As health services around the world continue to focus their resources on ending the coronavirus pandemic, they threaten to derail decades of hard-won progress in the response to HIV, TB and many other diseases. That’s according to a new report by the International AIDS Society publishing this week.
The society will raise its concerns during the 23rd International AIDS conference, which began Monday. Over the course of the week officials will be highlighting the impact the pandemic has had on control programs for HIV and other diseases worldwide — adding to a series of fears raised in recent months.
“The social distancing efforts and lockdowns to control the spread of it [coronavirus], have disrupted HIV prevention and treatment programs and put vital HIV research on hold,” said Dr. Anton Pozniak, president of the International AIDS Society, last week, ahead of the conference.
Various surveys proved this to be true, including one released in June by the Global Fund to fight AIDS, Tuberculosis and Malaria, an international financing nongovernmental organization. It found that across 106 of the countries it works in, 85% reported disruptions to their HIV services and 78% and 73% to tuberculosis and malaria services, respectively. Nearly 20% reported severe disruptions for all three diseases.
Models by the World Health Organization, Stop TB partnership and Imperial College London have predicted that such disruptions could lead to over 1 million extra deaths across these three diseases.
For example, recent models commissioned by the World Health Organization and Joint United Nations Programme on HIV and AIDS (UNAIDS) estimated that a six-month disruption to services in sub-Saharan Africa alone could lead to an extra 500,000 deaths from AIDS-related illnesses in 2021. This is on top of a likely 470,000 deaths that would have occurred, based on 2018 numbers.
This would take progress in HIV control back by more than 12 years.
“There is a risk that the hard-earned gains of the AIDS response will be sacrificed to the fight against COVID-19,” said UNAIDS Executive Director Winnie Byanyima in a statement in May, when the models were published. “But the right to health means that no one disease should be fought at the expense of the other.”
Many experts in the field believe that fighting Covid-19 has done exactly that.
“When your outreach services are transferred to Covid and Covid-testing, nobody is testing for HIV,” Pozniak told CNN.
These services are not testing for anything other than Covid-19, impacting not just HIV, but also tuberculosis, malaria and most other diseases as a result, including vaccine preventable ones.
Hundreds of thousands of extra deaths
Last month, mathematical models released by the Stop TB partnership estimated that a two-month global lockdown followed by two-month recovery — considered a best-case scenario — could result in more than 1.8 million extra cases of TB globally, and more than 340,000 extra deaths by 2025. This is again on top of the 10 million typically infected and 1.5 million who die each year based on 2018 WHO figures.
Controlling TB means knowing who is infected and putting them on treatment, to benefit both the person infected as well as the people in their community. Like coronavirus, TB is spread through droplets released into the air by infected people, and it’s estimated that someone with an active infection could infect as many as 10 to 15 people in a year, according to the International Federation of Red Cross and Red Crescent services.
Malaria is also going to surge, according to experts. Models published at the beginning of May by Imperial College London estimated that malaria deaths could double this year, compared to 2019, reaching more than 760,000 deaths, due to fewer people having access to bed nets to protect them from mosquito bites and limited access to testing or treatment when they do become infected.
“You’ll see transmission increase” Pozniak said, but the extent of the damage will only be discovered later, “once we get back to widespread testing,” he said.
Pozniak stressed that models like these are estimates, based on many assumptions. This means it could be better, but it could also be worse. “It could be worse than they say and that would be disastrous,” he said. “But we hope that the efforts organizations are putting in place will mitigate any loss.”
Efforts include creating village-level drop-off points for things like HIV and TB drugs, which need to be taken daily for extensive periods of time, as well as insecticide-treated bed nets. Volunteer community workers provide many of the community services in sub-Saharan Africa, but recruiting more of them is also not straightforward as the availability of equipment to protect them in the field is also limited.
So, just how bad does he think it will to be? “It’s very difficult to say,” Pozniak said.
‘We’ll be thrown back five years’
Fears on the ground can be glimpsed through a window into the small landlocked country of eSwatini, formerly Swaziland, which has the highest levels of HIV in the world.
An estimated 27.3% of the population there was living with HIV in 2018 — more than one in four people — according to UNAIDS. But it’s seen relatively low numbers of coronavirus cases compared to the rest of the world, though not for the African continent. As of July 1, there have been 954 cases and 13 deaths in eSwatini as of July 5.
But the pandemic has still overwhelmed the health sector, and the virus is still spreading, and as resources continue to be diverted to tackle it, health experts are extremely aware of the other infections ready to erupt in its wake.
“Our main focus in the last years was on HIV and tuberculosis,” said Dr. Bernhard Kerschberger, country director and head of mission for the humanitarian NGO Medecins sans Frontieres. After years of progress in fighting these diseases, he fears a rebound, and a big one at that. “Maybe we’ll be thrown back five years.”
Since the first case of coronavirus was first reported there on March 14, subsequent lockdowns and fears around contracting the virus have kept people away from the clinics MSF supports — with outpatient numbers falling by 50%. Populations are mostly rural, meaning that visiting a clinic often requires extensive travel on public transport.
Mobile health services provided by MSF have been stopped, as they typically encourage crowds to gather in public spaces. Because of all this, HIV testing fell by 40% in April and the number of people starting antiretroviral treatment for the infection declined by 50%, Kerschberger told CNN. “We are very concerned,” he said.
But the true impact and the extent of the damage won’t be felt for some months, maybe years.
Learning from Ebola
Some insight on the likely impact of the pandemic can be garnered from the outcomes of previous large-scale outbreaks, such as the Ebola epidemic that devastated West Africa in 2014, infecting more than 28,000 people and causing more than 11,000 deaths.
