What impact has COVID-19 had on HIV testing?

The COVID-19 pandemic has severely disrupted access to healthcare services. As a result, there has been a significant fall in people accessing HIV testing. While the pandemic has accelerated many advances in healthcare access, experts encourage health services to continue to improve access to HIV tests.

COVID-19 and HIV testing

Almost two years in to the coronavirus (COVID-19) pandemic, speakers at the recent 18th European AIDS Conference (EACS 2021) have raised concerns over the significant impact that COVID-19 has had on HIV testing and diagnosis. While HIV care and treatment have also been affected, HIV testing has been more severely impacted across the globe.

The COVID-19 pandemic has caused huge disruptions in healthcare services. As a result, the impact of COVID-19 extends beyond those who have been infected with the disease, affecting patients with other conditions, such as people with HIV.

What are the two types of HIV testing?

Rapid blood tests for HIV can give results within 30 minutes and may be undertaken at sexual health clinics or through self-testing at home. HIV home testing kits became legal to sell in the UK in 2014. It's important to check that the kit carries the CE (Conformité Européenne) mark which indicates it is safe for home use. GPs can also arrange blood tests that will then be sent and analysed in a laboratory.

What is the window period for HIV testing?

The window period refers to the time after contracting HIV that the signs of HIV infection can remain absent or undetectable. HIV testing cannot always detect infection during this window. For rapid HIV tests, this window period can last up to 90 days, while for modern laboratory blood tests this time is halved to 45 days.

COVID-19: reduction in HIV testing and increase in positive diagnoses

Speaking at EACS 2021, Elena Vovc from the World Health Organization (WHO) felt that HIV testing has been too severely affected during the COVID-19 pandemic to assume that the overall reductions in HIV diagnoses were solely caused by lockdown restrictions limiting people having sex with new partners.

The UNAIDS HIV services tracking tool, which collects monthly global HIV data, found that HIV tests decreased significantly during the first wave of COVID-19 in most reporting countries. These also remained below pre-COVID times in all but one country in June 2020.

Several data sets, comparing HIV testing during the pandemic in 2020 to previous figures in 2019, also show a significant reduction in people being tested for HIV. Of those that did get tested, they found that the percentage of people receiving a positive HIV result increased.

The EuroTest survey: countries in the WHO European region

Comparison of March to May and June to August 2020 with equivalent 2019 period found:

  • In March to May 95% of respondents reported decreases in HIV testing.
  • In June to August 58% of respondents reported decreases in HIV testing.
  • In March to May estimations of positive results tended to decrease or remain stable.
  • In June to August estimations of positive results remained stable or increased slightly.

A cohort study of four continents using data from the AIDS Healthcare Foundation (AHF): 44 countries across Asia, Latin America and the Caribbean, Africa, and Europe

Comparison of January to August 2020 with equivalent 2019 period found:

  • Reduction rates in HIV testing ranged from 26.19% in Europe to 44.62% in Latin America/the Caribbean.
  • Overall reduction in HIV testing was 35.40%.
  • An increased percentage in positive results among HIV tests done, ranging from 2.19% in Africa to 43.95% in Europe.
  • Overall relative increase in positive tests was 9.52%.

The four continent study also looked at the impact of COVID-19 on HIV care and treatment. A reduction of in-person consultations and in the number of new enrolments in care was apparent across most continents. In contrast, Europe actually experienced an increase of HIV cases across both of these areas.

Why has COVID-19 affected HIV testing?

There are several ways in which the pandemic is likely to have prevented people from taking an HIV test:

  • Lockdown restrictions causing the closure of testing sites.
  • Lack of testing appointment slots in clinics, due to backlog caused by lockdowns.
  • Reduced staff due to redistribution and employment cuts.
  • Reduced attendance and fewer scheduled appointments, potentially due to fear of contracting COVID-19.

According to the EuroTest survey, 41 out of 52 community-based testing sites and 19 out of 36 secondary-level care sites reported severe disruptions to HIV testing.

It's important to note that although data reveal an increase in the percentage of positive HIV tests, this does not necessarily mean that HIV transmission rates have gone up. A higher percentage of positive results can still mean that the total number of positive results has gone down, if a significantly lower number of tests is being done overall.

It's possible that these data are the result of the targeted testing strategies used during the pandemic. These may have included prioritising the testing of individuals who have a higher risk or those presenting AIDS-related symptoms.

Current and future measures to support HIV testing

Despite these outcomes, the researchers of the four continent study believe that the negative impact of COVID-19 on HIV testing could have been worse. The pandemic has accelerated technical innovations and introduced new measures that have allowed many people to both take an HIV test and consult with their doctor:

  • Telemedicine (health services provided via electronic technologies).
  • Virtual appointments.
  • Scheduled facility-based appointments, including community-based testing.
  • Referral to other testing sites.
  • Staff reinforcements.
  • Home-based HIV blood test sampling and self-testing.

Future measures

It is the belief of the four continent study researchers that healthcare services must be prepared to respond to the impact of COVID-19 on HIV testing, care and treatment for years to come. This is vital for reducing the long-term impact on AIDS and HIV transmission rates.

"The consequences of the disruption of health systems will include an increase in new infections that may continue for decades, as well as a resurgence in the rates of AIDS and mortality corresponding to individuals who failed to access testing."

Experts are suggesting that the measures which can support HIV testing efforts over the pandemic should also be continued post-pandemic. While many locations have been able to provide the above alternative measures and technologies, others have not.

In the EuroTest survey, the need for additional human resources, more financial support and better regulation of self-testing and community-based testing are key short-comings reported by many of the respondents.

It's also important for sexual and reproductive health services to continue to protect pregnant and breastfeeding women in the prevention of mother-to-child transmission of HIV. Experts have described protecting this group from COVID-19 while sustaining essential HIV services as "an immense global health challenge".

Measures taken by sexual health services could include:

  • Bundling services in the same visit.
  • Providing HIV testing outside of facilities to the extent possible to reduce exposure risk to COVID-19.
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