Africa: tackle HIV and COVID-19 together - Nature
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People in Mombasa, Kenya, hold empty boxes of antiretrovirals in an April protest over drug shortages caused by the COVID-19 pandemic.
Africa: tackle HIV and
COVID-19 together
Nokukhanya Msomi, Richard Lessells, Koleka Mlisana & Tulio de Oliveira
A
Failure to get COVID-19 s scientists and clinical practitioners to the interactions between COVID-19 and HIV.
working in hospitals and labora- Various studies from before the rollout of
vaccines to nations with tories across South Africa, we’ve COVID-19 vaccines show that people with HIV
high rates of uncontrolled seen at first hand the devastation are 30–50% more likely to die from COVID-19.
that COVID-19 has brought to the What’s more, a failure to tackle the pandemic
advanced HIV puts people country. Many of our colleagues (including with sufficient urgency in countries with high
living with that virus at leading scientists and health-care profession- rates of uncontrolled advanced HIV could
even greater risk, and could als) have died. We have also seen how much lead to the emergence of variants of the
harder it has become for people with HIV to coronavirus SARS-CoV-2 that spread more
drive the emergence of get treatment and monitoring, which has easily between people or render the vaccines
coronavirus variants. meant more people being admitted to hospi- less effective. Conversely, both diseases could
tal with serious illnesses such as tuberculosis be curbed more effectively if they are tackled
and cryptococcal meningitis. simultaneously, with public-health responses
As the world shifts gear in the COVID-19 strengthened by the lessons learnt from both.
pandemic — from tackling the immediate
crisis to a long-term public-health response Risk analysis
— we urge governments, health ministries, In 2020, the World Health Organization (WHO)
researchers and other stakeholders worldwide created a platform for standardized clinical
to devote more of their resources and attention data obtained from people with suspected or
Nature | Vol 600 | 2 December 2021 | 33
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Comment
confirmed COVID-19. A preliminary analysis evolution of SARS-CoV-2, and some of the among other reasons.
of these data from 37 countries (most of variants emerging had similar mutations to What’s more, the COVID-19 pandemic is
which come from South Africa) revealed that, those observed in three of the VOCs. continuing to cause significant disruption to
controlling for other factors, people with HIV In short, it is plausible that a prolonged HIV treatment and prevention programmes.
were 30% more likely to die from COVID-19 COVID-19 infection in someone who is Part of the problem is strained health-
among those hospitalized with the disease1. immunocompromised could lead to the emer- care systems. More than 1,300 health-care
In a more detailed analysis2 of hospitalized gence of a variant that is more transmissible workers died from COVID-19 between March
cases in South Africa, only people with HIV at even than the Delta variant, or that renders 2020 and August 2021 in South Africa alone .
an advanced stage were more likely to die from current COVID-19 vaccines less effective. Thousands more could leave the profession
COVID-19. People in this group are severely because of the impact of COVID-19 on their
immunocompromised: individuals have a HIV crisis physical and mental health, according to a
blood count of fewer than 200 CD4 T cells per Sub-Saharan Africa is home to two out of every report by the International Council of Nurses.
microlitre, compared with 500–1,500 cells per three people living with HIV worldwide. Last Overseas funding for HIV has also declined.
microlitre in people without HIV. (CD4 T cells year, 19.5 million people in sub-Saharan Africa For instance, the UK government slashed
are white blood cells crucial for fighting infec- received antiretroviral therapy, a cocktail international aid spending this year, lead-
tion.) In a population-based analysis of around of drugs that stop HIV from making copies ing to funding cuts of more than 80% for key
3.5 million people from the Western Cape of itself and so lessen the damage the virus organizations involved in the global response
Province of South Africa (around 500,000 causes to the immune system. This is up from to HIV, including the Joint United Nations Pro-
of whom were HIV-positive), people with 12.1 million people 5 years ago. The increase gramme on HIV/AIDS (UNAIDS).
HIV were twice as likely to die from COVID-19 is largely thanks to a stronger commitment Key testing and prevention services declined
(ref. 3). But for those with uncontrolled or by African governments to tackle the HIV in 13 countries supported by the Global Fund
advanced HIV, the risk of dying from COVID‑19 between 2019 and 2020. Of these, 12 are in
was almost four times higher3. “The COVID-19 pandemic Africa. Compared with 2019, HIV testing, for
Other reports over the past year from vari- instance, dropped by 22%; voluntary medical
ous countries indicate that people with weak-
is continuing to cause male circumcision, which reduces female-
ened immune systems can be infected with significant disruption to HIV to-male sexual transmission of HIV by 60%,
SARS-CoV-2 for several weeks or months. (By treatment and prevention dropped by 27%; and the number of mothers
contrast, those who are otherwise healthy take, receiving medicine to prevent the transmis-
on average, around two weeks to clear an infec-
programmes.” sion of HIV to their babies dropped by 4.5%
tion.) Such prolonged infections have mainly (ref. 6).
