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AIDS, TB And Malaria Set To Get Deadlier Due To Coronavirus

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The ‘Big Three’ are predicted to get bigger. AIDS, TB and malaria are predicted to kill many more in the coming months and years. COVID-19 could potentially double the number of malaria deaths in sub-Saharan Africa in 2020 when compared with 2018. The world could see an additional 6.3 million cases of TB between 2020 and 2025 and an additional 1.4 million TB deaths during that same period. A six-month disruption of antiretroviral (ARV) therapy could lead to more than 500 000 extra deaths from AIDS-related illnesses in sub-Saharan Africa in 2020–2021. These are projections from three mathematical models published recently.

When the coronavirus pandemic exploded in many European countries in March, experts fighting older epidemics like tuberculosis (TB), AIDS, and malaria were watching with growing anxiety. They knew coronavirus will eventually hit low- and middle-income countries (LMIC) hard, where these infections were preeminent, preexisting killers. Their worst fears (and mine) are turning out to be true.

Investigative reports from many countries show severe disruption of routine healthcare services in many countries due to lockdowns imposed, diversion of healthcare workforce to COVID-19 response, and disruption of travel and supply chains. Even basic immunization services have come to a grinding halt in many settings.

But how bad can it get for AIDS, TB and malaria services? Three reports have attempted to answer this question using mathematical modeling. Although these models must be viewed as preliminary, in light of the rapidly evolving pandemic and the uncertainties inherent in any modeling, the forecast is grim.

Impact of COVID-19 on TB

The TB modeling study was commissioned by the Stop TB Partnership in collaboration with the Imperial College, Avenir Health and Johns Hopkins University, and was supported by USAID. The model used assumptions drawn from a rapid assessment done by The Stop TB Partnership on the impact of the COVID-19 pandemic and related measures on the TB response in 20 high-burden TB countries..

The results show that with a three-month lockdown and a protracted 10-month restoration of services, global TB incidence and deaths in 2021 could increase to levels last seen in between 2013 and 2016 respectively, implying a setback of at least five to eight years in the fight against TB. Globally, we could see an additional 6.3 million cases of TB between 2020 and 2025 and an additional 1.4 million TB deaths during that same period.

“It is heartbreaking to see the devastating effect the COVID -19 pandemic has on TB - additional people ill, additional deaths and years of efforts lost in our fight with TB. TB services should not be disrupted and people must have access to diagnosis, treatment and care, even during lockdown,” said Lucica Ditiu, Executive Director of the Stop TB Partnership. “This is non negotiable,” she emphasized.

Nimalan Arinaminpathy, one of the modelers involved in this study, is a professor at Imperial College, London. “Each month of lockdown in a setting like India could cause an additional 40,685 deaths, over the next 5 years,” he said. “These long-term impacts could be minimized by dedicated efforts immediately upon lifting a lockdown, to ‘catch up’ with the diagnoses that were missed,” he added.

India, the world’s highest TB burden country, reported over 1000 deaths every day, even before COVID-19. India is now in its 6th week of its harshly enforced lockdown, with devastating impact on all health services, including TB care. New TB case numbers have dropped precipitously, and large numbers of TB patients on treatment are at risk of discontinuing their TB treatment due to challenges in getting medicines and other support services (e.g. direct cash payments).

Impact of COVID-19 on malaria

The malaria modelling analysis by the Global Malaria Programme at WHO and partners, including PATH, the Malaria Atlas Project, and the Bill & Melinda Gates Foundation, considered nine scenarios for potential disruptions in access to core malaria control tools during the pandemic in 41 countries, and the resulting increases that may be seen in cases and deaths. Under the worst-case scenario, in which all insecticide-treated net campaigns are suspended and there is a 75% reduction in access to effective antimalarial medicines, the estimated tally of malaria deaths in sub-Saharan Africa in 2020 would reach 769 000, twice the number of deaths reported in the region in 2018. This would represent a return to malaria mortality levels last seen in the year 2000.

“Africa has made significant progress over the past 20 years in stopping malaria from claiming lives. While COVID-19 is a major health threat, it’s critical to maintain malaria prevention and treatment programmes. The new modeling shows deaths could exceed 700 000 this year alone. We haven’t seen mortality levels like that in 20 years. We must not turn back the clock,” said Matshidiso Moeti, WHO, Regional Director for Africa.

Fredros Okumu, Director of Science at the Ifakara Health Institute in Tanzania, is passionate malaria fighter who argues for aggressively tackling malaria despite the coronavirus pandemic. “Since the start of this year, malaria has killed 100 times more people in Africa than COVID-19. And today, there will be another 1100 malaria deaths, tomorrow the same number. So, we must keep up the fight through the cloud of COVID19,” he said.

“We have a precious window in which to act before the arrival of peak malaria season in many parts of Africa and the further spread of COVID-19 across the continent. Countries must continue, safely, the distribution of long-lasting insecticide treated nets, indoor spraying campaigns, and other preventive measures for pregnant women and children, focusing on reaching those at highest risk,” said Abdourahmane Diallo, CEO of the RBM Partnership to End Malaria.

“The Ebola outbreak taught us that the best defense is a good offense. Both malaria and COVID-19 present as fevers, making it critical to safely expand current frontline health worker efforts. By preventing, screening, diagnosing and treating malaria symptoms at the local level, countries can avert a devastating surge in severe-malaria cases at district and national hospitals,” said Martin Edlund, CEO of Malaria No More.

