HIV testing amid COVID-19: community efforts to reach men who have sex with men in three Kenyan counties

Abstract

In comparison to European and American countries, Kenya has been less impacted by the COVID-19 pandemic in terms of reported cases and mortalities. However, everyday life has been dramatically affected by highly restrictive government-imposed measures such as stay-at-home curfews, prohibitions on mobility across national and county boundaries, and strict policing, especially of the urban poor, which has culminated in violence. This open letter highlights the effects of these measures on how three community-based organizations (CBOs) deliver HIV programs and services to highly stigmatized communities of men who have sex with men living in the counties of Kisumu, Kiambu and Mombasa. In particular, emphasis is placed on how HIV testing programs, which are supported by systematic peer outreach, are being disrupted at a time when global policymakers call for expanded HIV testing and treatment targets among key populations. While government measures have greatly undermined local efforts to deliver health services to members and strengthen existing HIV testing programs, each of the three CBOs has taken innovative steps to adapt to the government restrictions and to the COVID-19 pandemic itself. Although HIV testing in clinical spaces among those who were once regular and occasional program attendees dropped off noticeably in the early months of the COVID-19 lockdown, the program eventually began to rebound as outreach approaches shifted to virtual platforms and strategies. Importantly and unexpectedly, HIV self-testing kits proved to fill a major gap in clinic-based HIV testing at a time of crisis.

The impact of the COVID-19 lockdown on HIV care in 65 South African primary care clinics: an interrupted time series analysis

“…A single-site, pre-exposure prophylaxis study 22 of 455 pregnant women in South Africa reported that 34% of patients missed visits before lockdown, increasing to 57% after lockdown (odds ratio 2•36, 95% CI 1•73-3•16). In keeping with our findings, two descriptive analyses from small studies in Kenya (two sites 14 and three sites 15 ) reported that 15-30% fewer HIV tests were done in April, 2020, than were done per month in January to March, 2020. 14,15 National laboratory data 23 from South Africa comparing the 2 months prelockdown with the first month of lockdown showed decreases of 33% in CD4 cell count (usually done at HIV diagnosis or ART initiation) and 22% in viral load testing (usually done for ART monitoring).…”

“…In keeping with our findings, two descriptive analyses from small studies in Kenya (two sites 14 and three sites 15 ) reported that 15-30% fewer HIV tests were done in April, 2020, than were done per month in January to March, 2020. 14,15 National laboratory data 23 from South Africa comparing the 2 months prelockdown with the first month of lockdown showed decreases of 33% in CD4 cell count (usually done at HIV diagnosis or ART initiation) and 22% in viral load testing (usually done for ART monitoring). However, decreased HIV viral load PCR testing could reflect changes in laboratory system capacity due to increased SARS-CoV-2 PCR testing, rather than changes in patient clinic attendance and ART provision.…”

“…An interrupted time series analysis 13 of data from 11 rural clinics in South Africa found a 20% increase in HIV-related primary care visits after lockdown implemen tation. By contrast, two small studies in Kenya 14,15 described 16-30% decreases in HIV testing after lockdown. However, these analyses were from few sites and might be biased by long-term trends that were not accounted for.…”

Competing Health Risks Associated with the COVID-19 Pandemic and Early Response: A Scoping Review

“…In some settings, there have been reported adaptations in the implementation of HIV service delivery to mitigate interruptions, including adoption of telemedicine [19, 31-36], home-based HIV testing and self-testing[37-39], home or mobile delivery of antiretrovirals[34, 35, 40], use of curbside pickup (i.e. pickup of supplies without stepping out of a vehicle) for condoms, lubricants, and medications[41], and designation of surrogates such as peers to motivate and support ongoing treatment.…”

“…[32] Access to non-medical support, including cash transfers, reimbursement for the costs associated with accessing care,[19] and housing and food supplementation support, has been key to promoting ongoing engagement in care. [29, 39] However, medical support and telemedicine strategies alone are unlikely to fully mitigate the poorer HIV outcomes observed; one study from a safety-net HIV clinic in San Francisco found that the odds of viral non-suppression were 31% higher after a shelter-in place mandate compared to before the mandate, even with telemedicine services. [14] Notably, most studies describing adaptations have been in higher-income settings, though this may be a publication bias.…”