As of 25 May 2020, the Swiss government has announced 30 746 confirmed coronavirus disease 2019 (COVID-19) cases; an estimated 3927 people were hospitalized and a further 1642 died. While there is currently no evidence that people living with HIV (PLWH) differ in their risk of acquiring a severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection, or whether they may present a more severe course of illness compared with the general population, it is widely assumed that untreated PLWH or those with low CD4+ cell counts (<200 cells/μl) may be at increased risk of COVID-19 disease.[2,3] In addition, a number of risk factors associated with severe clinical COVID-19 are also shared by PLWH, such as cardiovascular disease risks factors (including diabetes, hypertension and obesity).[4–6]
Several countries have implemented lockdown policies aimed at slowing the spread of COVID-19. However, one of the unplanned consequences is the impact on the HIV care continuum, including a reduction in access to antiretroviral therapy (ART) and care delivery. This concern was first highlighted in China where the WHO, the Joint United Nations Program on HIV/AIDS (UNAIDS) and the Global Network for PLWH joined forces to ensure continuity of HIV-related services, such as testing, treatment and care.
Switzerland has not been immune to this double HIV and COVID-19 epidemic. In Geneva, the team of the HIV Unit at Geneva University Hospitals (HUG), together with the network of treating physicians and patient representative groups, has had to act quickly to both tailor its services and optimize clinical care for PLWH patients infected with COVID-19. We discuss here some of the issues observed and measures taken, as well as some clinical challenges among PLWH patients hospitalized with COVID-19 at our healthcare facility.
When the country began its lockdown on 13 March 2020, the team at the HUG HIV Unit worked rapidly to reinforce the continuum of care, that is HIV testing; access to treatment; and continued clinical consultations. With regard to HIV testing and prevention, the decision was made to temporarily postpone the voluntary counselling and routine testing for asymptomatic people without a documented exposure risk. However, other prevention and testing services were maintained in town. These included a hotline that provided remote counselling, risk evaluation and encouragement of self-testing if indicated, in association with local partnerships. A separate hotline for postexposure prophylaxis was also maintained and served to screen those in need of further services, thus removing the need for in-person visits. All individuals who required services were given appointments and seen in person for testing or prescribed postexposure prophylaxis.
To ensure that no HIV-positive patient or preexposure prophylaxis user suffered medication shortage or treatment interruption during lockdown, the team carried out a rapid assessment. Prescriptions and the last medication supply were checked to confirm an adequate supply for at least 3 months. For those with insufficient stock, a dedicated medication supply chain was set up within 1 week and all patients were provided with a 3-month stock within a week by order of urgency. Medication from the hospital pharmacy was delivered either directly to their home (by medical students), or a prescription was sent to their local pharmacy. A particular challenge, was that of patients who found themselves in lockdown in another country with no access to ART and no immediate solutions to travel home. We overcame this by sending a prescription by e-mail and referring them to a local pharmacy.
With regard to clinical follow-up, all routine blood and laboratory tests were postponed for vulnerable patients (particularly for patients aged 65 or more) and the HIV Unit shifted its services to telemedicine where possible. This was achieved by systematically contacting each patient followed at our outpatient clinic. First, to ensure that each had a follow-up appointment booked to avoid any loss to follow-up. Second, to inform those with upcoming appointments that these would be teleconsultations. Third, each call to the patient was also an opportunity to answer their questions about the risk related to their HIV status and thus respond to a certain anxiety and to remind them to follow the measures recommended by the federal authorities. Finally, planned blood tests appointments were postponed by 3 months, to a time when limitations to hospital visits would be lifted.
Of note, no medical consultations were cancelled. When calling the patient, we observed that some had tried to spare medication by taking them intermittently for fear of running out during lockdown. For our team, this highlighted the importance of our comprehensive approach, combining telephone calls and the set-up of a medication supply. A close medical follow-up of all HIV-RNA results based on the laboratory database was also maintained on a monthly basis. We observed a 60% increase in patients with a detectable viral load more than 50 copies/ml (24 patients versus 15, based on the average of the previous 3 months). While it remains unclear if this was a direct consequence of the COVID-19 pandemic, this observation had a temporal association with the start of social distancing policies in Switzerland.
