What the HIV Pandemic Experience Can Teach the United States About the COVID-19 Response

Abstract

INTRODUCTION The COVID-19 epidemic that first began in China in early 2020 has quickly become a pandemic that is having a tremendous impact on the physical and mental health of populations and how they live, work, and socialize. The last time a respiratory virus caused a pandemic with such far-reaching consequences was in 1918, when H1N1 influenza killed nearly 50 million people worldwide.1 However, since the early 1980s, the world has been dealing with another devastating pandemic, when the virus first known as Human T-cell Lymphotrophic Virus III—and later HIV—was first identified as the causative agent responsible for AIDS. By the end of 2018, 75 million people had been infected with HIV, of whom 32 million have died and 1.7 million people were newly infected that year.2 The number of reported HIV cases in the United States overall is relatively low (1.2 million) and has been relatively stable for the past several years (13.3 per 100,000) relative to many low-income and middle-income countries, especially those in Africa, Central and Southeast Asia, and Eastern Europe. However, national HIV surveillance data mask disproportionate incidence among Blacks and Latinx, especially young men who have sex with men (MSM), and those living in southern states,3 as well as people who inject drugs (PWID) in many rural and semiurban areas.4 For more than 30 years, researchers, civil society, and policymakers have worked to prevent HIV transmission by developing and scaling up interventions aimed at individual-level and community-level behavior changes. International teams and networks of researchers, philanthropists, nongovernmental organizations, and pharmaceutical companies have also strived to develop efficacious antiviral treatments and ensure equitable access and are still pursuing efficacious preventive and therapeutic HIV vaccines. For those on the frontlines of the HIV pandemic, the early days of the COVID-19 pandemic has brought a surreal sense of déjà vu. Although HIV and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have different viral lineages and their transmission routes differ, the world's experience with the HIV pandemic can still offer insights about how we can improve our response to COVID-19. In their recent commentary, Hargreaves et al offered 3 lessons that the HIV epidemic has taught us to anticipate and address inequalities, create an enabling environment for behavior change, and launch a multidisciplinary effort to design and evaluate interventions that promote behavior change.5 We agree and offer additional lessons from the HIV epidemic that can help chart a path to reduce morbidity and mortality associated with COVID-19. We focus our discussion primarily on the United States, which has borne the greatest burden of reported COVID-19 cases to date. THE IMPORTANCE OF SURVEILLANCE AND DIAGNOSTIC TESTING Although the history of the HIV pandemic is well known to most JAIDS readers, it is helpful to review hallmarks of its epidemiology to compare with the recent COVID-19 pandemic. In 1981, it was first reported that young gay men were dying of rare illnesses associated with immune suppression in cities such as Los Angeles and New York,6 followed by similar observations among blood transfusion recipients and PWID. Health officials recognized that they were dealing with a new infectious disease that eventually spread to every continent through infected body fluids, predominantly infected blood and semen. However, it was not until 1984 that its etiology was linked to a novel virus: HIV.7,8 Although it was determined years later that HIV had jumped from chimpanzees to humans in the 1950s and subsequently spread widely in the US gay male community in the 1970s,9 numerous conspiracy theories persisted that HIV was invented by the US government or the pharmaceutical industry, which at times has significantly hampered efforts to promote HIV prevention and treatment.10,11 Once the syndrome was described, scientists started work on identifying the etiology and developing a diagnostic test. Yet, it took almost 4 years from the first report of AIDS in the literature to the time when an HIV antibody test was available, and another 12 to develop a viral detection assay to diagnose acute HIV infection.12 In contrast to HIV, SARS-CoV-2 was detected relatively quickly. Astute health officials and epidemiologists identified new respiratory infections and deaths from an unknown cause in Wuhan, China, between November and December 2019, although some speculate it may have first appeared months earlier.13 Using next generation amplification and sequencing technologies that were not available in the 1980s, scientists worked quickly to identify the pathogen as a novel coronavirus that was eventually designated as SARS-CoV-2.14 Teams investigating the infection benefited from lessons learned from the relatively recent epidemics of related coronaviruses, SARS-CoV-1 that emerged in 200315 and Middle East Respiratory Syndrome (MERS) in 2012.16 Despite rumors that SARS-CoV-2 was genetically engineered in Wuhan or the United States, sequencing of the SARS-CoV-2 genome confirmed that it was not derived or purposefully manipulated in a laboratory.17 All 3 coronaviruses have been found to originate in animals, with SARS-CoV-1 being found in civets and MERS being traced to camels.18 SARS-CoV-2's genetic composition closely resembles that of bats, although some studies have implicated an intermediate host such as a pangolin.16,18 With the sequence of the pathogen known, scientists quickly turned to develop polymerase