Living with HIV in An Age of COVID-19

By Dr Wong Chen Seong, Deputy Director and Assoc Prof Sophia Archuleta, Director, National HIV Programme, NCID

It has been more than two years since the COVID-19 pandemic started, and more than 30 years since the first case of HIV infection was reported in Singapore. Much has changed in the way we live our lives due to the effect of both these viruses, and many more changes are likely to come.

All evidence points towards COVID-19 becoming an endemic infection – which may have seasonal variations or mutate into variants from time to time. This means that the way in which we live our lives will be shaped by our response to COVID-19; and these changes have bearing on the way HIV is treated as well. 

The global community, led by the United Nations HIV/AIDS Programme (UNAIDS), has developed an ambitious campaign to End AIDS by 2030.(1) Ending AIDS does not necessarily mean that we intend to eradicate the HIV virus in the same way that we have successfully eradicated the smallpox virus. Rather, we are working to end HIV as a major public health problem, by reducing the rate of new HIV infections globally to less than one per 1,000 population, as well as ensuring that as many people as possible who are infected are diagnosed, get started on effective HIV treatment, achieve an undetectable viral load and enjoy good health.(2)

It is easy to see how this goal bears similarities with our current move towards 'Living with COVID-19' – that is, COVID-19 endemicity. We are learning to live in a new reality where COVID-19 and HIV are ever-present. However, we should not become complacent or blasé about either, for they remain as infections that have the potential to be severe, and can significantly affect both the individual and the community. Instead, the goals of 'Ending HIV' and 'Living with COVID-19' both underline the importance of learning to co-exist with these diseases, and yet to never stop trying to overcome them. 

In this “new world order”, there are other ways in which COVID-19 and HIV are interrelated – particularly in the way we must learn to live with them. 

Firstly, we must continue to capitalise on the leaps we have made in science and healthcare to reduce the risks posed by both HIV and COVID-19. These include the introduction of many evidence-based treatments for COVID-19 (including new drugs like remdesivir and a number of monoclonal antibodies, and familiar remedies such as steroids), which have greatly reduced the mortality from severe illness.(3) COVID-19 vaccines across various platforms have proven to greatly ameliorate the risk of becoming seriously ill or dying from infection, and regular boosters seem likely to be needed to provide ongoing protection. In essence, we have developed the necessary weaponry to fight this war in the long term.(4)

Similarly, we have at our disposal the means to reduce the impact HIV has on the health and wellbeing of individuals and populations alike. These include accurate testing technology, and highly effective antiretroviral drugs that can be used for the treatment and prevention of HIV infection. HIV-positive individuals who are adherent to regular HIV treatment will achieve an undetectable viral load in their bloodstream, which not only means that their immune systems remain strong and healthy, but they are also effectively incapable of transmitting the virus to their sexual partners – a phenomenon now known as ‘Undetectable Equals Untransmittable’, or U=U.(5) Certain HIV medications can also be used by HIV-negative individuals at risk of HIV infection to greatly reduce this risk, through a strategy known as pre-exposure prophylaxis or PrEP.(6) PrEP places the power of HIV prevention squarely in the hands of the person at risk, and in this way, is a great additional tool to our existing armamentarium of behavioural interventions to prevent HIV – the “ABCD” approach (namely Abstinence, Being faithful to one’s partner, the Correct and consistent use of condoms, all of which require the co-operation and agreement of both partners to work; and the early Detection and treatment for viral suppression).(7)

Secondly, we must recognise that a major enemy in our war against both COVID-19 and HIV is not the viruses themselves, but rather, misinformation and stigma. 

