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      Two years after lockdown: reviewing the effects of COVID‐19 on health services and support for adolescents living with HIV in South Africa

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          Abstract

          Introduction

          South Africa's progress towards the 95‐95‐95 goals has been significantly slower among adolescents living with HIV (ALHIV), among whom antiretroviral therapy (ART) adherence, retention in care and viral suppression remain a concern. After 2 years of living with COVID‐19, it is important to examine the direct and indirect effects of the pandemic on healthcare resources, access to HIV services and availability of support structures, to assess their impact on HIV care for ALHIV.

          Discussion

          The COVID‐19 response in South Africa has shifted healthcare resources towards combatting COVID‐19, affecting the quality and availability of HIV services—especially for vulnerable populations, such as ALHIV. The healthcare system's response to COVID‐19 has threatened to diminish fragile gains in engaging ALHIV with HIV services, especially as this group relies on overburdened public health facilities for their HIV care. Reallocation of limited health resources utilized by ALHIV disrupted healthcare workers’ capacity to form and maintain therapeutic relationships with ALHIV and monitor ALHIV for ART‐related side effects, treatment difficulties and mental health conditions, affecting their ability to retain ALHIV in HIV care. Prevailing declines in HIV surveillance meant missed opportunities to identify and manage opportunistic infections and HIV disease progression in adolescents. “Lockdown” restrictions have limited access to healthcare facilities and healthcare workers for ALHIV by reducing clinic appointments and limiting individual movement. ALHIV have had restricted access to social, psychological and educational support structures, including national feeding schemes. This limited access, coupled with reduced opportunities for routine maternal and sexual and reproductive health services, may place adolescent girls at greater risk of transactional sex, child marriages, unintended pregnancy and mother‐to‐child HIV transmission.

          Conclusions

          Adolescent HIV care in South Africa is often overlooked; however, ART adherence among ALHIV in South Africa is particularly susceptible to the consequences of a world transformed by COVID‐19. The current structures in place to support HIV testing, ART initiation and adherence have been reshaped by disruptions to health structures, new barriers to access health services and the limited available education and psychosocial support systems. Reflecting on these limitations can drive considerations for minimizing these barriers and retaining ALHIV in HIV care.

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          Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study

          Timothy Roberton, Emily Carter, Victoria Chou … (2020)
          Summary Background While the COVID-19 pandemic will increase mortality due to the virus, it is also likely to increase mortality indirectly. In this study, we estimate the additional maternal and under-5 child deaths resulting from the potential disruption of health systems and decreased access to food. Methods We modelled three scenarios in which the coverage of essential maternal and child health interventions is reduced by 9·8–51·9% and the prevalence of wasting is increased by 10–50%. Although our scenarios are hypothetical, we sought to reflect real-world possibilities, given emerging reports of the supply-side and demand-side effects of the pandemic. We used the Lives Saved Tool to estimate the additional maternal and under-5 child deaths under each scenario, in 118 low-income and middle-income countries. We estimated additional deaths for a single month and extrapolated for 3 months, 6 months, and 12 months. Findings Our least severe scenario (coverage reductions of 9·8–18·5% and wasting increase of 10%) over 6 months would result in 253 500 additional child deaths and 12 200 additional maternal deaths. Our most severe scenario (coverage reductions of 39·3–51·9% and wasting increase of 50%) over 6 months would result in 1 157 000 additional child deaths and 56 700 additional maternal deaths. These additional deaths would represent an increase of 9·8–44·7% in under-5 child deaths per month, and an 8·3–38·6% increase in maternal deaths per month, across the 118 countries. Across our three scenarios, the reduced coverage of four childbirth interventions (parenteral administration of uterotonics, antibiotics, and anticonvulsants, and clean birth environments) would account for approximately 60% of additional maternal deaths. The increase in wasting prevalence would account for 18–23% of additional child deaths and reduced coverage of antibiotics for pneumonia and neonatal sepsis and of oral rehydration solution for diarrhoea would together account for around 41% of additional child deaths. Interpretation Our estimates are based on tentative assumptions and represent a wide range of outcomes. Nonetheless, they show that, if routine health care is disrupted and access to food is decreased (as a result of unavoidable shocks, health system collapse, or intentional choices made in responding to the pandemic), the increase in child and maternal deaths will be devastating. We hope these numbers add context as policy makers establish guidelines and allocate resources in the days and months to come. Funding Bill & Melinda Gates Foundation, Global Affairs Canada.
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            Risk and Protective Factors for Prospective Changes in Adolescent Mental Health during the COVID-19 Pandemic

            Natasha R. Magson, Justin Freeman, Ronald M. Rapee … (2020)
            The restrictions put in place to contain the COVID-19 virus have led to widespread social isolation, impacting mental health worldwide. These restrictions may be particularly difficult for adolescents, who rely heavily on their peer connections for emotional support. However, there has been no longitudinal research examining the psychological impact of the COVID-19 pandemic among adolescents. This study addresses this gap by investigating the impact of the COVID-19 pandemic on adolescents’ mental health, and moderators of change, as well as assessing the factors perceived as causing the most distress. Two hundred and forty eight adolescents (M age  = 14.4; 51% girls; 81.8% Caucasian) were surveyed over two time points; in the 12 months leading up to the COVID-19 outbreak (T1), and again two months following the implementation of government restrictions and online learning (T2). Online surveys assessed depressive symptoms, anxiety, and life satisfaction at T1 and T2, and participants’ schooling, peer and family relationships, social connection, media exposure, COVID-19 related stress, and adherence to government stay-at-home directives at T2 only. In line with predictions, adolescents experienced significant increases in depressive symptoms and anxiety, and a significant decrease in life satisfaction from T1 to T2, which was particularly pronounced among girls. Moderation analyses revealed that COVID-19 related worries, online learning difficulties, and increased conflict with parents predicted increases in mental health problems from T1 to T2, whereas adherence to stay-at-home orders and feeling socially connected during the COVID-19 lockdown protected against poor mental health. This study provides initial longitudinal evidence for the decline of adolescent’s mental health during the COVID-19 pandemic. The results suggest that adolescents are more concerned about the government restrictions designed to contain the spread of the virus, than the virus itself, and that those concerns are associated with increased anxiety and depressive symptoms, and decreased life satisfaction.
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              Potential effects of disruption to HIV programmes in sub-Saharan Africa caused by COVID-19: results from multiple mathematical models

