# Service delivery challenges in HIV care during the first year of the COVID-19 pandemic: results from a site assessment survey across the global IeDEA consortium

Ellen Brazier, Rogers Ajeh, Fernanda Maruri, Beverly Musick, Aimee Freeman, C. William Wester, Man-po Lee, Tinei Shamu, Brenda Crabtree Ramírez, Marcelline d'Almeida, et al.

<figure><img src="image_1.png" /></figure>

## To cite this version:

Ellen Brazier, Rogers Ajeh, Fernanda Maruri, Beverly Musick, Aimee Freeman, et al. Service delivery challenges in HIV care during the first year of the COVID-19 pandemic: results from a site assessment survey across the global IeDEA consortium. Journal of the International AIDS Society, 2022, 25 (12), 10.1002/jia2.26036/full. [https://doi.org/10.1002/jia2.26036](https://doi.org/10.1002/jia2.26036)

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# Service delivery challenges in HIV care during the first year of the COVID-19 pandemic: results from a site assessment survey across the global IeDEA consortium

Ellen Brazier, Rogers Ajeh, Fernanda Maruri, Beverly Musick, Aimee Freeman, C. William Wester, Man-po Lee, Tinei Shamu, Brenda Crabtree Ramírez, Marcelline d'Almeida, et al.

► To cite this version:

Ellen Brazier, Rogers Ajeh, Fernanda Maruri, Beverly Musick, Aimee Freeman, et al. Service delivery challenges in HIV care during the first year of the COVID-19 pandemic: results from a site assessment survey across the global IeDEA consortium. Journal of the International AIDS Society, 2022, 25 (12), pp.e26036. 10.1002/jia2.26036. hal-04551215

HAL Id: hal-04551215

https://hal.science/hal-04551215v1

Submitted on 18 Apr 2024

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>
RESEARCH ARTICLE

# Service delivery challenges in HIV care during the first year of the COVID-19 pandemic: results from a site assessment survey across the global IeDEA consortium

Ellen Brazier¹,²,§, Rogers Ajeh³ ID, Fernanda Maruri⁴, Beverly Musick⁵, Aimee Freeman⁶, C. William Wester⁴ ID, Man-Po Lee⁷, Tinei Shamu⁸,⁹, Brenda Crabtree Ramírez¹⁰ ID, Marcelline d'Almeida¹¹, Kara Wools-Kaloustian⁵, N. Kumarasamy¹², Keri N. Althoff⁶, Christella Twizere¹³ ID, Beatriz Grinsztejn¹⁴, Frank Tanser¹⁵, Eugène Messou¹⁶, Helen Byakwaga¹⁷, Stephany N. Duda¹⁸,¹⁹, Denis Nash¹,² and on behalf of the International epidemiology Databases to Evaluate AIDS*

## Abstract

**Introduction:** Interruptions in treatment pose risks for people with HIV (PWH) and threaten progress in ending the HIV epidemic; however, the COVID-19 pandemic's impact on HIV service delivery across diverse settings is not broadly documented.

**Methods:** From September 2020 to March 2021, the International epidemiology Databases to Evaluate AIDS (IeDEA) research consortium surveyed 238 HIV care sites across seven geographic regions to document constraints in HIV service delivery during the first year of the pandemic and strategies for ensuring care continuity for PWH. Descriptive statistics were stratified by national HIV prevalence (<1%, 1-4.9% and ≥5%) and country income levels.

**Results:** Questions about pandemic-related consequences for HIV care were completed by 225 (95%) sites in 42 countries with low (n = 82), medium (n = 86) and high (n = 57) HIV prevalence, including low- (n = 57), lower-middle (n = 79), upper-middle (n = 39) and high- (n = 50) income countries. Most sites reported being subject to pandemic-related restrictions on travel, service provision or other operations (75%), and experiencing negative impacts (76%) on clinic operations, including decreased hours/days, reduced provider availability, clinic reconfiguration for COVID-19 services, record-keeping interruptions and suspension of partner support. Almost all sites in low-prevalence and high-income countries reported increased use of telemedicine (85% and 100%, respectively), compared with less than half of sites in high-prevalence and lower-income settings. Few sites in high-prevalence settings (2%) reported suspending antiretroviral therapy (ART) clinic services, and many reported adopting mitigation strategies to support adherence, including multi-month dispensing of ART (95%) and designating community ART pick-up points (44%). While few sites (5%) reported stockouts of first-line ART regimens, 10-11% reported stockouts of second- and third-line regimens, respectively, primarily in high-prevalence and lower-income settings. Interruptions in HIV viral load (VL) testing included suspension of testing (22%), longer turnaround times (41%) and supply/reagent stockouts (22%), but did not differ across settings.

**Conclusions:** While many sites in high HIV prevalence settings and lower-income countries reported introducing or expanding measures to support treatment adherence and continuity of care, the COVID-19 pandemic resulted in disruptions to VL testing and ART supply chains that may negatively affect the quality of HIV care in these settings.

**Keywords:** continuity of patient care; COVID-19; health systems; HIV continuum of care; human immunodeficiency virus; telemedicine

Additional information may be found under the Supporting Information tab of this article.

<footnote>§Corresponding author: Ellen Brazier, Institute for Implementation Science in Population Health, City University of New York, 55 West 125th Street, New York, NY 10027, USA. Tel: +1-646-364-9622. (ellen.brazier@sph.cuny.edu)</footnote>

<footnote>*Members are listed in the Supporting Information.</footnote>
<figure><img src="image_2.png" /></figure>

RESEARCH ARTICLE

# Service delivery challenges in HIV care during the first year of the COVID-19 pandemic: results from a site assessment survey across the global IeDEA consortium

Ellen Brazier¹,²,§, Rogers Ajeh³, Fernanda Maruri⁴, Beverly Musick⁵, Aimee Freeman⁶, C. William Wester⁴, Man-Po Lee⁷, Tinei Shamu⁸,⁹, Brenda Crabtree Ramírez¹⁰, Marcelline d'Almeida¹¹, Kara Wools-Kaloustian⁵, N. Kumarasamy¹², Keri N. Althoff⁶, Christella Twizere¹³, Beatriz Grinsztejn¹⁴, Frank Tanser¹⁵, Eugène Messou¹⁶, Helen Byakwaga¹⁷, Stephany N. Duda¹⁸,¹⁹, Denis Nash¹,² and on behalf of the International epidemiology Databases to Evaluate AIDS*

## Abstract

**Introduction:** Interruptions in treatment pose risks for people with HIV (PWH) and threaten progress in ending the HIV epidemic; however, the COVID-19 pandemic's impact on HIV service delivery across diverse settings is not broadly documented.

**Methods:** From September 2020 to March 2021, the International epidemiology Databases to Evaluate AIDS (IeDEA) research consortium surveyed 238 HIV care sites across seven geographic regions to document constraints in HIV service delivery during the first year of the pandemic and strategies for ensuring care continuity for PWH. Descriptive statistics were stratified by national HIV prevalence (<1%, 1-4.9% and ≥5%) and country income levels.

**Results:** Questions about pandemic-related consequences for HIV care were completed by 225 (95%) sites in 42 countries with low (n = 82), medium (n = 86) and high (n = 57) HIV prevalence, including low- (n = 57), lower-middle (n = 79), upper-middle (n = 39) and high- (n = 50) income countries. Most sites reported being subject to pandemic-related restrictions on travel, service provision or other operations (75%), and experiencing negative impacts (76%) on clinic operations, including decreased hours/days, reduced provider availability, clinic reconfiguration for COVID-19 services, record-keeping interruptions and suspension of partner support. Almost all sites in low-prevalence and high-income countries reported increased use of telemedicine (85% and 100%, respectively), compared with less than half of sites in high-prevalence and lower-income settings. Few sites in high-prevalence settings (2%) reported suspending antiretroviral therapy (ART) clinic services, and many reported adopting mitigation strategies to support adherence, including multi-month dispensing of ART (95%) and designating community ART pick-up points (44%). While few sites (5%) reported stockouts of first-line ART regimens, 10-11% reported stockouts of second- and third-line regimens, respectively, primarily in high-prevalence and lower-income settings. Interruptions in HIV viral load (VL) testing included suspension of testing (22%), longer turnaround times (41%) and supply/reagent stockouts (22%), but did not differ across settings.

**Conclusions:** While many sites in high HIV prevalence settings and lower-income countries reported introducing or expanding measures to support treatment adherence and continuity of care, the COVID-19 pandemic resulted in disruptions to VL testing and ART supply chains that may negatively affect the quality of HIV care in these settings.

**Keywords:** continuity of patient care; COVID-19; health systems; HIV continuum of care; human immunodeficiency virus; telemedicine

Additional information may be found under the Supporting Information tab of this article.

<footnote>§Corresponding author: Ellen Brazier, Institute for Implementation Science in Population Health, City University of New York, 55 West 125th Street, New York, NY 10027, USA. Tel: +1-646-364-9622. (ellen.brazier@sph.cuny.edu)</footnote>

<footnote>*Members are listed in the Supporting Information.</footnote>
# 1 | INTRODUCTION

The COVID-19 pandemic has had major direct and indirect impacts on population health globally, through disruptions in the accessibility and quality of basic health services [1], in supply chains for essential medications and commodities [2, 3], and in the availability of health workers [4-6]. These disruptions threaten to slow or reverse progress towards various global health priorities, including efforts to end the HIV epidemic [7, 8]. A modelling group convened by the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) in mid-2020 estimated that a 6-month disruption of antiretroviral therapy (ART) could lead to close to 500,000 excess deaths from AIDS-related illnesses, including tuberculosis, in sub-Saharan Africa in 2020-2021 [9, 10]. Subsequent modelling studies estimated that pandemic-related disruptions in care could raise new HIV infections and AIDS-related mortality by 10% over 2-5 years [11, 12], with higher increases among infants and children [13].

In view of the population health impacts of service delivery disruptions for people with HIV (PWH) and those at risk for HIV, the WHO, UNAIDS, the United States President's Emergency Plan for AIDS Relief (PEPFAR) and other partners recommended changes in HIV service delivery to minimize unnecessary clinic visits and risks of exposure to SARS-CoV-2 and reduce burdens on healthcare systems, while averting treatment interruption and disengagement from care [14-19]. Recommended measures included rapid initiation of ART among those not on treatment; expansion of differentiated service delivery (DSD) strategies, such as community distribution of ART and provision of multi-month supplies of ART, pre-exposure prophylaxis (PrEP) and tuberculosis preventive therapy; alignment of HIV care with treatment for coinfections and comorbidities; and introduction of telemedicine and virtual consultations.

While there have been efforts to document the impact of the COVID-19 pandemic on HIV care and treatment programmes, most existing studies have been narrow in geographic, programmatic and temporal scope—that is focused on single clinics [20-22] or countries [23-25], as well as services for special populations [26-28] and the initial months of the pandemic [24, 25, 29]. There are limited cross-country data on the pandemic's impacts on HIV service delivery, apart from reporting on the expansion of multi-month dispensing of ART in PEPFAR countries [30], along with disruptions to HIV programmes reported by the Global Fund [31].

This study aimed to document service delivery constraints posed by the COVID-19 pandemic for HIV care and treatment programmes across diverse country settings, along with strategies used to minimize treatment interruption and care disengagement. Such data are important for understanding and mitigating the impacts of the ongoing pandemic on global efforts to end the HIV epidemic.

# 2 | METHODS

## 2.1 | Data sources

The International epidemiology Databases to Evaluate AIDS (IeDEA) is a global research consortium comprising HIV care and treatment sites in 44 countries across seven geographic regions: the Asia-Pacific; the Caribbean, Central and South America (CCASAnet); Central Africa; East Africa; Southern Africa; West Africa; and North America (NA-ACCORD) [32]. IeDEA regularly conducts general and specialized surveys of participating clinics to collect data on site characteristics and topics related to HIV care that constitute gaps in the scientific literature.

IeDEA's 2020 site assessment survey was a cross-sectional survey of 238 HIV care and treatment clinics at academic and community-based hospitals and health centres participating in the consortium in 2020 as described elsewhere [33]. The survey collected data on site characteristics, such as facility type and location, patient population served and routine HIV care (e.g. ART initiation and viral load [VL] monitoring practices) prior to the start of the pandemic. In addition, the survey captured data on the impact of the COVID-19 pandemic on HIV care via questions exploring whether each site's location (i.e. municipality, district, etc.) had ever been subject to restrictions on travel, service provision or business operations; whether HIV services had ever been suspended because of the pandemic; and the timing and duration of any lockdowns and service-delivery suspensions. Other questions explored pandemic-related changes in clinic operations (e.g. staffing shortages, space reconfiguration, use of telemedicine, etc.); community-based services and programmes for PWH (e.g. HIV testing, support groups, community-based ART distribution and community tracing); ART initiation and routine ART services; HIV VL testing services; and stockouts of HIV-related commodities and supplies (e.g. HIV test kits, antiretroviral medications and VL testing supplies). Sites that did not provide a given service prior to the pandemic (e.g. same-day ART initiation or third-line ART) were instructed to report "Not applicable" for the service.

The survey was designated a non-human subjects operational/quality improvement project by the Vanderbilt University Medical Center (VUMC) Institutional Review Board (#200013). Informed consent was not required because the survey collected only site-level data and did not involve human subjects. Launched in English (11 September 2020) and French (16 October 2020) depending on the country context, the survey was distributed as a self-administered printable form for completion on paper and as an online questionnaire using REDCap (Research Electronic Data Capture) tools hosted at VUMC [34]. The survey was closed on 1 March 2021.

Site-level data were linked to national HIV prevalence estimates for 2019, compiled from UNAIDS and categorized as low (<1%), medium (1-4.9%) or high (≥5%) HIV prevalence [35], and country income levels in 2020 compiled from
# 1 | INTRODUCTION

The COVID-19 pandemic has had major direct and indirect impacts on population health globally, through disruptions in the accessibility and quality of basic health services [1], in supply chains for essential medications and commodities [2, 3], and in the availability of health workers [4-6]. These disruptions threaten to slow or reverse progress towards various global health priorities, including efforts to end the HIV epidemic [7, 8]. A modelling group convened by the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) in mid-2020 estimated that a 6-month disruption of antiretroviral therapy (ART) could lead to close to 500,000 excess deaths from AIDS-related illnesses, including tuberculosis, in sub-Saharan Africa in 2020-2021 [9, 10]. Subsequent modelling studies estimated that pandemic-related disruptions in care could raise new HIV infections and AIDS-related mortality by 10% over 2-5 years [11, 12], with higher increases among infants and children [13].

In view of the population health impacts of service delivery disruptions for people with HIV (PWH) and those at risk for HIV, the WHO, UNAIDS, the United States President's Emergency Plan for AIDS Relief (PEPFAR) and other partners recommended changes in HIV service delivery to minimize unnecessary clinic visits and risks of exposure to SARS-CoV-2 and reduce burdens on healthcare systems, while averting treatment interruption and disengagement from care [14-19]. Recommended measures included rapid initiation of ART among those not on treatment; expansion of differentiated service delivery (DSD) strategies, such as community distribution of ART and provision of multi-month supplies of ART, pre-exposure prophylaxis (PrEP) and tuberculosis preventive therapy; alignment of HIV care with treatment for coinfections and comorbidities; and introduction of telemedicine and virtual consultations.

While there have been efforts to document the impact of the COVID-19 pandemic on HIV care and treatment programmes, most existing studies have been narrow in geographic, programmatic and temporal scope—that is focused on single clinics [20-22] or countries [23-25], as well as services for special populations [26-28] and the initial months of the pandemic [24, 25, 29]. There are limited cross-country data on the pandemic's impacts on HIV service delivery, apart from reporting on the expansion of multi-month dispensing of ART in PEPFAR countries [30], along with disruptions to HIV programmes reported by the Global Fund [31].

This study aimed to document service delivery constraints posed by the COVID-19 pandemic for HIV care and treatment programmes across diverse country settings, along with strategies used to minimize treatment interruption and care disengagement. Such data are important for understanding and mitigating the impacts of the ongoing pandemic on global efforts to end the HIV epidemic.

# 2 | METHODS

## 2.1 | Data sources

The International epidemiology Databases to Evaluate AIDS (IeDEA) is a global research consortium comprising HIV care and treatment sites in 44 countries across seven geographic regions: the Asia-Pacific; the Caribbean, Central and South America (CCASAnet); Central Africa; East Africa; Southern Africa; West Africa; and North America (NA-ACCORD) [32]. IeDEA regularly conducts general and specialized surveys of participating clinics to collect data on site characteristics and topics related to HIV care that constitute gaps in the scientific literature.

