As a country, Eswatini is lucky that we haven't had major cases of People Living with HIV (PLHV) and on treatment, who have lost their lives to COVID-19, due to a weakened immune system. This is commendable as it proves that the country's efforts to enrol PLHIV on life saving treatment in the early 2000s was a great move. As health care services worldwide undergo major reconfiguration to respond to the COVID-19 crisis, there are simple and affordable ways to improve outcomes that relate to both HIV and COVID-19 care.
The first step is voluntary HIV testing for people hospitalised with suspected or diagnosed COVID-19, whose HIV status is unknown. It is paramount that in a COVID-19 focused environment, health workers do not forget the importance of HIV testing in the work up for acute pneumonia and respiratory failure and, as such, do not delay diagnosis of HIV-related conditions such as pneumonia, which can present in a similar way. By definition, people with undiagnosed HIV will not be on ART and will commonly have reduced immune function and increased inflammation, both of which are likely to increase the risk of COVID-19 complications. Critical decisions about starting ART after a new HIV diagnosis, are paramount for every LiSwati. There is currently no data to inform the risk/benefit of initiating HIV treatment in people with COVID-19 but it is hoped that dedicated studies will be designed to address this important question. Meanwhile, an HIV diagnosis will ensure appropriate linkage with specialist HIV care during admission and upon discharge from hospital. This strategy will improve health outcomes for those individuals who do not currently know they are HIV positive and will counteract their risk of transmission to partners.
The second step is for People Living with HIV to ensure they record their status on all hospital admissions relating to COVID-19. This in turn will ensure that antiretroviral treatment (ART) is maintained during hospital stay, including during intensive care. Interrupting ART typically results in the rapid rebound of HIV replication, with a detrimental effect on immune and inflammatory responses that can complicate the management of COVID-19.
Establishing HIV status and access to expert opinion will be beneficial to the management of HIV-positive patients with COVID-19 and supportive of overburdened care teams. Examples include guidance on drug formulations suitable for critically ill patients and advice on drug-drug interactions. In addition to aiding clinical management, recording HIV status serves an important public health function: it can enrich research-based data collection platforms, and enable researchers to generate a much-needed dataset to inform guidelines and policies for both people with HIV and those affected by COVID-19. Currently, advice from specialists is based on extremely limited data and expert opinion.
Healthcare workers – doctors, nurses, laboratory personnel and all members of hospital staff – are responding amazingly well to the urgency of large numbers of people needing acute care for COVID-19.
As NERCHA, we make a call for increased awareness on the importance of recording one's HIV status, continuing HIV treatment for those known to be HIV-positive and establishing a diagnosis for those who have an unknown HIV status, as essential for all hospitals dealing with COVID-19.