Since the coronavirus disease pandemic response began in March 2020, tests, vaccinations, diagnoses, and treatment initiations for sexual health, HIV, and viral hepatitis in England have declined. The shift towards online and outreach services happened rapidly during 2020 and highlights the need to evaluate the effects of these strategies on health inequalities

Brown, Alison E

Costella, Annastella

Delpech, Valerie

Glancy, Megan

Hughes, Gwenda

Kirsebom, Freja

Mandal, Sema

Mitchell, Holly D

Mohammed, Hamish

Penman, Celia

Ratna, Natasha

Shah, Ammi

Simmons, Ruth

Sinka, Katy

Vilaplana, Tatiana Garcia

PubMed

UK Health Security Agency National STI, HIV and Viral Hepatitis

LSHTM Research Online

Beginning March 23, 2020, the UK government introduced social and physical distancing (SPD) measures to reduce transmission of severe acute respiratory syndrome 2 (SARS-CoV-2), and health staff were redeployed to the coronavirus disease (COVID-19) pandemic response. The staffi ng shift and SPD measures affected clinical services for sex-ually transmitted infections (STIs), HIV, and hepa-titis A, B, and C (HAV, HBV, and HCV) provided through the National Health Service (1,2). We as-sessed the effects of COVID-19 measures in England on service provision in this area and on health out-comes for persons with STIs, HIV, or hepatitis.The StudyIn England, surveillance of STIs, HIV, and hepatitis relies on patient-level data on consultations, tests, di-agnoses, vaccinations, treatment, and outcomes from sexual health services (SHS), general practitioners, hospital outpatient clinics, and drug treatment cen-ters (3). Laboratories also submit patient-level reports of tests and diagnoses for hepatitis and chlamydia. Given the disruption in routine reporting in 2020 (only 71%–98% complete for STI and HIV data), when possible, we analyzed data from clinics and laborato-ries who provided complete reports for January–Sep-tember in both 2019 and 2020.Testing at SHS declined by 77%, from 95,455 to 22,332, for HIV and by 71%, from 391,006 to 112,441, for STIs during January–April 2020, and although there was a modest increase beginning in May, test-ing remained far lower than in 2019 (Figure 1). For January–September 2020 compared with the same pe-riod in 2019, overall numbers of tests were lower by 36% (768,216 vs. 494,433) for HIV and 28% (3,137,537 vs. 2,244,153) for STIs (Appendix, https://wwwnc.cdc.gov/EID/article/28/3/21-1998-App1.pdf). However, the proportion of tests accessed through internet services (self-sampling kits returned directly to the laboratory with results provided by text mes-sage, email, letter, or online) increased substantially beginning in April 2020 (Appendix). Internet services accounted for ≥63% of HIV and >51% of STI tests dur-ing April–September 2020, compared with 25% for HIV and 22% for STIs in 2019.During January–April 2020, the largest propor-tional declines in testing occurred among persons 15–19 years of age (79% for HIV, 75% for STIs) and ≥45 years of age (80% for HIV, 76% for STIs); for per-sons 20–44 years of age, testing for HIV declined by 76% and for STIs by 70%. The 15–19- and >45-year age groups also showed the slowest relative recov-ery towards prepandemic levels of testing during June–September 2020.  Over the same period, we ob-served larger proportional declines in testing among Eff ects of COVID-19 Pandemic Response on Service Provision for Sexually Transmitted Infections, HIV, and Viral Hepatitis, EnglandHolly	D.	Mitchell,	Tatiana	Garcia	Vilaplana,	Sema	Mandal,	Natasha	Ratna,	Megan	Glancy,	Ammi	Shah,	Ruth	Simmons,	Celia	Penman,	Freja	Kirsebom,	Annastella	Costella,	Alison	E.	