When are in-person HIV services worth the risk of COVID-19 and other communicable illnesses? Optimizing choices when virtual services are less effective

摘要/摘要 撒哈拉以南非洲(SSA)是三分之二艾滋病毒携带者(PLHIV)的家园。新冠肺炎期间 在大流行期间，撒哈拉以南非洲的艾滋病毒服务已被调整为接触较少的替代方案，以减少 暴露于SARS-CoV-2，保持了一些服务的有效性，但降低了有效性 其他人的。例如，数月的抗逆转录病毒治疗(ART)并没有减少病毒滞留或病毒感染。 负荷抑制，而许多涉及导航、社会支持和心理健康的服务变得更少 以较少接触的方式交付时有效。三项此类服务对实现艾滋病毒治疗至关重要 预防目标是艾滋病毒检测、抑郁症治疗和抗逆转录病毒药物治疗支持。亲身感染艾滋病毒 咨询和测试被调整为远程自我测试，与护理和治疗的联系比率较低 艾滋病毒治疗启动的相应下降。抑郁症(一种疾病)的面对面心理治疗 影响SSA中10%-15%的PLHIV)被适应于远程治疗，减少了治疗完成率和 有效性。对坚持抗逆转录病毒治疗的面对面同行支持被改编为电话和远程保健 依从性支持，依从率较低，病毒载量受到抑制。截至2021年年中，SSA国家 继续实施这些低接触替代方案，并且缺乏关于何时以及针对谁的证据， 接触程度较高的服务应该恢复。我们将与赞比亚和肯尼亚卫生部合作，并 当地非政府组织查明已改装成低接触替代方案的服务并进行估计(目标1) 在治疗和预防艾滋病毒方面的增量有效性，(目标2)增量暴露于COVID-19， 结核病和流感，以及(目标3)哪些患者应该在什么时间使用接触较少的服务。至 评估增量效率，我们将使用计划数据来比较特定服务方面的结果 指标，如艾滋病毒检测，抑郁评分的变化，ART滞留和病毒感染的变化 负载抑制。使用艾滋病毒传播和进展模型，我们将把这些特定于服务的 将各项指标纳入残疾调整生命年的可比估计数。估计SARS-CoV-2，结核病， 通过不同的服务选择接触到流感，我们将进行实地考察，以获得 呼吸道疾病传播的Wells-Riley模型的参数。我们将把这些估计与 不同流行条件下接触风险的数学模型及其产生的风险 按伤残调整生命年计算的健康。最后，我们将比较艾滋病毒相关福利和SARS-CoV-2- 不同新冠肺炎流行状况和患者亚群的相关风险，以确定 应恢复高接触服务的门槛。我们还将为多少建立目标 低接触服务的有效性需要改进，才能在 新冠肺炎时代。

ABSTRACT/SUMMARY Sub-Saharan Africa (SSA) is home to two-thirds of all people living with HIV (PLHIV). During the COVID-19 pandemic, HIV services in sub-Saharan Africa have been adapted to lower-contact alternatives that reduce exposure to SARS-CoV-2, which maintained the effectiveness of some services but reduced the effectiveness of others. For example, multi-month dispensing of antiretroviral therapy (ART) did not reduce retention or viral load suppression, whereas many services involving navigation, social support, and mental health became less effective when delivered in lower-contact manners. Three such services critical to achieving the HIV treatment and prevention targets are HIV testing, treatment of depression, and ART adherence support. In-person HIV counseling and testing was adapted into remote self-testing, with lower rates of linkage to care and commensurate declines in HIV treatment initiation. In-person psychotherapy for depression (a condition affecting 10-15% of PLHIV in SSA) was adapted into teletherapy, with reduced treatment completion and effectiveness. In-person peer support for ART adherence was adapted into telephone and telehealth adherence support, with lower rates of adherence and viral load suppression. As of mid-2021, SSA countries continue to implement these lower-contact alternatives and lack evidence regarding when, and for whom, higher-contact services should resume. We will partner with the Ministries of Health of Zambia and Kenya and local NGOs to identify services that have been adapted into lower-contact alternatives and estimate (Aim 1) incremental effectiveness at treating and preventing HIV, (Aim 2) incremental exposure to COVID-19, tuberculosis, and influenza, and (Aim 3) which patients should use lower-contact services at what times. To estimate incremental effectiveness, we will use program data to compare outcomes in terms of service-specific indicators such as HIV tests performed, changes in depression scores, and changes in ART retention and viral load suppression. Using an HIV transmission and progression model, we will translate these service-specific indicators into comparable estimates of disability-adjusted life-years. To estimate SARS-CoV-2, tuberculosis, and influenza exposure through different service alternatives, we will perform in-field visits to obtain parameters for a Wells-Riley model of respiratory disease transmission. We will combine these estimates with mathematical modeling to the risk of exposure under different pandemic conditions and the resulting risk to health in terms of disability-adjusted life years. Finally, we will compare HIV-related benefits and SARS-CoV-2- related risks for different COVID-19 pandemic conditions and patient sub-populations in order to determine thresholds when higher-contact services should resume. We will furthermore establish targets for how much the effectiveness of lower-contact services would need to improve in order to be widely recommended in the era of COVID-19.