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HIV and COVID: Maintaining Progress During the Pandemic

June 11, 2020

Challenges in areas ranging from education to the environment, gender to governance, health to housing don’t exist in a vacuum. Each month, Abt experts from two disciplines explore ideas for tackling these challenges in our monthly podcast, The Intersect. Sign up for monthly e-mail notifications here. Catch up with previous episodes here.

With all the progress we’ve made against HIV, how do we maintain momentum during COVID? And how can we leverage successful HIV strategies to battle the coronavirus? From contact tracing to service delivery, Cathy Thompson and Jane Fox compare notes on their work with HIV in the U.S. and around the globe.

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Read the Transcript

Eric Tischler: Hi, and welcome to the Intersect. I'm Eric Tischler. Abt Associates tackles complex challenges around the world, ranging from improving health and education to assessing the impact of environmental changes. For any given problem, we bring multiple perspectives to the table. Today, I'm joined by two of those colleagues, Cathy Thompson and Jane Fox.

Cathy provides technical and management oversight to Abt programs in East, Central, and Southern Africa. She's an expert in infectious diseases and HIV and AIDS, and has more than 30 years of public health experience, including 18 years living in eastern and southern Africa and four years in South Asia.

Jane focuses on health services research and the evaluation of community health programs, using her expertise in enhancing access to quality care for persons living with HIV/AIDS. This includes her more than 20 years of experience working at Health Resources and Services Administration-funded HIV care services programs.

Welcome!

Cathy Thompson: Thank you, nice to be here.

Jane Fox: Thanks, Eric.

Eric: To start, I want to point out that the two of you coauthored a white paper and you'll be presenting it at a breakout session during the AIDS 2020 virtual conference, which runs July 6th to 10th. The paper’s on the bi-directional view of your respective work on HIV in the U.S. and internationally. I'd love to provide an overview of that work, and then let's talk about how it parallels work that's being done on COVID-19. Jane, can we start with what you're doing in the Ryan White HIV/AIDS program?

Jane: Certainly. So, much of the work that I've done in the past in the Ryan White HIV/AIDS program, particularly in the last 15 years, has been around evaluations, both outcome and the implementation of innovative models to engage people living with HIV [to get] into HIV care and to maintain them in care in the United States. Here, at Abt, I am the principal investigator and PD of several projects [including] one that is specifically funded in Massachusetts to implement an intervention at three HIV clinics, serving women who have not been able to remain in care or who have life challenges that make it difficult for them to remain in care. I work very closely providing technical assistance with each of the clinics, as well as with the intervention staff to follow and track the work that they're doing to engage these women back in care, and to provide them with the services and support that they need to remain in HIV care.

Eric: Great. And Cathy, you want to talk about the work you're doing with PEPFAR, President's Emergency Plan for AIDS Relief?

Cathy: Yes, thanks, Eric. I started working in HIV 30 years ago in New York City, so I have a little domestic experience as well. But my work overseas started ... PEPFAR started in 2004. In that time, I was working for USAID in Namibia and worked on the first country operational plan for PEPFAR. Then I went to Zambia and I did service delivery projects and scaling up HIV/AIDS services and treatment in five of the nine provinces. This was innovative and new for Africa. At first, they weren't doing treatment. They didn't think treatment was possible. And then we showed how possible it was and how exciting it is.

Since then, I've been working with Abt. In our work in Mozambique, we had a service delivery project that finished in 2015. And we just started another very large service delivery project in Mozambique this past year in October. So that project is scaling up treatment. It's treatment, testing, and service delivery in four provinces in Mozambique. In addition, part of PEPFAR is also voluntary male medical circumcision, and we have a project in Namibia doing that work under PEPFAR.

Eric: Great. So let's talk about Mozambique for a minute … we're helping address COVID-19 in Mozambique, is that correct?

Cathy: What's happening in Mozambique is you don't want to lose the services that you've gained in HIV service delivery because of COVID-19. So what we're finding is that people are not coming to the facilities as often as they should to get their medicine. So we're working on some innovative systems [through which] we can then get services to the clients. So we're going to be bringing drugs to the community with community health workers giving out the services. We're going to be doing multi-month dispensing. So someone can come in and get three months’ worth of drugs and be able to only come back every three months for this.

And we're working with groups of HIV clients who will come in and collect the drugs for everyone else in their group. For COVID, CDC is doing the work in COVID in Mozambique and has asked us, since we're in four large provinces, to do the studies to determine how many COVID patients there are and to get the data together to assist with COVID. All of the work we're doing, it's vital that we're able to keep the HIV services going so people remain on treatment, which is vital for their health at the same time as address COVID issues as they come up.

