supply chain, community and data reporting systems can play an important role in mitigating the 23 impact of COVID-19 in sub-Saharan Africa. 24 25 Conclusions: As community transmission of COVID-19 continues and the number of country cases 26 rise, fragile health systems may be strained. Utilizing the adaptive, data-driven program approaches 27 in facilities and communities established and supported by PEPFAR provides the opportunity to 28 strengthen the COVID-19 response while protecting the immense gains spanning HIV prevention, 29 testing and treatment reached thus far. 31 Less than three months from the first reported cases of COVID-19 in China, the pandemic reached 32 Nigeria, the first sub-Saharan African country to report a confirmed case of COVID-19, at the end of 33 February 2020 [1] . COVID-19 response plans were rapidly developed and instituted as governments 34 and donor organizations braced themselves for the impact of COVID-19 in low-and middle-income 35 countries with high burdens of people living with HIV (PLHIV) [2, 3] . 36 Despite sweeping measures to mitigate COVID-19 transmission, as of 1 July 2020, 303,986 37 confirmed cases, and 6,155 deaths were reported across the World Health Organization's African 38 Region Member States [4] , including 11 countries with a >5% adult HIV prevalence [5] . Information 39 about the impact of HIV co-infection on COVID-19 transmission, morbidity and mortality is limited. inadequate [11] .The potential negative impact of COVID-19 in these countries is currently uncertain, 48 but COVID-19 is anticipated to contribute both directly and indirectly to the morbidity and mortality 49 of PLHIV, requiring countries to leverage existing resources and infrastructure to propel COVID-19 50 responses while protecting PLHIV and HIV program gains.
Although it is unclear whether PLHIV have increased risk of SARS-CoV-2 acquisition or progression 54 to severe disease [12] [15, 16] . Health systems strengthening efforts of large, successful public health programs 67 such as PEPFAR have been predominantly focused on outpatients, and significant gaps in critical care 68 capacity persist in low-and-middle income countries [17] .
Of further concern, laboratory instruments, supplies and staff needed for HIV viral load (VL) 70 monitoring, early infant HIV diagnosis (EID), and tuberculosis testing may be diverted to SARS-
CoV-2 testing. The net result will be a dangerous inability to meet the prevention, testing, and 72 treatment needs for either HIV or COVID-19. In the West Africa experience with Ebola, modeling 73 suggests more deaths were attributed to disruptions in HIV, TB, and malaria services than directly to 74 Ebola infection [18] . 75 As in the West African Ebola outbreak [18] , fears of healthcare-associated transmission may 76 exacerbate healthcare worker shortages and discourage people from seeking crucial HIV services at 77 facilities. Additionally, healthcare workers have been disproportionately impacted by COVID-19 due 78 to insufficient quantities of personal protective equipment and resulting exposure [19] . COVID-19 79 mitigation strategies are limiting importation and distribution of critical health commodities required 80 for essential HIV services [20] . Furthermore, concerns have been raised that COVID-19 plans will 81 divert resources from HIV, TB, and malaria programs [21] . 83 In anticipation of these disruptions, PEPFAR established guidance to rapidly adapt HIV programs to 84 maintain essential HIV services while protecting recipients of care and staff from COVID-19. The 85 general principles prioritize protecting recent gains in the HIV response while minimizing exposure to 86 COVID-19 at healthcare facilities and reducing the burden on these facilities [22] [23] [24] . Congruent to 87 recent advocacy by the International AIDS Society [25] , there is special emphasis on continuity of reported increases in domestic violence [26] and can increase child protection risks [27] . Orphans, 98 vulnerable children, adolescent girls, and young women (AGYW) have been prioritized to receive 99 virtual risk screening and linkage to essential services, including referrals if at risk for or experiencing 100 abuse, neglect, or violence. Specific guidance has been provided on how to deliver virtual support to 101 beneficiaries of PEPFAR's Determined, Resilient, Empowered, Mentored, and Safe (DREAMS) 102 program for AGYW [28] . In response to reduced access to facility-based services, strategic adaptions to testing services include 126 leveraging private public partnerships and community platforms for distribution of HIV self-testing 127 kits in accordance with national guidance. Decentralized distribution of HIV self-testing kits has 128 provided a valuable platform to broaden COVID-19 health messaging, screening, and contact tracing.
HIV self-testing is also being leveraged to assist with index testing, especially in settings where active In response to ongoing concern over the unknown economic impact of COVID-19 among vulnerable Aligned with host countries' needs, PEPFAR's current human resources for health (HRH) strategy utilization, investing in HRH retention, service quality improvements, and sustainable financing for 216 healthcare workers who deliver HIV services [29] . PEPFAR has supported nearly 300,000 healthcare 217 workers at more than 3,000 laboratories and 70,000 health facilities [30] . PEPFAR-supported health 218 workers, lab personnel, supply chain advisors, and policy makers have equipped countries to be able 219 to respond to HIV and emerging infectious diseases such as COVID-19. The COVID-19 pandemic 220 has required mobility and flexibility in service delivery teams, with task sharing and redeployment in 