chain reaction-based methods for the detection of SARS-CoV-2 RNA. Because HIV is a chronic viral infection and SARS-CoV-2 is limited to an acute infection, their testing strategies are different. In general, any test that identifies the presence of HIV RNA or past infection with HIV through serology reflects that the person has been HIV infected, whereas only a test that can detect the presence of virus such as a nucleic acid or antigen test is useful for identifying active (ie, acute) infection with SARS-CoV-2. The main advantage of serological testing for SARS-CoV-2 is epidemiologic surveillance, but because SARS-CoV-2 infection may cause disease long after active infection is resolved, antibody testing may be helpful in identifying the cause of associated symptoms, although specific treatment for such sequalae is currently lacking. Given strides in technology that were first developed for HIV, molecular SARS-CoV-2 assays were rapidly deployed around the world. Although the validity of many tests was initially suboptimal, they were sufficient for diagnosing most people who had become infected and provided alarming evidence that the scope of the epidemic was quickly expanding.19,20 The first tests for HIV usually took weeks for results to return, and if the test was positive, confirmatory tests such as the western blot were required. This not only delayed diagnosis of persons with HIV but also implementation of contact tracing. New tests were eventually developed to reliably diagnose a person at point-of-care (POC), within minutes of testing.12 These next generation POC tests allowed persons with HIV to immediately initiate life-saving antiretroviral treatment (ART).21 A similar testing process is happening with the COVID-19 pandemic, albeit at a faster pace. Encouraged by diagnostic companies, next-generation diagnostics are materializing, including POC viral nucleic acid or antigen tests and serologies. Once available, POC tests can be rapidly deployed to diagnose persons with SARS-CoV-2, enabling people to learn when they should self-isolate and allowing health officials to use rapid contact tracing. Such procedures would greatly enhancement prevention measures.19 Because of ongoing delays in the scale up of SARS-CoV-2 testing in the United States, health officials are also turning to pooling approaches that proved to be cost-effective and scalable earlier in the HIV epidemic and in resource-limited settings.22–24 HIV AND COVID-19 DISPROPORTIONATELY AFFECT DISADVANTAGED POPULATIONS AND COMMUNITIES OF COLOR Since the beginning of the HIV epidemic, communities of color and disadvantaged populations have been disproportionately affected. As of 2018, Black and Latinx populations in the United States accounted for 69% of new HIV infections.3 Compared with Whites, Blacks and Latinx have an 8.2 and 3.4 times greater HIV incidence, respectively. HIV mortality is also higher for Blacks and Latinx with rates being 6.5 and 1.8 times greater than Whites,3 respectively. Globally, other populations that have disproportionately high burdens of HIV infection are those with unequal opportunities and/or social exclusion, including sex workers,25 MSM,26 PWID,27 prisoners,28 and transgender persons.29 Racial and ethnic minorities and disadvantaged populations also have poor outcomes along the HIV care continuum, including lower rates of linkage and retention in care, later initiation of ART, and lower adherence leading to suboptimal viral suppression.30,31 Existing surveillance data on COVID-19 similarly indicate a disproportionate burden of morbidity and mortality is borne among communities of color.32,33 Racial/ethnic minorities are more likely to test positive for SARS-CoV-2 than Whites.34 Blacks account for 22% of infections, yet comprise 13% of the US population; Latinx account for 33% of infections but 18% of the population.35 Blacks are almost 3 times more likely to be hospitalized for COVID-19 than Whites.36 Across the United States, COVID-19 mortality rates are 80% higher for Blacks and over 50% higher for Latinx relative to Whites.37 COVID-19 data for disadvantaged populations are currently limited to outbreaks in concentrated settings, but these highlight emerging disparities among people who are incarcerated and unstably housed or homeless.38–40 SOCIAL AND STRUCTURAL FACTORS ARE POTENT EPIDEMIC DRIVERS Social and structural determinants are those that are exogenous to the individual, which can fuel disparities in viral transmission and disease among communities of color and disadvantaged populations. For example, stigma and discrimination can increase HIV risk and undermine HIV prevention and treatment, especially among racial and ethnic minorities and socially marginalized populations. HIV stigma is grounded in the intersectionality of HIV infection, racism, homophobia, and sexism41,42; stigmatization often manifests into fear of and experience of discrimination in health care settings.43 In the beginning of the HIV epidemic, MSM were singled out for abuse as they were blamed for spreading HIV. AIDS was initially referred to as “Gay-Related Infectious Disease”,44 a label that was seized on by sensational media outlets that published headlines referring to the “gay plague.” Human rights violations, stigma, and discrimination perpetuated against sexual minorities, and PWID continue to be major barriers to accessing HIV prevention interventions, testing, and ART.45,46 Mistrust in the health care system consistently translates to reduced engagement in HIV prevention behaviors47,48 and poor retention in HIV care and medication adherence.49,50 Fear of discrimination due to testing positive has been