The impact of COVID-19 on HIV treatment and care delivery in South and Southeast Asia: a qualitative study

Abstract

The COVID-19 pandemic has significantly impacted HIV treatment worldwide, but its effects on South and Southeast Asia, particularly in India, Indonesia, and Thailand, have been less evident. Our aim was to study the perceptions of providers and policymakers to understand how interventions were implemented as part of pandemic responses and how their effectiveness was viewed. We conducted a qualitative study with semi-structured interviews focusing on the shifts in HIV care in response to the pandemic. Between June and July 2021, 40 individuals were invited for interviews; 33 (83%) agreed. Participants included 25 (76%) providers and 8 (24%) policymakers, who were from India (10; 30%), Indonesia (10; 30%), and Thailand (10; 30%), along with 3 (9.1%) regional policymakers. Sixteen (48%) were female. Our findings revealed four major themes: (1) limitations in accessing HIV care due to movement restrictions and shutdowns, such as transportation issues; (2) diversion of healthcare resources away from HIV care to COVID-19 responses, leading to reallocation of providers and hospital space; (3) setbacks in HIV-related policy implementation as COVID-19 emergency responses took priority; (4) the expansion of HIV differentiated service delivery interventions, allowing longer gaps between visits and larger-volume prescription refills to delay returns to healthcare facilities. These changes have raised concerns about the long-term consequences on HIV epidemic control and future pandemic responses. However, they have also presented opportunities for innovative care delivery, which should be sustained to address these challenges effectively.

Keywords:

• Human immunodeficiency virus
• COVID-19
• pandemic
• South Asia
• Southeast Asia

Introduction

The emergence of the COVID-19 pandemic led to substantial morbidity, mortality, and impacts on social and economic stability. Resources were diverted to manage COVID-19, interrupting care for other conditions and severely straining health systems [1]. The impacts of the pandemic and national responses caused especially concerning outcomes among people with HIV [2].

In South and Southeast Asia, India, Indonesia, and Thailand have been heavily impacted by both HIV and COVID-19. During the height of the regional epidemic in 2021, India had the second-highest number of COVID-19 cases in the world and Indonesia was number 14 [3]. Thailand had been relatively successful in its efforts to contain COVID-19 through early 2021 but faltered in the summer of 2021 [3]. In 2021, the estimated HIV prevalence across India’s states ranged between 0 to 1.6%, representing 2.5 million people with HIV and the largest burden in the region, and was 0.3% in Indonesia (540,000) and 1.1% in Thailand (560,000) [4, 5].

It remains unclear to what extent COVID-19-related interventions qualitatively changed HIV treatment in South and Southeast Asia, and what the long-term effects of these modifications may be. We studied the perceptions of providers and policymakers in India, Indonesia, and Thailand to understand how those involved with HIV care delivery and policy viewed the interventions implemented as part of pandemic responses and whether there were viable pathways to their continuation over time.

Materials and methods

Study setting

HIV-related care in these three countries was impacted along with other services as public health programs responded to the extent of the COVID-19 health emergency, with the first lockdowns starting in mid-March 2020 (India, March 24; Indonesia, March 15; Thailand, March 22) [6; Wikipedia 2024). In India, the initial relaxation of the lockdown started in May 2020. In Indonesia, although restrictions were loosened in June 2020, they were reinstated in September 2020. The public curfew was lifted in Thailand in July 2020, and targeted interventions were used during subsequent surges (e.g., mass testing or restrictions in specific provinces). Reductions in access to healthcare services included limitations in HIV testing and care for people living with HIV, which was exacerbated in some contexts by disruptions to antiretroviral drug supplies [7].

Study design and sample selection

We conducted a qualitative study to assess the impact of the COVID-19 pandemic in India, Indonesia, and Thailand and the region using semi-structured interviews with providers and policymakers with different roles in HIV care delivery. The sample was primarily selected from HIV clinics and governmental contacts through the TREAT Asia network, a regional research consortium, which included three HIV clinics in India (located in Chennai and Pune), two in Indonesia (located in Bali and Jakarta), and six in Thailand (located in Bangkok, Chiang Mai, and Chiang Rai). This was complemented by representatives of regional HIV policy organizations responsible for multiple countries in the Asia-Pacific.

Convenience and purposive sampling were used to identify participants across the target categories. Specifically, we aimed to include at least two physicians, two non-physician providers, and two national policymakers in each country, along with three regional policymakers. Information gathered during the initial interviews was used to guide subsequent sample selection in order to reach theoretical saturation, following theoretical sampling principles [8]. While we focused recruitment on public sector providers, we also included providers from the private sector. Recruitment emails were sent to eligible potential participants who confirmed their interest before scheduling a virtual interview from their location of choice.