This emergency spanned two years and again diverted resources away from infections already affecting populations in the region, such as HIV and malaria, particularly in Liberia, Guinea and Sierra Leone.
“You can see from other pandemics that affected communities, you’re going to get disruption,” Pozniak said.
A 2016 study by researchers at the Yale School of Public Health estimated an extra 10,000 people died from HIV, TB and malaria following the Ebola epidemic, based on a 50% reduction in access to health care during that time.
This year’s pandemic and the 2014 epidemic “are very similar in certain ways,” said Dr. Emanuele Capobianco, director of health and care for the IFRC. “I remember there was a very huge spike for malaria, because malaria was not being diagnosed,” he told CNN. To alleviate this, tests were taken out to the community, allowing malaria to be diagnosed and treated more easily.
The IFRC is currently involved in delivering hundreds of millions of insecticide-treated bed nets at the community level across 30 countries around the pandemic — with a target of 250 million nets by the end of 2020. But this presents it own challenges with respect to speed of delivery, having sufficient protective equipment for those providing the nets and making sure small numbers of people come to collect them and are spaced out when they do. “The biggest problem is congregation of people,” Capobianco said.
Delivering things like antiretroviral drugs as a stock supply, covering people for two to three months, however, also requires a certain level of supervision, he explained, to make sure the drugs are taken as they should be and are also not sold on if people are struggling financially.
“We know this is a very delicate time for household financial security and drugs are a commodity and can be sold,” he pointed out. “Community workers following families and supporting them is important.”
But while these things are in motion, “the disruption is severe and the consequences are going to be felt for a long time,” he said.
Immunizations on pause
Further consequences include an impending surge in infections that would have otherwise been prevented through routine immunization programs — such as measles, polio and rubella — because while community points can be created to simply drop off medicines and nets, the same can’t be said for vaccines.
“It’s more complex,” Capobianco said, as immunizing children means being close to both the child receiving the vaccine — to inject it — and the mother holding them. “There is an element of physical proximity you cannot avoid,” he said. “It’s not impossible, but it needs more planning.”
The global NGO follows the guidance of the countries it works in, and in many of them immunization campaigns have been suspended. This followed WHO guidance in March that advised temporarily postponing such campaigns in places that weren’t experiencing outbreaks of these diseases.
Data released by WHO last month showed that routine immunizations had been impacted in at least 68 countries worldwide, affecting around 80 million babies under age 1 in those countries. But subsequent funding commitments pledged at the Global Vaccine Summit in June, and new guidance from WHO on how to safely resume immunization campaigns, are hoped to mitigate this to a certain extent, according to WHO.
But infections like measles are among the most contagious, and outbreaks continue to occur, with more than 22,500 cases of measles reported globally to WHO in February, before coronavirus was declared a pandemic. Since then, thousands of measles cases have been reported but gaps in reporting numbers make the data less reliable.
Either way, cases of measles — as well as rubella and diphtheria, to name a few — continue to occur, and experts fear that as lockdown restrictions continue to lift and people are in more contact with one another, the children who remain unvaccinated will be extremely vulnerable — and mass outbreaks may result.
New vaccine development delayed
If that’s not a bleak enough picture, new opportunities for infection control have also been damaged by the pandemic as the race to find a much-needed coronavirus vaccine has, inevitably, diverted resources away from ones that were in the works for at least 12 other diseases, including malaria, the Zika virus and Middle East respiratory syndrome (MERS) — a relative of Covid-19.
This is the case, for example, at the University of Oxford’s Jenner Institute, which currently has a Covid-19 vaccine candidate undergoing human trials in the United Kingdom, Brazil and South Africa.
“All the other vaccine programmes at the Jenner Institute have been delayed by COVID-19 work: both pre-clinical work and clinical trials,” said Adrian Hill, director of The Jenner Institute and a professor of human genetics, in an email to CNN. “For the last three months only COVID-19 work has been permitted during lockdown and our phase III trial of the new COVID-19 vaccine is using all the capacity of our clinical center.” This includes staff and students who were redeployed from other programs.
Hill suspected the delay in getting the center’s other programs back on track will be about six months — longer than delays resulting from the 2014 Ebola epidemic.
But of particular concern is the group’s malaria vaccine, which was set to start a trial that could lead to it being licensed, Hill explained. “Starting this trial is behind schedule and so potential deployment of this malaria vaccine could be delayed by COVID-19,” he said.
Hill hopes his team’s malaria vaccine may provide better protection than one created by GSK, known as RTS,S, which began rolling out in Africa last year but is only 40% effective.
There were an estimated 228 million cases of malaria worldwide in 2018, according to WHO, with 405,000 deaths. “Global malaria mortality has been similar to that of COVID-19 mortality over the last nine months,” Hill said.
Finding a vaccine against Covid-19 is a global priority. It’s what leaders worldwide are hoping for to end the pandemic and restore the global economy. And while the focus on this has delayed progress against other infectious diseases significantly, one piece of silver lining is that the speed at which this vaccine is being developed could set a precedent for the rest — if they too are prioritized.
Poor discovery processes and financing structures around vaccine development have been highlighted, Hill said, and Covid-19 has shown that vaccine development “can actually go from virus discovery to phase III trials and large scale vaccine manufacture in six months.” This usually takes 10 years.
“We probably can’t go so fast for all new vaccines,” Hill said. “But it shouldn’t take 20 times as long as with COVID-19 to develop vaccines that could save more lives.”