              Britta Jewell, Edinah Mudimu, John Stover … (2020)
              Summary Background The COVID-19 pandemic could lead to disruptions to provision of HIV services for people living with HIV and those at risk of acquiring HIV in sub-Saharan Africa, where UNAIDS estimated that more than two-thirds of the approximately 38 million people living with HIV resided in 2018. We aimed to predict the potential effects of such disruptions on HIV-related deaths and new infections in sub-Saharan Africa. Methods In this modelling study, we used five well described models of HIV epidemics (Goals, Optima HIV, HIV Synthesis, an Imperial College London model, and Epidemiological MODeling software [EMOD]) to estimate the effect of various potential disruptions to HIV prevention, testing, and treatment services on HIV-related deaths and new infections in sub-Saharan Africa lasting 6 months over 1 year from April 1, 2020. We considered scenarios in which disruptions affected 20%, 50%, and 100% of the population. Findings A 6-month interruption of supply of antiretroviral therapy (ART) drugs across 50% of the population of people living with HIV who are on treatment would be expected to lead to a 1·63 times (median across models; range 1·39–1·87) increase in HIV-related deaths over a 1-year period compared with no disruption. In sub-Saharan Africa, this increase amounts to a median excess of HIV deaths, across all model estimates, of 296 000 (range 229 023–420 000) if such a high level of disruption occurred. Interruption of ART would increase mother-to-child transmission of HIV by approximately 1·6 times. Although an interruption in the supply of ART drugs would have the largest impact of any potential disruptions, effects of poorer clinical care due to overstretched health facilities, interruptions of supply of other drugs such as co-trimoxazole, and suspension of HIV testing would all have a substantial effect on population-level mortality (up to a 1·06 times increase in HIV-related deaths over a 1-year period due to disruptions affecting 50% of the population compared with no disruption). Interruption to condom supplies and peer education would make populations more susceptible to increases in HIV incidence, although physical distancing measures could lead to reductions in risky sexual behaviour (up to 1·19 times increase in new HIV infections over a 1-year period if 50% of people are affected). Interpretation During the COVID-19 pandemic, the primary priority for governments, donors, suppliers, and communities should focus on maintaining uninterrupted supply of ART drugs for people with HIV to avoid additional HIV-related deaths. The provision of other HIV prevention measures is also important to prevent any increase in HIV incidence. Funding Bill & Melinda Gates Foundation.
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                Author and article information

                Contributors
                Quintin van Staden:
                ORCID: https://orcid.org/0000-0002-5004-2490
                vanstadenquintin4@gmail.com
                Journal
                Journal ID (nlm-ta): J Int AIDS Soc
                Journal ID (iso-abbrev): J Int AIDS Soc
                Journal ID (doi): 10.1002/(ISSN)1758-2652
                Journal ID (publisher-id): JIA2
                Title: Journal of the International AIDS Society
                Publisher: John Wiley and Sons Inc. (Hoboken )
                ISSN (Electronic): 1758-2652
                Publication date (Electronic): 26 April 2022
                Publication date Collection: April 2022
                Volume: 25
                Issue: 4 ( doiID: 10.1002/jia2.v25.4 )
                Electronic Location Identifier: e25904
                Affiliations
                [ 1 ] Department of Sociology University of Cape Town Cape Town South Africa
                [ 2 ] Universitas Hospital Bloemfontein South Africa
                [ 3 ] Institute for Life Course Health Research Department of Global Health Faculty of Medicine and Health Sciences Stellenbosch University Tygerberg South Africa
                [ 4 ] Centre for Social Science Research University of Cape Town Cape Town South Africa
                [ 5 ] Department of Social Policy and Intervention University of Oxford Oxford UK
                Author notes
                [*] [* ] Corresponding author: Quintin van Staden, Department of Sociology, University of Cape Town, Rondebosch, Cape Town 7700, South Africa. Tel: +2784 627 1996. ( vanstadenquintin4@ 123456gmail.com )

                Author information
                https://orcid.org/0000-0002-5004-2490
                https://orcid.org/0000-0001-9648-4473
                https://orcid.org/0000-0002-3800-3173
                Article
                Publisher ID: JIA225904
                DOI: 10.1002/jia2.25904
                PMC ID: 9042673
                PubMed ID: 35475319
                SO-VID: c85cc138-1b94-4a41-8b90-0b8ea97697ec
                Copyright © © 2022 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.
                License:

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 16 December 2021
                Date accepted : 23 March 2022
                Page count
                Figures: 0, Tables: 0, Pages: 6, Words: 5729
                Categories
                Subject: Commentary
                Subject: Commentary
                Custom metadata
                source-schema-version-number 2.0
                cover-date April 2022
                details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_JATSPMC version:6.1.4 mode:remove_FC converted:26.04.2022

                ScienceOpen disciplines: Infectious disease & Microbiology
                Keywords: adolescents living with hiv,covid‐19,art adherence,resource reallocation,barriers,limited support
                Data availability:
                ScienceOpen disciplines: Infectious disease & Microbiology
                Keywords: adolescents living with hiv, covid‐19, art adherence, resource reallocation, barriers, limited support

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