IeDEA's 2020 site assessment survey was a cross-sectional survey of 238 HIV care and treatment clinics at academic and community-based hospitals and health centres participating in the consortium in 2020 as described elsewhere [33]. The survey collected data on site characteristics, such as facility type and location, patient population served and routine HIV care (e.g. ART initiation and viral load [VL] monitoring practices) prior to the start of the pandemic. In addition, the survey captured data on the impact of the COVID-19 pandemic on HIV care via questions exploring whether each site's location (i.e. municipality, district, etc.) had ever been subject to restrictions on travel, service provision or business operations; whether HIV services had ever been suspended because of the pandemic; and the timing and duration of any lockdowns and service-delivery suspensions. Other questions explored pandemic-related changes in clinic operations (e.g. staffing shortages, space reconfiguration, use of telemedicine, etc.); community-based services and programmes for PWH (e.g. HIV testing, support groups, community-based ART distribution and community tracing); ART initiation and routine ART services; HIV VL testing services; and stockouts of HIV-related commodities and supplies (e.g. HIV test kits, antiretroviral medications and VL testing supplies). Sites that did not provide a given service prior to the pandemic (e.g. same-day ART initiation or third-line ART) were instructed to report "Not applicable" for the service.

The survey was designated a non-human subjects operational/quality improvement project by the Vanderbilt University Medical Center (VUMC) Institutional Review Board (#200013). Informed consent was not required because the survey collected only site-level data and did not involve human subjects. Launched in English (11 September 2020) and French (16 October 2020) depending on the country context, the survey was distributed as a self-administered printable form for completion on paper and as an online questionnaire using REDCap (Research Electronic Data Capture) tools hosted at VUMC [34]. The survey was closed on 1 March 2021.

Site-level data were linked to national HIV prevalence estimates for 2019, compiled from UNAIDS and categorized as low (<1%), medium (1-4.9%) or high (≥5%) HIV prevalence [35], and country income levels in 2020 compiled from
the World Bank [36]. For countries and geographic entities not available in UNAIDS 2019 data (i.e. Canada, China, India, South Korea and Taiwan), the most recent HIV prevalence estimates available were compiled from other public databases [37] and local sources [38–40], and the same prevalence cut-offs were applied.

## 2.2 | Statistical analysis

Frequencies and descriptive statistics of site-level constraints and responses to the COVID-19 pandemic were calculated overall and stratified by national HIV prevalence levels and country income levels. Sites that reported not providing a given service prior to the pandemic were excluded when calculating the proportion of sites whose services had been impacted by the pandemic. Fisher's exact tests were used to assess independence, with Chi-squared tests used when exact tests could not be estimated.

All statistical analyses and descriptive mapping were performed using SAS 9.4 (SAS Institute, Cary, NC).

# 3 | RESULTS

Out of 238 sites in 43 countries, 227 (95%) responded to the survey, and 225 (99%) in 42 countries completed questions on the pandemic's impact on HIV services and care. Sites were distributed across IeDEA's seven geographic regions (Asia-Pacific, Central Africa, East Africa, Southern Africa, West Africa, CCASAnet and NA-ACCORD) (Figure 1). Of 225 sites, 57 (25%) were in high HIV prevalence settings, with 86 (38%) in medium HIV prevalence settings, and 82 (36%) in low-prevalence settings (Table 1). Most sites were in low (25%) and lower-middle-income countries (35%), with 17% and 22% in upper-middle and high-income countries, respectively.

## 3.1 | Site characteristics

Of 225 sites completing the survey, 54% were health centres, 8% were district hospitals and 38% were tertiary regional/provincial or university teaching hospitals. One-fifth reported serving a predominantly rural population, with 38% serving a predominantly urban population and 42% serving a mixed urban/rural population. Half of the sites reported serving both adult and paediatric patients, including almost all sites in high HIV prevalence settings (88%) and low-income countries (84%). In contrast, most sites in low-prevalence settings (83%) and high-income countries (100%) served adult patients only.

## 3.2 | Routine pre-pandemic ART initiation practices and VL testing capacity at participating sites

All 225 sites reported initiating patients on treatment before the pandemic and 172 provided information on routine pre-pandemic ART initiation practices, with 58% reporting that they had typically initiated patients on ART on the same day as enrolment in HIV care, including 32% of sites in low-prevalence settings, 67% in medium-prevalence settings and

82% in high-prevalence settings. Most sites in high-prevalence settings (71%) and low-income countries (63%) reported that patients were typically required to complete a single pre-ART counselling session prior to the pandemic, whereas sites in low-prevalence settings and high-income countries were more likely to report that no counselling sessions or two or more such sessions had been required. The majority of clinics surveyed (63%) reported that patients stable on ART had received 3-month ART supplies before the pandemic, with 3-month refill frequencies more commonly reported in high-prevalence and low-income settings (70% and 84%, respectively) compared with low-prevalence (42%) and high-income (38%) settings.

Just over half of sites surveyed (53%) reported being able to provide on-site VL testing prior to the pandemic, ranging from 85% of sites in low-prevalence settings to 30% of sites in high-prevalence settings, with VL testing capacity strongly associated with country income levels (26% of sites in low-income countries provided on-site testing, compared with 92% of sites in high-income countries). Comparable differences across settings were observed in VL testing turnaround times, with 63% of sites in low-prevalence settings (80% in high-income countries) reporting that results were received within 1 week, compared with 26% and 16% of sites in high-prevalence settings and low-income countries, respectively.

## 3.3 | Changes in clinic environment or operations related to the COVID-19 pandemic

Changes in clinic operations reported by survey respondents are shown in Table 2. Overall, 75% of sites reported that their clinic location had been subject to some form of pandemic-related restrictions on travel, service provision or other business operations. Sites in high HIV prevalence settings reported longer periods of lockdowns and restrictions, with 58% reporting lockdowns lasting 4–7 months (56% of sites in low-income countries). Only 19% of sites in low-prevalence settings and 12% in high-income countries reported lockdowns of this duration. Few sites (8%) reported completely suspending HIV service provision in response to the pandemic, with service suspensions being more common in settings with low HIV prevalence (17%), compared with medium- and high-prevalence settings (4% and 0%, respectively).

Most sites (76%) reported at least one negative impact of the pandemic on clinic operations, with no differences across HIV prevalence or income levels. Negative impacts included: the reconfiguration of hospital/clinic space to accommodate COVID-19-related services (52%), reduced provider availability because of illness, self-isolation or quarantine (39%), reduced provider availability because of reassignment to assist with the COVID-19 response (37%), withdrawal or suspension of support from non-governmental partners engaged in HIV care (32%), reduced hours/days for the provision of HIV services (26%) and interruptions in medical record-keeping or data entry (21%).

Almost all sites (92%) reported increased use of personal protective equipment in response to the pandemic, with no significant differences across settings. In contrast, sites in
the World Bank [36]. For countries and geographic entities not available in UNAIDS 2019 data (i.e. Canada, China, India, South Korea and Taiwan), the most recent HIV prevalence estimates available were compiled from other public databases [37] and local sources [38–40], and the same prevalence cut-offs were applied.

## 2.2 | Statistical analysis

Frequencies and descriptive statistics of site-level constraints and responses to the COVID-19 pandemic were calculated overall and stratified by national HIV prevalence levels and country income levels. Sites that reported not providing a given service prior to the pandemic were excluded when calculating the proportion of sites whose services had been impacted by the pandemic. Fisher's exact tests were used to assess independence, with Chi-squared tests used when exact tests could not be estimated.

All statistical analyses and descriptive mapping were performed using SAS 9.4 (SAS Institute, Cary, NC).

# 3 | RESULTS

Out of 238 sites in 43 countries, 227 (95%) responded to the survey, and 225 (99%) in 42 countries completed questions on the pandemic's impact on HIV services and care. Sites were distributed across IeDEA's seven geographic regions (Asia-Pacific, Central Africa, East Africa, Southern Africa, West Africa, CCASAnet and NA-ACCORD) (Figure 1). Of 225 sites, 57 (25%) were in high HIV prevalence settings, with 86 (38%) in medium HIV prevalence settings, and 82 (36%) in low-prevalence settings (Table 1). Most sites were in low (25%) and lower-middle-income countries (35%), with 17% and 22% in upper-middle and high-income countries, respectively.

## 3.1 | Site characteristics

Of 225 sites completing the survey, 54% were health centres, 8% were district hospitals and 38% were tertiary regional/provincial or university teaching hospitals. One-fifth reported serving a predominantly rural population, with 38% serving a predominantly urban population and 42% serving a mixed urban/rural population. Half of the sites reported serving both adult and paediatric patients, including almost all sites in high HIV prevalence settings (88%) and low-income countries (84%). In contrast, most sites in low-prevalence settings (83%) and high-income countries (100%) served adult patients only.

## 3.2 | Routine pre-pandemic ART initiation practices and VL testing capacity at participating sites

All 225 sites reported initiating patients on treatment before the pandemic and 172 provided information on routine pre-pandemic ART initiation practices, with 58% reporting that they had typically initiated patients on ART on the same day as enrolment in HIV care, including 32% of sites in low-prevalence settings, 67% in medium-prevalence settings and

82% in high-prevalence settings. Most sites in high-prevalence settings (71%) and low-income countries (63%) reported that patients were typically required to complete a single pre-ART counselling session prior to the pandemic, whereas sites in low-prevalence settings and high-income countries were more likely to report that no counselling sessions or two or more such sessions had been required. The majority of clinics surveyed (63%) reported that patients stable on ART had received 3-month ART supplies before the pandemic, with 3-month refill frequencies more commonly reported in high-prevalence and low-income settings (70% and 84%, respectively) compared with low-prevalence (42%) and high-income (38%) settings.

Just over half of sites surveyed (53%) reported being able to provide on-site VL testing prior to the pandemic, ranging from 85% of sites in low-prevalence settings to 30% of sites in high-prevalence settings, with VL testing capacity strongly associated with country income levels (26% of sites in low-income countries provided on-site testing, compared with 92% of sites in high-income countries). Comparable differences across settings were observed in VL testing turnaround times, with 63% of sites in low-prevalence settings (80% in high-income countries) reporting that results were received within 1 week, compared with 26% and 16% of sites in high-prevalence settings and low-income countries, respectively.

## 3.3 | Changes in clinic environment or operations related to the COVID-19 pandemic

Changes in clinic operations reported by survey respondents are shown in Table 2. Overall, 75% of sites reported that their clinic location had been subject to some form of pandemic-related restrictions on travel, service provision or other business operations. Sites in high HIV prevalence settings reported longer periods of lockdowns and restrictions, with 58% reporting lockdowns lasting 4–7 months (56% of sites in low-income countries). Only 19% of sites in low-prevalence settings and 12% in high-income countries reported lockdowns of this duration. Few sites (8%) reported completely suspending HIV service provision in response to the pandemic, with service suspensions being more common in settings with low HIV prevalence (17%), compared with medium- and high-prevalence settings (4% and 0%, respectively).

Most sites (76%) reported at least one negative impact of the pandemic on clinic operations, with no differences across HIV prevalence or income levels. Negative impacts included: the reconfiguration of hospital/clinic space to accommodate COVID-19-related services (52%), reduced provider availability because of illness, self-isolation or quarantine (39%), reduced provider availability because of reassignment to assist with the COVID-19 response (37%), withdrawal or suspension of support from non-governmental partners engaged in HIV care (32%), reduced hours/days for the provision of HIV services (26%) and interruptions in medical record-keeping or data entry (21%).

Almost all sites (92%) reported increased use of personal protective equipment in response to the pandemic, with no significant differences across settings. In contrast, sites in
<figure><img src="image_3.png" /><figcaption>Figure 1. Countries represented in the International epidemiology Databases to Evaluate AIDS (IeDEA) 2020 site assessment survey, by national HIV prevalence level. †Numbers in parentheses indicate the number of sites surveyed per country. ‡Indicates that a surveyed site represents a cohort of sites.</figcaption></figure>

<table><thead><tr><th>North America<br>(N = 28)†</th><th>Caribbean, Central<br>& South America<br>(N = 9)</th><th>Central Africa<br>(N = 21)</th><th>West Africa<br>(N = 14)</th><th>Southern Africa<br>(N = 28)</th><th>East Africa<br>(N = 74)</th><th>Asia-Pacific<br>(N = 51)</th></tr></thead><tbody><tr><td>Canada (2)</td><td>Argentina (1)</td><td>Burundi (3)</td><td>Benin (2)</td><td>Lesotho‡ (1)</td><td>Kenya (42)</td><td>Australia (18)</td></tr><tr><td>United States (26)</td><td>Brazil (3)<br>Chile (1)<br>Haiti (1)<br>Honduras (1)<br>Mexico (1)<br>Peru (1)</td><td>Cameroon (3)<br>Democratic Republic of Congo (1)<br>Republic of Congo (2)<br>Rwanda (12)</td><td>Burkina Faso (1)<br>Cote d'Ivoire (7)<br>Ghana (1)<br>Mali (1)<br>Senegal (1)<br>Togo (1)</td><td>Malawi (2)<br>Mozambique‡ (1)<br>South Africa‡ (14)<br>Zambia‡ (5)<br>Zimbabwe‡ (5)</td><td>Tanzania (3)<br>Uganda (29)</td><td>Cambodia (2)<br>China (1)<br>India (3)<br>Indonesia (4)<br>Japan (1)<br>Korea (1)<br>Malaysia (6)<br>Philippines (1)<br>Taiwan (1)<br>Thailand (8)<br>Vietnam (5)</td></tr></tbody></table>

low-prevalence settings (85%) and high-income countries (100%) were more than twice as likely as sites in medium- and high-prevalence settings and low-income countries to report increased use of telemedicine (i.e. consultations by telephone or web-based conferencing) in the provision of HIV-related care.

### 3.4 | Effects of the pandemic on HIV service provision

Pandemic-related changes in HIV service provision are shown in Table 3. Overall, 26% of sites reported suspending HIV testing and diagnostic services, and 10% reported
<figure><img src="image_3.png" /><figcaption>Figure 1. Countries represented in the International epidemiology Databases to Evaluate AIDS (IeDEA) 2020 site assessment survey, by national HIV prevalence level. †Numbers in parentheses indicate the number of sites surveyed per country. ‡Indicates that a surveyed site represents a cohort of sites.</figcaption></figure>

<table><thead><tr><th>North America<br>(N = 28)†</th><th>Caribbean, Central<br>& South America<br>(N = 9)</th><th>Central Africa<br>(N = 21)</th><th>West Africa<br>(N = 14)</th><th>Southern Africa<br>(N = 28)</th><th>East Africa<br>(N = 74)</th><th>Asia-Pacific<br>(N = 51)</th></tr></thead><tbody><tr><td>Canada (2)</td><td>Argentina (1)</td><td>Burundi (3)</td><td>Benin (2)</td><td>Lesotho‡ (1)</td><td>Kenya (42)</td><td>Australia (18)</td></tr><tr><td rowspan="6">United States (26)</td><td>Brazil (3)</td><td>Cameroon (3)</td><td>Burkina Faso (1)</td><td>Malawi (2)</td><td>Tanzania (3)</td><td>Cambodia (2)</td></tr><tr><td>Chile (1)</td><td>Democratic Republic of<br>Congo (1)</td><td>Cote d'Ivoire (7)</td><td>Mozambique‡ (1)</td><td>Uganda (29)</td><td>China (1)</td></tr><tr><td>Haiti (1)</td><td>Republic of Congo (2)</td><td>Ghana (1)</td><td>South Africa‡ (14)</td><td></td><td>India (3)</td></tr><tr><td>Honduras (1)</td><td>Rwanda (12)</td><td>Mali (1)</td><td>Zambia‡ (5)</td><td></td><td>Indonesia (4)</td></tr><tr><td>Mexico (1)</td><td></td><td>Senegal (1)</td><td>Zimbabwe‡ (5)</td><td></td><td>Japan (1)</td></tr><tr><td>Peru (1)</td><td></td><td>Togo (1)</td><td></td><td></td><td>Korea (1)</td></tr></tbody></table>

low-prevalence settings (85%) and high-income countries (100%) were more than twice as likely as sites in medium- and high-prevalence settings and low-income countries to report increased use of telemedicine (i.e. consultations by telephone or web-based conferencing) in the provision of HIV-related care.