Brown,	Hamish	Mohammed,	Valerie	Delpech,	Katy	Sinka,1	Gwenda	Hughes,1	on	behalf	of	the	UK	Health	Security	Agency	National	STI,	HIV	and	Viral	Hepatitis	Surveillance	Group2	 Emerging	Infectious	Diseases	•	www.cdc.gov/eid	•	Vol.	28,	No.	3,	March	2022	 739Author	affi		liation:	UK	Health	Security	Agency,	London,	UKDOI:	https://doi.org/10.3201/eid2803.2119981These	senior	authors	contributed	equally	to	this	article.2Additional	group	members	who	contributed	are	listed	at	the	end	of	this	article.Since	the	coronavirus	disease	pandemic	response	began	in	March	2020,	tests,	vaccinations,	diagnoses,	and	treat-ment	initiations	for	sexual	health,	HIV,	and	viral	hepatitis	in	England	have	declined.	The	shift	 towards	online	and	outreach	 services	 happened	 rapidly	 during	 2020	 and	highlights	the	need	to	evaluate	the	eff	ects	of	these	strate-gies	on	health	inequalities.DISPATCHESheterosexual men (81% for HIV, 79% for STIs) and heterosexual or bisexual women (women who have sex with men or women; 76% for HIV, 75% for STIs) compared with gay, bisexual, and other men who have sex with men (MSM) (67% for HIV, 71% for STIs) and lesbian and other women who have sex ex-clusively with women (66% for HIV, 65% for STIs); recovery was slowest among heterosexual men. We observed the largest declines among persons of Asian (81% for HIV, 77% for STIs), Black (81% for HIV, 76% for STIs), and other (81% for HIV, 76% for STIs) races; persons of Black race showed the slowest recovery. We also observed a sharp decline in the number of persons tested for hepatitis during January–April 2020: by 63% (from 4,295 to 1,610) for HAV, 61% (from 57,392 to 22,224) for HBV, and 74% (from 43,238 to 11,250) for HCV (Appendix). The number of persons tested for HCV in community drug treatment facilities showed the greatest decline (98%, from 3,324 to 74) and a slow recovery to prepandemic levels; testing was 58% lower in September 2020 than for 2019 (3).Consistent with testing patterns, the number of diagnoses for HIV, STIs, and hepatitis declined dur-ing January–April 2020, followed by a partial recov-ery (Appendix Figure 1). Bacterial STI positivity (Ap-pendix) increased during March and April 2020 (12% in January 2020 vs. 17% in April 2020) then returned to 2019 and early 2020 levels, whereas HIV test posi-tivity peaked in April 2020 (0.20%) and remained at a higher level until September 2020 (0.09% vs 0.10% in September 2019). By contrast, HBV and HCV posi-tivity declined during January–April 2020 (from 0.8% to 0.4% for HBV surface antigen and from 2.8% to 1.4% for HCV antibody); although there was a slight increase thereafter, positivity remained lower for the rest of 2020 than in 2019.The number of first-dose vaccinations adminis-tered to MSM at SHS during January–April 2020 fell by 97% for HAV (from 841 to 22) and human papil-lomavirus (from 1,507 to 47) and by 96% (from 757 to 34) for HBV (Appendix Figure 2). A slight increase was reported beginning in May 2020, but rates for HAV, HBV, and HPV vaccinations were >50% lower in September 2020 than in September 2019.HCV treatment initiations declined by 66% (from 1,004 to 341) during January–April 2020; although recovering slightly, the overall number of treatment initiations during January–September 2020 was 27% lower than in the same period in 2019 (Figure 2). We saw the largest relative declines for referrals from drug services and prisons, with some recovery dur-ing June–September 2020. Delays commonly occur between HCV diagnoses and treatment, so reductions in treatment initiations likely reflected reduced access to services rather than new diagnoses alone.ConclusionsThe COVID-19 pandemic response in England, in-cluding the introduction of SPD measures, coincided with a decline in the provision of, and access to, health services for STIs, HIV, and hepatitis. We observed the greatest decline in services that cannot be provided remotely, such as vaccination.These findings are supported by staff and peer-support surveys in SHS and community drug treat-ment services (4,5). Some reduction in infections and need for services might be a consequence of reduced exposure because of compliance with SPD measures, leading to fewer opportunities for socializing and meeting sexual partners. The partial rebound in the summer of 2020 might indicate some recovery in 740	 Emerging	Infectious	Diseases	•	www.cdc.gov/eid	•	Vol.	28,	No.	3,	March	2022Figure 1.	