How COVID-19 could benefit tuberculosis and HIV services in South Africa
Authors: Claire Keene, Erika Mohr-Holland, Tali Cassidy, Vera Scott, Aurelie Nelson, Jennifer Furin, Laura Triviño-Duran
Journal: The Lancet Respiratory Medicine (2020)

At the time of writing, more than 17 million people have contracted COVID-19 globally and more than half a million have died.1Johns Hopkins University & MedicineCOVID-19 dashboard.https://coronavirus.jhu.edu/map.htmlDate accessed: July 29, 2020Google Scholar However, the health impact of COVID-19 is likely to be far more substantial and long-lasting in countries with high incidences of tuberculosis and HIV2Drain P Garrett N SARS-CoV-2 pandemic expanding in sub-Saharan Africa: considerations for Covid-19 in people living with HIV.EClinicalMedicine. 2020; (published online April 22.)https://doi.org/10.1016/j.eclinm.2020.100342Summary Full Text Full Text PDF PubMed Scopus (31) Google Scholar than in those with low incidences. Tuberculosis and HIV each have more than double the mortality rate of COVID-19, as shown in the Western Cape, South Africa.3Davies M-A Western Cape: COVID-19 and HIV / Tuberculosis. Presentation at the Bhekesisa Health Forum.https://bhekisisa.org/multimedia/2020-06-09-standing-by-when-epidemics-collide-does-hiv-tb-cause-worse-covid-19/Date: June 9, 2020Date accessed: June 13, 2020Google Scholar The biological interactions between tuberculosis, HIV, and COVID-19, as well as health system factors contribute to the impact of COVID-19 on vulnerable populations. Modelling data show that COVID-19 could trigger an excess of 6 million tuberculosis deaths by 2025, with decreased diagnosis, treatment initiation, and successful treatment completion.4Stop TB PartnershipThe potential impact of the COVID-19 response on tuberculosis in high-burden countries: a modelling analysis.http://www.stoptb.org/assets/documents/news/Modeling%20Report_1%20May%202020_FINAL.pdfDate: May 20, 2020Date accessed: June 13, 2020Google Scholar Similarly, a 6-month disruption in antiretroviral therapy (ART) delivery for HIV could result in up to half a million additional deaths, double mother-to-child transmission in sub-Saharan Africa over one year, and increase mortality by up to 40% over the next 5 years.5Jewell BL Mudimu E Stover J Kelly SL Phillips A Potential effects of disruption to HIV programmes in sub-Saharan Africa caused by COVID-19: results from multiple mathematical models.FigShare. 2020; (published online May 11.) (preprint)https://doi.org/10.6084/M9.FIGSHARE.12279914.V1Google Scholar In addition, disrupted drug supplies could lead to drug resistance, amplifying the costs of managing these entrenched epidemics. Although modelling has limitations, COVID-19 will no doubt have a lasting negative impact on both diseases. South Africa has had remarkable successes in the management of HIV and tuberculosis in the past 10 years,6Reniers G Blom S Calvert C et al.Trends in the burden of HIV mortality after roll-out of antiretroviral therapy in KwaZulu-Natal, South Africa: an observational community cohort study.Lancet HIV. 2017; 4: e113-e121Summary Full Text Full Text PDF PubMed Scopus (46) Google Scholar but these gains are threatened by COVID-19. Médecins Sans Frontières has collaborated with the South African Department of Health for two decades to support community-based, differentiated HIV and drug-resistant tuberculosis service delivery in the periurban township of Khayelitsha in the Western Cape, South Africa.7Cox H Hughes J Daniels J et al.Community-based treatment of drug-resistant tuberculosis in Khayelitsha, South Africa.Int J Tuberc Lung Dis. 2014; 18: 441-448Crossref PubMed Scopus (85) Google Scholar, 8Bemelmans M Baert S Goemaere E et al.Community-supported models of care for people on HIV treatment in sub-Saharan Africa.Trop Med Int Health. 2014; 19: 968-977Crossref PubMed Scopus (145) Google Scholar Khayelitsha now has one of the highest burdens of COVID-19 in the Western Cape, which in turn accounts for more than half South Africa's known cases.9Department of Health, South AfricaUpdate on COVID-19.https://sacoronavirus.co.za/2020/06/17/update-on-covid-19-17th-june-2020/Date: June 17, 2020Date accessed: June 18, 2020Google Scholar Although routine activities have required adaptation during the COVID-19 pandemic, disruptions caused by the emergency response highlight potentially unnecessary health system interactions between people with tuberculosis and people with HIV, including facility-based counselling, long clinic waiting times to receive medications, and frequent follow-up, even for patients who are clinically well. This situation presents an opportunity for positive, long-term, systematic change to transform inefficient, paternalistic policies and practices. For example, clinical or counselling consultations over the telephone support patients (particularly those initiating treatment or re-engaging with services) while reducing contact for both the health-care providers and recipients. The need to reduce clinic attendance to shield the vulnerable and reduce exposure to health-care workers is also an opportunity to build home-based care, strengthen community and self-administered tuberculosis therapy, further decentralise medication pick-up, and extend ART and pre-exposure prophylaxis medication refills. Interventions developed specifically for COVID-19 could also enhance tuberculosis and HIV services. For example, community networks developed for COVID-19 screening could be repurposed to support tuberculosis and HIV: to expand tuberculosis screening and HIV self-testing, identify individuals who need additional support (eg, social grants), and link new cases or patients lost to follow-up to care. Stigma reduction campaigns for COVID-19 could also embrace positive messages about HIV and tuberculosis. Conversely, the COVID-19 pandemic has exposed systemic weaknesses, such as reduced medication supply and staff shortages, which will require dedicated health system strengthening and substantial investments