By Sarah Varney, Kaiser Health News
Wednesday, April 21, 2021 (Kaiser News) – Faced with a year-long siege by the coronavirus, the defenses in another, older war are stalling.
For the past two decades, HIV / AIDS has been kept in check through effective antiviral drugs, aggressive testing, and inventive public awareness campaigns. But the COVID-19 pandemic has caused profound disruption in almost every aspect of this struggle, grounding response teams, severely restricting testing, and diverting critical personnel away from laboratories and medical centers.
The exact effects of one pandemic on another are still under focus, but preliminary evidence is bothering experts who have hailed tremendous advances in HIV treatment. While the shift in priorities is nationwide, delays in testing and treatment are particularly risky in the southern states, which are now the epicenter of the country’s HIV crisis.
“This is a major derailment,” said Dr. Carlos del Rio, professor of medicine at Emory University in Atlanta and director of the international training and research program for Emory AIDS. “There will be damage. The question is how much? “
Clinics have suspended limited in-person visits and routine HIV screening in doctor’s offices and emergency rooms. Instead, doctors rely on video calls with patients. This is a pointless alternative for the homeless who fear family members will discover their status. Rapid test vehicles that were once parked in front of nightclubs and bars distributing condoms are being mothballed. In the state capitals and county cities, government expertise has been focused solely on the COVID response on deck.
Concrete signs of the impact on HIV surveillance abound: A large commercial laboratory reported nearly 700,000 fewer HIV screening tests nationwide – a 45% decrease – and 5,000 fewer diagnoses between March and September 2020 compared to the same period last year. Prescriptions for PrEP, a pre-exposure prophylaxis that can prevent HIV infection, have also fallen sharply, according to new research presented at a conference last month. State health departments saw similarly sharp decreases in tests.
This lack of new data has led to a precarious, unrecognizable moment: for the first time in decades, the country’s lauded HIV surveillance system is blind to the virus’ movement.
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Nowhere will the lack of data be more palpable than in the south: the region accounts for 51% of all new infections, eight of the ten states with the highest rate of new diagnoses and half of all HIV-related deaths, the latest data from the centers for the Disease control and prevention are available.
Even before the COVID pandemic, Georgia had the highest rate of new HIV diagnoses of any state, although it was lower than Washington, DC. The Georgia Department of Health last spring saw a 70% decrease in tests compared to spring 2019.
The slowdown in HIV patient services “was felt for years,” said Dr. Melanie Thompson, principal researcher at the AIDS Research Consortium in Atlanta.
She added, “Any new HIV infection continues the epidemic and is likely to be passed on to one or more people in the coming months if people are not diagnosed and offered HIV treatment.”
Coronavirus testing has commanded the machines previously used for HIV / AIDS testing and has further weighed on surveillance efforts. The polymerase chain reaction, or PCR, devices that detect and measure the genetic material of human immunodeficiency virus are the same devices that perform COVID tests around the clock.
Over the decades as HIV migrated inland from coastal cities like San Francisco, Los Angeles, and New York, it took root in the south, where poverty is endemic, poor health insurance is common, and HIV stigma is rampant.
“There is the stigma that is real. There is legacy racism, “said Dr. Thomas Giordano, medical director of the Thomas Street Health Center in Houston, one of the largest HIV clinics in the US Black, Latino and Gay. It’s just not mainstream at the state level. “
Blacks make up 13% of the US population, but about 40% of HIV cases – and deaths. In many southern states, the differences are large: in Alabama, blacks make up 27% of the population and 70% of new diagnoses; In Georgia, blacks make up 33% of the population and 69% of the people living with HIV.
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HIV clinics that care for low-income patients also face restrictions on the use of video and phone appointments. Clinic directors say poor patients often lack data plans and many homeless patients simply do not have phones. You also have to struggle with fear. “If a friend gives you a room to sleep in and your friend finds out you have HIV, you may lose that place to sleep,” said Del Rio of Emory University.
Texting can also be difficult. “We have to be careful with text messages,” said Dr. John Carlo, President of PRISM Health Care North Texas in Dallas. “When someone sees their phone, it can be devastating.”
In Mississippi, HIV exposure tracing, which has been used as a model for some local coronavirus tracking efforts, has been restricted by COVID-related travel restrictions designed to “protect both staff and customers,” said Melverta Bender, director of the STD / HIV Office at the Mississippi Department of Health.
Of all regions in the United States, the south has the weakest health protection networks. And southern states have far fewer resources than states like California and New York. “Our public health infrastructures have been chronically underfunded and undermined over the decades,” said Thompson, the Atlanta researcher. “So we will deteriorate by many key figures.”
The high rate of HIV infection in Georgia and the slow pace of COVID vaccinations in the state are unrelated, Thompson said.
The porous safety net extends to health insurance, a vital need for people living with HIV. Almost half of Americans without health insurance live in the south, where many states haven’t expanded Medicaid under the Affordable Care Act. As a result, many people living with HIV can rely on the Ryan White Federal HIV / AIDS Program and Government AIDS Drug Assistance Programs (ADAPs), which have limited coverage.
“For the sake of justice, insurance is vital to the lives and thriving of people living with HIV,” said Tim Horn, director of health care access for NASTAD, the National Alliance of State and Territorial AIDS Directors. Ryan White and ADAPs “are unable to provide this comprehensive coverage,” he said.
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Roshan McDaniel, ADAP program manager in South Carolina, says 60% of South Carolinians enrolled in ADAP would qualify if their state expanded Medicaid. “We thought about it for the first few years,” said McDaniel. “We don’t even think about it these days.”
Admission to the Ryan White program skyrocketed in the early months of the pandemic as state economies froze and Americans huddled in the midst of a major pandemic. Data from state health authorities reflect the increased demand. In Texas, enrollment in the state AIDS drug program increased 34% from March to December 2020. In Georgia, enrollment increased 10%.
State health officials attribute the increase in enrollment to pandemic-related job losses, particularly in states where Medicaid has not been expanded. Antiretroviral treatment, the established regimen that suppresses the amount of virus in the body and prevents AIDS, costs up to $ 36,000 a year, and drug interruptions can lead to virus mutations and drug resistance. However, it is difficult to qualify for government assistance: approval can take up to two months, and lack of documentation can result in coverage being canceled.
Southern states have generally lagged behind in bringing patients to health care and suppressing their viral loads, and people with HIV infection tend to go undiagnosed there longer than in other regions, according to federal health experts. For example, in Georgia, almost 1 in 4 people who learned they were infected developed AIDS within a year, indicating that their infections had not been diagnosed for a long time.
As vaccinations become widespread and restrictions wear off, the directors of the HIV clinic search their patient lists to determine who to see first. “We look at how many people haven’t seen us in over a year. We think it’s over several hundred. They moved? Have you moved providers? “Said Carlo, the doctor and CEO of Healthcare in Dallas. “We don’t know what the long-term consequences will be.”
KHN (Kaiser Health News) is a national newsroom that produces extensive journalism on health issues. Alongside Policy Analysis and Polling, KHN is one of the three most important operational programs of the KFF (Kaiser Family Foundation). KFF is a foundation that provides health information to the nation.
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