV physician face-to-face in the past month [52]. In Mexico, 44.3% of patients experienced follow-up failures due to structural barriers such as transportation difficulties and distance to the hospital [58]. In Peru, 37.2% reported difficulty accessing routine HIV care, with the most common reason being temporary closure of their primary HIV clinic [42]. A study in Atlanta, Georgia found that 19% of PLHIV had missed a scheduled HIV care appointment in the previous 30 days [59], while another study among men who have sex with men in 20 countries reported that 20% of PLHIV were unable to access their HIV care provider, even via telemedicine [27]. In contrast, this study documented a lower impact on non-compliance with medical consultations (11.9%), possibly due to the non-prolonged interruption of consultation services and greater regularization of services after the first year of the pandemic, as has been documented in other studies [46, 56]. The main causes for the general decline in clinical appointments were inadequate transport, police abuse, insufficient transportation funds [60], lockdowns [61], limited access to health services, reduced income, inability to afford travel to health facilities or facemasks, fear of COVID-19 [55], and fear of visiting hospitals [56].
During the pandemic, ART-producing pharmaceutical companies faced challenges with international shipping due to border restrictions, transportation delays, increased lead times, and rising costs, contributing to global ART disruptions [62, 63]. However, surveys and observational studies have shown variability in ART refill interruptions. A global study in 20 countries reported that more than half were unable to access ART refills remotely, with the least access in Belarus, Brazil, Kazakhstan, Mexico, and Russia [27]. In Ethiopia, 27.4% of participants missed visits for refills [55], while in Peru, 24% reported difficulty picking up their ART due to cancelled appointments or lack of transportation [42]. A study in Italy documented a 23.1% decrease in dispensed ART during early 2020 compared to 2019, but this trend normalized after the first few months of the pandemic [46]. Similarly, a study in Haiti observed an 18% decline in ART refills [51], while in Brazil, only 17.2% reported an impact on ART refills [30]. In Taiwan, only 9.1% of PLHIV self-reported interrupted ART [49], while this study found that only 3% experienced interruption as a result of the pandemic, similar to reports from Brazil [43], Argentina [44], Northern Italy [46], and Indonesia [56] (4.2%, 3.9%, 3.2%, and 3%, respectively). A multi-country survey among PLHIV reported that 3.6% were unable to refill their ART [52], while a similar study in China found that 2.7% experienced interruption with a median duration of 3 (IQR 1–6) days and higher risk for those with a history of treatment abandonment [64]. The low rate of interruption in this study may be due to continued operation of the ARV dispensary during the pandemic and the strategy of providing three months of ART at a time, as implemented in other countries [51, 64]. Thus, evidence of HIV care disruption and ART interruption during the COVID-19 pandemic was primarily during the early months and varied by region depending on measures implemented by each country. Despite these interruptions (self-reported or electronically recorded), adherence was maintained in several studies [30, 42, 43].
Although studies have shown discrepancies, PLHIV appear to be at high risk for adverse clinical outcomes from COVID-19, with some evidence of higher hospitalization and mortality rates [65–67]. Despite the effectiveness of COVID-19 vaccination in preventing these outcomes [14–17], almost half (44.5%) of participants in this study expressed vaccine hesitancy due to fear and mistrust, similar to reasons reported in Latin America [68], the United States, India, and China [69–71]. The rate of vaccine hesitancy among PLHIV in this study was lower than in Nigeria (57.7%) but higher than in India (38.4%) [71], France (28.7%) [72], China (27.5%) [73], Trinidad and Tobago (39%) [74], Brazil (23.9%) [52], and other Latin American countries (12.8%) [68]. Most patients with vaccine hesitancy were low-income young men with recent HIV diagnoses, consistent with other studies [19]. The highest proportion of vaccine hesitancy was found among those with recent diagnoses (< 1 year), possibly due to lack of knowledge about COVID-19 vaccination and HIV infection [75–77]. This highlights the importance of designing education strategies focused on COVID-19 vaccination in the context of HIV infection.
This study has several limitations. First, it is based on a non-probabilistic sample from a single center with a small sample size and may not be representative despite the institution being the main referral center for PLHIV in the country. Second, the cross-sectional design limits causal inference and only provides a snapshot of challenges during a specific period of the pandemic. Additionally, information was collected at different times throughout the study period, so perceptions (e.g., vaccine willingness) may have been influenced by the rapidly evolving pandemic. Third, the low availability of T-CD4 lymphocyte count results limited our ability to correlate this value with other variables. Fourth, some medical histories were incomplete or inadequate and were supplemented with direct patient questioning, introducing potential recall bias. Finally, it was not possible to accurately calculate ART interruption and missed scheduled consultations from available records due to data quality issues.