Three years into the COVID-19 pandemic, researchers are still trying to determine the full scope of the negative impact it had on various healthcare services, including HIV testing.
There have always been barriers to HIV testing—much of it focused around stigma and trust—and the pandemic set everyone back, experts said. They are trying to generate a rebound that increases rates to at least pre-pandemic levels, according to new research.
Nonemergency clinical services in the United States were limited or suspended during the pandemic in 2020, and researchers hypothesized that these restricted services could adversely affect established epidemics of importance, such as HIV and the access to testing—the cornerstone of prevention efforts (Lancet Reg Health Am 2022;7:100159).
During their observational study, researchers collected HIV testing and positivity rates from four geographically diverse U.S. healthcare systems in New Orleans; Minneapolis; Providence, R.I.; and Seattle. Data from 2019 to 2020 were analyzed to evaluate the changes in HIV testing administered at community centers, emergency departments and other outpatient settings. The researchers explored trends in HIV testing through phases of the pandemic by using a Poisson regression model.
They found that in outpatient settings, there was a 68% to 97% reduction in the number of HIV tests per week during each state’s “stay-at-home” order period in 2020 compared with the period before the stay-at-home order. They also documented a sustained reduction by 11% to 54% in number of HIV tests per week after the states had transitioned to advisory phases—lifting the restrictions.
No Surprises
“What we found—no surprise—was that HIV testing rates decreased across our sites, most dramatically in those early weeks and months [of the pandemic], when most areas and states had stay-at-home orders,” Ethan Moitra, PhD, a clinical psychologist and an associate professor in the Department of Psychiatry and Human Behavior at the Warren Alpert Medical School of Brown University, in Providence, told Infectious Disease Special Edition.
The researchers also found the HIV positivity rate increased slightly in outpatient settings, except in New Orleans where it fell.
“We’ve seen generally a little bit of a rebound, but overall testing rates, at least based on our data, had not returned to their pre-pandemic levels,” added Dr. Moitra, who also served as one of the study’s researchers.
This trend of substantially decreased HIV testing across four geographically diverse sites was concerning and suggested that new HIV infections within the United States may be undiagnosed and not yet linked to clinical care and/or services, according to the researchers.
As of 2021, nearly 65% of eligible adults have never been tested for HIV (BRFss Prevalence & Trends Data). The CDC recommends all people between 13 and 64 years of age be tested for HIV at least once as part of routine healthcare.
The CDCreportedthat nearly 40% of new HIV infections are transmitted by people who are unaware of their infection.
Making people go to a clinic for testing puts up immediate barriers, such as making appointments, cost, transportation to and from a clinic, and the emotional and psychological challenges associated with stigma, according to Dr. Moitra.
One of the strategies that showed promise during the study was mobile or community testing, but the program was derailed by the pandemic, according to Dr. Moitra, who added a similar push might help testing rebound.
“Literally going out into the communities, going to bars, going to busy areas in the city and offering testing—really bringing testing to the people,” he said. “And what our data showed was that sort of community-based testing basically stopped as the pandemic kicked in, and really has not recovered, at least when we did our study.
“These community-based outreach efforts I think are critical, because they work around some of those barriers,” Dr. Moitra said.
Trust Lost in Translation
Recently, the CDC published a report to better understand clusters of rapid HIV transmission among men who have sex with men (MSM) (MMWR Morbid Mortal Wkly Rep 2022;71[38]:1201-1206). The CDC found that these populations accounted for 68% of new HIV diagnoses in the United States in 2020. They characterized large HIV clusters with molecular similarities detected using an analysis of HIV-1 nucleotide sequence data from the National HIV Surveillance System. Thirty-eight such clusters were detected during 2018 to 2019; 29 of the clusters occurred primarily among MSM.
In the state of Georgia, four or more people diagnosed with HIV with similar strains in a 12-month period constitute a molecular cluster.
