Rapid rebound in HIV service utilization following initial interruptions to HIV prevention and treatment for key populations during COVID-19 in South Africa


BACKGROUND: COVID-19 pandemic lockdown measures interrupted the delivery of HIV prevention and treatment services globally, including in South Africa. For key populations (KP), little is known about the impact of lockdowns on HIV service utilization.
METHODS: We conducted an interrupted time series analysis using weekly HIV program data collected by three USAID implementing partners between October 2019 and September 2020. Segmented linear regression models were used to assess the immediate and sustained impact of level 5 lockdown (March 26-May 1, 2020) on HIV case finding and treatment initiation for female sex workers (FSW), men who have sex with men (MSM), and transgender persons (TG).
RESULTS: Study period reporting shows a total of 30,113 HIV tests resulting in 3,359 new HIV cases and 3,247 ART initiations, for KP. The first week of lockdown was associated with a significant reduction in HIV case finding for FSW (decrease of 33.3 cases/week (95%CI: -61.6,-5.1)) and MSM (decrease of 16.9 cases/week (95%CI: -26.5,-7.38)) compared to pre-lockdown. Thereafter, HIV case finding rebounded with higher weekly rates through 2020 for FSW (increase of 1.2 cases/week (95%CI: 0.3,2.2)), MSM (increase of 1.2 cases/week (95%CI: 0.69,1.8)), and TG (increase of 0.3 cases/week, (95%CI: 0.1,0.60)) compared to pre-lockdown trends. Similar immediate and long-term associations were observed for ART initiation.

Figure 1. Trends in HIV case finding before and after lockdown among (A) FSW, (B) MSM, (C) TG in South Africa
CONCLUSIONS: The COVID-19 pandemic circumstances highlighted South African programmatic resiliency in maintaining essential HIV services for KP. While trends varied pre-lockdown, we demonstrate a rapid rebound in HIV service utilization in the weeks following initial service interruptions. These results may reflect the gradual lessening of lockdown stringency coupled with program-led service delivery innovations including increased mobile testing, ART home delivery, and amplified peer navigation. These adaptations may have positively altered the trajectory of program performance beyond pre-pandemic levels, offering a potential roadmap to maintain continuity of services and improve the health of KP beyond COVID-19.