An Appeal to UNAIDS to Seize Leadership in the COVID-19 Crisis
We are concerned by the message the Joint United Nations Programme on HIV/AIDS (UNAIDS) has repeated in its public pronouncements to date, noting that there is “currently no strong evidence that people living with HIV are at an especially increased risk of contracting COVID-19 or if they do contract it they will experience a worse outcome.”
In fact, there is no strong evidence either way, but there are clear inferences that can be made and obvious warnings to convey. We strongly urge UNAIDS to revise its messaging.
In its “Q and A on COVID-19, HIV and antiretrovirals,” published on March 17, the World Health Organization (WHO) says that so far there is "no evidence to suggest that there is an increased risk of infection and increased severity of illness for PLHIV" from COVID-19. But WHO takes care to point out that "this can rapidly change as the virus spreads."
Along with full, factual information, we urge UNAIDS to also step up at once with immediate solutions for people living with HIV.
The first imperative is to put pressure on all governments to implement the WHO guidelines on allowing people with prescriptions to procure at least three months’ of ARVs at once.
Those guidelines go back several years, but their implementation is now more important than ever. Personal ARV stores may be quickly depleted; the fear of stock-outs is real, as is the fear of losing the income needed to purchase ARVs and, equally important, tuberculosis (TB) drugs. Social distancing may be impossible for those required to frequently refill their prescriptions for ARVs or TB drugs, especially if they can only reach drug dispensaries by crowded public transport, or if dispensaries are located in multipurpose health facilities that may soon be off-limits to all but the sick and dying.
But UNAIDS goes on to recommend that individuals consider “working with others in your community to persuade health-care providers and decision-makers to provide multi-month prescriptions for your essential medicines.”
This strikes us as ill-advised and unrealistic. Community gatherings should be avoided. UNAIDS itself can and must advocate directly, and firmly, with governments on behalf of affected individuals and communities.
The second imperative is to press for extraordinary emergency measures to ensure that the COVID-19 pandemic does not reverse all the gains made against AIDS. We urge UNAIDS to call on all governments to waive payments for ART for a sufficient and appropriate period of time.
UNAIDS has an unparalleled global platform at an unparalleled point in time. In the midst of the worsening COVID-19 crisis, UNAIDS must offer resolute and active leadership on behalf of everyone living with HIV and everyone who is suffering from, has survived, or is at risk of contracting tuberculosis, the number one killer of people living with HIV.
In its public statements so far, UNAIDS has provided reassurance (which is sometimes overstated) when what is most needed now is leadership.
While there is a great deal that scientists are still scrambling to understand about the virus that causes COVID-19, there is also a great deal we do know.
Like HIV, this novel coronavirus entered the human population through a zoonotic event, from non-human animals to humans; it is a retrovirus; and, at this point, its spread must be prevented through a combination of behavioral interventions and government action.
As the UNAIDS statement on March 17 correctly noted, people living with HIV should, like everyone across the globe, follow the universal precautions to block the spread of this coronavirus. But the world population of people living with HIV covers a broad spectrum, ranging from those who are income-secure and ART-adherent to millions who live hand-to-mouth or have not yet been tested; from people in resource-rich countries to those in low-income to conflict-afflicted countries; from key populations to the millions of individuals and families affected by HIV who are managing to cope with challenging circumstances but are now facing frightening new and unforeseen ones.
The mantra of UNAIDS is as applicable here as it was a decade ago: Know your epidemic. Global leadership is essential, but local adaptations are crucial. A person living with HIV in Geneva may have ready access to clean water for handwashing and space to self-isolate; someone in Kibera or Harare may not.
We urge the UNAIDS leadership to work with the World Health Organization and the other UNAIDS co-sponsors to provide strong, clear, and appropriate guidance to health ministries and, through them, to local health providers. It must be emphasized: UNAIDS has a mandate to coordinate the work of the co-sponsors to apply pressure and persist on behalf of the people they represent. The time for nuanced diplomacy has passed.
Now is also the moment for UNAIDS to rally its networks; we are especially concerned about TB. Everything outlined in this statement applies equally to HIV and to TB and, of course, to people affected by both.
“The issue of HIV and COVID-19 co-morbidity has received little attention to date,” writes Professor Alan Whiteside, an internationally recognized academic and AIDS expert, in a March 18 statement. But, he continues, this is because “we have not yet seen significant cases in places with high HIV burden.”
In Forbes magazine, Madhukar Pai, Director of the McGill International Tuberculosis Centre, writes, “Although there are no data yet, I suspect lung damage might make TB patients more prone to COVID-19 and its negative outcomes.”
The WHO makes a similar assertion in its March 20 Information Note on TB and COVID-19, highlighting the particular vulnerability of TB patients whose treatment is interrupted.
"While experience on COVID-19 infection in TB patients remains limited, it is anticipated that people ill with both TB and COVID-19 may have poorer treatment outcomes, especially if TB treatment is interrupted,” according to the WHO. “TB patients should take precautions as advised by health authorities to be protected from COVID-19 and continue their TB treatment as prescribed."
What is happening in Italy is unbelievable. If it is mirrored in Nigeria, the Democratic Republic of the Congo, or South Africa, or in any country with a high burden of HIV and TB, the consequences will be unimaginable.
This is not a time for optimistic reassurance from global institutions. This is a time for uncompromising leadership, correct information as it develops, tangible action, and clear communication of particular concern to people living with and affected by HIV and TB. This is a time for urgent, forceful advocacy with governments.
UNAIDS, the world is counting on you.
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Media contact:
Peter Duffy
AIDS-Free World
TEL: +1-646-924-1710
Email: media@aidsfreeworld.org