been documented in people receiving cancer crisis; agreements with antiretroviral-therapy Meanwhile, Africa is being completely left
chemotherapy and other immunosuppressive producers to reduce prices; and more funds behind as COVID-19 diagnostics, therapeutics
agents. But they have also been seen in people provided by organizations such as the US and vaccines are deployed throughout much
with advanced uncontrolled HIV. President’s Emergency Plan for AIDS Relief of the rest of the world. By mid-November,
Some researchers have proposed that pro- (PEPFAR) and the Global Fund to Fight AIDS, more than 40% of people globally had been
longed infection could explain the emergence Tuberculosis and Malaria. fully vaccinated. In Africa, it was less than 7%
of SARS-CoV-2 ‘variants of concern’ (VOCs)4. Nevertheless, 8 million people with HIV (see ‘Left behind’). In Africa, as elsewhere,
Such variants are more transmissible than in sub-Saharan Africa (around 21% of the older age groups are being prioritized for
the originally identified SARS-CoV-2, or are 37.7 million people affected worldwide) are vaccination, as is appropriate. But this means
able to partially evade the immune responses not receiving effective antiretroviral ther- further delays to vaccinating Africa’s main
that arise from infection or vaccination. We apy. Some people have difficulty accessing immunocompromised population. Around
described a case from South Africa in June clinics to obtain treatment. Others might not 80% of people with HIV across the continent
in which SARS‑CoV-2 persisted in a person have been diagnosed. Yet others might be are under 50 years old7.
with advanced uncontrolled HIV for more unaware of the testing and treatment options The initial aim of COVAX, an initiative
than six months5.Repeated genomic sequenc- available, or resist contact with health-care launched in April 2020 by various groups,
ing revealed significant step changes in the providers because they fear stigmatization, including the WHO, to distribute vaccines
to low- and middle-income countries, was to
LEFT BEHIND make two billion vaccine doses available by
On many continents, people who have been fully vaccinated are now receiving an additional dose to boost the end of 2021. By mid-November, in large
immunity. In Africa, most people have not had a single dose; less than 7% are fully vaccinated.
part because of donor countries’ failure to
140 deliver on their commitments, only 507 mil-
South America
Total number of doses administered
North America lion doses had been delivered.
120
Europe All these factors together make sub-Saharan
Oceania Africa especially vulnerable to continued
100
Asia
per 100 people*
Africa and potentially worsening devastation from
80 COVID-19 and HIV. They will also negatively
60
affect the rest of Africa and the wider world.
40 Two birds, one stone
SOURCE: OUR WORLD IN DATA
We urge stakeholders to commit to four goals.
20
0 Vaccinate Africa. For people living with HIV,
Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov protection from COVID-19 requires a renewed
2021
commitment to vaccine equity between coun-
*For vaccines that require multiple doses, each individual dose is counted. Because the same person
might receive more than one dose, the number of doses per 100 people can be higher than 100. tries. This must come from high-income
34 | Nature | Vol 600 | 2 December 2021
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.BRAM JANSSEN/AP/SHUTTERSTOCK
A person living with HIV (right) talks to a worker at a mobile clinic in Johannesburg, South Africa, during the COVID-19 pandemic.
nations and multilateral initiatives such as less than 1% of the participants in the phase III Centers for Disease Control and Prevention,
COVAX8. Over and above the ethical argu- COVID-19 vaccine trials conducted by Pfizer– already recommend that health-care
ments to address vaccine nationalism and BioNTech, Moderna, AstraZeneca and providers give an additional dose to people
reduce deaths globally, the available data Johnson & Johnson. (These have all reported with advanced uncontrolled HIV. But govern-
strongly indicate that vaccinating people safety and efficacy results, but participant fol- ments of low- and middle-income countries
in Africa will help to reduce transmission low-up is ongoing.) In fact, our own investiga- might well demand stronger scientific evi-
rates globally, limit the emergence of new tion found that, for some of the vaccines now dence before they fund the distribution of
variants and accelerate global control of the being rolled out in Africa (such as Sinopharm, additional doses to immunocompromised
pandemic9. Sinovac and Sputnik), people living with HIV populations. Also, it is not yet clear which
were excluded from the phase III trials. subgroups of people living with HIV might
Prioritize research. Several gaps in knowl- Individuals on antiretroviral therapy benefit, or what the optimal timing of the
edge around the interaction of COVID-19 and who have well-controlled HIV seem to have additional vaccine dose might be, particularly
HIV urgently need addressing to inform the immune responses to COVID-19 vaccination in people starting or restarting antiretroviral
long-term public-health response. that are similar to those of people without therapy.