to correct. South Africa has a 60 000 strong cadre of community health workers but attempts to build on their community knowledge and access for contact tracing have revealed the poor integration of these workers into the health system—highlighted, for example, by their difficulty in accessing personal protective equipment and training. COVID-19 has also publicised the extreme economic vulnerability of individuals living with tuberculosis and HIV, and a commitment to mitigating the socioeconomic drivers and effects of both diseases must be maintained in the years to come.10Dheda K Gumbo T Maartens G et al.The Lancet Respiratory Medicine Commission: 2019 update: epidemiology, pathogenesis, transmission, diagnosis, and management of multidrug-resistant and incurable tuberculosis.Lancet Respir Med. 2019; 7: 820-826Summary Full Text Full Text PDF PubMed Scopus (91) Google Scholar The panel shows a summary of the potential collateral benefits from the COVID-19 pandemic to tuberculosis and HIV services.PanelStrategies to decrease the impact of COVID-19 on tuberculosis and HIVExisting interventions to scale up nationally or internationallyTuberculosis•Alternatives to directly observed therapy, such as self-administered therapy, improved treatment literacy•Community-based treatment initiation for all populations•Expanded use of all-oral, shorter regimens•Scaling up adapted, individualised counselling•Integrated tuberculosis and COVID-19 screening and testingHIV•Differentiated models of care for stable HIV•Extended multimonth antiretroviral therapy (ART) refills (more than 6 months) for stable patients•Community-based initiation and delivery of ART•Integrated HIV and COVID-19 testingAdapted and expanded modelsTuberculosis•Home-based care•Medical triage by telephone and individualised counselling and support (for substance use and for people who are not managing well on treatment)•Home-delivery of medication supplies to patients, as with other chronic diseasesHIV•Medical triage by telephone and individualised counselling and support, especially for those disengaged from care•Home delivery of chronic medication for stable patients•Longer refills (more than 2 months) for patients restarting treatment•Home-based care for patients with advanced HIVNew opportunities for using COVID-19 interventions for tuberculosis and HIVTuberculosis•Trained and paid community health workers to do active case finding, contact assessments, postexposure management, linkage to care for newly identified cases and those who have been lost to follow-up•Incorporate tuberculosis into COVID-19 stigma reduction messagesHIV•Trained and paid community health workers to support self-testing, provision of pre-exposure prophylaxis with nursing support, linkage to care for newly identified cases and those who have been lost to follow-up•Incorporate HIV into COVID-19 stigma reduction messagesInvestment and systematic changes needed•Address precarious socioeconomic circumstances•Strengthen health system to improve staffing and reduce stock-outs•Integrate tuberculosis, HIV, and chronic health services Existing interventions to scale up nationally or internationally Tuberculosis •Alternatives to directly observed therapy, such as self-administered therapy, improved treatment literacy•Community-based treatment initiation for all populations•Expanded use of all-oral, shorter regimens•Scaling up adapted, individualised counselling•Integrated tuberculosis and COVID-19 screening and testing HIV •Differentiated models of care for stable HIV•Extended multimonth antiretroviral therapy (ART) refills (more than 6 months) for stable patients•Community-based initiation and delivery of ART•Integrated HIV and COVID-19 testing Adapted and expanded models Tuberculosis •Home-based care•Medical triage by telephone and individualised counselling and support (for substance use and for people who are not managing well on treatment)•Home-delivery of medication supplies to patients, as with other chronic diseases HIV •Medical triage by telephone and individualised counselling and support, especially for those disengaged from care•Home delivery of chronic medication for stable patients•Longer refills (more than 2 months) for patients restarting treatment•Home-based care for patients with advanced HIV New opportunities for using COVID-19 interventions for tuberculosis and HIV Tuberculosis •Trained and paid community health workers to do active case finding, contact assessments, postexposure management, linkage to care for newly identified cases and those who have been lost to follow-up•Incorporate tuberculosis into COVID-19 stigma reduction messages HIV •Trained and paid community health workers to support self-testing, provision of pre-exposure prophylaxis with nursing support, linkage to care for newly identified cases and those who have been lost to follow-up•Incorporate HIV into COVID-19 stigma reduction messages Investment and systematic changes needed •Address precarious socioeconomic circumstances•Strengthen health system to improve staffing and reduce stock-outs•Integrate tuberculosis, HIV, and chronic health services South Africa is valiantly fighting COVID-19; the national response to the pandemic has gained unprecedented political support and mobilised resources that would have been unimaginable a year ago. There has been a massive refocusing of the political agenda on health and the opportunity—yet to be fully realised—to address the underlying social determinants that increase communities' vulnerability and result in differentiated mortality outcomes. The increased solidarity creates the opportunity for broader public participation and for addressing health as a public good, not just for COVID-19 but also for the other major health problems in the country, including HIV and tuberculosis. Though devastating, COVID-19 has offered the opportunity for true service delivery transformation that could result in lasting benefits when it comes to care for people with HIV and tuberculosis. We declare no competing interests.