2020 was supposed to be the year we took control of the HIV epidemic. Four years ago, governments around the world – including Canada – committed to achieve three targets: 90% of people with HIV diagnosed, 90% of those diagnosed on treatment, and 90% of those on treatment managing to suppress the virus to undetectable levels.
Since suppressing HIV through treatment eliminates the risk of passing it on to a sexual partner, scientists projected that meeting these targets by 2020 would eliminate HIV/AIDS as a public health threat by 2030.
Then COVID-19 happened.
At first glance, you might think that physical distancing measures to protect us from COVID-19 would similarly limit opportunities to transmit HIV. However, the reality on the ground is not so straightforward.
After all, consensual sex is healthy for both the body and the mind, and it can offer the physical and emotional intimacy that many are craving so much right now.
Similarly, many people use drugs to help them cope in times of stress.
People having sex or using drugs is not new. What makes this a greater risk now is that our public health infrastructure has been hampered.
HIV testing clinics have had to reduce their hours or shut down entirely – either to reallocate their staff and resources to the COVID-19 response or to ensure adequate distancing.
Prevention and support services have also been under strain: supervised consumption sites, HIV prevention clinics, counselling services and more.
These prevention, testing and treatment programs have been the cornerstone of Canada’s efforts to eliminate HIV transmission.
A threat to any of these pillars could topple the entire foundation of our HIV response and trigger a resurgence in the epidemic. In fact, researchers from the British Columbia Centre for Excellence in HIV/AIDS recently projected that a 50% disruption to HIV services due to COVID-19 could result in a 9% increase in new HIV infections.
It doesn’t have to be this way.
Even before the COVID-19 pandemic, community-based service providers had been piloting innovative approaches to delivering HIV services remotely – primarily to offer greater convenience to patients and clients, but also to find efficiencies in the healthcare system.
HIV self-testing, recently approved by Health Canada, is one tool that could be effectively leveraged to diagnose people at a time when clinics are unable to handle the same capacity of in-person appointments.
Self-testing could also alleviate the burden on testing labs – currently handling backlogs of COVID-19 tests – by screening out negative test results and only forwarding preliminary positive results for confirmatory lab testing.
Although the self-test has been approved in Canada, it is still a long way from becoming accessible to the average person, with the retail price being a major impediment.
Programs are emerging across the country to get kits into the hands of the people who need them, but this will require ongoing financial support.
Given the public health benefit of HIV diagnosis and the potential to alleviate the burden on testing labs, governments should view financial support for HIV self-testing as a cost-effective investment.
Researchers had also been investigating ways to make it easier to take PrEP – a pill taken on a regular basis by an HIV-negative person to prevent HIV infection. Canadian guidelines recommend that those who take PrEP see their doctor and get tested for sexually transmitted infections every few months.
That’s especially difficult during a pandemic, when clinics are full, distance must be maintained, and everyone wants to avoid any unnecessary visits to the doctor.
Research projects have already demonstrated ways to ease this burden, such as offering remote clinical consultations or allowing patients to take their own test samples at home and submit them to labs directly.
Many healthcare providers have been compelled to offer these services because of the pandemic, but now is the time to scale up the offer of at-home PrEP services for anyone who wants it. It’s not just about convenience anymore; it’s also about preserving our healthcare capacity in a pandemic.
The same applies to preventing HIV transmission through injection drug use.
Needle exchanges, supervised consumption sites and other harm reduction services are proven to reduce HIV infections by providing sterile equipment and prevention information to people who use drugs.
The overdose crisis had already strained these services to the limit over the past few years, and the COVID-19 pandemic only added fuel to the fire.
Harm reduction workers already have solutions that can be leveraged in this crisis.
“Satellite sites” offer similar services to community-based health centres, but they are delivered by the peers of people who use drugs, right in their homes. It allows for people who use drugs to access the sterile equipment and prevention information they need, while also reducing the risk of becoming ill with COVID-19.
Researchers and community advocates have been calling for these types of peer-driven harm reduction programs, along with a safe drug supply, to be supported and implemented well before COVID-19, but the pandemic has made these programs a necessity.
Rather than risk an HIV epidemic resurgence that will further strain our public healthcare system during a pandemic, let’s leverage this opportunity to deliver HIV services differently.
Laurie Edmiston is executive director of CATIE, Canada’s source for HIV and hepatitis C information.