The HUG being the largest Swiss university hospital dedicated exclusively to COVID-19, these efforts were made extremely challenging due to the human resource shortage, with many physicians relocated from the HIV Unit to the hospital wards to reinforce the response for the expected wave of COVID-19 patients. In addition, some staff members were unable to work either because they were considered at high-risk for severe COVID-19 or were self-isolating after coming in contact with a confirmed case. One of the solutions employed was to recruit a recently retired physician back into the HIV Unit who was dedicated to HIV care.
A total of 1024 people were hospitalized at HUG for COVID-19 as of 1 May 2020. Eight were HIV-positive (Table 1), an expected number according to the overall regional HIV prevalence. Fifty-seven percentage were male; mean age, 63 years. All patients had undetectable viral loads on ART. None was on a boosted-protease inhibitor-containing regimen. Three of the eight HIV-positive COVID-19 patients had a CD4+ cell count less than 200 cells/μl in the context of COVID-19-related lymphopenia, with a preserved CD4+ cell count percentage. Seven had at least one of the risk factors for severe COVID-19 illness, with older age and cardiovascular conditions the most frequent. Three of eight patients required intensive care management with orotracheal intubation.
Three of the eight were admitted to intensive care and intubated, one of whom had a tracheotomy. Where appropriate, and according to local recommendations, a drug from the protease inhibitor class (preferably lopinavir/ritonavir) was added to their current ART regimen. For example, one patient who was on nevirapine, abacavir and lamivudine, received lopinavir–ritonavir at an increased dosage to avoid a suboptimal exposure to the third component, nevirapine. Darunavir (instead of lopinavir/ritonavir) was added for another patient who was on a cobicistat-boosted elvitegravir regimen to avoid the double-boosting molecule. Six also received a single hydroxychloroquine dose of 800 mg. This was given either alone or in combination with azithromycin for the three cases requiring intensive care management. One patient also received remdesevir as part of a clinical trial. Only two patients remained hospitalized and are in rehabilitation. Average hospitalization among those discharged was approximately 1 month.
The COVID-19 pandemic has highlighted issues that PLWH must face in connection with measures taken to limit the spread of SARS-CoV2. Shared experience is critical to inform the HIV community network how best to adapt to this exceptional situation. We showed that by implementing well constructed solutions to meet the challenges of caring for PLWH during a pandemics and lockdown situations, the continuum of HIV care can be assured. This is paramount and should be the primary focus of actions not just today, but also in the future. The use of telemedicine, the systematic review of HIV-RNA results, and ensuring access to medication through home delivery were among the important measures taken in Geneva for PLWH.
For the more challenging cases, such as patients caught in lockdown outside their country with no access to medication, this calls for a coordinated global response, including organizations such as WHO and UNAIDS, to put in place a system to allow access to emergency ART. While this situation is unique, it is also important to ensure that every single patient, whenever possible, has a minimum of 3 months of treatment when travelling abroad as other issues can go beyond this extraordinary pandemic situation. We aimed at ensuring that none would be left behind.
Although Switzerland is currently the third most affected European country by SARS-CoV2, we did not observe an excessive number of PLWH compared with the known regional prevalence. Indeed, Switzerland is a country where UNAIDS targets are being met and more than 90% of PLWH have a suppressed HIV-RNA and CD4+ cell count more than 500 cells/μl. Significantly, none of the eight hospitalized patients were on a boosted-protease inhibitor, a drug class used as an off-label experimental treatment in COVID-19 patients in some settings, raising the hypothesis of a boosted-protease inhibitor-associated protective effect.[10,11]
In summary, in a country heavily affected by the COVID-19 pandemic, careful assessment and tailoring of care to a moving environment is critical to ensure appropriate access to medication and care for PLWH.
We thank the team of the HIV Unit and partners who helped us in the implementation of these measures, particularly Laurent Kaiser, Sabine Yerly, Nathalie Fraile and the nursing team, Christelle Martin, Sonja Vincent-Suter, Catia Guedes Queiros, medical students (Oriane Calmy, Leila Michel, Thibaud Zanone) Clementine Esclapez for their active support during this challenging period.
The current article received ethics approval to publish patient data (SwissEthics ID 2020–01083).
AIDS. 2021;35(3):355-358. © 2021 Lippincott Williams & Wilkins
Lippincott Williams & Wilkins