### 3.4 | Effects of the pandemic on HIV service provision

Pandemic-related changes in HIV service provision are shown in Table 3. Overall, 26% of sites reported suspending HIV testing and diagnostic services, and 10% reported
<table><caption>Table 1. Characteristics of HIV care and treatment at 225 leDEA sites prior to the COVID-19 pandemic, by national HIV prevalence and country income level</caption><thead><tr><th rowspan="2">Site characteristic-N (%)</th><th colspan="4">National HIV prevalence</th><th colspan="4">Country income level</th></tr><tr><th>All<br/>N = 225</th><th>Low<br/>(<1%)<br/>n = 82<br/>(36%)</th><th>Medium<br/>(1-4.9%)<br/>n = 86<br/>(38%)</th><th>High<br/>(≥5%)<br/>n = 57<br/>(25%)</th><th>p-value<sup>a</sup></th><th>Low<br/>income<br/>n = 57<br/>(25%)</th><th>Lower-<br/>middle<br/>income<br/>n = 79<br/>(35%)</th><th>Upper-<br/>middle<br/>income<br/>N = 39<br/>(17%)</th><th>High<br/>income<br/>n = 50<br/>(22%)</th><th>p-value<sup>a</sup></th></tr></thead><tbody><tr><td>leDEA region</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Asia-Pacific</td><td>51 (23)</td><td>43 (52)</td><td>8 (9)</td><td>0 (0)</td><td>&lt;0.0001<sup>b</sup></td><td>0 (0)</td><td>11 (14)</td><td>19 (49)</td><td>21 (42)</td><td>&lt;0.0001<sup>b</sup></td></tr><tr><td>Central Africa</td><td>21 (9)</td><td>1 (1)</td><td>20 (23)</td><td>0 (0)</td><td></td><td>19 (33)</td><td>2 (3)</td><td>0 (0)</td><td>0 (0)</td><td></td></tr><tr><td>Caribbean, Central and South America (CCASAnet)</td><td>9 (4)</td><td>8 (10)</td><td>1 (1)</td><td>0 (0)</td><td></td><td>1 (2)</td><td>1 (1)</td><td>6 (15)</td><td>1 (2)</td><td></td></tr><tr><td>East Africa</td><td>74 (33)</td><td>0 (0)</td><td>45 (52)</td><td>29 (51)</td><td></td><td>29 (51)</td><td>45 (57)</td><td>0 (0)</td><td>0 (0)</td><td></td></tr><tr><td>North America (NA-ACCORD)</td><td>28 (12)</td><td>28 (34)</td><td>0 (0)</td><td>0 (0)</td><td></td><td>0 (0)</td><td>0 (0)</td><td>0 (0)</td><td>28 (56)</td><td></td></tr><tr><td>Southern Africa</td><td>28 (12)</td><td>0 (0)</td><td>0 (0)</td><td>28 (49)</td><td></td><td>3 (5)</td><td>11 (14)</td><td>14 (36)</td><td>0 (0)</td><td></td></tr><tr><td>West Africa</td><td>14 (6)</td><td>2 (2)</td><td>12 (14)</td><td>0 (0)</td><td></td><td>5 (9)</td><td>9 (11)</td><td>0 (0)</td><td>0 (0)</td><td></td></tr><tr><td>Country income level</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Low income</td><td>57 (25)</td><td>2 (2)</td><td>23 (27)</td><td>32 (56)</td><td>&lt;0.0001</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Lower-middle income</td><td>79 (35)</td><td>13 (16)</td><td>55 (64)</td><td>11 (19)</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Upper-middle income</td><td>39 (17)</td><td>17 (21)</td><td>8 (9)</td><td>14 (25)</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>High income</td><td>50 (22)</td><td>50 (61)</td><td>0 (0)</td><td>0 (0)</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Facility level</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Health centre</td><td>122 (54)</td><td>37 (45)</td><td>46 (54)</td><td>39 (68)</td><td>&lt;0.0001</td><td>36 (63)</td><td>45 (57)</td><td>7 (18)</td><td>34 (68)</td><td>&lt;0.0001</td></tr><tr><td>District hospital</td><td>17 (8)</td><td>0 (0)</td><td>13 (15)</td><td>4 (7)</td><td></td><td>3 (5)</td><td>14 (18)</td><td>0 (0)</td><td>0 (0)</td><td></td></tr><tr><td>Regional, provincial or university hospital</td><td>86 (38)</td><td>45 (55)</td><td>27 (31)</td><td>14 (25)</td><td></td><td>18 (32)</td><td>20 (25)</td><td>32 (82)</td><td>16 (32)</td><td></td></tr><tr><td>Population served (residence)</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Predominantly urban</td><td>86 (38)</td><td>53 (65)</td><td>17 (20)</td><td>16 (28)</td><td>&lt;0.0001</td><td>10 (18)</td><td>15 (19)</td><td>24 (62)</td><td>37 (74)</td><td>&lt;0.0001</td></tr><tr><td>Predominantly rural</td><td>44 (20)</td><td>2 (2)</td><td>22 (26)</td><td>20 (35)</td><td></td><td>20 (35)</td><td>21 (27)</td><td>1 (3)</td><td>2 (4)</td><td></td></tr><tr><td>Mixed urban/rural</td><td>95 (42)</td><td>27 (33)</td><td>47 (55)</td><td>21 (37)</td><td></td><td>27 (47)</td><td>43 (54)</td><td>14 (36)</td><td>11 (22)</td><td></td></tr><tr><td>Patients served (age groups)</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Adults only</td><td>82 (36)</td><td>68 (83)</td><td>10 (12)</td><td>4 (7)</td><td>&lt;0.0001</td><td>5 (9)</td><td>12 (15)</td><td>15 (39)</td><td>50 (100)</td><td>&lt;0.0001</td></tr><tr><td>Adults and paediatric patients</td><td>115 (51)</td><td>1 (1)</td><td>64 (74)</td><td>50 (88)</td><td></td><td>48 (84)</td><td>58 (73)</td><td>9 (23)</td><td>0 (0)</td><td></td></tr><tr><td>Paediatric patients only</td><td>28 (12)</td><td>13 (16)</td><td>12 (14)</td><td>3 (5)</td><td></td><td>4 (7)</td><td>9 (11)</td><td>15 (39)</td><td>0 (0)</td><td></td></tr></tbody></table>

(Continued)
<table><caption>Table 1. Characteristics of HIV care and treatment at 225 leDEA sites prior to the COVID-19 pandemic, by national HIV prevalence and country income level</caption><thead><tr><th rowspan="2">Site characteristic-N (%)</th><th colspan="4">National HIV prevalence</th><th colspan="4">Country income level</th></tr><tr><th>All<br/>N = 225</th><th>Low<br/>(<1%)<br/>n = 82<br/>(36%)</th><th>Medium<br/>(1-4.9%)<br/>n = 86<br/>(38%)</th><th>High<br/>(≥5%)<br/>n = 57<br/>(25%)</th><th>p-value<sup>a</sup></th><th>Low<br/>income<br/>n = 57<br/>(25%)</th><th>Lower-<br/>middle<br/>income<br/>n = 79<br/>(35%)</th><th>Upper-<br/>middle<br/>income<br/>N = 39<br/>(17%)</th><th>High<br/>income<br/>n = 50<br/>(22%)</th><th>p-value<sup>a</sup></th></tr></thead><tbody><tr><td><strong>leDEA region</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Asia-Pacific</td><td>51 (23)</td><td>43 (52)</td><td>8 (9)</td><td>0 (0)</td><td>&lt;0.0001<sup>b</sup></td><td>0 (0)</td><td>11 (14)</td><td>19 (49)</td><td>21 (42)</td><td>&lt;0.0001<sup>b</sup></td></tr><tr><td>Central Africa</td><td>21 (9)</td><td>1 (1)</td><td>20 (23)</td><td>0 (0)</td><td></td><td>19 (33)</td><td>2 (3)</td><td>0 (0)</td><td>0 (0)</td><td></td></tr><tr><td>Caribbean, Central and South<br/>America (CCASAnet)</td><td>9 (4)</td><td>8 (10)</td><td>1 (1)</td><td>0 (0)</td><td></td><td>1 (2)</td><td>1 (1)</td><td>6 (15)</td><td>1 (2)</td><td></td></tr><tr><td>East Africa</td><td>74 (33)</td><td>0 (0)</td><td>45 (52)</td><td>29 (51)</td><td></td><td>29 (51)</td><td>45 (57)</td><td>0 (0)</td><td>0 (0)</td><td></td></tr><tr><td>North America (NA-ACCORD)</td><td>28 (12)</td><td>28 (34)</td><td>0 (0)</td><td>0 (0)</td><td></td><td>0 (0)</td><td>0 (0)</td><td>0 (0)</td><td>28 (56)</td><td></td></tr><tr><td>Southern Africa</td><td>28 (12)</td><td>0 (0)</td><td>0 (0)</td><td>28 (49)</td><td></td><td>3 (5)</td><td>11 (14)</td><td>14 (36)</td><td>0 (0)</td><td></td></tr><tr><td>West Africa</td><td>14 (6)</td><td>2 (2)</td><td>12 (14)</td><td>0 (0)</td><td></td><td>5 (9)</td><td>9 (11)</td><td>0 (0)</td><td>0 (0)</td><td></td></tr><tr><td><strong>Country income level</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Low income</td><td>57 (25)</td><td>2 (2)</td><td>23 (27)</td><td>32 (56)</td><td>&lt;0.0001</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Lower-middle income</td><td>79 (35)</td><td>13 (16)</td><td>55 (64)</td><td>11 (19)</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Upper-middle income</td><td>39 (17)</td><td>17 (21)</td><td>8 (9)</td><td>14 (25)</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>High income</td><td>50 (22)</td><td>50 (61)</td><td>0 (0)</td><td>0 (0)</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td><strong>Facility level</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Health centre</td><td>122 (54)</td><td>37 (45)</td><td>46 (54)</td><td>39 (68)</td><td>&lt;0.0001</td><td>36 (63)</td><td>45 (57)</td><td>7 (18)</td><td>34 (68)</td><td>&lt;0.0001</td></tr><tr><td>District hospital</td><td>17 (8)</td><td>0 (0)</td><td>13 (15)</td><td>4 (7)</td><td></td><td>3 (5)</td><td>14 (18)</td><td>0 (0)</td><td>0 (0)</td><td></td></tr><tr><td>Regional, provincial or university<br/>hospital</td><td>86 (38)</td><td>45 (55)</td><td>27 (31)</td><td>14 (25)</td><td></td><td>18 (32)</td><td>20 (25)</td><td>32 (82)</td><td>16 (32)</td><td></td></tr><tr><td><strong>Population served (residence)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Predominantly urban</td><td>86 (38)</td><td>53 (65)</td><td>17 (20)</td><td>16 (28)</td><td>&lt;0.0001</td><td>10 (18)</td><td>15 (19)</td><td>24 (62)</td><td>37 (74)</td><td>&lt;0.0001</td></tr><tr><td>Predominantly rural</td><td>44 (20)</td><td>2 (2)</td><td>22 (26)</td><td>20 (35)</td><td></td><td>20 (35)</td><td>21 (27)</td><td>1 (3)</td><td>2 (4)</td><td></td></tr><tr><td>Mixed urban/rural</td><td>95 (42)</td><td>27 (33)</td><td>47 (55)</td><td>21 (37)</td><td></td><td>27 (47)</td><td>43 (54)</td><td>14 (36)</td><td>11 (22)</td><td></td></tr><tr><td><strong>Patients served (age groups)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Adults only</td><td>82 (36)</td><td>68 (83)</td><td>10 (12)</td><td>4 (7)</td><td>&lt;0.0001</td><td>5 (9)</td><td>12 (15)</td><td>15 (39)</td><td>50 (100)</td><td>&lt;0.0001</td></tr><tr><td>Adults and paediatric patients</td><td>115 (51)</td><td>1 (1)</td><td>64 (74)</td><td>50 (88)</td><td></td><td>48 (84)</td><td>58 (73)</td><td>9 (23)</td><td>0 (0)</td><td></td></tr><tr><td>Paediatric patients only</td><td>28 (12)</td><td>13 (16)</td><td>12 (14)</td><td>3 (5)</td><td></td><td>4 (7)</td><td>9 (11)</td><td>15 (39)</td><td>0 (0)</td><td></td></tr></tbody></table>

(Continued)
<table><caption>Table 1. (Continued)</caption><thead><tr><th rowspan="2">Site characteristic-N (%)</th><th rowspan="2">All<br/>N = 225</th><th colspan="4">National HIV prevalence</th><th colspan="4">Country income level</th></tr><tr><th>Low<br/>(<1%)<br/>n = 82<br/>(36%)</th><th>Medium<br/>(1-4.9%)<br/>n = 86<br/>(38%)</th><th>High<br/>(≥5%)<br/>n = 57<br/>(25%)</th><th>p-value<sup>a</sup></th><th>Low<br/>income<br/>n = 57<br/>(25%)</th><th>Lower-<br/>middle<br/>income<br/>n = 79<br/>(35%)</th><th>Upper-<br/>middle<br/>income<br/>N = 39<br/>(17%)</th><th>High<br/>income<br/>n = 50<br/>(22%)</th><th>p-value<sup>a</sup></th></tr></thead><tbody><tr><td>Sites reporting on pre-pandemic ART initiation practices</td><td>172 (76)</td><td>63 (77)</td><td>64 (74)</td><td>45 (79)</td><td>0.814</td><td>51 (90)</td><td>52 (66)</td><td>27 (69)</td><td>42 (84)</td><td>0.004</td></tr><tr><td>Timing of ART initiation pre-pandemic<sup>c</sup></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Same day</td><td>100 (58)</td><td>20 (32)</td><td>43 (67)</td><td>37 (82)</td><td>&lt;0.0001</td><td>34 (67)</td><td>39 (75)</td><td>13 (48)</td><td>14 (33)</td><td>&lt;0.0001<sup>b</sup></td></tr><tr><td>1-7 days</td><td>48 (28)</td><td>26 (41)</td><td>16 (25)</td><td>6 (13)</td><td></td><td>16 (32)</td><td>10 (19)</td><td>5 (19)</td><td>17 (41)</td><td></td></tr><tr><td>8-14 days</td><td>13 (8)</td><td>7 (11)</td><td>5 (8)</td><td>1 (2)</td><td></td><td>1 (2)</td><td>2 (4)</td><td>6 (22)</td><td>4 (10)</td><td></td></tr><tr><td>2-4 weeks</td><td>9 (5)</td><td>8 (13)</td><td>0 (0)</td><td>1 (2)</td><td></td><td>0 (0)</td><td>1 (2)</td><td>3 (11)</td><td>5 (12)</td><td></td></tr><tr><td>&gt;1 month</td><td>2 (1)</td><td>2 (3)</td><td>0 (0)</td><td>0 (0)</td><td></td><td>0 (0)</td><td>0 (0)</td><td>0 (0)</td><td>2 (5)</td><td></td></tr><tr><td>ART counselling sessions required pre-pandemic<sup>c</sup></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>0</td><td>20 (12)</td><td>14 (22)</td><td>5 (8)</td><td>1 (2)</td><td>0.0003</td><td>3 (6)</td><td>1 (1.9)</td><td>2 (7)</td><td>14 (33)</td><td>&lt;0.0001<sup>b</sup></td></tr><tr><td>1</td><td>95 (55)</td><td>28 (44)</td><td>35 (55)</td><td>32 (71)</td><td></td><td>32 (63)</td><td>27 (52)</td><td>16 (59)</td><td>20 (48)</td><td></td></tr><tr><td>2</td><td>23 (13)</td><td>13 (21)</td><td>6 (9)</td><td>4 (9)</td><td></td><td>9 (18)</td><td>4 (8)</td><td>4 (15)</td><td>6 (14)</td><td></td></tr><tr><td>3</td><td>25 (15)</td><td>3 (5)</td><td>14 (22)</td><td>8 (18)</td><td></td><td>7 (14)</td><td>13 (25)</td><td>4 (15)</td><td>1 (2)</td><td></td></tr><tr><td>4 or more</td><td>9 (5)</td><td>5 (8)</td><td>4 (6)</td><td>0 (0)</td><td></td><td>0 (0)</td><td>7 (13.5)</td><td>1 (4)</td><td>1 (2)</td><td></td></tr><tr><td>Pre-pandemic ART refill frequency for stable patients<sup>c</sup></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Every 1-2 months</td><td>47 (21)</td><td>28 (34)</td><td>8 (9)</td><td>11 (19)</td><td>&lt;0.0001</td><td>4 (7)</td><td>10 (13)</td><td>19 (49)</td><td>14 (28)</td><td>&lt;0.0001<sup>b</sup></td></tr><tr><td>Every 3 months</td><td>141 (63)</td><td>34 (42)</td><td>67 (78)</td><td>40 (70)</td><td></td><td>48 (84)</td><td>59 (75)</td><td>15 (39)</td><td>19 (38)</td><td></td></tr><tr><td>Every 4-6 months</td><td>34 (15)</td><td>19 (23)</td><td>10 (12)</td><td>5 (9)</td><td></td><td>4 (7)</td><td>9 (11)</td><td>5 (13)</td><td>16 (32)</td><td></td></tr><tr><td>Other</td><td>3 (1)</td><td>1 (1)</td><td>1 (1)</td><td>1 (2)</td><td></td><td>1 (2)</td><td>1 (1)</td><td>0 (0)</td><td>1 (2)</td><td></td></tr><tr><td>Pre-pandemic viral load testing services</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No on-site viral load testing</td><td>106 (47)</td><td>12 (15)</td><td>54 (63)</td><td>40 (70)</td><td>&lt;0.0001</td><td>42 (74)</td><td>53 (67)</td><td>7 (18)</td><td>4 (8)</td><td>&lt;0.0001</td></tr><tr><td>On-site viral testing (within HIV unit or facility)</td><td>119 (53)</td><td>70 (85)</td><td>32 (37)</td><td>17 (30)</td><td></td><td>15 (26)</td><td>26 (33)</td><td>32 (82)</td><td>46 (92)</td><td></td></tr><tr><td>Pre-pandemic turnaround time for viral load test results</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>0-7 days</td><td>100 (44)</td><td>52 (63)</td><td>33 (38)</td><td>15 (26)</td><td>&lt;0.0001</td><td>9 (16)</td><td>29 (37)</td><td>22 (56)</td><td>40 (80)</td><td>&lt;0.0001<sup>b</sup></td></tr><tr><td>14 days</td><td>50 (22)</td><td>15 (18)</td><td>29 (34)</td><td>6 (11)</td><td></td><td>9 (16)</td><td>26 (33)</td><td>8 (2)</td><td>7 (14)</td><td></td></tr><tr><td>15-30 days</td><td>58 (26)</td><td>13 (16)</td><td>19 (22)</td><td>26 (46)</td><td></td><td>29 (51)</td><td>18 (23)</td><td>8 (2)</td><td>3 (6)</td><td></td></tr><tr><td>30-60 days</td><td>14 (6)</td><td>1 (1)</td><td>4 (5)</td><td>9 (16)</td><td></td><td>9 (16)</td><td>5 (6)</td><td>0 (0)</td><td>0 (0)</td><td></td></tr><tr><td>Not available</td><td>3 (1)</td><td>1 (1)</td><td>1 (1)</td><td>1 (2)</td><td></td><td>1 (2)</td><td>1 (1)</td><td>1 (3)</td><td>0 (0)</td><td></td></tr></tbody></table>

