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Professor of Medicine
University Hospital Bonn
Department of Medicine I
Jürgen K. Rockstroh, MD, has disclosed that he has received consulting fees from Abivax, Galapagos, Gilead Sciences, Merck, and ViiV and fees for non-CME/CE services from Gilead Sciences, Janssen, Merck, Theratechnologies, and ViiV.
HIV care in 2020 and 2021 has been severely affected by the COVID-19 pandemic. In the wake of lockdowns, many services for people with HIV (PWH) have been disrupted, including both prevention services and direct HIV care. In 2020, the number of HIV tests decreased dramatically as did the refilling of pre-exposure prophylaxis (PrEP) prescriptions and new PrEP starts. Moreover, first reports document small increases in the number of PWH under continuous antiretroviral therapy who have developed HIV blips.
Lockdowns have also created barriers in supply and distribution of antiretroviral medicines, leading to unintended treatment interruptions. This was found most often in PWH who were abroad and unable to return to their home country because of COVID-19–associated travel restrictions. Finding solutions for bridging HIV therapies during these interruptions has required close collaboration with community organizations.
To overcome the difficulties in having face-to-face appointments in many countries, telemedicine was rapidly introduced or upscaled. It must be emphasized, however, that HIV-associated issues around stigma and mental health can be difficult to discuss on a video call. Indeed, the close connection between patients and healthcare professionals built on many years of establishing trust is of particular importance in HIV care, as it improves treatment adherence. Unfortunately, that relationship can be difficult to maintain in a purely digital format. This is particularly true for some vulnerable populations, including older PWH, where social isolation and mental health issues are more prevalent. Indeed, more than 50% of PWH in Western Europe and the United States are now older than 50 years of age and require additional attention on increasing comorbidities and comedications. In particular, it has been challenging to maintain the guideline recommended frequency of cancer screenings such as colonoscopy or screening for anal/rectal cancer during the pandemic. This has led to delays in cancer diagnosis with detrimental clinical consequences. Clearly, more work is needed to reinforce health messaging and shape services delivery to ensure PWH remain engaged in clinical care.
Social Benefits of Virtual Platforms
Despite the obvious limitations of telemedicine, digital developments—including smartphone-guided secondary prevention for patients with coronary artery disease or diabetes—could promote patient involvement in their own disease management and support lifestyle changes. The health disparities experienced by people aging with HIV, such as high rates of non-AIDS–defining cancer, coronary heart disease, and depression, make them especially at risk for adverse outcomes from the virus itself and for the psychological and social challenges it presents. The COVID-19 lockdown and shelter-in-place orders further increased isolation and social distancing faced by people aging with HIV and created barriers and hardships in accessing medications, health services, and other resources.
One possible solution to address the increased risk of depression and isolation among people aging with HIV is to facilitate social connections in the form of virtual villages. A virtual village can be a platform for centralizing communication across all parties, allowing people aging with HIV to quickly connect with medical and social service professionals and systems to meet their health needs while providing continuously updated information to improve the quality and continuity of care. Moreover, PWH can be brought into contact with each other.
Returning to In-Person Visits
Nevertheless, rapid reorganization of face-to-face appointments under clear safety measures (mask requirement, controlled number of patients in waiting area, etc) have allowed us to deal with the increased clinical challenges of aging PWH with additional comorbidities. Creating multidisciplinary teams (including cardiologist, bone specialist, diabetes specialist, etc) has helped to minimize clinic visit days while allowing us to care for the increasing plethora of comorbidities among our aging patients.
Sharing good practice examples and learnings from this pandemic will allow not only better management of our patients today but also better preparedness for the next pandemic.
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