COVID-19 and HIV, Worst-case scenario...

Written and updated by Dr.Deyn Natthakhet Yaemim, 1 April 2020


"When you control the supply of medicines, you control the world." --- Rosemary Gibson


China's attempts to limit the spread of coronavirus outbreak have stopped factories that produce everything from clothes to cars and electronics. That, in turn, has reminded the rest of the world just how dependent it is on China as a source of components and finished products. Its dominance of that segment of the industry is largely due to its commanding position in the production and export of so-called active pharmaceutical ingredients (APIs). These are the chemical raw materials for many drugs, including penicillin, ibuprofen, diabetes drug and HIV medications. The World Health Organization reckons that China accounts for 20 percent of the global output of APIs. The United Kingdom's Medicines and Healthcare products Regulatory Agency estimates the figure to be double that.

Supply chain: As factories in China are closed, India, the world largest manufacturer of generic drugs, is working to maintain supplies of APIs. India supplies low-cost generic drugs to millions of people, both domestic and outside the country. But Indian pharmaceutical companies procure almost 70% of the APIs for their medicines from China, the world's leading producer and exporter of APIs by volume. As factories in China are closed to try to stem the coronavirus disease 2019 outbreak, pharmaceutical companies and the Indian Government become concerned over the vulnerability of the pharmaceutical supply chain. India's dependence on China for APIs is increasingly seen as a matter of health security.

Problems with continuous HIV treatment: Because of this lockdown, some people are stuck in different countries where it can be difficult for them to get their medication refilled even though the regimen is available. So-called developed countries in the Global North are using the latest medications that are often not available in developing countries in the Global South. When patients from these countries visit and, due to travel restrictions, get stuck in developing countries where their regimen are not available or the services are limited or staff are not being HIV or LGBT friendly, this could lead to disruption of continuous HIV care. If these patients miss their HIV medication for just 2 weeks, it might allow HIV to develop a mutation which will resist to their standard treatment and will lead to treatment failure. That means their standard treatment that has been working for years and years will fail. There will be the need of newer medications. If it’s not available, people can get sick of AIDS again, but this time, not with wild type HIV but drug-resistant HIV, and AIDS may come back as a consequence of the coronavirus crisis. Now, there is an urgent need for novel anti-HIV/AIDS drugs for global concern.
With the threatened of HIV drugs shortage, many government hospitals in Thailand allowed their doctors to prescribe only 2 weeks of HIV medications to their patients, that’s why a network of private healthcare like  P U L S E clinics stay open throughout the region to help people refill their medications and avoid unnecessary trips to hospitals.

Struggle in PrEP implementation and PrEP does not prevent against drug-resistant  HIV: After 6 years of PrEP discovery, it is the fact that our world is still struggle in PrEP implementation. In 2019, only 14 European and Central Asian countries provided reimbursed HIV pre-exposure prophylaxis (PrEP). There is an estimation that 500,000 men who have sex with men in the EU cannot access PrEP, although they would be very likely to use it. PrEP’s potential to eliminate HIV is currently unrealised by national healthcare systems. The international community has committed to the Sustainable Development Goal of ending the AIDS epidemic by 2030 (SDG 3.3). To achieve SDG 3.3, the Joint United Nations Programme on HIV/AIDS (UNAIDS) has recommended as one of its global targets that 3 million people access PrEP by 2020. However, the PrEP that is available right now can only prevent against wild type HIV, if the worst case scenario happens, that means some PrEP users who are currently protected by PrEP will be infected by new drug-resistant HIV which, up until today, there's no PrEP available to protect against.

Disruption of continuous treatment for other STIs such as latent syphilis, hepatitis C virus.
There are a number of patients with latent syphilis who need treatment with injection once a week for three consecutive weeks, lockdown and travel ban means some people will not receive a full course of treatment. According to our experience, patients under syphilis treatment prefer injections with Penicillin. The alternative treatment with a longer course of doxycycline has more side effects, takes longer and patients usually do not want it and/or can’t finish it. This may lead to treatment failure in some cases and they will continue to spread the infection. Another example is Hepatitis C treatment, nowadays hepatitis C virus is treated with medication one pill once a day for 3 months, and any disruption in continuous healthcare can decrease the effectiveness of this treatment.

 

People are still having sex: Physical distancing makes people feel horny. Look at Pornhub letting people subscribe premium for free, Grindr is letting people use their filter function for free. People do not want to be alone and have the urge to meet someone and they are still trying to meet up and hook up even though during this lockdown. In terms of COVID-19, it doesn’t spread through sex but it does spread through the air that you breathe on each other when you have sex. In terms of STI, if one person is infected with an STI and he doesn’t want to go to the hospital because he doesn’t want to risk being exposed to coronavirus, he may then pass the infection on to other people he has sex with. And we know that a lot of bacterial and viral STDs can transmit through kissing, licking, rimming and oral sex. If you are sexually active, sexual health screening is still important and this is a good time to do so because many of us has never tested at all and these bacteria and virus do not care if you are at the hospital or at home, which country are you from, or if you sleep with men or women or both. If you are sexually active, you need to get tested and treated. 


Mental wellbeing and drug use in context of having sex, chemsex, and hepatitis C infection: Physical distancing makes people feel lonely. As mentioned, people are still trying to meet up and hook up through dating application. Humans need bodily contact to feel connected, we are social animals. In these time, we lack contact and try to substitute it through hook-ups. It is very important to stay physically, mentally and socially healthy during this crisis.

Phylogenetic analysis showing a high degree of clustering confirms that the HCV epidemic in the HIV-infected MSM community in Bangkok is recent and rapidly expanding. This epidemic is independent of past HCV transmission among people who inject drugs in Thailand. Crystal methamphetamine use is high in patients with HCV infection, and previous reports have identified chemsex and group sex parties as factors associated with HCV transmission. 


Reduced access to healthcare:
 Lockdown in some cities makes it more difficult for a lot of people to go to their hospital to refill their medications, you also have to understand that with the increased number of covid-19 patients and with the limited number of ICU units and medical instruments such as ventilators as well as healthcare providers such as doctors and nurses, some general hospitals may lack of general health services because they are needed for something more urgent and more emergency to take care of. So even if someone with an STI who experiences symptoms may want to get tested and treated may get turned away at a general hospital, we, as specialized clinic, are available.


What is the proposal for managing patients to receive continuous medication and treatment?   

                                                                               

Short term management:

  • HIV services must continue:  This includes ensuring the availability of condoms, pre-exposure prophylaxis (PrEP), HIV testing and HIV treatment, opioid substitution therapy, sterile needles and syringes, harm reduction.
  • Let patients have 3-6 months of their medications: to make sure that HIV treatment are not disrupted, to prevent people from running out of medicines and to reduce the need to access the health system
  • Allow home delivery especially to the people on area that's far from healthcare providers.
  • Use technology to develop services around healthcare

 

Sustainable long term management: 

  • Online services including online consultation, online prescription for stable patients and regular PrEP users must be legalized and officially available.
  • Other important interventions are communication, good quality in patient- nurse relationship, and collaboration of a team of healthcare professionals.
  • Health authorities should focus on improving accessibility of PrEP to key populations such as men who have sex with men and transgender. Increase PrEP  uptake among women and heterosexual men at high risk of HIV, as well as an expansion of PrEP availability more generally.
  • HCV antibody testing should be regularly performed for MSM on ART, and direct-acting antivirals being offerred to all MSM with HCV infection might contain this HCV epidemic from spreading further.
  • Every patient is unique, healthcare provider must always provide personalized solution to each individuals.

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