Data collection and analysis

After informed consent was obtained, interviews were conducted in English by one of two study team members (SA, AHS) using an online video conferencing platform (i.e. Zoom or Skype) and were recorded. Two separate interview guides were used for HIV care providers (both physicians and non-physician providers) and national and key regional policymakers (Supplemental Files 1 and 2). The guides were adapted (with permission) from a study examining the impact of COVID-19 on HIV care services in California, USA, with revisions to the questions to better fit the roles of our study participants and local contexts [9]. Interviews were transcribed for analysis. Template analysis allows for rapid analysis of qualitative data while data collection is ongoing and was used to identify common themes that arose during participant interviews [10]. Transcripts were studied following a deductive process, where emergent themes were used to guide further analysis.

Ethical considerations

Participants electronically consented to be interviewed and recorded using a Qualtrics form. Participants were informed that they were able to withdraw from the study at any time; in which case, audio and video-recorded data would be destroyed. No financial compensation was provided. All interview transcripts were de-identified and anonymized, and any mention of participant names was excluded from the final interview summaries used for analysis. This study was approved by the University of California, San Francisco Institutional Review Board under the study number 21-33995.

Results

Between June and July 2021, 40 individuals were invited for interviews; 33 (83%) consented to participate, including 25 (76%) providers and 8 (24%) policymakers, who were in India (10; 30%), Indonesia (10; 30%), Thailand (10; 30%), and the region (3; 9.1%). We were only able to recruit one of the two national policymakers targeted for India. Sixteen (48%) participants were female (Table 1).

Table 1. Participant demographics by country & region.

Participants	India (n = 10)	Indonesia (n = 10)	Thailand (n = 10)	Regional (n = 3)	Total (N = 33)
Female sex	3	4	7	2	16
Physician	6	6	6	0	18
Non-physician	3	2	2	0	7
Policymaker	1	2	2	3	8

Overall, participants identified four major themes related to the impacts of the COVID-19 pandemic on HIV care delivery in their local and regional contexts: (1) limitations in access to HIV care, (2) diversion of healthcare resources away from HIV care, (3) setbacks in HIV-related policy implementation, and (4) expansion of HIV differentiated service delivery interventions.

Limitations in access to HIV care

The most common issues reported by respondents were related to access to HIV care. Government-imposed lockdowns contributed to decreased usage of medical services and heightened fear, leading to a decline in HIV services offered by providers. Spikes in COVID-19 cases, as well as the uncertainty surrounding outcomes for people with HIV with COVID-19, led to reduced uptake of in-person HIV services.

All participants spoke directly about lockdowns in their region. An Indian physician said, ‘people living with HIV couldn’t travel to the clinic for routine care and for collecting medication and doing their routine labs, like CD4 and viral loads’ (Provider-physician, male, India). In Indonesia, physicians spoke about the pandemic especially affecting people with HIV who lived far from clinics. A policymaker in Thailand spoke about how lockdowns acted as a deterrent for patients because ‘when they go back to their hometown, they need to be quarantined for 14 days’ (Policymaker, female, Thailand). In addition, providers were afraid to come into contact with patients who may have been infected with COVID-19. An Indonesian policymaker recounted that at one point, ‘90% of the nurses and the doctors [were] also infected’ (Policymaker, female, Indonesia).

People with HIV were fearful because many were unsure of what their positive HIV status meant in the context of COVID-19. A provider in Thailand noted that:

The number of clients coming into our clinics and other large sexual health or STI [sexually transmitted infection] clinics has decreased to the level of just 30 to 50% of the normal number of clients coming in. But it’s more for HIV testing, STI testing, and PrEP [pre-exposure prophylaxis] and PEP [post-exposure prophylaxis]. (Provider-physician, female, Thailand).

Medication stock-outs of antiretrovirals (ARV) due to COVID-19-related closures and supply-chain disruptions further limited access to HIV treatment. This had local as well as global impacts due to India’s role as the world’s largest producer of generic ARVs. An Indian policymaker explained that:

It was because of the lockdown and non-availability of the labor that they were not able to really transport the drugs to other countries where they were required, because there were no flights, there were no trucks to carry these from their manufacturing sites to the airports. (Policymaker, male, India).

In Indonesia, a regional policymaker described that:

Due to the issues of procurement and distribution, many services have experienced ARV stock-outs in Indonesia and 44% of young people living with HIV surveyed at that time reported that they had less than one month supply of ARV only. (Policymaker, female, regional).

The Thai government changed their policy to limit HIV medicine distribution to district hospitals, which caused some people with HIV to have to opt out of receiving the free government-funded ARVs and instead pay for their own medicines at clinics closer home.

Diversion of healthcare resources away from HIV care

The diversion of human and physical resources toward COVID-19 and away from HIV was especially apparent in hospitals flooded with patients seeking COVID-19 care. At one point during the pandemic, an Indian provider stated that his province was advised to set aside 80% of hospital beds for COVID-19 patients, by law. The influx of COVID-19 patients into healthcare systems reduced the focus on HIV care, as it was infectious disease specialists who cared for both people with HIV and COVID-19 patients.