More clinical and basic studies could reveal HIV10,11. But several observational studies As vaccines are rolled out in countries
whether prolonged SARS-CoV-2 infections suggest that immune responses to COVID-19 that have high rates of HIV, governments,
are routine in people with advanced uncon- vaccination might be blunted in people with with leadership from organizations such as
trolled HIV or extremely rare — and whether low CD4 T-cell counts12.This is consistent with the WHO and the Africa Centres for Disease
such infections still occur after people have what we know about how the immune systems Control and Prevention, must support
been vaccinated. Studying the interaction of people living with HIV respond to other surveillance and monitoring systems for eval-
between COVID-19 and HIV must not detract vaccines13. uating the effectiveness of COVID-19 vaccines
from promptly providing individuals with Clinical-trial data suggest that an addi- in people living with HIV.
proper care — in particular, antiretroviral tional COVID-19 vaccine dose might enhance
therapies, or new types of antiretroviral the immune response in other immuno Maintain HIV services. Governments, depart-
treatment if previous ones have not worked. compromised groups 14. These include ments of health and organizations such as
Although COVID-19 vaccines have been people who have had an organ transplant PEPFAR and the Global Fund need to take
shown to be safe in people living with HIV, and are receiving treatment to suppress their steps now to ensure that the progress made
there are some uncertainties when it comes immune systems. over the past few years to control the HIV
to COVID-19 vaccination strategies. International guidelines, such as those pandemic does not go into reverse.
Overall, people living with HIV represent from the British HIV Association and the US Across sub-Saharan Africa, health-care
Nature | Vol 600 | 2 December 2021 | 35
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.Comment
AFRICA’S HIV TREATMENT GAP stigmatization of people living with HIV. It
Around one-third of people living with HIV in sub-Saharan Africa could also encourage the application of unfair
in 2020 were not getting effective antiretroviral treatment.
public-health measures (such as travel restric-
25.3 million people (estimate) tions) to countries with high rates of HIV.
HIV load Treatment Diagnosed, Undiagnosed The United States banned non-citizens who
suppressed by treatment not effective not treated HIV had tested positive for HIV from entering the
17.3 (million) 2.2 2.4 3.4
country for 22 years. (The ban was lifted only
in 2010.) And many other countries, such as
SOURCE: UNAIDS (2020 DATA)
Australia and New Zealand, still refuse to give
citizenship to people with HIV, even though
effective antiretroviral treatments are now
Around 8 million people urgently available.
need effective antiretroviral
treatment for HIV, as well as The best way for governments to protect
vaccination against COVID-19. their citizens is not by further stigmatizing
those infected with HIV; it is by quickly pro-
providers have used various approaches to try that people in these countries are offered HIV viding vaccines to protect the world’s most
to protect essential health services from dis- testing whenever they have any contact with vulnerable. Only global solidarity — not dis-
ruptions caused by the COVID-19 pandemic. the health system. (In practice, this happens crimination, blockage or the hoarding of
Examples in HIV programmes include pro- patchily.) Thus, providing people with preven- resources — will end the COVID-19 pandemic.
viding people with several months’ worth tion and care for COVID-19 provides an oppor-
of antiretroviral therapy instead of one- or tunity to boost care and treatment for HIV.
two-months’ supply; providing antiretroviral Ultimately, sustained efforts to ensure The authors
therapies or ways to check CD4 T-cell levels at that people with HIV are diagnosed, given
people’s homes or at community centres; and antiretroviral treatment and then followed Nokukhanya Msomi is head of the Virology
online appointments with physicians15. Care up to ensure that their viral load is being sup- Department, University of KwaZulu-Natal,
providers and others can use the experiences pressed (see ‘Africa’s HIV treatment gap’) are Durban, South Africa, and a clinical virologist
of the past two years to map out how best to at the National Health Laboratory Services,
scale up effective strategies in the future. “Ongoing complacency Inkosi Albert Luthuli Central Hospital,
In the longer term, stakeholders could also Durban, South Africa. Richard Lessells
apply some of the innovations in the global
about how the COVID-19 is an infectious-diseases specialist at the
COVID-19 response to HIV. Extraordinary pandemic is playing out in KwaZulu-Natal Research Innovation and
achievements, for instance, in the tracking Africa is misplaced.” Sequencing Platform, University of KwaZulu-
of cases and deaths, in genomic surveillance Natal, Durban, South Africa. Koleka Mlisana
and in data sharing have demonstrated the is the executive manager of academic
degree to which ‘knowing your epidemic’ crucial to reducing the burden of advanced affairs, research and quality assurance at
in near-real time can help to guide a pub- HIV in the population — and so limiting the the National Health Laboratory Services,
lic-health response at local, national and potential for cases of prolonged infection from Johannesburg, South Africa. Tulio de
global scales. SARS-CoV-2. Encouragingly, in our case study Oliveira is director of the Centre for Epidemic
In fact, besides impressive global collab- from South Africa, the individual cleared the Response and Innovation, Stellenbosch
oration, the scientific response to COVID-19 SARS-CoV-2 infection three weeks after being University, Stellenbosch, South Africa, and of
has strengthened local and regional col- given effective HIV treatment5. the KwaZulu-Natal Research Innovation and
laboration across Africa, including in Sequencing Platform.