<sup>a</sup>Fisher's exact test.

<sup>b</sup>Chi-squared test.

<sup>c</sup>Denominators exclude sites that did not report ART initiation services prior to the pandemic.
<table><caption>Table 1. (Continued)</caption><thead><tr><th rowspan="2">Site characteristic-N (%)</th><th rowspan="2">All<br/>N = 225</th><th colspan="4">National HIV prevalence</th><th colspan="4">Country income level</th></tr><tr><th>Low<br/>(<1%)<br/>n = 82<br/>(36%)</th><th>Medium<br/>(1-4.9%)<br/>n = 86<br/>(38%)</th><th>High<br/>(≥5%)<br/>n = 57<br/>(25%)</th><th>p-value<sup>a</sup></th><th>Low<br/>income<br/>n = 57<br/>(25%)</th><th>Lower-<br/>middle<br/>income<br/>n = 79<br/>(35%)</th><th>Upper-<br/>middle<br/>income<br/>N = 39<br/>(17%)</th><th>High<br/>income<br/>n = 50<br/>(22%)</th><th>p-value<sup>a</sup></th></tr></thead><tbody><tr><td>Sites reporting on pre-pandemic ART initiation practices</td><td>172 (76)</td><td>63 (77)</td><td>64 (74)</td><td>45 (79)</td><td>0.814</td><td>51 (90)</td><td>52 (66)</td><td>27 (69)</td><td>42 (84)</td><td>0.004</td></tr><tr><td>Timing of ART initiation pre-pandemic<sup>c</sup></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Same day</td><td>100 (58)</td><td>20 (32)</td><td>43 (67)</td><td>37 (82)</td><td>&lt;0.0001</td><td>34 (67)</td><td>39 (75)</td><td>13 (48)</td><td>14 (33)</td><td>&lt;0.0001<sup>b</sup></td></tr><tr><td>1-7 days</td><td>48 (28)</td><td>26 (41)</td><td>16 (25)</td><td>6 (13)</td><td></td><td>16 (32)</td><td>10 (19)</td><td>5 (19)</td><td>17 (41)</td><td></td></tr><tr><td>8-14 days</td><td>13 (8)</td><td>7 (11)</td><td>5 (8)</td><td>1 (2)</td><td></td><td>1 (2)</td><td>2 (4)</td><td>6 (22)</td><td>4 (10)</td><td></td></tr><tr><td>2-4 weeks</td><td>9 (5)</td><td>8 (13)</td><td>0 (0)</td><td>1 (2)</td><td></td><td>0 (0)</td><td>1 (2)</td><td>3 (11)</td><td>5 (12)</td><td></td></tr><tr><td>&gt;1 month</td><td>2 (1)</td><td>2 (3)</td><td>0 (0)</td><td>0 (0)</td><td></td><td>0 (0)</td><td>0 (0)</td><td>0 (0)</td><td>2 (5)</td><td></td></tr><tr><td>ART counselling sessions required pre-pandemic<sup>c</sup></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>0</td><td>20 (12)</td><td>14 (22)</td><td>5 (8)</td><td>1 (2)</td><td>0.0003</td><td>3 (6)</td><td>1 (1.9)</td><td>2 (7)</td><td>14 (33)</td><td>&lt;0.0001<sup>b</sup></td></tr><tr><td>1</td><td>95 (55)</td><td>28 (44)</td><td>35 (55)</td><td>32 (71)</td><td></td><td>32 (63)</td><td>27 (52)</td><td>16 (59)</td><td>20 (48)</td><td></td></tr><tr><td>2</td><td>23 (13)</td><td>13 (21)</td><td>6 (9)</td><td>4 (9)</td><td></td><td>9 (18)</td><td>4 (8)</td><td>4 (15)</td><td>6 (14)</td><td></td></tr><tr><td>3</td><td>25 (15)</td><td>3 (5)</td><td>14 (22)</td><td>8 (18)</td><td></td><td>7 (14)</td><td>13 (25)</td><td>4 (15)</td><td>1 (2)</td><td></td></tr><tr><td>4 or more</td><td>9 (5)</td><td>5 (8)</td><td>4 (6)</td><td>0 (0)</td><td></td><td>0 (0)</td><td>7 (13.5)</td><td>1 (4)</td><td>1 (2)</td><td></td></tr><tr><td>Pre-pandemic ART refill frequency for stable patients<sup>c</sup></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Every 1-2 months</td><td>47 (21)</td><td>28 (34)</td><td>8 (9)</td><td>11 (19)</td><td>&lt;0.0001</td><td>4 (7)</td><td>10 (13)</td><td>19 (49)</td><td>14 (28)</td><td>&lt;0.0001<sup>b</sup></td></tr><tr><td>Every 3 months</td><td>141 (63)</td><td>34 (42)</td><td>67 (78)</td><td>40 (70)</td><td></td><td>48 (84)</td><td>59 (75)</td><td>15 (39)</td><td>19 (38)</td><td></td></tr><tr><td>Every 4-6 months</td><td>34 (15)</td><td>19 (23)</td><td>10 (12)</td><td>5 (9)</td><td></td><td>4 (7)</td><td>9 (11)</td><td>5 (13)</td><td>16 (32)</td><td></td></tr><tr><td>Other</td><td>3 (1)</td><td>1 (1)</td><td>1 (1)</td><td>1 (2)</td><td></td><td>1 (2)</td><td>1 (1)</td><td>0 (0)</td><td>1 (2)</td><td></td></tr><tr><td>Pre-pandemic viral load testing services</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No on-site viral load testing</td><td>106 (47)</td><td>12 (15)</td><td>54 (63)</td><td>40 (70)</td><td>&lt;0.0001</td><td>42 (74)</td><td>53 (67)</td><td>7 (18)</td><td>4 (8)</td><td>&lt;0.0001</td></tr><tr><td>On-site viral testing (within HIV unit or facility)</td><td>119 (53)</td><td>70 (85)</td><td>32 (37)</td><td>17 (30)</td><td></td><td>15 (26)</td><td>26 (33)</td><td>32 (82)</td><td>46 (92)</td><td></td></tr><tr><td>Pre-pandemic turnaround time for viral load test results</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>0-7 days</td><td>100 (44)</td><td>52 (63)</td><td>33 (38)</td><td>15 (26)</td><td>&lt;0.0001</td><td>9 (16)</td><td>29 (37)</td><td>22 (56)</td><td>40 (80)</td><td>&lt;0.0001<sup>b</sup></td></tr><tr><td>14 days</td><td>50 (22)</td><td>15 (18)</td><td>29 (34)</td><td>6 (11)</td><td></td><td>9 (16)</td><td>26 (33)</td><td>8 (2)</td><td>7 (14)</td><td></td></tr><tr><td>15-30 days</td><td>58 (26)</td><td>13 (16)</td><td>19 (22)</td><td>26 (46)</td><td></td><td>29 (51)</td><td>18 (23)</td><td>8 (2)</td><td>3 (6)</td><td></td></tr><tr><td>30-60 days</td><td>14 (6)</td><td>1 (1)</td><td>4 (5)</td><td>9 (16)</td><td></td><td>9 (16)</td><td>5 (6)</td><td>0 (0)</td><td>0 (0)</td><td></td></tr><tr><td>Not available</td><td>3 (1)</td><td>1 (1)</td><td>1 (1)</td><td>1 (2)</td><td></td><td>1 (2)</td><td>1 (1)</td><td>1 (3)</td><td>0 (0)</td><td></td></tr></tbody></table>

<sup>a</sup>Fisher's exact test.

<sup>b</sup>Chi-squared test.