We have seen the effect of widely-peddled mistruths and fake news from the start of the COVID-19 pandemic. These have ranged from speculations about the source of the SARS-CoV-2 virus, to falsehoods about the safety and trustworthiness of vaccines (leading to slow uptake of lifesaving immunisation and sickness and death from taking dangerous, unproven medications).(8,9) If we are to eventually prevail over COVID-19, we must not neglect the war against misinformation. Efforts must be redoubled to publicly address them, and where they result in harm, then action must be taken against the perpetrators. Resources must also be directed towards public education so that the community as a whole is kept abreast of the rapidly advancing science.(10)

In parallel, HIV stigma has existed since the very beginning. This stigma stems from a lack of knowledge and misconceptions about HIV, including the fact that HIV cannot be easily transmitted through casual contact; and only affects certain sectors of society like sexual and gender minorities. Stigma leads to discrimination of people living with HIV, and is a major cause of poor quality of life and health outcomes. Studies have shown that anticipated and experienced HIV stigma is a major deterrent to seeking HIV testing and treatment for people who are most at risk of HIV infection, and is also a barrier to staying engaged in care.(11) If we are to realistically hope to end HIV by the end of this decade, we will have to work hard to increase HIV-related knowledge and fight HIV stigma, and build a more compassionate world for people living with HIV. 

Thirdly, we must rethink conventional attitudes towards healthcare and harness innovations that democratise health and give more responsibility and ownership to individuals in the fight against both COVID-19 and HIV. 

We have already seen how effectively this works with COVID-19, particularly with the rapid development, rollout and adoption of home-based testing. The introduction of home testing has been, in general, smooth – and the acceptance of this testing strategy nearly universal. Home tests are now available for sale in retail pharmacies as well as online and via vending machines, allowing almost everyone to take control of their own health and wellbeing. Awareness of the importance of home testing has also grown rapidly, with public campaigns to educate the public on when, and how, to perform these tests. Through our experience with COVID-19, it has been shown that members of the public are able to perform diagnostic test procedures at home, and that self-testing can be an integral part of the health ecosystem – complementing facility-based testing in the diagnosis and management of diseases of public health importance. People who test positive are still able to access care and support where needed, and the risk of poor outcomes (such as emotional distress) from home-testing is low.

We should move quickly to replicate these gains in the realm of HIV testing. Singapore has done well in terms of achieving the second and third of the UNAIDS 90-90-90 goals – that is, getting 90% of those who are HIV-positive on medications, and achieving an undetectable viral load in 90% of those on treatment.(12) However, we have yet to achieve the all-important first 90: ensuring that at least 90% of those who are HIV-infected are aware of their diagnosis. In other words, we need to increase the rates of HIV testing. Studies done both locally and overseas have demonstrated that a major barrier to early and regular HIV testing is the need to get tested at healthcare or community-based facilities – even those that offer anonymous tests.(13) Some local studies have also shown that people who have either never tested for HIV, or seldom do so despite being at risk, would be more likely to get tested if they had the option of purchasing self-test kits to get tested in the privacy and convenience of their own homes.(14) If we are to truly commit to 'Ending HIV' by 2030, we must increase HIV testing – and self-testing will be crucial on this front. As of 1 August 2022, the National HIV Programme has initiated a pilot programme for HIV self-testing together with community and professional partners (Action for AIDS Singapore (AfA) and the Department for Sexually Transmitted Infections Control Clinic (DSC)), with the aims of assessing the feasibility and acceptability of self-funded HIV home testing. The self-testing kits are available at the DSC and AfA at 31 Kelantan Lane, costing between $20 and $32 per kit.

As we progress towards the end of 2022, HIV remains as relevant as ever and we must take stock of how far we have come. More importantly, we must be prepared to put in the work needed to get to where we need to go: a world where both COVID-19 and HIV may still remain, but where we no longer live in fear of how they affect our lives.

References

(1) “Fast-Track - Ending the AIDS Epidemic by 2030.” UNAIDS. Accessed June 27, 2022. https://www.unaids.org/en/resources/documents/2014/JC2686_WAD2014report. 

(2) Granich, Reuben, Brian Williams, Julio Montaner, and José M Zuniga. “90-90-90 And Ending Aids: Necessary and Feasible.” The Lancet 390, no. 10092 (2017): 341–43. https://doi.org/10.1016/s0140-6736(17)31872-x. 