Total	number	of	HIV	tests	provided	through	sexual	health	services	(SHS)	and	proportion	of	those	accessed	through	internet	services,	England,	January	2019–September	2020.	Bars	compare	HIV	test	data	from	SHS	that	reported	complete	data	for	January–September	in	both	2019	(light	green)	and	2020	(dark	green).	Dashed	line	represents	the	total	number	of	HIV	tests	from	all	SHS	reported	in	each	month	in	2019.	Solid	lines	indicate	the	percentages	of	total	tests	accessed	through	the	internet	for	2019	(red)	and	2020	(orange).	Data	are	from	routine	specialist	and	nonspecialist	SHS	reporting	to	the	GUMCAD	STI	Surveillance	System.Figure 2.	Hepatitis	C	virus	treatment	initiations,	England,	January	2019–September	2020.	Data	are	from	the	National	Health	Service	England	Hepatitis	C	Patient	Registry	and	Treatment	Outcome	system.	Bars	indicate	the	number	of	persons	having	treatment	initiated	by	month	for	2019	(light	green)	and	2020	(dark	green).COVID-19	Response	and	Service	for	STIsservice provision and demand, with increased de-mand also influenced by changes in risk perception and behaviors. However, these levels remained be-low prepandemic levels.Declines in the numbers of STI, HIV, and hepa-titis tests (6–8) and diagnoses (8–11) after COVID-19 restrictions began have also been reported across Eu-rope and elsewhere. Disruption in HCV treatment provision is of concern as direct-acting antivirals clear the virus, minimizing long-term harms. HCV treat-ment disruptions have also been reported in Spain (12) and Germany (13); in Germany, a minority of treatment providers also reported an increase in de-layed diagnoses of liver decompensation and hepato-cellular carcinoma (13).During the early stages of the pandemic, there was a rapid shift in service delivery toward online, remote, and outreach provision in England; similar shifts were reported in the United States and Croa-tia (14,15). While enabling service access during the pandemic, it will be important to evaluate the effects on health inequalities of changing to remote services, because hepatitis, HIV, and STIs already disproportionately affect socially disadvantaged and excluded groups. Whereas our findings suggest SHS were accessed by some populations of need, such as MSM, the decline in access by young adults and persons of Asian, Black, or other races requires further investigation. Furthermore, early indications of adverse effects on access to harm reduction and bloodborne virus testing services for people who inject drugs is concerning and requires mitigating actions. The full effects of the COVID-19 pandemic response on STI, HIV, and hepatitis infection con-trol, including efforts to eliminate HIV and hepati-tis, and longer-term health outcomes will take time to emerge. These effects warrant close monitoring and assessment to ensure services are accessible and used by all who need them.Additional members of the UK Health Security Agency National STI, HIV and Viral Hepatitis Surveillance Group who contributed to data collection, analysis and  interpretation: Ana Harb, Galena Kuyumdzhieva,  Tamilore Sonubi, Alireza Talebi, Stephen Duffell, Mateo Prochazka, Louise Thorn, Hannah Charles, Koye Balogun, Rebecca Wilkinson, Sara Croxford, Claire Edmundson, Mark McCall, Louise Logan, Adam Winter, Helen Harris, Kate Folkard, and Emily Phipps.This work was conducted by the UK Health Security