clinical research, in the trials of vaccines Avoid stigmatization e-mail: tulio@sun.ac.za
and therapeutics, and in epidemiology and What the past year has shown is that early —
1. World Health Organization. Clinical Features and
genomics 16–18. The scientific community and ongoing — complacency about how the Prognostic Factors of COVID-19 in People Living with HIV
globally should support these networks and COVID-19 pandemic is playing out in Africa Hospitalized with Suspected or Confirmed SARS-CoV-2
expand their scope to help address HIV as is misplaced. Infection (WHO, 2021).
2. Jassat, W. et al. Lancet HIV 8, e554–e567 (2021).
well as the other public-health priorities in Comparing only cases and deaths across 3. Boulle, A. et al. Clin. Infect. Dis. 73, e2005–e2015 (2021).
Africa — tuberculosis, malaria and neglected countries or continents with different demo- 4. Corey, L. et al. N. Engl. J. Med. 385, 562–566 (2021).
tropical diseases. graphics, and obtained using different testing 5. Karim, F. et al. Preprint at medRxiv https://doi.
org/10.1101/2021.06.03.21258228 (2021).
strategies and reporting systems, can give a 6. The Global Fund. Results Report 2021 (Global Fund, 2021).
Integrate health systems. Governments, misleading picture19. A rolling analysis of excess 7. Autenrieth, C. S. et al. PLoS ONE 13, e0207005 (2018).
departments of health and HIV programmes deaths in South Africa, for instance, indicates 8. World Health Organization. Strategy to Achieve Global
Covid-19 Vaccination by Mid-2022 (WHO, 2021).
need to find better ways to integrate COVID‑19 that deaths from COVID‑19 could be between 9. Wagner, C. E. et al. Science 373, eabj7364 (2021).
and HIV services. Providing COVID-19 vacci- two and three times higher than reported 10. Madhi, S. A. et al. Lancet HIV 8, E568–E580 (2021).
nation at clinics and centres that currently deaths, and that South Africa has been one 11. Frater, J. et al. Lancet HIV 8, e474–e485 (2021).
12. Spinelli, M. A. et al. Preprint at SSRN https://doi.
offer testing and antiretroviral therapies for of the hardest-hit countries in the world (see
org/10.2139/ssrn.3909785 (2021).
HIV could help to ensure that people with go.nature.com/3r6dt3j). Certainly, a 30–50% 13. Kernéis, S. et al. Clin. Infect. Dis. 58, 1130–1139 (2014).
advanced or uncontrolled HIV are prioritized increased chance of death from COVID-19 for a 14. Hall, V. G. et al. N. Engl. J. Med. 385, 1244–1246 (2021).
15. Inzaule, S. C. et al. PLoS Med. 18, e1003666 (2021).
for COVID-19 vaccination, including any addi- young sector of the population that makes up
16. Salyer, S. J. et al. Lancet 397, 1265–1275 (2021).
tional doses that might be recommended. most of the workforce could have devastating 17. Wilkinson, E. et al. Science 374, 423–431 (2021).
Similarly, people living in countries that consequences in the long term. 18. Biccard, B. M. et al. Lancet 397, 1885–1894 (2021).
19. Burki, T. K. Lancet Respir. Med. https://doi.org/10.1016/
have high rates of HIV should be offered HIV On the flip side, an obvious risk of drawing
S2213-2600(21)00504-X (2021).
testing whenever they receive a COVID-19 attention to the interactions between
vaccine. Currently, the WHO recommends SARS-CoV-2 and HIV is increasing the The authors declare no competing interests.
36 | Nature | Vol 600 | 2 December 2021
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