HIV Care During COVID-19 in México: Challenges and Solutions

As of November 24, 2020, there have been 59 million global cases of confirmed COVID-19 and 1.4 million deaths, challenging all healthcare systems worldwide. After more than 10 months of the COVID-19 pandemic, it is clear that no country was prepared for this event, but adverse outcomes have disproportionately affected resource-limited settings. México, with an unprepared healthcare system and a vacillating governmental response, has struggled to contain the pandemic, which has now reached over 1 million cases and 100,000 deaths in the country, and to mitigate the difficult economic consequences.

Challenges to HIV Care
Partially due to nonpharmaceutical interventions and redirecting of resources to fight the COVID-19 pandemic, HIV care has been sidelined. In México, HIV care is provided through individual social insurance for those who have it, but approximately 65% of the patients with HIV lack this insurance. For the latter patients, ARVs and laboratory tests are obtained at federally operated HIV clinics that are often located in the state’s capital city and may require patients to travel for several hours, increasing the potential for exposure to SARS-CoV-2. Fortunately, HIV care in México City is available at many specialized and referral institutions, making it more accessible to the city’s > 20 million inhabitants. When our hospital, a National Institutes of Health facility with an HIV clinic that provides care for approximately 2000 patients, was transformed into a COVID-19–only facility by the federal government, patients with HIV were left without access to direct care.

We immediately gave our patients 2 to 3 months of ART to limit hospital visits. As the pandemic unfolded and going to the hospital became a potential health risk for immunocompromised patients, we saw that a significant number of patients stopped or delayed coming for their ART supply, resulting in involuntary and unexpected treatment interruptions.

Since the first COVID-19 case in México 8 months ago, we have observed that less than 1.5% of patients with HIV in care at our institution developed COVID-19, of whom 1 patient unfortunately died. We were able to use this information about the limited impact of COVID-19 to reassure our patients and to encourage them to continue engaging in care, safely.

The Response
To continue to provide HIV care to our patients, our institution was able to implement some creative solutions:

1. We established phone contact with patients to provide information on how best to protect themselves from acquiring SARS-CoV-2 and to offer psychological support. This was welcomed by our patients, and resulted in fewer treatment interruptions or modifications. Maintenance of patient confidentiality and patient confidence in confidentiality were critical factors for successful phone contact. We found that our patients often harbored misconceptions regarding COVID-19, nurtured by misinformation circulating in the media. Changing those beliefs has been one of the most important challenges we have faced.
2. For patients requiring urgent hospital care for non-COVID–related reasons, we established space in a private facility. As the facility was located some distance from the hospital and lacked hospital resources, this was an additional burden on clinicians.
3. As new COVID-19 cases increased and COVID-19–related hospitalizations remained high, we extended our ART supply program from 3-4 months to limit patient travel. By using a drug supply register, we found that medications were not picked up on time by 20% of our patients, putting viral suppression at risk and potentially resulting in increased HIV transmissions in the community. Those patients received phone calls to explain that it was safe for them to pick up their drugs and to advise them on how to implement precautions for safe travel to our site. Fortunately, the place where we supply ART is not located in the hospital, so our patients avoid potential COVID-19 exposure.
4. Because our patients must have viral load and CD4+ cell counts assessed to obtain their medications, we established a safe room to draw blood < 10 meters from the ART pickup site. This provided a safe space to collect samples, as the main laboratory sampling facility remained closed. This system has enabled us to follow up with more than 70% of our patients, and we identified a few patients with detectable viral loads.
5. With the consent of our government, patients with viral rebound are seen in the outpatient clinic to reinforce adherence and to provide counselling on HIV protection measures and psychological support. Ideally, reinforcement combined with counselling will help our patients return to undetectable viral loads with few long-term consequences.

The Future
With these responses, we have addressed some of the challenges presented by the COVID-19 pandemic. However, local and countrywide concerns remain as the pandemic continues and the general response of the public regarding protective measures has been very limited. Some of my concerns are:

• We still don’t have a clear idea when to return to normal clinic work, given the recent increase in new COVID-19 cases. Going back to our normal activity will give providers and patients certainty about their continuum of care.
• With winter approaching, we need to provide the flu vaccine to our patients with HIV, and that means bringing them to the hospital, though many remain reluctant to make the trip.
• The real consequences of the pandemic on our patients are still to be seen. Transient drug interruptions could affect long-term suppression, but this remains to be seen. Considering the high percentage of patients in our clinic and in México using integrase inhibitors, we believe that the consequences will be limited due to the high genetic barrier to resistance of integrase inhibitors.
• Many sites that provide HIV care are still closed or with limited services, lacking solutions to overcome challenges imposed by the pandemic, and these sites may have worse long-term consequences.
• At this moment, drugs and laboratory supplies have not been affected, but we need to ensure that access to necessary medications and supplies remains. In our laboratory, we process samples for viral loads and CD4+ cell counts from approximately 30% of México’s HIV care clinics. Most of the clinics stopped all patient blood draws at the start of the pandemic, but have begun sending samples again in the past 2 months. Unfortunately, we are seeing more viral rebounds from these HIV care clinics compared with our center.
• The number of new HIV diagnoses has decreased by 50% countrywide, due to the closing of many facilities and the fear of going to any healthcare facility. Not only are the 90-90-90 goals for 2020 at risk, but most importantly, the current environment favors late diagnosis and increased transmission, drug resistance, opportunistic infections, and malignancies.
• How the continued use of personal protective equipment and social distancing practices will affect HIV care and the possible development of a safe and effective SARS-CoV-2 vaccine remain to be seen.

Now is the time to be creative with new ways to deliver HIV care. Before the pandemic, in response to the high number of patients with HIV who needed care through our clinic, we started a program consisting of annual visits to the outpatient clinic and a hotline for emergencies. We have learned how best to use video calls as a way to deliver routine care and urgent care. With the limited contact that we have had with our patients, we could be missing some of their important concerns, and we must create a program to assess patients’ concerns and outcomes to better address their needs.

Conclusions
The challenges that the SARS-CoV-2/COVID-19 pandemic has created for the continuum of HIV care are evident, especially in many of the HIV clinics in México that were closed or had services limited. We have met these challenges with many creative initiatives to maintain close contact with our patients via phone calls and to provide counselling, psychological support, long-term ART supplies, safe sites for obtaining laboratory blood work, and limited outpatient visits. We believe that our intense, sincere, and transparent effort to help our patients with HIV navigate these difficult times will limit the effects of the pandemic on their health outcomes.

Working together as a world and as a resource-limited country, we should learn from this pandemic and strengthen our health systems, as many other infectious threats will surely occur in the future, limiting the advances in HIV care and affecting long-term goals in this field.

Your Thoughts
What strategies have you implemented to overcome barriers and retain patients with HIV in care during the COVID-19 pandemic? Please answer the polling question and share your thoughts in the discussion section.

Two Opportunities to Join Us!
Register for an upcoming webinar with me and my colleagues Dra. Leticia Pérez Saleme, Dr. Samuel Navarro, and Dr. Luis Gerardo García Demuner, discussing these strategies and more to overcome challenges imposed on HIV care in México during the COVID-19 pandemic.