Mitigating the COVID-19 challenges to HIV prevention efforts in Africa: A socio-behavioral perspective

ABSTRACT

In this commentary, the authors highlight how the COVID-19 pandemic has a range of negative effects on HIV prevention in Africa, both well documented HIV service interruptions and less well appreciated effects of the socio-structural context that put people at risk of HIV (e.g. loss of earnings, stigma). The authors call on the global community to unpack and address these factors as the pandemic surges in Africa. They point to best practices and tools from decades of socio-behavioural research and programming responses in the HIV field that can be applied to COVID-19 efforts, including for vaccines being rolled out.

KEYWORDS:

• HIV
• Africa
• socio-behavioural
• COVID-19

Recent developments show the COVID-19 pandemic exploding in several regions of the world that were not as hard hit in the original pandemic waves, including sub-Saharan Africa (Mwai, 2021). Impacts from COVID-19 in Africa – which has burgeoning populations of young people who face some of the highest risk of acquiring HIV worldwide – are disrupting several decades of progress in combatting HIV/AIDS. We must consider the many challenges to HIV prevention efforts due to COVID and formulate an effective response.

COVID-19 can facilitate HIV transmission through multiple pathways. Fear of getting exposed to COVID combined with lockdowns to slow its spread have severely limited people's ability (and willingness) to seek HIV services at clinics. Documented interruptions in key services such as HIV testing (UNAIDS, 2020), and the added burdens on health workers and facilities, also pose setbacks to HIV prevention – and reproductive health efforts more broadly.

It has been less widely appreciated, however, that there are important effects of COVID-19 on the structural, social, and behavioural contexts that put people at risk of HIV. For example, a loss of earnings has led to increased food insecurity (Teachout & Zipfel, 2020), which in turn may impact people's ability to tolerate antiretroviral therapy and pre-exposure prophylaxis. Food insecurity can also be exacerbated by local policy contexts that prohibit access of certain sub-groups (like immigrants) to social welfare programmes (Odunitan-Wayas et al., 2021). For groups particularly vulnerable to HIV transmission, such as sex workers and people who inject drugs, underlying stigmas can further exacerbate the challenges brought by COVID-19 (Iversen et al., 2020). Sex workers, for example, have experienced various intersecting challenges due to COVID-19, including a loss of income coupled with increased potential exposure to COVID infection plus existing stigmas (Kimani et al., 2020). And research prior to COVID-19 has shown that transactional sex increases when women are faced with economic shocks (Robinson & Yeh, 2011).

COVID-19 also has notable psycho-social effects on individuals and couples. Increased stress and depression due to COVID-19 can lead to a lack of HIV-related self-care (WHO, 2020). And reports of surges in intimate partner violence (IPV) surfaced in many countries – including in Africa – from the very beginning of the pandemic (e.g. Betron et al., 2020; Taub, 2020). The links between HIV risk and IPV are well known, and relevant data in the context of COVID-19 are growing. One study with 603 adolescent girls and young women (AGYW) in Kenya – conducted during COVID-related lockdowns – found that 47% reported increased feelings of depression and hopelessness, and 13% had experienced physical abuse in the past month (Population Council, 2020).

Drawing upon social and behavioural science insights and conceptual models – such as the socio-ecological model (Bronfenbrenner, 1989; Haberer et al., 2021), which outlines the need to simultaneously address structural, community, interpersonal, and individual factors – can help guide a response to these challenges.

On the structural level, we should expand cash transfer programmes to lessen the economic impacts of COVID-19, and consequently the knock-on HIV-related effects. The World Bank has noted that over 60 countries have introduced such cash transfer programmes. We should ensure that these programmes include populations at high risk of acquiring HIV in Africa, like AGYW.

On the community level, more effectively drawing upon communications strategies and methods is required. We should incorporate community-designed and differentiated messages that encourage different subgroups of people to continue using HIV services and bring in a range of trusted messengers including community leaders and young people. We should take advantage of the latest e/m-Health strategies and tools (e.g. mobile phones) to maximize continuity of HIV care, and expand telemedicine and virtual counselling options.

On the interpersonal and individual level, we should actively tackle the parallel pandemic of IPV, such as by including IPV services in COVID-19 programming and implementing communication campaigns to shift gender norms that facilitate violence. We should also address the substantial psychological effects by incorporating mental health services into both HIV and COVID-19 responses.

We need to prepare for long-term effects of COVID-19 on HIV prevention in Africa, including how to best roll-out COVID-19 vaccines among vulnerable communities as they increasingly become available. Appropriate responses will vary based on the economic and health infrastructures of individual countries (Hodgins & Saad, 2020), and well as cultural differences. Socio-behavioural lessons learned from confronting the HIV pandemic regarding, for example, how to link health facility-based services with community-based programming, will be important templates (e.g. Vanhamel et al., 2020). Long-standing experience combatting HIV stigma can also be applied to stigma now associated with COVID-19 (e.g. Logie, 2020). Deploying and evaluating strategies with an explicit socio-behavioural lens will be key for ensuring that we can both address COVID-19 challenges and that new HIV infections do not increase in the months and years ahead. Recent data demonstrate that people living with HIV experience poorer COVID-related outcomes (including higher rates of severe disease requiring hospitalisation) compared to those without an HIV diagnosis, which further emphasises the urgency around this issue (Tesoriero et al., 2021). And strategies that balance public health needs with socio-behavioural considerations (e.g. Logie & Turan, 2020) will also help prepare us for the next unexpected health crisis.

Acknowledgements

Co-authors are all members of the Socio-Behavioral and Structural Working Group (SBSWG) of the HIV Prevention Trials Network (HPTN), and this work was supported by the HPTN. Thank you to the broader SBSWG, the Community Working Group, and HPTN leadership for their review of this commentary. Overall support for the HPTN is provided by the National Institute of Allergy and Infectious Diseases (NIAID), Office of the Director (OD), National Institutes of Health (NIH), National Institute on Drug Abuse (NIDA), the National Institute of Mental Health (NIMH), and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), under Award Number UM1AI068619-15 (HPTN Leadership and Operations Center), UM1AI068617-15 (HPTN Statistical and Data Management Center), and UM1AI068613-15 (HPTN Laboratory Center). The content is solely the responsibility of the authors and does not necessarily represent the official views of NIAID, OD, NIH, NIDA, NIMH, or the HPTN.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability

Data sharing is not applicable to this article as no new data were created or analysed in this study.

Additional information

Funding

This work was supported by the HIV Prevention Trials Network (HPTN).