HIV and COVID-19 pandemic collision: turning challenges into opportunity

Abstract

Since the first onset of the SARS-CoV-2 pandemic in China, it clearly appeared that the healthcare systems around the world would be severely challenged, in particular regarding their capability to handle patients with chronic conditions [1]. HIV infection is among these and the continuum of care such as the availability of diagnostic and preventive resources are particularly important to combat the HIV pandemic. In fact, multifaceted strategies are required to curb the HIV pandemic and to approach the ambitious goal of 90-90-90 [2]. In particular, these goals include that by 2020, 90% of people living with HIV will be aware of their status, 90% of people diagnosed will receive antiretrovirals and 90% of people on therapy will have their HIV-RNA under control. The 90-90-90 strategy relies on HIV diagnosis and prevention which requires the availability of outpatients’ facilities to perform HIV screening and to give counseling and distribute pre-exposure prophylaxis. Moreover, for people living with HIV and AIDS (PLWHA) the continuum of care is one of the key points to maintain the treatment and consolidate the so called ‘third 90’ [2]. As the two pandemics collided, several concerns on HIV diagnosis and management have been raised (Supplementary Figure 1). First, the measures enforced by most of the countries to reduce the spread of SARS-CoV-2 comprehended national or local lockdowns and restriction on travel between countries [3]. This type of confinement, if on the one hand has been demonstrated to be the most effective strategy, able to reduce the burden and diffusion of SARSCoV-2, on the other hand, it creates more barriers for patients with chronic diseases such as those PLWHA [4]. Moreover, most of the outpatients’ facilities were temporary closed and consequently both HIV new diagnosis [5], postexposure prophylaxis [6,7] and pre-exposure prophylaxis dropped due to healthcare resources re-allocated to fight the COVID-19 pandemic [8]. Second, contradicting evidence from the possible therapeutic effect of some antiretrovirals (i.e., lopinavir/ ritonavir) came to public attention in the early days of the pandemic. These evidences were subsequently disproved by several studies, which showed no benefit on patient survival [9,10]. Nevertheless, contradictory messages coming from the media suggested the wrong message, in other words, PLWHA on treatment with such medications could have a decreased risk of disease severity [11]. Third, the emergence of a viral disease which affected the most fragile groups, such as elderly people and those with underlying medical conditions, added fear to PLWHA about a possibly more severe course of the diseases related to the immunosuppression. Nevertheless, it seems that PLWHA do not show a more severe phenotype of the disease since the first preliminary reports [12]. These observations were subsequently confirmed by large observational studies which identified age and comorbidities as the most important drivers toward a worse outcome in PLWHA [13,14]. As far as HIV specific immunological deficiency, those patients without antiretroviral treatment, such as those with lower CD4 cell counts, appeared to be at increased risk of severe disease and worse outcomes [15].