Agency (formerly Public Health England) as part of  routine public health surveillance. No additional funds were received for this analysis.No specific consent was required from the patients whose data were used in these analyses. The UK Health Security Agency has authority to handle patient data for public health monitoring and infection control under Regulation 3 of the Health Service (Control of Patient Information) Regulations 2002.About the AuthorDr. Mitchell is an epidemiologist at the UK Health Security Agency. Her work focuses on surveillance and prevention of STIs and HIV.References  1. Association of Directors of Public Health (UK). COVID-19 prioritisation of sexual and reproductive health service [cited 2020 Jul 21]. https://www.adph.org.uk/2020/04/ covid-19-prioritisation-of-sexual-reproductive-health-services  2. Public Health England. People who inject drugs: HIV and viral hepatitis monitoring [cited 2020 July 28]. https://www.gov.uk/government/publications/people-who-inject-drugs-hiv-and-viral-hepatitis-monitoring.  3. Public Health England. COVID-19: impact on STIs, HIV and viral hepatitis [cited 2020 Dec 15]. https://www.gov.uk/government/publications/covid-19-impact-on-stis-hiv-and-viral-hepatitis  4. British Association for Sexual Health and HIV. BASHH  COVID-19 survey finds over half of services have been closed [cited 2020 Jul 21]. https://www.bashh.org/news/news/bashh-covid-19-survey-finds-over-half-of-services-have-been-closed  5. Action HCV; Public Health England. The impact of lock-down on hepatitis C services in England. June 2020 [cited 2020 Nov 27]. http://www.hcvaction.org.uk/sites/default/files/HCV%20Action%20e-update%20July%202020.pdf  6. Pinto CN, Niles JK, Kaufman HW, Marlowe EM,  Alagia DP, Chi G, et al. Impact of the COVID-19 pandemic on chlamydia and gonorrhea screening in the U.S. Am J  Prev Med. 2021;61:386–93. https://doi.org/10.1016/ j.amepre.2021.03.009  7. Simoes D, Stengaard AR, Combs L, Raben D. EuroTEST COVID-19 impact assessment consortium of partners. Impact of the COVID-19 pandemic on testing services for HIV, viral hepatitis and sexually transmitted infections in the WHO European region, March to August 2020. Euro Surveill. 2020;25:2001943. https://doi.org/10.2807/1560-7917.ES.2020.25.47.2001943  8. Darcis G, Vaira D, Moutschen M. Impact of coronavirus pandemic and containment measures on HIV diagnosis. Epidemiol Infect. 2020;148:e185. https://doi.org/10.1017/S0950268820001867  9. Crane MA, Popovic A, Stolbach AI, Ghanem KG.  Reporting of sexually transmitted infections during the  COVID-19 pandemic. Sex Transm Infect. 2021;97:101–2. https://doi.org/10.1136/sextrans-2020-05480510. Apalla Z, Lallas A, Mastraftsi S, Giannoukos A,  Noukari D, Goula M, et al. Impact of COVID-19 pandemic  on STIs in Greece. Sex Transm Infect. 2022;98:70.  https://doi.org/10.1136/sextrans-2021-05496511. Chia CC, Chao CM, Lai CC. Diagnoses of syphilis and HIV infection during the COVID-19 pandemic in Taiwan.  Sex Transm Infect. 2021;97:319. https://doi.org/10.1136/sextrans-2020-054802	 Emerging	Infectious	Diseases	•	www.cdc.gov/eid	•	Vol.	28,	No.	3,	March	2022	 741DISPATCHES12. Picchio CA, Valencia J, Doran J, Swan T, Pastor M, Martró E, et al. The impact of the COVID-19 pandemic on harm  reduction services in Spain. Harm Reduct J. 2020;17:87. https://doi.org/10.1186/s12954-020-00432-w13. Hüppe D, Niederau C, Serfert Y, Hartmann H,  Wedemeyer H; für das DHC-R. Problems in treating patients with chronic HCV infection due to the COVID-19 pandemic and during the lockdown phase in Germany [in German].  Z Gastroenterol. 