“Controlling malaria depends on access to essential services, like rapid diagnostic tests, antimalarial drugs, and insecticide-treated bed nets. If any or all of these are disrupted due to COVID-19, whether it’s through campaigns that don’t happen, supply chain interruptions, or people not able to access diagnosis and treatment, decades of progress could be undone in just months,” said Jennifer Gardy, a Deputy Director with the malaria team at the Bill & Melinda Gates Foundation.

Impact of COVID-19 on HIV/AIDS

The HIV modelling study, convened by the WHO and UNAIDS, used five well-described models of HIV epidemics to estimate the effect of various potential disruptions to HIV prevention and treatment services on HIV-related deaths and new infections in sub-Saharan Africa over 1- and 5-year periods. The analysis shows that a six-month interruption of supply of ARVs across the whole population of people living with HIV on treatment would be expected to lead to an approximately 2-fold increase in HIV-related deaths over a one year period compared to the case with no disruption. In sub-Saharan Africa this amounts to an excess of over 500,000 adult HIV deaths should such a high level of disruption occur. The coronavirus pandemic could effectively set the clock on AIDS-related deaths back to 2008, when more than 950000 AIDS-related deaths were observed in the region.

“These HIV models are a call to action for ministries of health and their partners to ensure that prevention and treatment services are maintained in sub-Saharan Africa during the COVID-19 pandemic. In particular, access to anti-retroviral therapy for all at-risk populations must be safeguarded,” said Meg Doherty, Director of the Department of HIV, Hepatitis and STI programmes at WHO. “These vital, life-saving services will need to be delivered in new and innovative ways – through, for example, multi-month dispensing of medicines and HIV treatment pick-up points,” she added.

“We cannot sit by and allow hundreds of thousands of people, many of them young, to die needless deaths. I urge governments to ensure that every man, women and child living with HIV gets regular supplies of antiretroviral therapy—something that’s literally a life-saver,” said Winnie Byanyima, Executive Director of UNAIDS.

How can we avert disaster?

It is clear that countries, even as they are responding to the COVID-19 pandemic, must not abandon the provision of essential and critical healthcare services. Immunization, access to contraception, maternal and newborn care, treatment of AIDS, TB and malaria are all examples of critical health services. Countries cannot wait for lockdowns to ease before addressing these essential needs. Pregnant mothers cannot wait for lockdowns to end, nor can children with malaria. Helpful guidance is now available for countries to continue essential TB and malaria and HIV services during this crisis.

Soumya Swaminathan, Chief Scientist at WHO points out that the brunt of the COVID-19 burden is being borne by the most vulnerable in society, the same communities that carry a higher burden of TB, malaria and HIV. She is worried about the real possibility of deaths due to these infections increasing rapidly, even as governments are focused on coping with COVID-19. “It is urgent, therefore, for health systems everywhere, but especially in endemic countries, to ensure that routine health services, including prevention, diagnosis and treatment of HIV, TB and malaria are not interrupted,” she said.

Chris Dendys, Director of Results Canada, agrees. “The collateral damage of COVID will be as devastating as pandemic, with millions succumbing to preventable, treatable illness and disease. Their death certificates may cite HIV, malaria or TB – but in fact it will be due to broken health systems, deepening poverty, scant resources that don’t meet the need, or a lack of political will,” she said.

Bhargavi Rao, an infectious diseases physician with MSF argues that the world is risking 20 years of progress made in the fight against HIV, TB and malaria. “My fear is that as we pivot almost entirely to a focus on COVID-19, those major killers, which are all treatable, are being neglected,” she said. “This neglect is manifest in manufacturers prioritizing availability and production of tests and treatments, but also in health systems with reduced access to care and preventative programmes being cancelled,” she added.

In fact, there is growing anxiety that diagnostic companies, in their rush to meet the demand for COVID-19 testing, are starting to de-prioritize production of TB, HIV and malaria diagnostics. Also, since India has been under a prolonged lockdown, its generic drug industry is badly impacted. If India does not resume production of TB, malaria and ARV medicines, or if India bans export of these essential medicines, many countries will struggle with major drug stockouts in the coming months. This could be disastrous.

“We need to get out of this dichotomy of COVID vs non-COVID healthcare problems,” said Sonali Vaid, a physician with the Medical Support Group in India, which has designated ‘COVID’ hospitals meant for all patients with COVID-like symptoms. “Soon South Asian countries will be in ‘dengue/malaria’ season. The numbers of patients with 'COVID-like symptoms' will go through the roof. All of these patients cannot be sent to COVID-designated hospitals – they will get overrun and patient care will suffer,” she said.

In many countries, lockdowns and restrictions are being eased this month. These countries must gear up for a massive surge of sick people who will seek care after deferring care seeking for several weeks. They will present with more advanced disease for two reasons: long delays in diagnosis, and interrupted regular treatments. In many settings, it is unlikely that the public health system alone can deal with this massive surge in patients. Governments must adopt a whole of government, whole of society approach, mobilizing both public and private health sectors, including community-based groups, in the collective COVID-19 response, which should also include essential TB, AIDS and malaria services.

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