HIV and COVID-19: Intersecting Epidemics With Many Unknowns

Catherine R. Lesko; Angela M. Bengtson


Am J Epidemiol. 2021;190(1):10-16. 

In This Article

Modifying, Measuring, and Monitoring Engagement in Care

Engagement in ongoing care is essential to the health of PLWH. HIV viral load and CD4 cell count should be monitored every 3–6 months.[28] In light of the risk of SARS-CoV-2 transmission associated with face-to-face contact, particularly in medical settings, many clinical encounters (for all people, including for PLWH) were rapidly changed to telehealth visits starting in March 2020 as SARS-CoV-2 cases started increasing rapidly.[29]

While telehealth visits eliminate potential exposure to SARS-CoV-2 and thus might be necessary for some period, the costs and benefits associated with telemedicine need to be enumerated and weighed. Prior to the SARS-CoV-2 outbreak, telehealth was studied as a potential intervention to increase access to care[30] particularly for PLWH with transportation difficulties and those living in rural settings.[31] However, offering telehealth to persons who opt in is a different intervention from requiring telehealth visits to all persons in the midst of a pandemic, and it might result in different outcomes.

There is, as yet, little data on the short- and long-term impacts of the transition to telehealth on engagement in care and ART adherence for PLWH. In a narrative report, >90% of patients in a Missouri HIV clinic (presumably among those who successfully completed a telehealth visit) reported that their telehealth visit during COVID-19 physical distancing restrictions was as good as or better than a traditional in-clinic visit.[29] Not provided was the number of patients who failed to complete a telehealth visit. At a clinic in Chicago, from late March to mid-April, only 21% of scheduled visits were carried out virtually; 31% were rescheduled, 2% occurred in person, and 46% were not attended.[16] The impact of telehealth on high-need patients and new patients who have not yet established rapport with their providers has yet to be described.[7]

Despite some good telehealth outcomes for some PLWH, telehealth has the potential to exacerbate disparities in care for people with lower socioeconomic status: Lack of necessary technology and services, technology literacy, or safe, confidential surroundings to participate fully in telehealth might be barriers to engagement in care.[32] There are not good, representative data on the prevalence of smartphone ownership and internet use among PLWH.[33] Among a sample of predominantly low-income women of color seeking HIV-related social or clinical services in the Bronx in 2014, 87% owned a cellphone, compared with 90%–92% of persons in the general population at the same time.[34] In a sample of PLWH in British Columbia, Canada, recruited in 2012, only 60% owned a cellphone at enrolment.[35] In the general US population, demographic characteristics associated with limited access to smartphones and home broadband services match the demographics of people with high prevalence of HIV infection: non-White persons, older adults, and persons with less education or lower income.[34,36] In addition, for telehealth to be effective, simply owning a cell phone is not sufficient. Patients might incur additional monetary costs for telehealth visits if they do not have access to unlimited telephone or internet service.

Additionally, PLWH could face privacy concerns engaging in medical care from outside the clinic, where they might not have control of their surroundings.[37] In a survey of PLWH about attitudes towards telehealth generally, nearly a quarter had concerns about their ability to express themselves in the absence of a face-to-face interaction, and over a quarter had concerns about the privacy of their health information over the internet.[38]

From a practical standpoint, to track ongoing engagement in care of PLWH and long-term impacts of telehealth, health-care systems must be proactive in ensuring that all scheduled patient encounters (attended, rescheduled, and missed) and the modality of the attended encounters (i.e., in-person, video conference, or telephone call) are being captured by the electronic medical system. Potential risks and benefits of, and preferences for, telehealth are likely heterogeneous across PLWH, and this heterogeneity will need to be considered to inform clinical practice (e.g., by prioritizing patients for in-clinic versus continued telehealth visits as clinics re-open but maintaining low in-clinic patient volume to accommodate physical distancing).[38] In particular, those factors likely to modify the effect of telehealth on engagement in care (access to internet and private, safe space from which to call in and distance and transportation to the clinic) should be routinely collected.

An additional factor likely to interrupt engagement in care in the United States is the economic crisis precipitated by the pandemic, in which millions lost their jobs and employer-sponsored insurance.[39] PLWH who previously had private insurance might experience gaps in care if they find themselves suddenly without means of paying for care. Clinical cohorts have a unique opportunity to track changes in insurance status and impact on engagement in care, access to ART, and viral suppression. This might require some additional follow-up of patients who are lost-to-clinic to determine why they have not returned.