<sup>c</sup>Denominators exclude sites that did not report ART initiation services prior to the pandemic.
<table><caption>Table 2. Changes in clinic operations during the first year of the COVID-19 pandemic at 225 IeDEA sites, by national HIV prevalence and country income level</caption><thead><tr><th rowspan="2">Change in clinic environment or operations<br>N (%)</th><th colspan="4">National HIV prevalence</th><th colspan="4">Country income level</th></tr><tr><th>All<br>N = 225</th><th>Low<br>(<1%)<br>n = 82</th><th>Medium<br>(1-4.9%)<br>n = 86</th><th>High<br>(≥5%)<br>n = 57</th><th>p-value<sup>a</sup></th><th>Low<br>income<br>n = 57</th><th>Lower-<br>middle<br>income<br>n = 79</th><th>Upper-<br>middle<br>income<br>N = 39</th><th>High<br>income<br>n = 50</th><th>p-value<sup>a</sup></th></tr></thead><tbody><tr><td>Geographic area surrounding this HIV clinic subject to any form of COVID-19 restrictions on travel, service provision or business operations</td><td>168 (75)</td><td>64 (78)</td><td>52 (60)</td><td>52 (91)</td><td>&lt;0.0001</td><td>45 (79)</td><td>52 (66)</td><td>30 (77)</td><td>41 (82)</td><td>0.167</td></tr><tr><td>Duration of lockdowns/restrictions at sites subject to COVID-19 restrictions<br>&lt;= 1 month</td><td>11 (7)</td><td>5 (8)</td><td>5 (10)</td><td>1 (2)</td><td>0.001</td><td>3 (7)</td><td>3 (6)</td><td>1 (3)</td><td>4 (10)</td><td>0.001<sup>b</sup></td></tr><tr><td>2-3 months</td><td>54 (32)</td><td>27 (42)</td><td>15 (29)</td><td>12 (23)</td><td></td><td>10 (22)</td><td>11 (21)</td><td>13 (43)</td><td>20 (49)</td><td></td></tr><tr><td>4-7 months</td><td>59 (35)</td><td>12 (19)</td><td>17 (33)</td><td>30 (58)</td><td></td><td>25 (56)</td><td>21 (40)</td><td>8 (27)</td><td>5 (12)</td><td></td></tr><tr><td>Ongoing</td><td>23 (14)</td><td>13 (20)</td><td>7 (14)</td><td>3 (6)</td><td></td><td>1 (2)</td><td>8 (15)</td><td>6 (20)</td><td>8 (20)</td><td></td></tr><tr><td>Do not know/recall<sup>c</sup></td><td>21 (12)</td><td>7 (10)</td><td>8 (15)</td><td>6 (11)</td><td></td><td>6 (13)</td><td>9 (17)</td><td>2 (7)</td><td>4 (10)</td><td></td></tr><tr><td>HIV services suspended</td><td>17 (8)</td><td>14 (17)</td><td>3 (4)</td><td>0 (0)</td><td>0.0001</td><td>0 (0)</td><td>7 (9)</td><td>6 (15)</td><td>4 (8)</td><td>0.016</td></tr><tr><td>Duration of service suspension among sites suspending HIV services<br>&lt;= 1 month</td><td>3 (18)</td><td>3 (21)</td><td>0 (0)</td><td>0 (0)</td><td>0.232</td><td>0</td><td>1 (14)</td><td>1 (17)</td><td>1 (25)</td><td>0.802</td></tr><tr><td>2-3 months</td><td>6 (35)</td><td>6 (43)</td><td>0 (0)</td><td>0 (0)</td><td></td><td>0</td><td>2 (29)</td><td>2 (33)</td><td>2 (50)</td><td></td></tr><tr><td>4-7 months</td><td>6 (35)</td><td>4 (29)</td><td>2 (67)</td><td>0 (0)</td><td></td><td>0</td><td>3 (43)</td><td>3 (50)</td><td>0 (0)</td><td></td></tr><tr><td>Ongoing at the time of survey completion</td><td>2 (12)</td><td>1 (7)</td><td>1 (33)</td><td>0 (0)</td><td></td><td>0</td><td>1 (14)</td><td>0 (0)</td><td>1 (25)</td><td></td></tr><tr><td>Negative impacts on clinic operations</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Decreased hours or days of service delivery for HIV patients</td><td>58 (26)</td><td>25 (31)</td><td>23 (27)</td><td>10 (18)</td><td>0.217</td><td>11 (19)</td><td>23 (29)</td><td>15 (39)</td><td>9 (18)</td><td>0.094</td></tr><tr><td>HIV care providers reassigned to assist with the COVID-19 response</td><td>83 (37)</td><td>38 (46)</td><td>17 (20)</td><td>28 (49)</td><td>0.0001</td><td>18 (32)</td><td>20 (25)</td><td>22 (56)</td><td>23 (46)</td><td>0.004</td></tr><tr><td>Reduced availability of HIV care providers due to COVID-19-related illness, self-isolation or quarantine</td><td>88 (39)</td><td>38 (46)</td><td>24 (28)</td><td>26 (46)</td><td>0.024</td><td>24 (42)</td><td>25 (32)</td><td>21 (54)</td><td>18 (36)</td><td>0.124</td></tr></tbody><tfoot><tr><td colspan="11">(Continued)</td></tr></tfoot></table>
<table><caption>Table 2. Changes in clinic operations during the first year of the COVID-19 pandemic at 225 IeDEA sites, by national HIV prevalence and country income level</caption><thead><tr><th rowspan="2">Change in clinic environment<br>or operations<br>N (%)</th><th colspan="4">National HIV prevalence</th><th colspan="4">Country income level</th></tr><tr><th>All<br>N = 225</th><th>Low<br>(<1%)<br>n = 82</th><th>Medium<br>(1-4.9%)<br>n = 86</th><th>High<br>(≥5%)<br>n = 57</th><th>p-value<sup>a</sup></th><th>Low<br>income<br>n = 57</th><th>Lower-<br>middle<br>income<br>n = 79</th><th>Upper-<br>middle<br>income<br>N = 39</th><th>High<br>income<br>n = 50</th><th>p-value<sup>a</sup></th></tr></thead><tbody><tr><td>Geographic area surrounding this HIV<br>clinic subject to any form of COVID-19<br>restrictions on travel, service provision<br>or business operations</td><td>168 (75)</td><td>64 (78)</td><td>52 (60)</td><td>52 (91)</td><td>&lt;0.0001</td><td>45 (79)</td><td>52 (66)</td><td>30 (77)</td><td>41 (82)</td><td>0.167</td></tr><tr><td>Duration of lockdowns/restrictions at sites subject to COVID-19 restrictions<br>&lt;= 1 month</td><td>11 (7)</td><td>5 (8)</td><td>5 (10)</td><td>1 (2)</td><td>0.001</td><td>3 (7)</td><td>3 (6)</td><td>1 (3)</td><td>4 (10)</td><td>0.001<sup>b</sup></td></tr><tr><td>2-3 months</td><td>54 (32)</td><td>27 (42)</td><td>15 (29)</td><td>12 (23)</td><td></td><td>10 (22)</td><td>11 (21)</td><td>13 (43)</td><td>20 (49)</td><td></td></tr><tr><td>4-7 months</td><td>59 (35)</td><td>12 (19)</td><td>17 (33)</td><td>30 (58)</td><td></td><td>25 (56)</td><td>21 (40)</td><td>8 (27)</td><td>5 (12)</td><td></td></tr><tr><td>Ongoing</td><td>23 (14)</td><td>13 (20)</td><td>7 (14)</td><td>3 (6)</td><td></td><td>1 (2)</td><td>8 (15)</td><td>6 (20)</td><td>8 (20)</td><td></td></tr><tr><td>Do not know/recall<sup>c</sup></td><td>21 (12)</td><td>7 (10)</td><td>8 (15)</td><td>6 (11)</td><td></td><td>6 (13)</td><td>9 (17)</td><td>2 (7)</td><td>4 (10)</td><td></td></tr><tr><td>HIV services suspended</td><td>17 (8)</td><td>14 (17)</td><td>3 (4)</td><td>0 (0)</td><td>0.0001</td><td>0 (0)</td><td>7 (9)</td><td>6 (15)</td><td>4 (8)</td><td>0.016</td></tr><tr><td>Duration of service suspension among sites suspending HIV services<br>&lt;= 1 month</td><td>3 (18)</td><td>3 (21)</td><td>0 (0)</td><td>0 (0)</td><td>0.232</td><td>0</td><td>1 (14)</td><td>1 (17)</td><td>1 (25)</td><td>0.802</td></tr><tr><td>2-3 months</td><td>6 (35)</td><td>6 (43)</td><td>0 (0)</td><td>0 (0)</td><td></td><td>0</td><td>2 (29)</td><td>2 (33)</td><td>2 (50)</td><td></td></tr><tr><td>4-7 months</td><td>6 (35)</td><td>4 (29)</td><td>2 (67)</td><td>0 (0)</td><td></td><td>0</td><td>3 (43)</td><td>3 (50)</td><td>0 (0)</td><td></td></tr><tr><td>Ongoing at the time of survey<br>completion</td><td>2 (12)</td><td>1 (7)</td><td>1 (33)</td><td>0 (0)</td><td></td><td>0</td><td>1 (14)</td><td>0 (0)</td><td>1 (25)</td><td></td></tr><tr><td>Negative impacts on clinic operations<br>Decreased hours or days of service<br>delivery for HIV patients</td><td>58 (26)</td><td>25 (31)</td><td>23 (27)</td><td>10 (18)</td><td>0.217</td><td>11 (19)</td><td>23 (29)</td><td>15 (39)</td><td>9 (18)</td><td>0.094</td></tr><tr><td>HIV care providers reassigned to assist<br>with the COVID-19 response</td><td>83 (37)</td><td>38 (46)</td><td>17 (20)</td><td>28 (49)</td><td>0.0001</td><td>18 (32)</td><td>20 (25)</td><td>22 (56)</td><td>23 (46)</td><td>0.004</td></tr><tr><td>Reduced availability of HIV care<br>providers due to COVID-19-related<br>illness, self-isolation or quarantine</td><td>88 (39)</td><td>38 (46)</td><td>24 (28)</td><td>26 (46)</td><td>0.024</td><td>24 (42)</td><td>25 (32)</td><td>21 (54)</td><td>18 (36)</td><td>0.124</td></tr></tbody><tfoot><tr><td colspan="11">(Continued)</td></tr></tfoot></table>
<table><caption>Table 2. (Continued)</caption><thead><tr><th rowspan="2">Change in clinic environment or operations N (%)</th><th colspan="4">National HIV prevalence</th><th colspan="4">Country income level</th></tr><tr><th>All N = 225</th><th>Low (&lt;1%) n = 82</th><th>Medium (1-4.9%) n = 86</th><th>High (≥5%) n = 57</th><th>p-value<sup>a</sup></th><th>Low income n = 57</th><th>Lower-middle income n = 79</th><th>Upper-middle income N = 39</th><th>High income n = 50</th><th>p-value<sup>a</sup></th></tr></thead><tbody><tr><td>Reconfiguration of hospital/clinic space to accommodate COVID-19-related services</td><td>118 (52)</td><td>54 (66)</td><td>40 (47)</td><td>24 (42)</td><td>0.008</td><td>29 (51)</td><td>35 (44)</td><td>24 (62)</td><td>30 (60)</td><td>0.208</td></tr><tr><td>Interruptions or changes in data recording (paper or electronic records) related to clinical management of patients</td><td>47 (21)</td><td>21 (26)</td><td>9 (11)</td><td>17 (30)</td><td>0.007</td><td>13 (23)</td><td>11 (14)</td><td>14 (36)</td><td>9 (18)</td><td>0.054</td></tr><tr><td>Withdrawal/suspension of activities of non-governmental partners that support care provision in the clinic (n = 177)<sup>d</sup></td><td>56 (32)</td><td>26 (42)</td><td>14 (19)</td><td>16 (37)</td><td>0.013</td><td>15 (36)</td><td>11 (17)</td><td>17 (50)</td><td>13 (37)</td><td>0.004</td></tr><tr><td>Any of the above negative impacts</td><td>172 (76)</td><td>71 (87)</td><td>54 (63)</td><td>47 (83)</td><td>0.001</td><td>46 (81)</td><td>49 (62)</td><td>36 (92)</td><td>41 (82)</td><td>0.001</td></tr><tr><td>Adaptive clinic responses</td><td>208 (92)</td><td>77 (94)</td><td>77 (90)</td><td>54 (95)</td><td>0.503</td><td>53 (93)</td><td>72 (91)</td><td>35 (90)</td><td>48 (96)</td><td>0.693</td></tr><tr><td>Increased use of personal protective equipment (masks, gloves, gowns, etc.) by HIV clinic staff</td><td>126 (56)</td><td>70 (85)</td><td>33 (38)</td><td>23 (40)</td><td>&lt;0.0001</td><td>20 (35)</td><td>31 (39)</td><td>25 (64)</td><td>50 (100)</td><td>&lt;0.0001</td></tr><tr><td>Increased use of telemedicine (i.e. consultations by phone/web) in HIV-related care</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr></tbody></table>

<footnote><sup>a</sup>Fisher's exact test.</footnote>

<footnote><sup>b</sup>Chi-squared test.</footnote>

<footnote><sup>c</sup>Do not know/recall responses excluded from significance testing.</footnote>

<footnote><sup>d</sup>Denominators (in parentheses) exclude sites that did not offer a given service prior to the pandemic.</footnote>
<table><caption>Table 2. (Continued)</caption><thead><tr><th rowspan="2">Change in clinic environment or operations N (%)</th><th colspan="4">National HIV prevalence</th><th colspan="4">Country income level</th></tr><tr><th>All N = 225</th><th>Low (&lt;1%) n = 82</th><th>Medium (1-4.9%) n = 86</th><th>High (≥5%) n = 57</th><th>p-value<sup>a</sup></th><th>Low income n = 57</th><th>Lower-middle income n = 79</th><th>Upper-middle income N = 39</th><th>High income n = 50</th><th>p-value<sup>a</sup></th></tr></thead><tbody><tr><td>Reconfiguration of hospital/clinic space to accommodate COVID-19-related services</td><td>118 (52)</td><td>54 (66)</td><td>40 (47)</td><td>24 (42)</td><td>0.008</td><td>29 (51)</td><td>35 (44)</td><td>24 (62)</td><td>30 (60)</td><td>0.208</td></tr><tr><td>Interruptions or changes in data recording (paper or electronic records) related to clinical management of patients</td><td>47 (21)</td><td>21 (26)</td><td>9 (11)</td><td>17 (30)</td><td>0.007</td><td>13 (23)</td><td>11 (14)</td><td>14 (36)</td><td>9 (18)</td><td>0.054</td></tr><tr><td>Withdrawal/suspension of activities of non-governmental partners that support care provision in the clinic (n = 177)<sup>d</sup></td><td>56 (32)</td><td>26 (42)</td><td>14 (19)</td><td>16 (37)</td><td>0.013</td><td>15 (36)</td><td>11 (17)</td><td>17 (50)</td><td>13 (37)</td><td>0.004</td></tr><tr><td>Any of the above negative impacts</td><td>172 (76)</td><td>71 (87)</td><td>54 (63)</td><td>47 (83)</td><td>0.001</td><td>46 (81)</td><td>49 (62)</td><td>36 (92)</td><td>41 (82)</td><td>0.001</td></tr><tr><td>Adaptive clinic responses</td><td>208 (92)</td><td>77 (94)</td><td>77 (90)</td><td>54 (95)</td><td>0.503</td><td>53 (93)</td><td>72 (91)</td><td>35 (90)</td><td>48 (96)</td><td>0.693</td></tr><tr><td>Increased use of personal protective equipment (masks, gloves, gowns, etc.) by HIV clinic staff</td><td>126 (56)</td><td>70 (85)</td><td>33 (38)</td><td>23 (40)</td><td>&lt;0.0001</td><td>20 (35)</td><td>31 (39)</td><td>25 (64)</td><td>50 (100)</td><td>&lt;0.0001</td></tr><tr><td>Increased use of telemedicine (i.e. consultations by phone/web) in HIV-related care</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr></tbody></table>

<footnote><sup>a</sup>Fisher's exact test.</footnote>

<footnote><sup>b</sup>Chi-squared test.</footnote>

<footnote><sup>c</sup>Do not know/recall responses excluded from significance testing.</footnote>