The increased burden of COVID-19 patients in hospitals had a significant impact on HIV care providers. A provider in Thailand explained:

I also don’t know how long we can do this work. It’s kind of double [the] amount of work and responsibilities. So I’m more afraid of the long-term – it may not be long from now – this burnout, now, from all the providers here. (Provider-physician, female, Thailand).

Similarly, an Indonesian policymaker described the increased physician workload and shift of focus, explaining ‘now, they have triple [the] job. 70% of their time [is] for COVID and 30% is to manage their own program, like HIV’ (Policymaker, male, Indonesia). Ultimately, a regional policymaker summed up the impact of COVID-19 by saying ‘Sometimes, I feel that HIV has become irrelevant to providers’ (Policymaker, female, regional).

Setbacks in HIV-related policy implementation

A concerning consequence of the COVID-19 pandemic has been its effects on slowing down HIV-related policy implementation. Prior to COVID-19, the top goal for HIV programs was to increase HIV detection among people with HIV to 90%, ART initiation among 90% of people who know their HIV status, and ART adherence to achieve undetectable HIV levels among 90% of people with HIV, representing the UNAIDS 90-90-90 targets. However, as reported by participants in all three countries, the obstacles created by COVID-19 shifted the goal to just maintaining treatment for those on ART. This was a serious issue in Indonesia, which even before COVID-19 had one of the lowest ART coverage and HIV viral suppression levels in the region. An Indonesian policymaker questioned whether these goals were even achievable, ‘I don’t think, at this pace, Indonesia can reach the 2030 target. And so, in the long-term, and after this pandemic, we’ll still have to work hard to get to 90-90-90’ (Policymaker, female, Indonesia). Many providers noted that because efforts became focused on maintaining access to ART during COVID-19, other goals, such as prevention, became secondary or were halted completely.

Expansion of HIV differentiated service delivery interventions

Respondents commented on one positive consequence of the pandemic, which was the scale-up of DSD. One regional policymaker expressed this positive outlook, saying ‘there are some opportunities. Right? There [are] problems. But, in the midst of that, opportunity emerges’ (Policymaker, female, regional).

One DSD intervention implemented in the region was multi-month dispensing, which allowed patients to receive larger refills of their ART and alleviate the workload on providers and pharmacies. Prior to the pandemic, ART was usually prescribed for 3–4 months in Thailand, 2–3 months in India, and 1 month in Indonesia. Some providers were reluctant to allow multi-month prescriptions because they were uncertain about medication adherence if patients came into clinics less often. However, in the context of COVID-19, providers were forced to implement multi-month dispensing and saw its benefits. In Thailand, providers and systems were prepared to scale up refills to six months because, according to a Thai physician:

We have been through some natural disaster scenarios a few years before, like the major flooding [where] people cannot travel. So like HIV nurses and doctors were quick to adapt themselves in like, okay, so, now, we just get this medication pack, and then, send it to clients. So it’s just like, okay, we initiate [those] measures again. (Provider-physician, female, Thailand).

However, other providers complained about the lack of standardized guidelines for multi-month dispensing and the lack of additional funding or support to clinics delivering HIV care. Multi-month dispensing was not as effective in India and Indonesia, due in part to medication stock-outs. An Indonesian policymaker stated that:

At first, stocks were very low, so we could only give 2 weeks, later this increased to one month, and then eventually 2-3 months at larger facilities. Overall, [Indonesia] did not have procurement and distribution mechanisms in place to effectively implement multi-month dispensing. (Policymaker, male, Indonesia).

Telehealth was another DSD intervention that was implemented or expanded in the region as a result of the COVID-19 pandemic, the lockdowns, and the widespread fear of going to a clinic to see a provider in person among both people with HIV and providers. One clinical researcher from India went so far as to say ‘before COVID, it was against the law of the land’ (Provider-non-physician, female, India). In Indonesia, a policymaker explained that providers were hesitant at first to use telemedicine, but this rapidly changed when travel to clinics was not possible or not preferred. However, some providers said they did not expect telemedicine to become routine in HIV care. A Thai provider stated that people are ready to return to their clinics in person, especially for preventative HIV services, explaining, ‘people want to come in for HIV testing. People want to come in for PrEP and PEP. They just don’t want to get telehealth anymore’ (Provider-physician, female, Thailand).

Another DSD intervention was the use of delivery services to send HIV medications directly to patient homes. In all three countries, public and private courier services were used (e.g. governmental post, and online delivery apps using motorbikes). Medication delivery directly to patient homes was already common practice in Thailand prior to COVID-19. A Thai provider explains that this was ‘because some patients live quite far away, like six hour or eight hours from Bangkok. So, sometimes they cannot come to Bangkok’ (Provider-physician, female, Thailand).

