HIV service delivery to key populations in the time of COVID-19: experiences from India


BACKGROUND: In March 2020, the Government of India revised HIV service delivery policies in response to COVID-19 to include community distribution and multi-month dispensation (MMD) of ART for stable and unstable PLHIV. There are limited data on the impact of COVID-19-associated disruptions and novel service strategies on HIV service access among key populations in low- and middle- income countries.
METHODS: Between November-December 2020, we conducted focus groups with purposively sampled men who have sex with men (MSM), female sex workers (FSW), and transgender women (TGW) in Telangana and Maharashtra, Indian states with high HIV burdens. Seven focus groups were conducted; five by phone and two in-person with safety precautions. Discussion topics included service access experiences, medication adherence, and preferences to ensure service continuation. Inductive coding identified themes across topics.
RESULTS: 44 individuals participated in focus groups (13 MSM; 16 FSW; 15 TGW) aged 20-49 years. 24 participants self-identified as living with HIV. HIV negative participants reported challenges to get HIV tests at hospitals due to lockdown travel restrictions and fear of contracting COVID-19. Some accessed HIV testing using transportation arranged by community-based organizations. Most PLHIV reported uninterrupted ART refills; however, some reported lapses in ART adherence and delayed viral load testing. Participants receiving MMD shared consistent appreciation for the service as it saved time, money and reduced exposure to COVID-19 and stigmatizing environments. PLHIV expressed gratitude for home deliveries which enabled access to ART, yet discouraged continuing home-based services due to the risk of a confidentiality breach to family/neighbors. Most suggested community dispensation points. Other themes included loss of livelihood and requests for economic support across groups, and concerns about telemedicine as a service option from FSW and TGW related to limited smartphone access.
CONCLUSIONS: COVID-19 had a greater impact on access to testing services (HIV testing, viral load) compared to treatment services. High acceptance of MMD and community-based services support the need for differentiated service delivery models to overcome COVID-19 disruptions. Varied preferences across key populations related to new service mechanisms and calls to address the impact of COVID-19 on livelihood options underscore the importance of tailoring HIV care to community needs.