Eric: Gotcha. Jane, you were talking earlier about keeping people in treatment. How are your respective work streams informing one another? How can they inform one another? What's that dialogue like?

Jane: Yeah, absolutely. I mean, similar to what Cathy is describing: Domestically, with clinics being shut down or being really pared down to just minimum capacity, seeing clients that desperately need to be seen. Those clients that may be on the verge of not remaining in care or who have a history of a chaotic lifestyle are definitely at high risk for dropping out of care if the services and the supports are not available. And so very similar, we're seeing many of our clinics domestically attempting to adopt other methodologies, particularly telehealth where they will reach out to a client with a phone call to see how they're doing, just checking in, what's going on, and attempt to then set up a telehealth appointment.

So there's at least some face-to-face interaction, so that an interventionist or nurse can put eyes on the client to see how they're doing. And there's that moment of at least connection for them to keep them engaged. So, yeah, I think that what Cathy has described is incredibly valuable information that we could transfer into some of the work that we're doing here, domestically.

This is a new moment for us and, certainly, the experience that we have to work on does not necessarily involve what to do in a pandemic. And so we're seeing that our clinics are trying to be as creative as possible. They've really done some workforce shifting so that not all staff are in the clinic at one time. They are trying to set it up so that, while clients may not get their regular level of care or continued monthly, three months care, they're at least trying to invite people in as best as they can to keep the connection going, but also remaining cognizant, and working within the physical distancing realms that they can.

Eric: Gotcha. Cathy, you were going to say?

Cathy: So, one of the things that started very early on, we were able to get personal protective equipment for our staff because our staff have to go into the clinics regardless. Finding personal protective equipment available in African clinics is not always possible.

Jane: Yes.

Cathy: So, trying to help the Ministry of Health, as well, get the equipment so they can keep doing the regular work they're doing, not only HIV/AIDS service, but regular immunization, well-child, antenatal care, delivery. All of those things have to continue in the midst of this pandemic. One thing we're finding of interest, though, in Namibia, where we're working with voluntary male medical circumcision, they're finding a lot of older men coming in because usually the older men were working. So they wouldn't have the time to come in and have a circumcision.

So instead, they decided, well, I'm not working out because everything shut down, so they're coming in. And this is a population we've been trying to reach: men over 29 to come in for circumcision. So it's actually been an interesting byproduct of the COVID epidemic.

Eric: That was not on my list of questions. I'll be honest.

Cathy: It's a good one, though, isn't it?

Eric: That's good, that's good!

Jane: I also want to note that the Ryan White Clinics recently were awarded $90 million of CARES funds. That's hard because it's the Ryan White Care Act. But then also these CARES funds that have just been distributed to buy PPE for both staff and for clients that may be exposed in their home, as well as to support testing and to support supportive services for clients to get in and get tested.

Cathy: One of the interesting things we were discussing before was that most HIV clients could be immunocompromised.

Eric: Right.

Jane: Right.

Cathy: So how do we deal with that and COVID? I don't think there's been many studies yet to look at the incidents of COVID cases in HIV positive clients. Some of them are older now, particularly in the United States, where they've been in treatment for so many years. And so they have other health issues that are associated with the long-term drug usage. So are we finding an increase in that? I think that would be something that would be interesting to look at.

Eric: Is there something that we're learning as we're engaging with COVID-19? Are we maybe creating new best practices we might want to bring forward? Or, to your point, Cathy, is there other stuff we should be starting to measure, starting to look for, starting to think about, both to deal with the situation on the ground now but that also might be helpful in the future?

Cathy: I think with HIV, we are looking at vulnerable populations. So the vulnerable populations are men who have sex with men, commercial sex workers, people are at high risk. Also, youth, a lot of youth are in vulnerable, particularly in Africa because it's not considered possible. They go in and the clinics aren't always friendly to the young people who need these services. So that's an issue. But with COVID, there's a whole different demographic of vulnerable populations. Those people over 65, people who have diabetes, people who are immunocompromised at all.

So I think we're looking at different vulnerable populations, but how to reach them is something we've been doing with HIV/AIDS work. And I think it's something that would be helpful for the COVID work.

Eric: Jane, how about in the U.S.?