While community trust and support have always been important in the delivery of HIV care, involvement of networks of people with HIV and other community organizations became essential during the pandemic. Community leaders stepped up in many ways, including educating people with HIV about COVID-19 and advocating for access to vaccination. A Thai policymaker noted the importance of community in HIV care, saying ‘the community is a core of the crisis response. In HIV, they always say that the community is the key, but COVID may make it more highlighted’ (Policymaker, male, Thailand). However, it was more challenging in the Indonesian context where such programs were already weaker before the pandemic. A regional policymaker described this by saying ‘the [Indonesian] civil societies are not very strong, not supported, not prioritized’ (Policymaker, female, regional).

Discussion

Our interviews with providers and policymakers in India, Indonesia, and Thailand described both negative and positive impacts of the COVID-pandemic on HIV care delivery and outcomes. There were some similarities in the approaches taken to address challenges related to the COVID-19 pandemic, but also unique aspects of their healthcare systems that impacted HIV testing and access to treatment for people with HIV [7,11–13]. For example, the resilience in Thailand’s national HIV program was felt to be in large part because the country already had a strong, centralized health system and a stable network of HIV care services, allowing them to quickly expand DSD interventions and adapt to the changing conditions. Meanwhile, India and Indonesia have been reported to have struggled more due to their decentralized health systems and medication stockouts. Our participants also shared that DSD interventions were not in place to a substantial degree prior to the pandemic, which meant that these countries needed to pilot and expand services at the same time.

The results of this study are similar to studies conducted in other geographic contexts. One multi-country study in sub-Saharan Africa on COVID-19 and treatment adherence in people with HIV noted that COVID-19 strained provider resources and impeded access to medical care and community-based support [14]. A study in East Africa described disruptions to HIV care and fear and anxiety, and highlighted multi-month dispensing to reduce patient interaction in clinics [15]. When looking at research conducted in higher-income countries like the US, United Kingdom, and Europe, similar innovations like multi-month dispensing and telehealth were used to support people with HIV during COVID-19 responses [16].

The majority of recommendations for the future given by both providers and policymakers in our study focused on the need to formalize and expand interventions. Respondents in Thailand called for the creation of standardized guidelines to facilitate the use of DSD and telehealth for providers. Studies have found that implementation of telehealth and similar DSD interventions have comparable effectiveness to standard in-person care in HIV; however, national support and resources will be required for sustained and effective implementation [17,18]. There also were recommendations to recognize community members and lay providers involved in delivering or supporting HIV care as frontline workers who deserved to be included in the initial roll-outs of vaccines and distribution of personal protective equipment. The opportunity to utilize community-led health services for these purposes is especially promising, as these have already been demonstrated to successfully deliver HIV testing, prevention, and treatment services in the region [19,20]. Increasing education among people with HIV and providers about the utility of DSD interventions, as well as creating coordinated systems among HIV care facilities were endorsed as key strategies to effectively ensure uninterrupted access to HIV care during pandemics and as tools to address pre-existing obstacles to care delivery.

A key limitation of the study was the sample size and the number of participants interviewed in each country. This is particularly notable when comparing country size between India and Indonesia relative to Thailand. The sample was further restricted because we interviewed only English-speaking participants from urbanized centers, which led to a predominance of physicians over other healthcare providers. We also did not speak to patients receiving HIV care, so we cannot compare our findings to their lived experiences. In addition, we used a virtual platform to conduct the interviews, which may have influenced how participants answered questions compared to if they had been in person. However, it was valuable to observe how their perspectives often converged around similar themes, which was confirmed by our analysis, and reflected the level of data saturation we believe was achieved.

Conclusions

The perspectives of providers and policymakers in India, Indonesia, Thailand, and the South and Southeast Asia region during the initial phases of the COVID-19 pandemic illustrate how local responses imposed substantial barriers to HIV care delivery. Limited access to care, repurposed medical personnel and resources, and delayed HIV policy implementation are just a few of the consequences with lasting repercussions. While many of these impacts have been observed in other global regions, our findings highlight the opportunities to advance the innovations put in place to address these challenges in Asian contexts. The emerging lessons learned around pandemic response can lead to improved pandemic preparedness as well as the integration of innovative interventions into ongoing care-delivery strategies.

Acknowledgments

We would like to thank our study participants, Noweed Charles and the amfAR’s TREAT Asia team in Bangkok, and Dr. Madhavi Dandu of the UCSF Global Health Sciences program for their support for the study.

Disclosure statement

AHS receives grants to her institution from ViiV Healthcare. Other authors report no competing interests to declare.

Data availability statement

The data are not publicly available due to participants not providing informed consent for the interview transcripts to be shared publicly.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.