(3) “Treatment Guidelines for Covid-19.” National Centre for Infectious Diseases, Singapore. Accessed June 27, 2022. https://www.ncid.sg/Health-Professionals/Diseases-and-Conditions/Pages/COVID-19.aspx. 

(4) Fiolet, Thibault, Yousra Kherabi, Conor-James MacDonald, Jade Ghosn, and Nathan Peiffer-Smadja. “Comparing Covid-19 Vaccines for Their Characteristics, Efficacy and Effectiveness against SARS-COV-2 and Variants of Concern: A Narrative Review.” Clinical Microbiology and Infection 28, no. 2 (2022): 202–21. https://doi.org/10.1016/j.cmi.2021.10.005. 

(5) Hayward, Peter. “Highlights of the 26th Croi 2019.” The Lancet HIV 6, no. 4 (2019). https://doi.org/10.1016/s2352-3018(19)30087-6.

(6) Choy, CY, CS Wong, PA Kumar, B Yeo, S Banerjee, YF Leow, DP Olyszyna, et al. “Guidance for the Prescription of Human Immunodeficiency Virus Pre-Exposure Prophylaxis in Singapore.” Singapore Medical Journal, 2022. https://doi.org/10.11622/smedj.2022043.

(7) “Prevent HIV with ABCD.” HealthHub. Accessed June 27, 2022. https://www.healthhub.sg/programmes/107/hiv-prevention.

(8) Bin Naeem, Salman, and Maged N. Kamel Boulos. “Covid-19 Misinformation Online and Health Literacy: A Brief Overview.” International Journal of Environmental Research and Public Health 18, no. 15 (2021): 8091. https://doi.org/10.3390/ijerph18158091.

(9) Ali, Sana, Atiqa Khalid, and Erum Zahid. “Is Covid-19 Immune to Misinformation? A Brief Overview.” Asian Bioethics Review 13, no. 2 (2021): 255–77. https://doi.org/10.1007/s41649-020-00155-x.

(10) Lai, Linette, and Clara Chong. “Half-Truths and Lies: How Covid-19 Misinformation Spreads in S'pore.” The Straits Times, May 27, 2022. https://www.straitstimes.com/singapore/pandemic-of-online-misinformation-on-covid-19-takes-its-toll. 

(11) Katz, Ingrid T, Annemarie E Ryu, Afiachukwu G Onuegbu, Christina Psaros, Sheri D Weiser, David R Bangsberg, and Alexander C Tsai. “Impact of HIV-Related Stigma on Treatment Adherence: Systematic Review and Meta-Synthesis.” Journal of the International AIDS Society 16 (2013): 18640. https://doi.org/10.7448/ias.16.3.18640.

(12) Goh, Timothy. “Singapore Surpasses UN Goals of HIV Treatment and Suppression but Still Lags behind in Diagnosis.” The Straits Times, December 7, 2020. https://www.straitstimes.com/singapore/health/singapore-surpasses-un-goals-of-treatment-suppression-for-hiv-but-still-lags-behind. 

(13) Tan, Rayner Kay, Nashwinder Kaur, P. Arun Kumar, Evonne Tay, Amanda Leong, Mark I-Cheng Chen, and Chen Seong Wong. “Clinics as Spaces of Costly Disclosure: HIV/STI Testing and Anticipated Stigma among Gay, Bisexual and Queer Men.” Culture, Health & Sexuality 22, no. 3 (2019): 307–20. https://doi.org/10.1080/13691058.2019.1596313.

(14) Tan, Yi-Roe, Nashwinder Kaur, Angeline Jiajun Ye, Yiwen Zhang, Jerald Xuan Lim, Rayner Kay Tan, Lai Peng Ho, et al. “Perceptions of an HIV Self-Testing Intervention and Its Potential Role in Addressing the Barriers to HIV Testing among at-Risk Heterosexual Men: A Qualitative Analysis.” Sexually Transmitted Infections 97, no. 7 (2021): 514–20. https://doi.org/10.1136/sextrans-2020-054773.

This article was first published in Infectious Disease Intelligence October 2022 Vol.1, No. 2. Read the full publication here.