<footnote><sup>d</sup>Denominators (in parentheses) exclude sites that did not offer a given service prior to the pandemic.</footnote>
<table><caption>Table 3. Changes in HIV services and programmes during the first year of the COVID-19 pandemic at 225 leDEA sites, by national HIV prevalence and country income level</caption><thead><tr><th rowspan="2">Service/programme attribute<sup>a</sup>—N (%)</th><th colspan="4">HIV prevalence</th><th colspan="4">Country income level</th></tr><tr><th>All<br>N = 225</th><th>Low<br>(<1%)<br>n = 82</th><th>Medium<br>(1-4.9%)<br>n = 86</th><th>High<br>(≥5%)<br>n = 57</th><th>p-value<sup>b</sup></th><th>Low<br>income<br>n = 57</th><th>Lower-<br>middle<br>income<br>n = 79</th><th>Upper-<br>middle<br>income<br>N = 39</th><th>High<br>income<br>n = 50</th><th>p-value<sup>b</sup></th></tr></thead><tbody><tr><td>Disruptions in services operated by the HIV clinic</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>HIV testing or diagnostic services suspended/reduced (n = 215)<sup>a</sup></td><td>56 (26)</td><td>25 (32)</td><td>13 (16)</td><td>18 (34)</td><td>0.020</td><td>22 (41)</td><td>13 (18)</td><td>9 (24)</td><td>12 (24)</td><td>0.037</td></tr><tr><td>New patient enrolments suspended</td><td>23 (10)</td><td>10 (12)</td><td>7 (8)</td><td>6 (11)</td><td>0.725</td><td>6 (11)</td><td>9 (11)</td><td>7 (18)</td><td>1 (2)</td><td>0.073</td></tr><tr><td>Non-urgent appointments for HIV patients suspended or postponed</td><td>94 (42)</td><td>53 (65)</td><td>23 (27)</td><td>18 (32)</td><td>&lt;0.0001</td><td>18 (32)</td><td>19 (24)</td><td>25 (64)</td><td>32 (64)</td><td>&lt;0.0001</td></tr><tr><td>ART clinics suspended</td><td>17 (8)</td><td>12 (15)</td><td>4 (5)</td><td>1 (2)</td><td>0.012</td><td>1 (2)</td><td>5 (6)</td><td>6 (15)</td><td>5 (10)</td><td>0.067</td></tr><tr><td>ART initiation services suspended</td><td>13 (6)</td><td>8 (10)</td><td>3 (4)</td><td>2 (4)</td><td>0.194</td><td>2 (4)</td><td>5 (6)</td><td>5 (13)</td><td>1 (2)</td><td>0.190</td></tr><tr><td>Adaptive measures introduced by the HIV clinic</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Same-day/rapid ART initiation expanded (n = 200)<sup>a</sup></td><td>67 (30)</td><td>20 (24)</td><td>27 (31)</td><td>20 (35)</td><td>0.661</td><td>22 (41)</td><td>28 (36)</td><td>7 (26)</td><td>10 (24)</td><td>0.265</td></tr><tr><td>Adherence counselling streamlined (n = 214)<sup>a</sup></td><td>61 (27)</td><td>22 (27)</td><td>23 (27)</td><td>16 (28)</td><td>0.926</td><td>18 (32)</td><td>22 (29)</td><td>13 (35)</td><td>8 (19)</td><td>0.364</td></tr><tr><td>Community ART pick-up points designated</td><td>52 (23)</td><td>10 (12)</td><td>17 (20)</td><td>25 (44)</td><td>&lt;0.0001</td><td>18 (32)</td><td>19 (24)</td><td>10 (26)</td><td>5 (10)</td><td>0.049</td></tr><tr><td>Patients given extra ART supplies to reduce refill frequency</td><td>182 (81)</td><td>55 (67)</td><td>73 (85)</td><td>54 (95)</td><td>0.0001</td><td>50 (88)</td><td>63 (80)</td><td>34 (87)</td><td>35 (70)</td><td>0.097</td></tr><tr><td>Viral load testing services</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>HIV VL sample collection suspended (n = 223)<sup>a</sup></td><td>49 (22)</td><td>23 (28)</td><td>15 (17)</td><td>11 (19)</td><td>0.226</td><td>15 (27)</td><td>18 (23)</td><td>7 (18)</td><td>9 (18)</td><td>0.710</td></tr><tr><td>HIV VL samples not accepted by laboratory (n = 221)<sup>a</sup></td><td>26 (12)</td><td>9 (11)</td><td>11 (13)</td><td>6 (11)</td><td>0.897</td><td>11 (20)</td><td>8 (10)</td><td>4 (10)</td><td>3 (6)</td><td>0.159</td></tr><tr><td>Longer turn-around time for VL results (n = 222)<sup>a</sup></td><td>92 (41)</td><td>38 (46)</td><td>30 (35)</td><td>24 (42)</td><td>0.331</td><td>29 (52)</td><td>32 (41)</td><td>14 (36)</td><td>17 (35)</td><td>0.279</td></tr><tr><td>Other disruptions (staffing shortages and lack of transport)</td><td>5 (2)</td><td>2 (2)</td><td>3 (4)</td><td>0 (0)</td><td>0.448</td><td>0 (0)</td><td>2 (3)</td><td>1 (3)</td><td>2 (4)</td><td>0.492</td></tr></tbody><tfoot><tr><td colspan="11" style="text-align: right;">(Continued)</td></tr></tfoot></table>
<table><caption>Table 3. Changes in HIV services and programmes during the first year of the COVID-19 pandemic at 225 leDEA sites, by national HIV prevalence and country income level</caption><thead><tr><th rowspan="2">Service/programme attribute<sup>a</sup>—N (%)</th><th colspan="4">HIV prevalence</th><th colspan="4">Country income level</th></tr><tr><th>All<br>N = 225</th><th>Low<br>(<1%)<br>n = 82</th><th>Medium<br>(1-4.9%)<br>n = 86</th><th>High<br>(≥5%)<br>n = 57</th><th>p-value<sup>b</sup></th><th>Low<br>income<br>n = 57</th><th>Lower-<br>middle<br>income<br>n = 79</th><th>Upper-<br>middle<br>income<br>N = 39</th><th>High<br>income<br>n = 50</th><th>p-value<sup>b</sup></th></tr></thead><tbody><tr><td>Disruptions in services operated by the HIV clinic</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>HIV testing or diagnostic services<br>suspended/reduced (n = 215)<sup>a</sup></td><td>56 (26)</td><td>25 (32)</td><td>13 (16)</td><td>18 (34)</td><td>0.020</td><td>22 (41)</td><td>13 (18)</td><td>9 (24)</td><td>12 (24)</td><td>0.037</td></tr><tr><td>New patient enrolments suspended</td><td>23 (10)</td><td>10 (12)</td><td>7 (8)</td><td>6 (11)</td><td>0.725</td><td>6 (11)</td><td>9 (11)</td><td>7 (18)</td><td>1 (2)</td><td>0.073</td></tr><tr><td>Non-urgent appointments for HIV<br>patients suspended or postponed</td><td>94 (42)</td><td>53 (65)</td><td>23 (27)</td><td>18 (32)</td><td>&lt;0.0001</td><td>18 (32)</td><td>19 (24)</td><td>25 (64)</td><td>32 (64)</td><td>&lt;0.0001</td></tr><tr><td>ART clinics suspended</td><td>17 (8)</td><td>12 (15)</td><td>4 (5)</td><td>1 (2)</td><td>0.012</td><td>1 (2)</td><td>5 (6)</td><td>6 (15)</td><td>5 (10)</td><td>0.067</td></tr><tr><td>ART initiation services suspended</td><td>13 (6)</td><td>8 (10)</td><td>3 (4)</td><td>2 (4)</td><td>0.194</td><td>2 (4)</td><td>5 (6)</td><td>5 (13)</td><td>1 (2)</td><td>0.190</td></tr><tr><td>Adaptive measures introduced by the HIV clinic</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Same-day/rapid ART initiation expanded<br>(n = 200)<sup>a</sup></td><td>67 (30)</td><td>20 (24)</td><td>27 (31)</td><td>20 (35)</td><td>0.661</td><td>22 (41)</td><td>28 (36)</td><td>7 (26)</td><td>10 (24)</td><td>0.265</td></tr><tr><td>Adherence counselling streamlined (n =<br>214)<sup>a</sup></td><td>61 (27)</td><td>22 (27)</td><td>23 (27)</td><td>16 (28)</td><td>0.926</td><td>18 (32)</td><td>22 (29)</td><td>13 (35)</td><td>8 (19)</td><td>0.364</td></tr><tr><td>Community ART pick-up points<br>designated</td><td>52 (23)</td><td>10 (12)</td><td>17 (20)</td><td>25 (44)</td><td>&lt;0.0001</td><td>18 (32)</td><td>19 (24)</td><td>10 (26)</td><td>5 (10)</td><td>0.049</td></tr><tr><td>Patients given extra ART supplies to<br>reduce refill frequency</td><td>182 (81)</td><td>55 (67)</td><td>73 (85)</td><td>54 (95)</td><td>0.0001</td><td>50 (88)</td><td>63 (80)</td><td>34 (87)</td><td>35 (70)</td><td>0.097</td></tr><tr><td>Viral load testing services</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>HIV VL sample collection suspended<br>(n = 223)<sup>a</sup></td><td>49 (22)</td><td>23 (28)</td><td>15 (17)</td><td>11 (19)</td><td>0.226</td><td>15 (27)</td><td>18 (23)</td><td>7 (18)</td><td>9 (18)</td><td>0.710</td></tr><tr><td>HIV VL samples not accepted by<br>laboratory (n = 221)<sup>a</sup></td><td>26 (12)</td><td>9 (11)</td><td>11 (13)</td><td>6 (11)</td><td>0.897</td><td>11 (20)</td><td>8 (10)</td><td>4 (10)</td><td>3 (6)</td><td>0.159</td></tr><tr><td>Longer turn-around time for VL results<br>(n = 222)<sup>a</sup></td><td>92 (41)</td><td>38 (46)</td><td>30 (35)</td><td>24 (42)</td><td>0.331</td><td>29 (52)</td><td>32 (41)</td><td>14 (36)</td><td>17 (35)</td><td>0.279</td></tr><tr><td>Other disruptions (staffing shortages<br>and lack of transport)</td><td>5 (2)</td><td>2 (2)</td><td>3 (4)</td><td>0 (0)</td><td>0.448</td><td>0 (0)</td><td>2 (3)</td><td>1 (3)</td><td>2 (4)</td><td>0.492</td></tr></tbody><tfoot><tr><td colspan="11" style="text-align: right;">(Continued)</td></tr></tfoot></table>
<table><caption>Table 3. (Continued)</caption><thead><tr><th rowspan="2">Service/programme attribute<sup>a</sup>—N (%)</th><th colspan="4">HIV prevalence</th><th colspan="4">Country income level</th></tr><tr><th>All<br>N = 225</th><th>Low<br>(<1%)<br>n = 82</th><th>Medium<br>(1-4.9%)<br>n = 86</th><th>High<br>(≥5%)<br>n = 57</th><th>Low<br>income<br>n = 57</th><th>Lower-<br>middle<br>income<br>n = 79</th><th>Upper-<br>middle<br>income<br>N = 39</th><th>High<br>income<br>n = 50</th><th>p-value<sup>b</sup></th></tr></thead><tbody><tr><td colspan="10"><strong>Stockouts</strong></td></tr><tr><td>PREP (n = 179)<sup>a</sup></td><td>11 (6)</td><td>2 (3)</td><td>7 (10)</td><td>2 (5)</td><td>0.250</td><td>4 (9)</td><td>5 (7)</td><td>2 (9)</td><td>0 (0)</td><td>0.129</td></tr><tr><td>HIV test kits (n = 207)<sup>a</sup></td><td>17 (8)</td><td>4 (6)</td><td>9 (11)</td><td>4 (7)</td><td>0.562</td><td>6 (11)</td><td>9 (12)</td><td>2 (6)</td><td>0 (0)</td><td>0.092</td></tr><tr><td>First-line ART (n = 221)<sup>a</sup></td><td>12 (5)</td><td>4 (5)</td><td>5 (6)</td><td>3 (5)</td><td>1.000</td><td>3 (5)</td><td>6 (8)</td><td>2 (5)</td><td>1 (2)</td><td>0.625</td></tr><tr><td>Second-line ART (n = 220)<sup>a</sup></td><td>25 (11)</td><td>5 (6)</td><td>6 (7)</td><td>14 (25)</td><td>0.002</td><td>12 (22)</td><td>9 (12)</td><td>3 (8)</td><td>1 (2)</td><td>0.012</td></tr><tr><td>Third-line ART (n = 139)<sup>a</sup></td><td>14 (10)</td><td>3 (4)</td><td>7 (16)</td><td>4 (17)</td><td>0.049</td><td>6 (22)</td><td>5 (17)</td><td>2 (6)</td><td>1 (2)</td><td>0.011</td></tr><tr><td>Supplies for viral load testing (n = 209)<sup>a</sup></td><td>45 (22)</td><td>12 (16)</td><td>18 (22)</td><td>15 (29)</td><td>0.221</td><td>23 (44)</td><td>15 (20)</td><td>4 (11)</td><td>3 (7)</td><td>&lt;0.0001</td></tr><tr><td colspan="10"><strong>Disruptions in community-based services, including services operated by partners</strong></td></tr><tr><td>Withdrawal/suspension of non-governmental partner support for community-based programmes for enrolled patients (n = 162)<sup>a</sup></td><td>65 (40)</td><td>31 (59)</td><td>14 (22)</td><td>20 (46)</td><td>0.0001</td><td>13 (31)</td><td>19 (31)</td><td>19 (66)</td><td>14 (48)</td><td>0.007</td></tr><tr><td>Community-based HIV testing suspended (n = 165)<sup>a</sup></td><td>117 (71)</td><td>38 (72)</td><td>40 (66)</td><td>39 (77)</td><td>0.462</td><td>31 (59)</td><td>40 (58)</td><td>20 (69)</td><td>7 (33)</td><td>0.735</td></tr><tr><td>Community-based ART refills suspended (n = 142)<sup>a</sup></td><td>59 (42)</td><td>11 (28)</td><td>29 (50)</td><td>19 (43)</td><td>0.077</td><td>16 (36)</td><td>30 (59)</td><td>12 (55)</td><td>1 (4)</td><td>&lt;0.0001</td></tr><tr><td>Community-based support group meetings/activities suspended (n = 169)<sup>a</sup></td><td>136 (81)</td><td>47 (84)</td><td>50 (78)</td><td>39 (80)</td><td>0.734</td><td>35 (76)</td><td>52 (81)</td><td>23 (79)</td><td>26 (87)</td><td>0.722</td></tr><tr><td>Community-based tracing of patients lost to follow-up suspended (n = 172)<sup>a</sup></td><td>98 (57)</td><td>25 (58)</td><td>36 (49)</td><td>37 (67)</td><td>0.105</td><td>31 (59)</td><td>40 (58)</td><td>20 (69)</td><td>7 (33)</td><td>0.091</td></tr></tbody></table>

<footnote><sup>a</sup>Denominators (in parentheses) exclude sites that did not offer a given service prior to the pandemic.</footnote>

<footnote><sup>b</sup>Fisher's exact test.</footnote>
<table><caption>Table 3. (Continued)</caption><thead><tr><th rowspan="2">Service/programme attribute<sup>a</sup>—N (%)</th><th colspan="4">HIV prevalence</th><th colspan="4">Country income level</th></tr><tr><th>All<br>N = 225</th><th>Low<br>(<1%)<br>n = 82</th><th>Medium<br>(1-4.9%)<br>n = 86</th><th>High<br>(≥5%)<br>n = 57</th><th>Low<br>income<br>n = 57</th><th>Lower-<br>middle<br>income<br>n = 79</th><th>Upper-<br>middle<br>income<br>N = 39</th><th>High<br>income<br>n = 50</th><th>p-value<sup>b</sup></th></tr></thead><tbody><tr><td><strong>Stockouts</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>PREP (n = 179)<sup>a</sup></td><td>11 (6)</td><td>2 (3)</td><td>7 (10)</td><td>2 (5)</td><td>0.250</td><td>4 (9)</td><td>5 (7)</td><td>2 (9)</td><td>0 (0)</td><td>0.129</td></tr><tr><td>HIV test kits (n = 207)<sup>a</sup></td><td>17 (8)</td><td>4 (6)</td><td>9 (11)</td><td>4 (7)</td><td>0.562</td><td>6 (11)</td><td>9 (12)</td><td>2 (6)</td><td>0 (0)</td><td>0.092</td></tr><tr><td>First-line ART (n = 221)<sup>a</sup></td><td>12 (5)</td><td>4 (5)</td><td>5 (6)</td><td>3 (5)</td><td>1.000</td><td>3 (5)</td><td>6 (8)</td><td>2 (5)</td><td>1 (2)</td><td>0.625</td></tr><tr><td>Second-line ART (n = 220)<sup>a</sup></td><td>25 (11)</td><td>5 (6)</td><td>6 (7)</td><td>14 (25)</td><td>0.002</td><td>12 (22)</td><td>9 (12)</td><td>3 (8)</td><td>1 (2)</td><td>0.012</td></tr><tr><td>Third-line ART (n = 139)<sup>a</sup></td><td>14 (10)</td><td>3 (4)</td><td>7 (16)</td><td>4 (17)</td><td>0.049</td><td>6 (22)</td><td>5 (17)</td><td>2 (6)</td><td>1 (2)</td><td>0.011</td></tr><tr><td>Supplies for viral load testing (n = 209)<sup>a</sup></td><td>45 (22)</td><td>12 (16)</td><td>18 (22)</td><td>15 (29)</td><td>0.221</td><td>23 (44)</td><td>15 (20)</td><td>4 (11)</td><td>3 (7)</td><td>&lt;0.0001</td></tr><tr><td><strong>Disruptions in community-based services, including services operated by partners</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Withdrawal/suspension of non-governmental partner support for community-based programmes for enrolled patients (n = 162)<sup>a</sup></td><td>65 (40)</td><td>31 (59)</td><td>14 (22)</td><td>20 (46)</td><td>0.0001</td><td>13 (31)</td><td>19 (31)</td><td>19 (66)</td><td>14 (48)</td><td>0.007</td></tr><tr><td>Community-based HIV testing suspended (n = 165)<sup>a</sup></td><td>117 (71)</td><td>38 (72)</td><td>40 (66)</td><td>39 (77)</td><td>0.462</td><td>31 (59)</td><td>40 (58)</td><td>20 (69)</td><td>7 (33)</td><td>0.735</td></tr><tr><td>Community-based ART refills suspended (n = 142)<sup>a</sup></td><td>59 (42)</td><td>11 (28)</td><td>29 (50)</td><td>19 (43)</td><td>0.077</td><td>16 (36)</td><td>30 (59)</td><td>12 (55)</td><td>1 (4)</td><td>&lt;0.0001</td></tr><tr><td>Community-based support group meetings/activities suspended (n = 169)<sup>a</sup></td><td>136 (81)</td><td>47 (84)</td><td>50 (78)</td><td>39 (80)</td><td>0.734</td><td>35 (76)</td><td>52 (81)</td><td>23 (79)</td><td>26 (87)</td><td>0.722</td></tr><tr><td>Community-based tracing of patients lost to follow-up suspended (n = 172)<sup>a</sup></td><td>98 (57)</td><td>25 (58)</td><td>36 (49)</td><td>37 (67)</td><td>0.105</td><td>31 (59)</td><td>40 (58)</td><td>20 (69)</td><td>7 (33)</td><td>0.091</td></tr></tbody></table>

<footnote><sup>a</sup>Denominators (in parentheses) exclude sites that did not offer a given service prior to the pandemic.</footnote>

<footnote><sup>b</sup>Fisher's exact test.</footnote>
suspending the enrolment of new patients into HIV care. Almost half (42%) of sites reported suspending or postponing non-urgent appointments for HIV patients, primarily in settings with low HIV prevalence settings (65%) and upper-middle- and high-income countries (64%).

While few sites (8%) reported suspending ART services, such suspensions were more commonly reported by sites in low-prevalence settings (15%), compared with medium- (5%) or high-prevalence (2%) settings. Among sites that offered ART initiation services, few (6%) reported suspending these services. In contrast, many reported the introduction or expansion of adaptive measures to mitigate the pandemic's impacts on treatment adherence, with 81% of sites reporting ever giving patients additional supplies of ART to reduce the frequency of refills and 23% reporting ever designating community ART pick-up points to reduce patients' travel burden. Both these mitigation strategies were more commonly reported by sites in high-prevalence settings (95% and 44%, respectively), compared with medium- (85% and 20%, respectively) and low-prevalence settings (67% and 12%, respectively). Other adaptive measures reported by clinics included the expansion of same-day ART initiation (30%) and streamlined ART adherence counselling (27%), with no significant differences across settings.

Across all settings, few sites reported stockouts of pre-exposure prophylaxis (PrEP) medications for HIV prevention (6%), HIV test kits (8%) or first-line antiretroviral medications (5%). In contrast, among sites providing second- and third-line ART, about 10% of sites reported stockouts of these medications, which were approximately four times as likely in high-prevalence settings, compared with low-prevalence settings. Stockouts were significantly more prevalent in low- and lower-middle-income countries than in upper-middle- and high-income countries.

Survey respondents reported negative impacts of the pandemic on HIV VL testing services, including longer turnaround times for results (41%), suspension of blood draws for VL testing (22%) and HIV VL samples not being accepted by laboratories (12%). In addition, 22% of sites conducting VL testing prior to the pandemic reported supply stockouts. VL testing disruptions did not differ by HIV prevalence or country income levels.

Among sites reporting the existence of various community-based services for PWH prior to the pandemic, including services operated by other partners, 71% reported that community-based HIV testing services had been suspended at some point during the pandemic, and 81% reported the suspension of community-based support group meetings/activities. Other pandemic impacts on community-based services for PWH included the suspension of tracing programmes (57%), withdrawal of non-governmental partner support (40%) and suspension of community-based ART refill programmes (42%). Few pandemic-related impacts on community-based programmes for PWH differed across HIV prevalence settings or country income levels.

4 | DISCUSSION

With data from 225 HIV treatment sites across 42 countries at the end of the first year of the COVID-19 pandemic, this study found that most had experienced disruptions in clinic operations and in the provision of HIV care. Such disruptions were reported by sites across high-, medium- and low-HIV prevalence settings and country income levels, reinforcing concerns raised by modelling studies [9, 11–13] and observational research [41–49] about the potential of COVID-19 to reverse progress towards 95-95-95 UNAIDS targets to end the HIV epidemic, particularly in settings with a high HIV burden [50].

