India has the third-largest HIV population, with over 2.1 million people living with HIV (PLHIV) since 2016 (UNAIDS, 2014). To maintain optimal quality of life, it is essential for PLHIV to have consistent and quality engagement with the health system. Prior research shows financial constraints, lack of privacy, and poor quality of care are barriers to accessing care and adhering to ART treatments (Joglekar et al., 2011; Kumarasamy et al., 2005). While structural challenges impede access to HIV prevention and treatment services, PLHIV also faces a host of navigational issues.
Because of stringent lockdown and measures adopted to halt the spread of Covid-19 in India, the already strained health system was further burdened. Staff and services were reallocated from routine care to pandemic response which resulted in lower access to medication, treatment, and care for PLHIV (Chattopadhyay, 2020). Experience with past epidemics and global emergencies has shown that vulnerable communities that are not directly affected by the prevailing emergency are often missed in provision of care and support.
We conducted a qualitative study among 150 participants in 5 Indian states to explore disruptions experienced while accessing health services, to contribute to development of strategies that ensure and improve HIV treatment and access during subsequent waves of COVID-19 or future outbreaks.
PLHIV and Access to Sexual and Reproductive Healthcare (SRH)
Findings from our study showed that PLHIV faced difficulties in accessing care due to lack of transportation, financial issues preventing travel, and challenges with police interaction including violence and harassment. These factors led to a considerable proportion of PLHIV having an interrupted supply of ART. The imposed lockdown (BMJ, 2020) resulted in disruptions in daily life with no access to care, loss of wages, and inability to provide for themselves and their families (Inamdar, 2020). Stringent restrictions on public transport cut off access to previously available free HIV treatment and testing (Beattie et al., 2012).
Limited interactions at ART centers due to Covid-19 precautions, delay in receiving medication, and unavailability of tests, left PLHIV dissatisfied with the care they received. Deprioritization of routine non-ART care including basic health services led to delayed health-seeking; further compounding existing in-access. Our results echo similar findings with access to care among PLHIV in other countries (Marbaniang et al., 2020; Shukla & Ramakant, 2020; Taylor Riley, Elizabeth Sully, Zara Ahmed, & Biddlecom., 2020).
Despite a multitude of challenges, participants showed tremendous resilience in this adversity. Providers formed multi-sectoral linkages with private, government, and community-based networks. Service adaptations like door-to-door deliveries, teleconsultation, and fund-raising to provide necessary supplies ensured that PLHIV had uninterrupted access to medicine supply as well as basic services. Our findings are similar to studies that show vulnerable groups to rely heavily on community-based organizations, highlighting the crucial role community-based organizations play in outreach and access to care, reinforcing the need to collaborate and strengthen these partnerships (Pinto & Park, 2020; Shukla & Ramakant, 2020).
Similarities of HIV and Covid-19 in terms of system preparedness required to control the disease have been echoed by public health experts (Edelman, Aoun-Barakat, Villanueva, & Friedland, 2020) and were reconfirmed in our findings. Covid-19 challenged the health system in multiple ways and reinforced the need for a multi-sectoral effort to prevent disruption in health access, especially for vulnerable groups. Socio-economic deprivation experienced by our respondents can have a long-term impact on mental health and care-seeking (Ng, Muntaner, Chung, & Eaton, 2014). In the wake of these realities, it is critical to design comprehensive health packages and policies that are rights centered, community-driven while responding to Covid-19 or any future pandemic to prevent complex health and social adversities for the PLHIV community.
Authors of the paper:
Dr. Angela Chaudhuri (MPH), Dr. Neha Parikh (MPH), Dr. Syama B Syam (MPH), Pratishtha Singh (MPH), Prachi Pal (MA), Dr. Praneeth Pillala (MBBS)
References:
Beattie, T. S. H., Bhattacharjee, P., Suresh, M., Isac, S., Ramesh, B. M., & Moses, S. (2012). Personal, interpersonal and structural challenges to accessing HIV testing, treatment and care services among female sex workers, men who have sex with men and transgenders in Karnataka state, South India. J Epidemiol Community Health, 66(Suppl 2), ii42. doi: 10.1136/jech-2011-200475
BMJ, I. C. (2020). Covid-19: India should abandon lockdown and refocus its testing policy, say public health specialists. BMJ, 370, m3422. doi: 10.1136/bmj.m3422
Chattopadhyay, S. (2020). India’s COVID-19 lockdown hits HIV+ and chronic patients hard, Aljazeera. Retrieved from https://www.aljazeera.com/news/2020/3/30/indias-covid-19-lockdown-hits-hiv-and-chronic-patients-hard
Edelman, E. J., Aoun-Barakat, L., Villanueva, M., & Friedland, G. (2020). Confronting Another Pandemic: Lessons from HIV can Inform Our COVID-19 Response. AIDS and Behavior, 1. doi: https://doi.org/10.1007/s10461-020-02908-z
Inamdar, N. (2020, 06/05/2020). Coronavirus lockdown: India jobless numbers cross 120 million in April, BBC News. Retrieved from https://www.bbc.com/news/world-asia-india-52559324
Joglekar, N., Paranjape, R., Jain, R., Rahane, G., Potdar, R., Reddy, K. S., & Sahay, S. (2011). Barriers to ART adherence & follow ups among patients attending ART centres in Maharashtra, India. The Indian journal of medical research, 134(6), 954-959. doi: 10.4103/0971-5916.92642
Marbaniang, I., Sangle, S., Nimkar, S., Zarekar, K., Salvi, S., Chavan, A., . . . Mave, V. (2020). The burden of anxiety among people living with HIV during the COVID-19 pandemic in Pune, India. BMC Public Health, 20(1), 1598. doi: 10.1186/s12889-020-09656-8
Ng, E., Muntaner, C., Chung, H., & Eaton, W. W. (2014). Socioeconomic Status and Mental Illness. [https://doi.org/10.1002/9781118410868.wbehibs570]. The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, 2232-2238. doi: https://doi.org/10.1002/9781118410868.wbehibs570
Pinto, R. M., & Park, S. (2020). COVID-19 Pandemic Disrupts HIV Continuum of Care and Prevention: Implications for Research and Practice Concerning Community-Based Organizations and Frontline Providers. AIDS and Behavior, 1.
Shukla, S., & Ramakant, B. (2020). Community networks playing a central role in ensuring access to HIV treatment during India’s COVID-19 lockdown. Retrieved 14/12/2020, from aidsmap https://www.aidsmap.com/news/apr-2020/community-networks-playing-central-role-ensuring-access-hiv-treatment-during-indias
Taylor Riley, Elizabeth Sully, Zara Ahmed, & Biddlecom., A. (2020). Estimates of the Potential Impact of the COVID-19 Pandemic on Sexual and Reproductive Health in Low- and Middle-Income Countries. International Perspectives on Sexual and Reproductive Health, 46, 73-76.
UNAIDS. (2014). The Gap Report (pp. 422).