2020;58:1182–5.14. Bogdanic N, Javoric I, Skugor SB, Zekan S, Lukas D,  Benkovic I, et al. Initial impact of COVID-19 epidemic on HIV services in Croatia. Infektol Glas. 2020;40:79–80.15. Melendez JH, Hamill MM, Armington GS,  Gaydos CA, Manabe YC. Home-based testing for  sexually transmitted infections: leveraging online  resources during the COVID-19 pandemic. Sex Transm  Dis. 2021;48:e8–10. https://doi.org/10.1097/OLQ.0000000000001309Address for correspondence: Holly D. Mitchell, Blood Safety, Hepatitis, STI and HIV Division, Clinical and Public Health Group, UK Health Security Agency, 61 Colindale Ave, London NW9 5EQ, UK; email: holly.mitchell@phe.gov.uk742	 Emerging	Infectious	Diseases	•	www.cdc.gov/eid	•	Vol.	28,	No.	3,	March	2022®CoronavirusTo revisit the February 2020 issue, go to:https://wwwnc.cdc.gov/eid/articles/issue/26/2/table-of-contents•  Middle East Respiratory Syndrome Coronavirus Transmission •  Acute Toxoplasmosis among Canadian Deer Hunters Associated with Consumption of Undercooked Deer  •  Public Health Program for Decreasing Risk for Ebola Virus Disease Resurgence from Survivors of the 2013–2016 Outbreak, Guinea•  Characteristics of Patients with Acute Flaccid Myelitis, United States,  2015–2018  •  Illness Severity in Hospitalized Influenza Patients by Virus Type and Subtype, Spain, 2010–2017 •  Exposure to Ebola Virus and Risk for Infection with Malaria Parasites,  Rural Gabon•  Cost-effectiveness of Screening Program for Chronic Q Fever,  the Netherlands   •  Unique Clindamycin-Resistant Clostridioides difficile Strain Related to Fluoroquinolone-Resistant Epidemic BI/RT027 Strain•  Porcine Deltacoronavirus Infection and Transmission in Poultry, United States   •  Chronic Human Pegivirus 2 without Hepatitis C Virus Co-infection•  Interspecies Transmission of Reassortant Swine Influenza A Virus Containing Genes from Swine Influenza A(H1N1)pdm09 and  A(H1N2) Viruses •  Neutralizing Antibodies against Enteroviruses in Patients with Hand, Foot and Mouth Disease•  Multiplex Mediator Displacement  Loop-Mediated Isothermal Amplification for Detection of Treponema pallidum and  Haemophilus ducreyi •  Novel Subclone of Carbapenem-Resistant Klebsiella pneumoniae Sequence Type 11 with Enhanced Virulence and Transmissibility, China   •  Influence of Rainfall on Leptospira Infection and Disease in a Tropical Urban Setting, Brazil•  Systematic Hospital-Based Travel Screening to Assess Exposure to  Zika Virus•  Rapid Nanopore Whole-Genome Sequencing for Anthrax Emergency Preparedness•  Elizabethkingia anophelis Infection in Infants, Cambodia, 2012–2018•  Global Expansion of Pacific Northwest Vibrio parahaemolyticus Sequence Type 36 •  Surge in Anaplasmosis Cases in Maine, USA, 2013–2017  •  Emergence of Chikungunya Virus, Pakistan, 2016–2017•  Mycoplasma genitalium Antimicrobial Resistance in Community and Sexual Health Clinic Patients, Auckland,  New Zealand•  Early Detection of Public Health Emergencies of International Concern through Undiagnosed Disease Reports in ProMED-Mail •  Ocular Spiroplasma ixodetis in Newborns, France•  Hepatitis E Virus in Pigs from Slaughterhouses, United States, 2017–2019 •  Rickettsia mongolitimonae Encephalitis, Southern France, 2018   •  Human Alveolar Echinococcosis, Croatia •  Two Cases of Newly Characterized Neisseria Species, Brazil•  Hepatitis A Virus Genotype IB Outbreak among Internally Displaced Persons, Syria  •  Rickettsia parkeri and Candidatus Rickettsia andeanae in Amblyomma maculatum Group Ticks•  Astrovirus in White-Tailed Deer,  United States, 2018  February 2020PHOTO QUIZ

Effects of COVID-19 Pandemic Response on Service Provision for Sexually Transmitted Infections, HIV, and Viral Hepatitis, England.

Effects of COVID-19 Pandemic Response on Service Provision for Sexually Transmitted Infections, HIV, and Viral Hepatitis, England

Effects of COVID-19 Pandemic Response on Service Provision for Sexually Transmitted Infections, HIV, and Viral Hepatitis, England

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