documented among people living with HIV who delay testing. Comparable stigmatization in communities of color stemming from systemic racism and discrimination has already influenced the COVID-19 pandemic. When the origin of the outbreak was reported in China, Asians and Asian Americans were targeted and labelled by key figures, including the President of the United States who referred to SARS-COV-2 as the “Chinese virus” and COVID-19 as “Kung Flu.” People of Chinese and other Asian descent became victims of physical and verbal abuse. Whereas HIV was used as justification to uphold homophobic legislation, COVID-19 is being used as an excuse to promote racism and social exclusion, further inciting racial tensions.51,52 When repercussions exist for testing positive for SARS-CoV-2, such as lost or being by it should be that some people delay testing and/or their positive test The physical environment in which people live, work, and time can HIV risk or For example, among physical HIV and as well as sex such as and offer access to and a lower risk of HIV transmission than sex work that in the Racial and ethnic minorities are also by an risk of HIV because of their living including racial whereas in and can increase the risk of to SARS-CoV-2. in poor or and poor due to on and additional in is limited access to health care likely to delayed COVID-19 testing and with more and are also infectious disease most industry, and are racial and ethnic minorities, more likely to with infected with Racial and ethnic minorities are more likely to be in they and experience or limited which to work or to for a In the early 1980s, US President was for on the not to AIDS or use the until the COVID-19 epidemic, President and until to As a of these and the prevention strategies to have been because they have become People who are at risk for or are living with HIV often in the of is in these that are more likely to experience a of that to and poor This has been a of the and marginalized and disadvantaged experience high rates of use and mental health and and and The a of that and that are associated with for HIV, such as use of among and poor engagement in HIV These to a number of other such as those caused by and infections, and The that fuel HIV transmission and their have a in the COVID-19 pandemic. For example, as can be a of sex work in low-income and it is also some people in low-income and middle-income out in or which can infections, such as HIV, and and to among disadvantaged and marginalized communities of and the of the and health consequences of as well as of from use and or structural to which is associated with a of mental health available to and higher rates of an people of color experience and discrimination that can immune and increase to and poor health and/or drugs may be used as a for discrimination and the that from poor As a (ie, from and social to individual-level outcomes and may to higher rates of The process is likely with to the For Black and Latinx who in use and experience poor mental health may further to THE IMPORTANCE OF STRUCTURAL in the HIV epidemic, prevention scientists on and individual-level determinants of poor health behavior and This that scientists have to the of social they are turning to approaches and those at HIV and mental health and HIV prevention have used community by in their and For example, to stigma and discrimination among MSM in the early 1980s, gay communities nongovernmental such as the and Health to prevention HIV care, and to promote access to The for AIDS was in followed by the International AIDS in which and of community and were responsible for among disadvantaged such as the of to people living with HIV in for for and of male among primarily Black men in Although it is early in the COVID-19 pandemic, some have to Such efforts may be not for social but to for health care because of people who have become the epidemic have lost health COVID-19 who health also be from health on the of having reduce morbidity and mortality related to community should be to promote testing, and health prevention strategies social and through social to be in HIV prevention efforts in communities of Because the ongoing Black have social and structural inequalities, is due to community to health that access to health By in the Black it may be to Black as an to reduce racial health For example, at a time when SARS-CoV-2 is in many US a in reduce stigma, and against Black men who continue to be disproportionately targeted by of in of people who to be by that with as has been for the response and to the HIV epidemic were known as AIDS This began as a response to HIV and its disproportionate impact on specific in which HIV was as not only a health but also a social that a as well as a AIDS for HIV care and treatment was or of as an to HIV prevention and treatment and among disproportionately the beginning of the COVID-19 epidemic, was a of were testing and However, is a for the of surveillance, testing, and treatment of COVID-19 into efforts for other that the efforts that are community and are of the COVID-19 especially those that address social and structural among disproportionately populations. interventions also changes. In the US a the AIDS that became the in the United States for people living with HIV, access to for disadvantaged the other the United States was than the United and in to for that can significantly reduce the risk of and HIV incidence among PWID. Yet, when the US on the use of to was in December after an HIV outbreak among PWID in rural it had In US that not the low-income people health may access to COVID-19 testing and However, by at a structural interventions may