Our study included several noteworthy findings. While clinics in high HIV prevalence settings were most likely to report being subject to pandemic-related restrictions affecting travel, service provision or business operations, they were less likely than clinics in low-prevalence settings to report suspending or postponing non-urgent appointments for HIV patients or having to reconfigure clinic space to accommodate COVID-19-related services. Clinics in high-prevalence settings were also less likely to report ever suspending ART clinics, and, in contrast with low- and medium-prevalence settings, none of the clinics in high-prevalence settings reported ever suspending HIV care and treatment services. Additionally, clinics in high-prevalence settings were more likely to report the adoption of mitigation strategies (e.g. establishing ART pick-up points in the community, providing additional stocks of ART, expanding same-day ART initiation and reducing adherence counselling requirements) to support patient adherence and reduce barriers to care. The resilience of clinics in high-prevalence settings may reflect the adoption of DSD strategies, such as community distribution and multi-month dispensing of ART, prior to the pandemic, as well as investments in strengthening the efficiency of ART service delivery in these settings—a capacity that could be leveraged and expanded to support uninterrupted treatment during the first year of COVID-19 [51].

While these findings are encouraging, the results of our study also point to resource disparities across countries that have implications for the continuity and quality of HIV care and its effectiveness in ensuring sustained viral suppression among PWH who are engaged in care. Although few clinics in low-income settings in our survey reported suspending routine ART clinics or ART initiation for new patients, well over one-third suspended HIV testing services, possibly reflecting resource constraints for laboratory and diagnostic services in these settings. We also observed significant disparities in the adoption of telemedicine for the provision of HIV care, with sites in high- and medium-HIV prevalence settings being less than half as likely as sites in low-prevalence settings to report increasing their use of telephone and web-based consultations for HIV patients. Correlated with country income levels, these disparities may reflect a range of barriers and challenges for telemedicine adoption, from socio-economic, digital literacy and linguistic barriers among patients to infrastructure, technology and regulatory obstacles for health systems [52]. While clinics in high-prevalence settings were less
suspending the enrolment of new patients into HIV care. Almost half (42%) of sites reported suspending or postponing non-urgent appointments for HIV patients, primarily in settings with low HIV prevalence settings (65%) and upper-middle- and high-income countries (64%).

While few sites (8%) reported suspending ART services, such suspensions were more commonly reported by sites in low-prevalence settings (15%), compared with medium- (5%) or high-prevalence (2%) settings. Among sites that offered ART initiation services, few (6%) reported suspending these services. In contrast, many reported the introduction or expansion of adaptive measures to mitigate the pandemic's impacts on treatment adherence, with 81% of sites reporting ever giving patients additional supplies of ART to reduce the frequency of refills and 23% reporting ever designating community ART pick-up points to reduce patients' travel burden. Both these mitigation strategies were more commonly reported by sites in high-prevalence settings (95% and 44%, respectively), compared with medium- (85% and 20%, respectively) and low-prevalence settings (67% and 12%, respectively). Other adaptive measures reported by clinics included the expansion of same-day ART initiation (30%) and streamlined ART adherence counselling (27%), with no significant differences across settings.

Across all settings, few sites reported stockouts of pre-exposure prophylaxis (PrEP) medications for HIV prevention (6%), HIV test kits (8%) or first-line antiretroviral medications (5%). In contrast, among sites providing second- and third-line ART, about 10% of sites reported stockouts of these medications, which were approximately four times as likely in high-prevalence settings, compared with low-prevalence settings. Stockouts were significantly more prevalent in low- and lower-middle-income countries than in upper-middle- and high-income countries.

Survey respondents reported negative impacts of the pandemic on HIV VL testing services, including longer turnaround times for results (41%), suspension of blood draws for VL testing (22%) and HIV VL samples not being accepted by laboratories (12%). In addition, 22% of sites conducting VL testing prior to the pandemic reported supply stockouts. VL testing disruptions did not differ by HIV prevalence or country income levels.

Among sites reporting the existence of various community-based services for PWH prior to the pandemic, including services operated by other partners, 71% reported that community-based HIV testing services had been suspended at some point during the pandemic, and 81% reported the suspension of community-based support group meetings/activities. Other pandemic impacts on community-based services for PWH included the suspension of tracing programmes (57%), withdrawal of non-governmental partner support (40%) and suspension of community-based ART refill programmes (42%). Few pandemic-related impacts on community-based programmes for PWH differed across HIV prevalence settings or country income levels.

4 | DISCUSSION

With data from 225 HIV treatment sites across 42 countries at the end of the first year of the COVID-19 pandemic, this study found that most had experienced disruptions in clinic operations and in the provision of HIV care. Such disruptions were reported by sites across high-, medium- and low-HIV prevalence settings and country income levels, reinforcing concerns raised by modelling studies [9, 11–13] and observational research [41–49] about the potential of COVID-19 to reverse progress towards 95-95-95 UNAIDS targets to end the HIV epidemic, particularly in settings with a high HIV burden [50].

Our study included several noteworthy findings. While clinics in high HIV prevalence settings were most likely to report being subject to pandemic-related restrictions affecting travel, service provision or business operations, they were less likely than clinics in low-prevalence settings to report suspending or postponing non-urgent appointments for HIV patients or having to reconfigure clinic space to accommodate COVID-19-related services. Clinics in high-prevalence settings were also less likely to report ever suspending ART clinics, and, in contrast with low- and medium-prevalence settings, none of the clinics in high-prevalence settings reported ever suspending HIV care and treatment services. Additionally, clinics in high-prevalence settings were more likely to report the adoption of mitigation strategies (e.g. establishing ART pick-up points in the community, providing additional stocks of ART, expanding same-day ART initiation and reducing adherence counselling requirements) to support patient adherence and reduce barriers to care. The resilience of clinics in high-prevalence settings may reflect the adoption of DSD strategies, such as community distribution and multi-month dispensing of ART, prior to the pandemic, as well as investments in strengthening the efficiency of ART service delivery in these settings—a capacity that could be leveraged and expanded to support uninterrupted treatment during the first year of COVID-19 [51].

While these findings are encouraging, the results of our study also point to resource disparities across countries that have implications for the continuity and quality of HIV care and its effectiveness in ensuring sustained viral suppression among PWH who are engaged in care. Although few clinics in low-income settings in our survey reported suspending routine ART clinics or ART initiation for new patients, well over one-third suspended HIV testing services, possibly reflecting resource constraints for laboratory and diagnostic services in these settings. We also observed significant disparities in the adoption of telemedicine for the provision of HIV care, with sites in high- and medium-HIV prevalence settings being less than half as likely as sites in low-prevalence settings to report increasing their use of telephone and web-based consultations for HIV patients. Correlated with country income levels, these disparities may reflect a range of barriers and challenges for telemedicine adoption, from socio-economic, digital literacy and linguistic barriers among patients to infrastructure, technology and regulatory obstacles for health systems [52]. While clinics in high-prevalence settings were less
likely to report suspending HIV services and appointments, other care-seeking barriers (e.g. lockdown restrictions, transportation and financial barriers, and concerns about COVID-19 exposure) may have presented insurmountable obstacles for patients in these settings, and early data from diverse settings have highlighted sharp decreases in healthcare-seeking for HIV-related services early in the pandemic, including HIV prevention [49, 53], diagnosis [24, 41, 42, 44-48, 53-55] and treatment [24, 43, 44, 53, 55, 56], as well as diagnostics and treatment for other infectious diseases and chronic conditions [55-58]. While some studies in sub-Saharan Africa have reported rebounds in HIV testing and ART initiation [24, 59], our findings related to stockouts of second- and third-line ART regimens in high-prevalence and low/lower-income settings are concerning, as the lack of such essential medicines may result in setbacks for both HIV treatment and prevention.

Given the importance of VL monitoring for detecting therapeutic failure and ensuring timely adherence support and regimen switching for the health of the individual with HIV and the reduced likelihood of transmission [60], disruptions in HIV VL testing services are of concern. Ranging from stockouts of essential supplies to suspension of VL testing services, laboratories not accepting HIV VL samples and longer turnaround times for results, such disruptions may reflect supply chain problems [2, 3, 61-63], as well as the reallocation of resources from HIV programmes to the COVID-19 response [57, 58, 63, 64]. While these disruptions were reported across all settings, they are of particular concern in settings with high HIV prevalence and in low/lower-income countries, given that the turnaround time for VL test results was already markedly longer in these settings before the pandemic. These gaps underscore the need for investment in integrated laboratory systems to increase access to critical diagnostics without having one infectious disease displace others [58, 63].

Our study had several limitations. Firstly, as the COVID-19 pandemic catalyzed the adoption of new service delivery strategies that were not explored in prior leDEA surveys, it is difficult to quantify the magnitude of some changes reported by respondents. Secondly, sites participating in leDEA may not be representative of HIV service delivery within a country or region, and in some settings, leDEA sites may be better resourced than many other HIV care and treatment sites, meaning that the pandemic's impact on HIV care could be underestimated in our survey. Accordingly, our findings may not be generalizable to all HIV clinical care settings in countries with low-, medium- and high-HIV prevalence or within country income groups. In addition, because disruptions to supply chains may have persisted or worsened after the end of the first year of the pandemic when our survey was conducted, the consequences for ART services and laboratory monitoring may not be fully captured. Finally, leDEA's global site assessment surveys rely on self-report by survey respondents, which may have introduced both selection and recall biases. While the high response and survey completion rate may help mitigate these biases, it should be noted that the survey was implemented during a period when healthcare systems and providers were at different phases of the pandemic response and when many changes in practice were being introduced to mitigate pandemic-related risks and burdens.

Providing early data on how COVID-19 has affected the availability of HIV services across a geographically diverse group of HIV care and treatment sites, our study complements other recent studies exploring the pandemic's impact on HIV testing, ART initiation, routine visits for HIV treatment, VL monitoring and viral suppression [24, 25, 59]—studies that found minimal changes in routine HIV care-seeking during 2020, along with rebounds following initial decreases in HIV testing and ART initiation. While the expansion of adaptive measures reported in our survey may explain these encouraging findings, our study also underscores the need for ongoing monitoring of service disruptions, as well as research to identify capacity and services—from integrated laboratory systems and telemedicine infrastructure to supply chains and community support groups—that need rebuilding and strengthening in the wake of the pandemic. Further research within and across countries is needed to assess the impact of the pandemic on clinical and programmatic outcomes among people living with and at risk for HIV and to examine the role of site-level adaptive measures, such as the use of telemedicine, multi-month dispensing of ART medications or the establishment of community-based ART pick-up points, in averting treatment interruptions and ensuring the provision of person-centred HIV care.

## 5 | CONCLUSIONS

While the first year of the COVID-19 pandemic resulted in widespread HIV service delivery disruptions, many leDEA sites in high HIV prevalence and low-resource settings introduced or expanded measures to minimize treatment interruption and care disengagement. Disruptions in VL testing and ART supplies in these settings raise concerns about the ongoing consequences of the pandemic on the availability, quality and comprehensiveness of HIV care.

## AUTHORS' AFFILIATIONS

¹Institute for Implementation Science in Population Health, City University of New York, New York, New York, USA; ²Graduate School of Public Health and Health Policy, City University of New York, New York, New York, USA; ³Clinical Research Education Networking and Consultancy, Yaoundé, Cameroon; ⁴Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA; ⁵Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA; ⁶Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA; ⁷Queen Elizabeth Hospital, Hong Kong, China; ⁸Newlands Clinic, Harare, Zimbabwe; ⁹Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland; ¹⁰Departamento de Infectología, Instituto Nacional de Ciencias Médicas y Nutrición, Mexico City, Mexico; ¹¹Centre National Hospitalier, Universitaire Hubert K. Maga, Cotonou, Benin; ¹²VHS Infectious Diseases Medical Centre, Voluntary Health Services, Chennai, India; ¹³Centre National de Reference en Matière de VIH/SIDA, Bujumbura, Burundi; ¹⁴Laboratory of Clinical Research in STD/AIDS (LAPCLIN-AIDS), Evandro Chagas National Institute of Infectious Diseases-Oswaldo Cruz Foundation (INI/FIOCRUZ), Rio de Janeiro, Brazil; ¹⁵Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa; ¹⁶ACONDA - Centre de Prise en Charge, de Recherche et de Formation (CePrEF), Abidjan, Côte d'Ivoire; ¹⁷Mbarara University of Science and Technology, Mbarara, Uganda; ¹⁸Department of Biomedical Informatics, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee, USA; ¹⁹Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee, USA
likely to report suspending HIV services and appointments, other care-seeking barriers (e.g. lockdown restrictions, transportation and financial barriers, and concerns about COVID-19 exposure) may have presented insurmountable obstacles for patients in these settings, and early data from diverse settings have highlighted sharp decreases in healthcare-seeking for HIV-related services early in the pandemic, including HIV prevention [49, 53], diagnosis [24, 41, 42, 44-48, 53-55] and treatment [24, 43, 44, 53, 55, 56], as well as diagnostics and treatment for other infectious diseases and chronic conditions [55-58]. While some studies in sub-Saharan Africa have reported rebounds in HIV testing and ART initiation [24, 59], our findings related to stockouts of second- and third-line ART regimens in high-prevalence and low/lower-income settings are concerning, as the lack of such essential medicines may result in setbacks for both HIV treatment and prevention.

Given the importance of VL monitoring for detecting therapeutic failure and ensuring timely adherence support and regimen switching for the health of the individual with HIV and the reduced likelihood of transmission [60], disruptions in HIV VL testing services are of concern. Ranging from stockouts of essential supplies to suspension of VL testing services, laboratories not accepting HIV VL samples and longer turnaround times for results, such disruptions may reflect supply chain problems [2, 3, 61-63], as well as the reallocation of resources from HIV programmes to the COVID-19 response [57, 58, 63, 64]. While these disruptions were reported across all settings, they are of particular concern in settings with high HIV prevalence and in low/lower-income countries, given that the turnaround time for VL test results was already markedly longer in these settings before the pandemic. These gaps underscore the need for investment in integrated laboratory systems to increase access to critical diagnostics without having one infectious disease displace others [58, 63].

Our study had several limitations. Firstly, as the COVID-19 pandemic catalyzed the adoption of new service delivery strategies that were not explored in prior leDEA surveys, it is difficult to quantify the magnitude of some changes reported by respondents. Secondly, sites participating in leDEA may not be representative of HIV service delivery within a country or region, and in some settings, leDEA sites may be better resourced than many other HIV care and treatment sites, meaning that the pandemic's impact on HIV care could be underestimated in our survey. Accordingly, our findings may not be generalizable to all HIV clinical care settings in countries with low-, medium- and high-HIV prevalence or within country income groups. In addition, because disruptions to supply chains may have persisted or worsened after the end of the first year of the pandemic when our survey was conducted, the consequences for ART services and laboratory monitoring may not be fully captured. Finally, leDEA's global site assessment surveys rely on self-report by survey respondents, which may have introduced both selection and recall biases. While the high response and survey completion rate may help mitigate these biases, it should be noted that the survey was implemented during a period when healthcare systems and providers were at different phases of the pandemic response and when many changes in practice were being introduced to mitigate pandemic-related risks and burdens.

Providing early data on how COVID-19 has affected the availability of HIV services across a geographically diverse group of HIV care and treatment sites, our study complements other recent studies exploring the pandemic's impact on HIV testing, ART initiation, routine visits for HIV treatment, VL monitoring and viral suppression [24, 25, 59]—studies that found minimal changes in routine HIV care-seeking during 2020, along with rebounds following initial decreases in HIV testing and ART initiation. While the expansion of adaptive measures reported in our survey may explain these encouraging findings, our study also underscores the need for ongoing monitoring of service disruptions, as well as research to identify capacity and services—from integrated laboratory systems and telemedicine infrastructure to supply chains and community support groups—that need rebuilding and strengthening in the wake of the pandemic. Further research within and across countries is needed to assess the impact of the pandemic on clinical and programmatic outcomes among people living with and at risk for HIV and to examine the role of site-level adaptive measures, such as the use of telemedicine, multi-month dispensing of ART medications or the establishment of community-based ART pick-up points, in averting treatment interruptions and ensuring the provision of person-centred HIV care.

## 5 | CONCLUSIONS

While the first year of the COVID-19 pandemic resulted in widespread HIV service delivery disruptions, many leDEA sites in high HIV prevalence and low-resource settings introduced or expanded measures to minimize treatment interruption and care disengagement. Disruptions in VL testing and ART supplies in these settings raise concerns about the ongoing consequences of the pandemic on the availability, quality and comprehensiveness of HIV care.