Jane: Yeah, absolutely. I think one of the things that I'm hoping will be studied, as we said, there's not a lot of studies right now about co-infection with COVID, with HIV. And part of why we're struggling, and very adamant of hanging on to clients that have difficulty maintaining their care regimen, is that we want them to be taking their medications. If they take their medications regularly, that boosts their immune system, so they're less likely vulnerable. They're still vulnerable to a certain extent, but the more you can boost your immune system, the better chance you have, I would imagine, in the event that you are exposed and/or infected with COVID. If you have a very weakened immune system, because you haven't been taking your medication, I would venture a guess that COVID could be extremely dangerous to a client such as that.

Eric: Sure.

Cathy: I also think the issue of co-infection with TB/HIV. So there's a lot of TB/HIV co-infections. So those clients, particularly, will be at high risk.

Jane: I think the other populations, they're populations that we're used to working with. We're used to working with people that are homeless, we're used to working with people who are transitioning in and out of jail. Homeless shelters, jails, as we're seeing, are huge populations of infections.

Eric: Can we apply, then, our HIV approaches, maybe, to COVID or is there some adaptation that could happen there?

Jane: Absolutely. Much of the work that we've done over the years in HIV with contact tracing, we're starting to see this momentum picking up with COVID. Right now, a lot of the COVID contract tracing is really digitally. So either you're using an app or you're using a telephone, which I think covers probably a decent amount of the population. But for those that are truly vulnerable—without a telephone, without great internet or living out on the street or in and out of jail, those are folks who are going to be very difficult to contact trace. And so I think the next step is how do we take the components of contact tracing and really kind of old school contact tracing.

Cathy: Mm-hmm (affirmative).

Jane: Or you go and you actually get out there and you find someone. Certainly, that requires that we provide PPE for folks that are out there. We also have very strict protocols about how it's done. And then there's also really strict protocols around collecting data. And once you find someone, what are you going to do? It's not helpful to just say, "Hey, we think you may have been exposed", but "Hey, we think you may have been exposed. Here's what to look for. And we're going to continue to check in on you to see how you're doing. And here's a way to access care when you need it."

Cathy: Yeah, I think as you said, old school, this goes back to basic public health services. You have an epidemic, you have these little spots of epidemic, and it all came from one party everyone went to, in say, Connecticut, there was something.

Jane: Mm-hmm (affirmative).

Cathy: Or people went to this restaurant, or they were all at the same church. And then you trace that back out. And I think in this day and age, we use old school and new school. So we have your basic going out and talking to people, at the same time, we have all of the technology now where we can easily trace people. So I think it's an interesting global pandemic approach. How do we do something? Because people aren't just staying in their little area anymore.

Jane: Now, they are.

Cathy: Now we all are, as we're talking from our various apartments in three different States, I think.

Jane: Yes. And we have many of those systems already in place. The HIV world has been great about engaging community health workers.

Cathy: Mm-hmm (affirmative).

Jane: So finding folks in the community, who are part of the community who have access to the community, those folks could be easily lifted up and shifted into a contact tracer role. Same with HIV-positive peer programs. Again, another group of people that we have been very successful in using for outreach efforts and for engagement efforts. Those are the types of folks that we can certainly lift up, provide this training to and have them out helping with some of the contact tracing.

And then I think there's opportunities in the healthcare world as well. Our nation has public schools. There are many public school nurses right now that are not working. How do we engage those people in that work force to do some of this contact tracing? So there are systems in place that we just need to access, train, and support to go out and do this work.

Cathy: Yeah. And at the AIDS 2020 conference, we're going to have a satellite session talking about learning from Ryan White and from PEPFAR. So how domestic and international work can learn from each other. And there are some of these crossover areas, like working capacity building of local organizations, of local clinics, the ability to work with community health workers. There's a lot of things that are similar, but we can learn from each other as we go. And I think this paper we put together outline some of those really clearly. And we're looking forward to that satellite session.

Eric: That's coming up. But that's great. I love that it's not just about the bi-directionality of the HIV work, but then also as you were just saying, how can we build those insights out and use them elsewhere? And so I'm glad we're having this conversation, because we sure could use it right now, right?

Cathy: Yes.

Jane: Absolutely.

Eric: And that's why we call this the Intersect. On that note, I want to thank you both for joining me.

Cathy: Thank you, Eric, it's been my pleasure.

Jane: Thanks so much.

Eric: And thank you for joining us at the Intersect.

Once again, Cathy and Jane will be presenting at a satellite session during AIDS 2020, which runs online July 6th to July 10th.

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