not only reduce incidence and deaths from HIV and COVID-19 but also of By testing and contact for infections of health HIV, infections, and it be to test for infections and contact when which would also reduce and access to can more with COVID-19 testing and care to who have lost their and health the was to improve diagnosis and care in HIV and chronic medication and overall health for low-income structural approaches that have a more impact on community transmission on and for who are and in with a higher of people THE OF AND When with a new infectious disease that has high incidence and scientists to develop treatments to reduce morbidity as well as that can prevent With the AIDS in the and on scientists and The first that against HIV, was a When it was that would not be a was by the of Health in to with pharmaceutical companies to in the and of new antiretroviral developed for HIV, the AIDS This has the of currently available HIV in the we have The was followed by the HIV and the HIV and for AIDS at US which were also by the of efforts are for with a initially developed for SARS-CoV-1 and being to drugs used to a of other that had against SARS-CoV-2 were also including and only has for the treatment of but in a reported that a relatively reduced mortality among COVID-19 but not in with The next generation of are already being developed and including viral RNA and These of also have a history in the treatment of they are being in with from pharmaceutical companies, including the These have benefited from the developed to to the HIV pandemic, as well as that to test numerous the HIV, is available for SARS-CoV-2. was widely in by that would be an HIV within a and yet after almost 4 the world is still are being about a for after SARS-CoV-2 was for numerous were on the enabling between scientists around the world that is the of Although it is that SARS-CoV-2 were in by 3 of which had SARS-CoV-2 that should be in the of an HIV strides have been in our of the immune to against HIV infection, and such greatly in the of a for SARS-CoV-2. are to address of and associated with the which is already of health efforts to for other infectious such as and Social media is an that be to promote and to about (ie, THE IMPORTANCE OF and are to and the HIV and COVID-19 can help epidemic and and However, they can also be which can to of HIV for found that lower with a in and may have been about the impact of on HIV This to an of for HIV treatment and prevention in Africa, which to experience some of the HIV incidence rates in the world. Compared with these at the overall and of the epidemic as well as mortality which was to in surveillance data the key lessons from these and other and data are for or for emerging infectious studies are to of such as rates of and In surveillance among and to that had the burden of HIV in the but found were by In the United the of SARS-CoV-2 testing and the to quickly and surveillance and to a major in and contact and the to and delayed key such as and and on these key in surveillance and data are and are to the epidemic and is also to in SARS-CoV-2 testing, and mortality data to epidemiologic and to When data are or are to how different may outcomes and can help data to be against data to and with new For example, in the United States and developed as of the health In some these on data from not to the United States or about the impact of social interventions and to and around the of social and of after of structural and disparities are to the prevention A response in structural and in risk and and epidemic for the HIV epidemic in the most to HIV infection are young Black MSM from rural US by rates of use and in health care access by continue to fuel disparities in HIV incidence and HIV prevention and care can increase access to among populations and the of COVID-19 in rural US after a in New and other and the approaches to social the for The disproportionate number of racial and ethnic minorities living in to and that a higher risk of SARS-CoV-2 transmission should be in a the of Blacks in and higher risk of SARS-CoV-2 infection and should be into that how to reduce of these structural and disparities that risk and by is for to the time of in the United States accounted for of the world's reported COVID-19 SARS-CoV-2 incidence in and the national for new cases and deaths was and respectively. Despite is still national for prevention such as or social Although the United States response to the HIV epidemic has had its prevention and treatment after the implementation of national AIDS and the for AIDS became known as a in scaling up HIV treatment in and middle-income By the United States response to COVID-19 has been an in testing of health and a of a national to ongoing that grounded in evidence is key to a path The United States from the Health only for a response to pandemic and have a on such as it is that COVID-19 of prevention for HIV, and In the United States the world of of the only drugs to have antiviral against SARS-CoV-2, the of the world fear that the US to SARS-CoV-2 and to scale by the end of 2020 are only for Americans and may because the those developed in The COVID-19 pandemic not end if the United States or other an by or to that the of is linked to that of and a of about access to life-saving treatments and should be and with through a process that from communities and on such as health as a COVID-19 has the in our is a national that the of to prevent a COVID-19 epidemic in the United States has already but it is not to a that can of The is the is to learn from its past and with the HIV epidemic and a that and

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