“We have right now 80 members in a total of five clusters; the smallest one is four individuals, and the largest one has 49 [people] primarily male, 60% Latino—a sizable proportion of them are born outside of the U.S.,” reported Carlos S. Saldana, MD, the chief fellow in the Division of Infectious Diseases at Emory University School of Medicine in Druid Hills, Ga. He discussed the public health response to the clusters of rapid transmission of HIV among Latino MSM in the Atlanta metro area at IDWeek 2022, held in Washington, D.C.
Dr. Saldana and his colleagues formed a cluster detection and response team in February, in which Dr. Saldana held monthly meetings with representatives of each of the districts in the Atlanta metro area and the Georgia Department of Public Health. Their goal was to find out what public health surveillance systems were trying to identify and whether the appropriate services and care were being distributed. They also performed medical chart reviews to see whether there were any other reoccurring social or psychosocial risk factors.
“We’ve partnered with two community organizations serving [the LGBTQ community]. So, in total, we interviewed 65 service providers, including clinicians, community-based organizations, staff and health department staff. We talked to Hispanic-Latino gay and bisexual men; we’ve talked to individuals with and without HIV, people engaged and not engaged in care, and also people born in the U.S. and outside of the U.S.,” he said.
Language was a significant barrier, according to Dr. Saldana. Many patients felt pushed aside when the clinician realized they could not speak English.
“One of our participants even said, ‘Trust is lost in translation,’” Dr. Saldana said.
A lack of rebound in testing rates also has been observed in San Francisco, according to Monica Gandhi, MD, MPH, an infectious disease and HIV specialist at the University of California, San Francisco, and the medical director of the Ward 86 HIV Clinic, in San Francisco.
“One thing I’ll say is that we’re in a crisis,” Dr. Gandhi told Infectious Disease Special Edition. “After the COVID pandemic, with HIV testing rates, diagnosis rates, prevention rates and treatment rates—we are getting behind. Our HIV response has been set back by the COVID pandemic.”
Dr. Gandhi said new strategies such as mobile and at-home HIV testing could help put the country’s HIV response back on track. Given the stigma that surrounds HIV testing centers and clinics, and HIV in general, these mobile and at-home strategies will get the tests in the hands of the people who need them most.
“For example, in the city of San Francisco, we are still 29% down [in HIV testing] than we were in 2019—we have not yet gotten back to pandemic testing levels in the community,” she said.
‘U Equals U’
Dr. Moitra also advocated for more targeted, community testing strategies. He said healthcare providers need a different mindset when thinking about ways to improve HIV testing rates in the United States. Living through the pandemic has brought more awareness and indications for at-home testing, something that could be applicable to at-risk HIV populations, he said.
“Just like with COVID-19, we’ve gotten used to the ability to be able to test at home—this is sort of where the HIV field is going in a lot of ways now,” Dr. Moitra said.
Dr. Gandhi also expressed similar sentiment around the newfound familiarity of at-home testing in the general U.S. population after COVID-19.
“We’ve had these tests for at least eight years, but we haven’t been employing them widely. And it may be that now we’re more comfortable using them,” she said. “[The HIV at-home tests are] pretty easy. They involve swabbing. Most of them are oral saliva, so you just kind of swab the inside of your cheek, then put the swab back in the tube and then it’s kind of just like what we’re used to: One line means you’re negative; two lines are positive.”
Both Drs. Gandhi and Moitra reaffirmed the advancement of HIV care and antiretroviral therapies that enable people with HIV to live longer, higher quality lives.
But testing is the first step to getting patients connected with the appropriate care.
“The phrase often used is ‘U equals U,’ which means ‘undetectable equals untransmissible,’” Dr. Moitra said. “A person knowing that they’re positive is the key piece toward getting on treatment, of course, but then on top of that, because of what we know—this ‘U equals U’ idea—leading them hopefully toward not passing the virus on to other people.”
Drs. Moitra and Gandhi reported no relevant financial disclosures.
This article is from the December 2022 print issue.