Amid HIV Outbreaks, Covid-19 Fractures Existing Public Health Efforts
“Every health disparity map in the United States is the same,” Alex Vance, Senior Director of Advocacy and Public Policy at the International Association of Providers in AIDS Care, has repeatedly stated when discussing the COVID-19 pandemic and the very real risks of “back sliding” in our moderate advancements in the United States’ effort to End the HIV Epidemic. There’s no better way to demonstrate this than by showing you.
As another “wave” of Covid-19 ravages the country, increasing cases, hospitalization rates, and eventually deaths, existing public health needs around HIV, viral hepatitis, and sexually transmitted infections continue to be strained, pushed to the back burner and most often in geographic areas where we need to be able to juggle more, not less; particularly across the South. Unlike Covid-19 outbreaks, which receive fairly immediate attention in terms of reporting and response, HIV outbreaks can and do often take a year or more to notice and begin action to address. While there’s concern about juggling the demands of addressing concurrent pandemics, some (certainly not all) of this reporting and response is beginning to speed up with regard to HIV.
West Virginia’s Kanawha County HIV outbreak is considered a 2020 outbreak, though just recently received a report from the Center’s for Disease Control & Prevention (CDC) on next steps and recommendations to address. Despite these recommendations including supporting syringe exchange programs and community-based services, local officials continue a politically oriented response by seeking to limit the support of syringe exchange programs, threatening their ability to operate and aid in addressing the needs of the local community. Another outbreak in Michigan’s Upper Peninsula was identified in July of this year, with rural Kalkaska County reporting a higher rate of new HIV diagnoses than even Detroit. Kalkaska County is so similarly situated to Scott County, Indiana, it’s striking. Louisville, Kentucky has reported almost as many new HIV diagnoses in the first half of 2021 as the area does annually. And Duluth, outside of Saint Louis, Minnesota, joined neighboring Hennepin and Ramsey Counties with declared outbreaks tied to 2019 and 2018, respectively.
What’s important to note about 2020’s marked reduction in HIV screenings is not just the delay in newly diagnosing people living with HIV, but the lack of ability to link people to care upon diagnosis, beginning antiretroviral therapy and taking steps to reduce the person’s viral load. With at-home testing being the substitute offering, linkage to care and counseling for people self-testing may be hampered according to some concerned advocates. Achieving viral suppression also reduces the possibility of transmitting HIV by way of sexual contact to zero (“Undetectable = Untransmittable”) – creating a process where people living with HIV are not just a patient group needing identification, but play a critical role in preventing new transmissions.
In reviewing the possibilities of delayed care and delayed screening, public health officials and advocates should remember a new diagnosis is not necessarily indicative of a new transmission. A potential problem in and of itself, in assessing Covid-19 disruptions in screening and care, is the possibility of a “bottle neck” of new testing revealing new HIV diagnoses which otherwise might have been identified in the previous year if not for stay-at-home orders, education and public awareness campaigns, and community health care providers having had to take a step or shift gears entirely from HIV to Covid-19. It will take years for us to truly understand the breadth and reach of Covid-19 on the world’s only concurrent pandemic, even in the “most advanced country in the world”.
What can already be well-appreciated and should be well-understood is we cannot afford to keep asking community-based health care providers and community partners in combatting the domestic HIV epidemic to keep sacrificing HIV screening and linkage to care in order to address Covid-19. What must be prioritized is funding, programming, training, and most importantly hiring of new talent in addition to existing programs in order to address both sets of needs.
As I summarized in a previous blog, capacity has been breached, we cannot afford to keep asking public health to do more with less and expect to succeed in addressing Covid-19, HIV, viral hepatitis, STIs, or the opioid epidemic.