The first two months after the pandemic start have produced important changes in the management of HIV-positive patients in our HIV care unit. The main goals during the COVID-19 pandemic have been to both prevent HIV-positive patients and health care professionals from SARS-CoV-2 infection and to maintain an appropriate HIV continuum of care.
Our findings highlight several issues. The first UNAIDS target (90% of all people living with HIV should know their HIV status) (3) is based on HIV testing and it is the first step towards initiation into the HIV care continuum. Our clinic receives patients from a large province with more than 1 million inhabitants, where the incidence of HIV infection is estimated to be one of the highest in Italy, 5.8/100000 compared to 4.7/100000 in the whole country (7). From a public health perspective, the reduction of the occurrence of new cases is detrimental in order to reduce viral circulation. Promoting HIV testing with early diagnosis represents the essential entry point for both treatment and prevention efforts. Here we show as the COVID-19 pandemic had a negative impact on HIV screening programs in our province. Indeed, we observed a drop in the number of new HIV cases in comparison with the monthly mean of new HIV diagnosis occurred in the 2019 (2.5 vs 6.7 new HIV cases/month, p = 0.01). On March 8th, 2020 the Italian government declared the implementation of community containment measures in order to contain the diffusion of SARS-CoV-2 (8), which included social distancing, movement restrictions and quarantine for certain or suspected cases. Predictably, these measures drastically reduced the access to routine HIV testing (9, 10). For a near future, it will be important to organize health services in order to guarantee a safe and continuous access to HIV testing, which is a fundamental health service and a detrimental step towards HIV elimination. Females and non-Italian patients resulted to be less adherent to follow-up visits during the pandemic period. This data needs to be further investigated and addressed.Anyway we believe that it is of fundamental importance to identify the more at-risk populations as auspicated by Hargreaves et al (11), in order to better address their needs and behaviors.
The second target (3), (90% of all people with HIV diagnosis should be maintained linked to HIV care) is based in offering and maintaining HIV care in all patients. Soon, hospital visits may be restricted again because of implementation of city lockdowns or traffic controls. From the beginning of March, we adopted the telemedicine tool with the purpose of avoiding the interruption of the continuum of HIV care. We performed structured phone interviews, where the physician together with collecting information about clinical status and ART adherence, also shared laboratory results and future appointments with HIV-positive patients. Telemedical consultations have helped to solve the otherwise unmanageable discrepancy between the #stayathome strategy and the need of a continuous medical assistance as also Ridgway et al experienced (12). Our preliminary experience shows that a large proportion of patients (67,3%) is eligible for a telemedical appointment. In the next years, we may think of this strategy for semesterly evaluation of stable patients. Moreover, this new tool may be helpful to avoid stigma related to be seen in an Infectious Diseases clinic, to decrease the loss of hours of work for medical visits and to reduce the illness perception. Nonetheless, we recommend that more complex cases keep on being considered for in-person medical evaluation and more often than every six months. Anyway, for a more comprehensive understanding of the efficacy of this approach and its impact on HIV care, we will need to evaluate HIV plasmatic suppression in the months to come.
The last target (3), (90% of HIV-positive patients with suppressed viral plasmatic loads) is based in assuring antiretroviral therapy to HIV-positive patients and in reinforcing adherence to ART. According to Italian regulations, HIV-positive patients need to collect their ART at the hospital pharmacy either personally or through a person authorized with a written approval form. Immediately after the beginning of the outbreak, many local charities began to offer home delivery services for ART medications through volunteers, in order to avoid patients exposure. At the beginning this service was not homogenous, relying on local associations or individual initiatives (e.g. municipal police, veterans, local charities, local Red Cross committee, etc..), while at the end of March, this service was coordinated on a national basis, and supported by Red Cross volunteers. In fact, we observed that although the mean decrease during the study period was − 23% compared to 2019, in March the decrease reached − 33,6%, when in April this trend tended to normalize (-12,6%). Once again, we will need to wait to better understand the consequences of this period on ART adherence and HIV replication.
Because many HIV-positive patients contacted us asking whether protease inhibitors would have been protective against SARS-CoV-2 infection (13–16), we analyzed the changes on the collection of STRs including protease inhibitors (darunavir/cobicistat/tenofovir alafenamide/emtricitabine) and STRs not including PIs (lamivudine/abacavir/dolutegravir) at our pharmacy. What we observed is that STRs including PIs had a smaller average drop than STR including integrase inhibitors (16,6% vs 21,6%, p < 0.05). Although we cannot assert whether patients on PIs have been more compliant to ART collection because of the possible effect of these drugs on COVID-19, we think that this data is interesting for it to be pointed out.
Lastly, we described the clinical consequences of SARS-CoV-2 infection in our cohort. We recorded almost a doubling in the number of hospitalizations in HIV-positive patients in comparison with 2019, with a mean of 12,5 patients per month in the second bimester in comparison with 7,6 patients per month in the first. This increase can be ascribed to SARS-CoV-2 infection in HIV-positive patients: indeed, on average, we recorded six HIV/SARS-CoV-2 coinfections per month in 2020. Overall, we managed few cases of HIV/SARS-CoV-2 coinfections. Most of them were admitted with a moderate COVID-19 disease and had optimal outcomes, despite a higher average age and a higher proportion of patients with comorbidities (75%) in comparison with other cohorts (17, 18). Besides, all patients, except three, had CD4 + T-cells > 350/mm3, indicating no severe immune deficiency. As more data were coming out for the efficacy of PIs against SARS-CoV-2 in vivo (19), half of our patients maintained their usual ART and did not switch to a PI during the time of hospitalization. Of those hospitalized, only one patient was prescribed chronically with darunavir/cobicistat and was virosuppressed at admittance. Our observation, although very modest, may add evidence for a lack of a protective role of darunavir against SARS-CoV-2 (20), while more robust evidences are awaited (21). At last, our experience does not support the idea of an excess of morbidity and mortality among PLWH with viral suppression affected by COVID-19 pneumonia. Moreover, we agree with the recent suggestion from Jones et al (22) of not modifying ART in order to attempt to treat SARS-CoV-2 infection.
Our study has important limitations. First, this is a retrospective study without follow-up, therefore it is not possible to ascertain the consequences and the efficacy of our strategies on the last 90 of our strategy (90% of all people receiving antiretroviral therapy with viral suppression). Moreover, the number of hospitalized HIV-positive patients may be small to offer a comprehensive understanding of COVID-19 disease in HIV-positive patients. About this, we may have “lost” some HIV/SARS-CoV-2 coinfections, due to eventual hospitalizations in hospitals other than ours. It must be said anyway, that HIV patients normally tend to be centralized and hospitalized in our ward.
Strength of this study is to have analyzed the main falls in the continuum of HIV care in our area during the emergency period. Now, we have learnt that telemedicine and home delivery services for ART medications are useful and powerful tools. Anyway, our data also emphasize the need to detect the populations at high risk for HIV care attrition (in our case, females and non-Italian patients) and to implement effective retention tools focused on these. We fell in maintaining high levels of routine HIV screening, which is crucial for early diagnosis and for reduction of viral circulation. Therefore, we learned that we have to keep on offering valid alternatives for HIV screening, where several health-care services and other community-based organizations were closed in this period due to the COVID-19 emergency. Moreover, in-person evaluations need to be maintained for those cases which are considered clinically more complicated or more at risk of loss.