## AUTHORS' AFFILIATIONS

¹Institute for Implementation Science in Population Health, City University of New York, New York, New York, USA; ²Graduate School of Public Health and Health Policy, City University of New York, New York, New York, USA; ³Clinical Research Education Networking and Consultancy, Yaoundé, Cameroon; ⁴Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA; ⁵Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA; ⁶Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA; ⁷Queen Elizabeth Hospital, Hong Kong, China; ⁸Newlands Clinic, Harare, Zimbabwe; ⁹Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland; ¹⁰Departamento de Infectología, Instituto Nacional de Ciencias Médicas y Nutrición, Mexico City, Mexico; ¹¹Centre National Hospitalier, Universitaire Hubert K. Maga, Cotonou, Benin; ¹²VHS Infectious Diseases Medical Centre, Voluntary Health Services, Chennai, India; ¹³Centre National de Reference en Matière de VIH/SIDA, Bujumbura, Burundi; ¹⁴Laboratory of Clinical Research in STD/AIDS (LAPCLIN-AIDS), Evandro Chagas National Institute of Infectious Diseases-Oswaldo Cruz Foundation (INI/FIOCRUZ), Rio de Janeiro, Brazil; ¹⁵Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa; ¹⁶ACONDA - Centre de Prise en Charge, de Recherche et de Formation (CePrEF), Abidjan, Côte d'Ivoire; ¹⁷Mbarara University of Science and Technology, Mbarara, Uganda; ¹⁸Department of Biomedical Informatics, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee, USA; ¹⁹Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee, USA
## COMPETING INTERESTS

KN Althoff is a consultant to the All of Us Research Program and TrioHealth, Inc. D Nash reports a research grant from Pfizer to assess the effect of COVID-19 vaccination on long-haul COVID. All authors have no competing interests.

## AUTHORS' CONTRIBUTIONS

EB, RA, DN, BM, FM, SND and CWW conceptualized the study and designed survey questions. FM coordinated data collection. EB performed the data analysis and drafted the manuscript. All authors participated in the interpretation of the results, revision of the manuscript, and have read and approved the final manuscript.

## ACKNOWLEDGEMENTS

The authors would like to thank Annette Sohn for her suggestions on a draft of this manuscript, along with investigators, clinicians and data managers at sites participating in the 2020 leDEA-wide site assessment survey; regional data centres; and members of the leDEA Site Assessment Working Group. A complete list of acknowledgements can be found in the Supporting Information.

## DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request. Individuals who wish to request access to data from the leDEA consortium for research purposes may submit a concept proposal, which is detailed at https://www.iedea.org/.

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3. Tirivangani T, Alpo B, Kibuule D, Gaeseb J, Adenuga BA. Impact of COVID-19 pandemic on pharmaceutical systems and supply chain - a phenomenological study. Explor Res Clin Soc Pharm. 2021;2:100037.

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5. Chutiyami M, Bello UM, Salihu D, Ndwiga D, Kolo MA, Maharaj R, et al. COVID-19 pandemic-related mortality, infection, symptoms, complications, comorbidities, and other aspects of physical health among healthcare workers globally: an umbrella review. Int J Nurs Stud. 2022;129:104211.

6. Gómez-Ochoa SA, Franco OH, Rojas LZ, Raguindin PF, Roa-Díaz ZM, Wyssmann BM, et al. COVID-19 in health-care workers: a living systematic review and meta-analysis of prevalence, risk factors, clinical characteristics, and outcomes. Am J Epidemiol. 2021;190(1):161-75.

7. Sands P. HIV, tuberculosis, and malaria: how can the impact of COVID-19 be minimised? Lancet Glob Health. 2020;8(9):e1102-3.

8. Guaraldi G, Milic J, Martinez E, Kamarulzaman A, Mussini C, Waters L, et al. HIV care models during the COVID-19 era. Clin Infect Dis. 2020;73(1):e1222-7. https://doi.org/10.1093/cid/ciaa1864

9. World Health Organization. The cost of inaction: COVID-19-related service disruptions could cause hundreds of thousands of extra deaths from HIV 2020 [cited April 27, 2021]. Available from: https://www.who.int/news/item/11-05-2020-the-cost-of-inaction-covid-19-related-service-disruptions-could-cause-hundreds-of-thousands-of-extra-deaths-from-hiv

10. Jewell BL, Mudimu E, Stover J, ten Brink D, Phillips AN, Smith JA, et al. Potential effects of disruption to HIV programmes in sub-Saharan Africa caused by COVID-19: results from multiple mathematical models. Lancet HIV. 2020;7(9):e629-40.

11. Stover J, Glaubius R, Teng Y, Kelly S, Brown T, Hallett TB, et al. Modeling the epidemiological impact of the UNAIDS 2025 targets to end AIDS as a public health threat by 2030. PLoS Med. 2021;18(10):e1003831.

12. Hogan AB, Jewell BL, Sherrard-Smith E, Vesga JF, Watson OJ, Whittaker C, et al. Potential impact of the COVID-19 pandemic on HIV, tuberculosis, and malaria in low-income and middle-income countries: a modelling study. Lancet Glob Health. 2020;8(9):e1132-41.

13. Flanagan CF, McCann N, Stover J, Freedberg KA, Ciaranello AL. Do not forget the children: a model-based analysis on the potential impact of COVID-19-associated interruptions in paediatric HIV prevention and care. J Int AIDS Soc. 2022;25(1):e25864.

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## COMPETING INTERESTS

KN Althoff is a consultant to the All of Us Research Program and TrioHealth, Inc. D Nash reports a research grant from Pfizer to assess the effect of COVID-19 vaccination on long-haul COVID. All authors have no competing interests.

## AUTHORS' CONTRIBUTIONS

EB, RA, DN, BM, FM, SND and CWW conceptualized the study and designed survey questions. FM coordinated data collection. EB performed the data analysis and drafted the manuscript. All authors participated in the interpretation of the results, revision of the manuscript, and have read and approved the final manuscript.

## ACKNOWLEDGEMENTS

The authors would like to thank Annette Sohn for her suggestions on a draft of this manuscript, along with investigators, clinicians and data managers at sites participating in the 2020 leDEA-wide site assessment survey; regional data centres; and members of the leDEA Site Assessment Working Group. A complete list of acknowledgements can be found in the Supporting Information.

## DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request. Individuals who wish to request access to data from the leDEA consortium for research purposes may submit a concept proposal, which is detailed at https://www.iedea.org/.

## REFERENCES

1. Kaczorowski J, Del Grande C. Beyond the tip of the iceberg: direct and indirect effects of COVID-19. Lancet Digit Health. 2021;3(4):e205-6.

2. Gizaw T, Jemal A, Gudeta T. Tracer pharmaceuticals availability and distribution trends prior to and during the Covid-19 pandemic: a comparative study. J Multidiscip Healthc. 2022;15:93-102.

3. Tirivangani T, Alpo B, Kibuule D, Gaeseb J, Adenuga BA. Impact of COVID-19 pandemic on pharmaceutical systems and supply chain - a phenomenological study. Explor Res Clin Soc Pharm. 2021;2:100037.

4. Sahu AK, Amrithanand VT, Mathew R, Aggarwal P, Nayer J, Bhoi S. COVID-19 in health care workers - a systematic review and meta-analysis. Am J Emerg Med. 2020;38(9):1727-31.

5. Chutiyami M, Bello UM, Salihu D, Ndwiga D, Kolo MA, Maharaj R, et al. COVID-19 pandemic-related mortality, infection, symptoms, complications, comorbidities, and other aspects of physical health among healthcare workers globally: an umbrella review. Int J Nurs Stud. 2022;129:104211.

6. Gómez-Ochoa SA, Franco OH, Rojas LZ, Raguindin PF, Roa-Díaz ZM, Wyssmann BM, et al. COVID-19 in health-care workers: a living systematic review and meta-analysis of prevalence, risk factors, clinical characteristics, and outcomes. Am J Epidemiol. 2021;190(1):161-75.

7. Sands P. HIV, tuberculosis, and malaria: how can the impact of COVID-19 be minimised? Lancet Glob Health. 2020;8(9):e1102-3.

8. Guaraldi G, Milic J, Martinez E, Kamarulzaman A, Mussini C, Waters L, et al. HIV care models during the COVID-19 era. Clin Infect Dis. 2020;73(1):e1222-7. https://doi.org/10.1093/cid/ciaa1864

9. World Health Organization. The cost of inaction: COVID-19-related service disruptions could cause hundreds of thousands of extra deaths from HIV 2020 [cited April 27, 2021]. Available from: https://www.who.int/news/item/11-05-2020-the-cost-of-inaction-covid-19-related-service-disruptions-could-cause-hundreds-of-thousands-of-extra-deaths-from-hiv

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55. Adugna A, Azanaw J, Sharew Melaku M. The effect of COVID-19 on routine HIV care services from health facilities in Northwest Ethiopia. HIV AIDS. 2021;13:1159-68.

56. de Lazzari E, Martínez-Mimbrero A, Chivite I, González-Cordón A, Mosquera MM, Laguno M, et al. Impact of COVID-19 epidemics on prevention and care for HIV and other sexually transmitted infections. AIDS. 2022;36(6):829-38.

57. Caren GJ, Iskandar D, Pitaloka DAE, Abdulah R, Suwantika AA. COVID-19 pandemic disruption on the management of tuberculosis treatment in Indonesia. J Multidiscip Healthc. 2022;15:175-83.

58. Nyaruhirira AU, Scholten JN, Gidado M, Suarez PG. COVID-19 diagnosis in low- and middle-income countries: the big new bully disrupting TB and HIV diagnostic services. J Mol Diagn. 2022;24(4):289-93.

59. Harris TG, Jaszi E, Lamb MR, Laudari CA, Furtado MLM, Nijirazana B, et al. Effects of the coronavirus disease 2019 pandemic on human immunodeficiency virus services: findings from 11 sub-Saharan African countries. Clin Infect Dis. 2021;75(1):e1046-53.

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61. Uwishema O, Taylor C, Lawal L, Hamidah N, Robert I, Nasir A, et al. The syndemic burden of HIV/AIDS in Africa amidst the COVID-19 pandemic. Immun Inflamm Dis. 2022;10(1):26-32.

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63. Karim Q, Karim S. COVID-19 affects HIV and tuberculosis care. Science. 2020;369(6502):366-8.

64. Karim Q, Baxter C. COVID-19: impact on the HIV and tuberculosis response, service delivery, and research in South Africa. Curr HIV/AIDS Rep. 2022.

## SUPPORTING INFORMATION

Additional information may be found under the Supporting Information tab for this article:

**Supporting Information:** Acknowledgments and members of the International epidemiology Databases to Evaluate AIDS.
36. The World Bank. World Bank country and lending groups, World Bank analytical classifications. World Bank; 2021.

37. Institute for Health Metrics and Evaluation. Prevalence - HIV/AIDS — sex: both — age: 15–49 years (percent) — 1997–2017 our world in data [cited September 24, 2021]. Available from: https://ourworldindata.org/grapher/share-of-population-infected-with-hiv-ihme

38. National AIDS Control Organization & ICMR-National Institute of Medical Statistics. India HIV Estimates 2019. New Delhi: Ministry of Health and Family Welfare, Government of India; 2020.

39. Korea Centers for Disease Control and Prevention. Annual Report on the Notified HIV/AIDS in Korea: 2019. Seoul; 2020.

40. Government of Canada. Estimates of HIV incidence, prevalence and Canada's progress on meeting the 90-90-90 HIV targets. 2021.

41. El Moussaoui M, Lambert N, Maes N, Fombellida K, Vaira D, Moutschen M, et al. Impact of the COVID-19 pandemic situation on HIV care in Liège, Belgium. *HIV Res Clin Pract.* 2021;22(3):63-70.

42. Shi L, Tang W, Hu H, Qiu T, Marley G, Liu X, et al. The impact of COVID-19 pandemic on HIV care continuum in Jiangsu, China. BMC Infect Dis. 2021;21(1):768.

43. Chilot D, Woldeamanuel Y, Manyazewal T. COVID-19 burden on HIV patients attending antiretroviral therapy in Addis Ababa, Ethiopia: a multicenter cross-sectional study. Res Sq. 2021.

44. Desta AA, Woldearegay TW, Gebremeskel E, Alemayehu M, Getachew T, Gebregzabiher G, et al. Impacts of COVID-19 on essential health services in Tigray, Northern Ethiopia: a pre-post study. PLoS One. 2021;16(8):e0256330.

45. Maurya SP, Sharma A, Singh R, Gautam H, Das BK. HIV testing & diagnosis in 2020 at the apex tertiary referral hospital of India: impact of COVID-19 pandemic. AIDS Care. 2021.

46. Quiros-Roldan E, Izzo I, Carriero C, Degli Antoni M, Storti S, Tiecco G, et al. Decrease in new diagnosis of HIV/AIDS in the two years period 2019–2020: impact of COVID-19 pandemic. J Public Health Res. 2021;11(1):2256.

47. Rick F, Odoke W, van den Hombergh J, Benzaken AS, Avelino-Silva VI. Impact of coronavirus disease (COVID-19) on HIV testing and care provision across four continents. HIV Med. 2021.

48. Wenlock RD, Shillingford C, Mear J, Churchill D, Vera JH, Dean G. The impact of COVID-19 on HIV testing in the UK's first Fast-Track HIV city. HIV Med. 2022;23(7):790-6.

49. Huang YA, Zhu W, Wiener J, Kourtis AP, Hall HI, Hoover KW. Impact of COVID-19 on HIV preexposure prophylaxis prescriptions in the United States - a time series analysis. Clin Infect Dis. 2022;75(1):e1020-7.

50. Joint United Nations Programme on HIV/AIDS (UNAIDS). Fast-Track: ending the AIDS epidemic by 2030. Geneva; 2014.

51. Grimsrud A, Wilkinson L. Acceleration of differentiated service delivery for HIV treatment in sub-Saharan Africa during COVID-19. J Int AIDS Soc. 2021;24(6):e25704.

52. Garg S, Gangadharan N, Bhatnagar N, Singh MM, Raina SK, Galwankar S. Telemedicine: embracing virtual care during COVID-19 pandemic. J Family Med Prim Care. 2020;9(9):4516-20.

53. Lee JA, Kim Y, Choi JY. Impact of the COVID-19 pandemic on HIV services in Korea: results from a cross-sectional online survey. Infect Chemother. 2021;53(4):741-52.

54. Magnani RJ, Wirawan DN, Sawitri AAS, Mahendra I, Susanti D, Utami Ds N, et al. The short-term effects of COVID-19 on HIV and AIDS control efforts among female sex workers in Indonesia. BMC Womens Health. 2022;22(1):21.

55. Adugna A, Azanaw J, Sharew Melaku M. The effect of COVID-19 on routine HIV care services from health facilities in Northwest Ethiopia. HIV AIDS. 2021;13:1159-68.

56. de Lazzari E, Martínez-Mimbrero A, Chivite I, González-Cordón A, Mosquera MM, Laguno M, et al. Impact of COVID-19 epidemics on prevention and care for HIV and other sexually transmitted infections. AIDS. 2022;36(6):829-38.

57. Caren GJ, Iskandar D, Pitaloka DAE, Abdulah R, Suwantika AA. COVID-19 pandemic disruption on the management of tuberculosis treatment in Indonesia. J Multidiscip Healthc. 2022;15:175-83.

58. Nyaruhirira AU, Scholten JN, Gidado M, Suarez PG. COVID-19 diagnosis in low- and middle-income countries: the big new bully disrupting TB and HIV diagnostic services. J Mol Diagn. 2022;24(4):289-93.

59. Harris TG, Jaszi E, Lamb MR, Laudari CA, Furtado MLM, Nijirazana B, et al. Effects of the coronavirus disease 2019 pandemic on human immunodeficiency virus services: findings from 11 sub-Saharan African countries. Clin Infect Dis. 2021;75(1):e1046-53.

60. World Health Organization. Guidelines: updated recommendations on HIV prevention, infant diagnosis, antiretroviral initiation and monitoring. 2021.

61. Uwishema O, Taylor C, Lawal L, Hamidah N, Robert I, Nasir A, et al. The syndemic burden of HIV/AIDS in Africa amidst the COVID-19 pandemic. Immun Inflamm Dis. 2022;10(1):26-32.

62. Nachega JB, Kapata N, Sam-Agudu NA, Decloedt EH, Katoto P, Nagu T, et al. Minimizing the impact of the triple burden of COVID-19, tuberculosis and HIV on health services in sub-Saharan Africa. Int J Infect Dis. 2021;113(Suppl 1):S16-21.

63. Karim Q, Karim S. COVID-19 affects HIV and tuberculosis care. Science. 2020;369(6502):366-8.

64. Karim Q, Baxter C. COVID-19: impact on the HIV and tuberculosis response, service delivery, and research in South Africa. Curr HIV/AIDS Rep. 2022.

## SUPPORTING INFORMATION

Additional information may be found under the Supporting Information tab for this article:

**Supporting Information:** Acknowledgments and members of the International epidemiology Databases to Evaluate AIDS.