Potential effects of disruption to HIV programmes in sub-Saharan Africa caused by COVID-19: results from multiple mathematical models

Background: The COVID-19 epidemic could lead to the disruptions to provision of HIV services for people living with HIV and those at risk of acquiring HIV in sub-Saharan Africa, where UNAIDS estimates that more than two thirds of the 37.9 million (32.7-44.0 million) people living with HIV reside in 2018. We set out to predict the potential effects of such disruptions on HIV-related deaths and new infections. Methods: Five well-described models of HIV epidemics (Goals, Optima HIV, HIV Synthesis, Imperial College model, EMOD) were each used 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 from 1 April 2020. Disruptions affecting 20%, 50% and 100% of the population were considered. In further analyses shorter term disruptions and the possibility of reductions in sexual activity during disruptions were considered. Findings: A six-month interruption of supply of antiretroviral (ARV) drugs across 50% of the population of people living with HIV on treatment would be expected to lead to a 1.63-fold (median across models; range 1.39 to 1.87) increase in HIV-related deaths over a one year period compared to with no disruption. In sub-Saharan Africa this amounts to an excess of 296,000 (median over model estimates, range 229,000 – 420,000) HIV deaths should such a high level of disruption occur. There would also be an approximately 1.6-fold increase in mother to child transmission of HIV. While an interruption of supply of ARV drug would have by far the largest impact of any potential disruptions, effects of poorer clinical care due to over-stretched health facilities, interruptions of supply of other drugs such as cotrimoxazole and suspension of HIV testing would all have significant population-level impact on mortality. Interruption to condom supplies and peer education would make populations more vulnerable to increases in HIV incidence, although physical distancing measures could lead to reductions in risky sex. Interpretation: During the COVID-19 pandemic the primary priority for governments, donors, suppliers and communities should focus on maintaining uninterrupted supply of ARV 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

Perspectives on the use of modelling and economic analysis to guide HIV programmes in sub-Saharan Africa

HIV modelling and economic analyses have had a prominent role in guiding programmatic responses to HIV in sub-Saharan Africa. However, there has been little reflection on how the HIV modelling field might develop in future. HIV modelling should more routinely align with national government and ministry of health priorities, recognising their legitimate mandates and stewardship responsibilities, for HIV and other wider health programmes. Importance should also be placed on ensuring collaboration between modellers, and that joint approaches to addressing modelling questions, becomes the norm rather than the exception. Such an environment can accelerate translation of modelling analyses into policy formulation because areas where models agree can be prioritised for action, whereas areas over which uncertainty prevails can be slated for additional study, data collection, and analysis. HIV modelling should increasingly be integrated with the modelling of health needs beyond HIV, particularly in allocative efficiency analyses, where focusing on one disease over another might lead to worse health overall. Such integration might also enhance partnership with national governments whose mandates extend beyond HIV. Finally, we see a need for there to be substantial and equitable investment in capacity strengthening within African countries, so that African researchers will increasingly be leading modelling exercises. Building a critical mass of expertise, strengthened through external collaboration and knowledge exchange, should be the ultimate goal

Perspectives on the use of modelling and economic analysis to guide HIV programmes in sub-Saharan Africa

HIV modelling and economic analyses have had a prominent role in guiding programmatic responses to HIV in sub-Saharan Africa. However, there has been little reflection on how the HIV modelling field might develop in future. HIV modelling should more routinely align with national government and ministry of health priorities, recognising their legitimate mandates and stewardship responsibilities, for HIV and other wider health programmes. Importance should also be placed on ensuring collaboration between modellers, and that joint approaches to addressing modelling questions, becomes the norm rather than the exception. Such an environment can accelerate translation of modelling analyses into policy formulation because areas where models agree can be prioritised for action, whereas areas over which uncertainty prevails can be slated for additional study, data collection, and analysis. HIV modelling should increasingly be integrated with the modelling of health needs beyond HIV, particularly in allocative efficiency analyses, where focusing on one disease over another might lead to worse health overall. Such integration might also enhance partnership with national governments whose mandates extend beyond HIV. Finally, we see a need for there to be substantial and equitable investment in capacity strengthening within African countries, so that African researchers will increasingly be leading modelling exercises. Building a critical mass of expertise, strengthened through external collaboration and knowledge exchange, should be the ultimate goal