These days are indeed scary and unpredictable, yet there is hope. People are leveraging their skills at innovation and adaptation to find ways to work safely and stay well at home. We are connecting in new ways and with new people as we endeavor to get through this together. These responses illustrate our ability to face crises with determination, compassion and creativity.
And yet, we cannot overlook COVID-19’s negative impacts. Disparities in access to medical care are more visible now, and the need for policies to ensure equitable access to healthcare and treatment are required. Compensation of essential workers, especially in healthcare, is inadequate and must be addressed. And research, harm reduction programs and treatment options have been disrupted, putting Americans at risk of developing these conditions, requiring more and more expensive care for them, or dying.
We’re closer than ever to ending the HIV epidemic by ensuring all people living with the disease have access to the medications and services they need, and ramping up prevention efforts to make sure HIV-negative people stay that way. We have the tools to end HIV and we cannot allow the pandemic to threaten this progress. In fact, long-term survivors have told each of us that the situation right now feels similar to the beginning of the HIV epidemic.
Treatment for people living with HIV
To continue the momentum of innovation and creativity in a post-COVID world, we’re going to have to look at treatment and prevention strategies with new insight and new policy.
Keeping people living with HIV healthy is a crucial component. With proper treatment, we can keep a patient’s viral load suppressed so that the amount of HIV in their bodies is so low they can’t pass HIV on to another individual.
Yet for many patients, restrictions related to the novel coronavirus have disrupted their managed care plans required to ensure suppression. Some people living with HIV are at higher risk of acquiring SARS-CoV-2, and staying at home reduces the chances of exposure. Unfortunately, this means that people living with HIV or those at risk of HIV may not be attending medical appointments, and many hospitals and clinics have reduced in-person visits to safeguard staff and patients.
While telemedicine provides great advantages, its benefit is severely limited in a rural state like ours where a large number of people don’t have a computer, access to the Internet or reliable mobile phone service. And phone-based visits, while better than nothing, rob providers and patients of things such as non-verbal cues and physical contact that add richness to patient-provider encounters and helps build trusting relationships. In addition, maintaining access to safety-net programs like state-funded and pharmaceutical medication assistance programs often requires patients to have access to email, printers/copiers and fax machines — services they often access during medical encounters. This includes enrollment in services like the state HIV Medication Assistance Program (HMAP), a state program that helps provide folks with low income with their HIV medications. Moving to an online enrollment process for these programs would eliminate many barriers both in accessibility and safety.
Finally, we cannot ignore the mental health impact of the pandemic. Isolation and worry over access to care or paying for it can lead to more serious conditions like anxiety, depression and suicidal ideation. These mental and emotional health issues can worsen physical health and the body’s ability to stay healthy, and decrease adherence to medical treatments like medication regimens.
Prevention and harm reduction
The pandemic is also affecting our ability to prevent new cases of HIV. We must continue to ensure access to medications that help HIV-negative people stay that way. Pre-Exposure Prophylaxis (PrEP) is a once-daily pill that reduces the chances of becoming HIV positive to almost zero. Post-Exposure Prophylaxis (PEP) is taken after an encounter that may have led to HIV transmission (think of it as the Plan-B of HIV.) Keeping PrEP accessible is particularly important for reducing new HIV diagnoses for adolescents, who make up 1 in 5 of all new cases in 2018 (the most recent year data is available). A scant 1.5 percent of eligible young people nationally are currently using PrEP.
Access to these drugs was challenging for some people even before the pandemic because they had difficulty finding PrEP prescribers in their area. With reduced access to healthcare providers — whether because of disruptions to clinic operations or patients’ fears about engaging with the medical system at this time — some people will undoubtedly forego getting a prescription. For those with adequate technology, telemedicine services may be an adequate solution but we also need new and easier ways for people to access PrEP and PEP services and must think strategically and thoughtfully about how at home STI testing (both blood and extragenital samples) are administered.
Several states have approved or are exploring options to train pharmacists to prescribe PEP and PrEP. Pharmacies are well-positioned in most North Carolina communities and would make it easier for people to secure these important interventions. Pharmacies could play a key role in reducing burden and barriers for folks who may not be able to see a provider due to the COVID-19 pandemic (and beyond).
We have seen the strain that COVID-19 has put on our medical system. It is time that our policy makers at the North Carolina General Assembly and Department of Health and Human Services write a standing order for the state for PEP to increase access to these critical services through pharmacist distribution.
We have the tools to end the HIV epidemic in North Carolina. Our efforts to combat the COVID-19 pandemic can work in tandem to address the HIV epidemic as well.
Dr. Mehri McKellar, M.D. is associate professor at Duke University School of Medicine, and infectious disease specialist at Duke University Medical Center. Matt Martin is grassroots advocacy manager at NC AIDS Action Network.