AIDS, TB And Malaria: Coronavirus Threatens The Endgame

Right now, as we speak, 1.3 billion Indians are on lockdown because of the Coronavirus COVID-19 pandemic. What happens to over 2.5 million Indians who are currently on tuberculosis treatment? Even without COVID-19, 5% of Indians with TB die.

Spare a thought for the 59 million South Africans on lockdown now. What happens to 7.7 million South Africans living with HIV? Even without COVID-19, AIDS-related illness kill 71000 South Africans every year.

Imagine a child in a malaria-endemic country right now. The child develops high fever. Will the child get a malaria test and anti-malarial medicines, if positive? Or will the child stay home because of quarantine? Every year, over 400,000 people, mostly children, die of malaria.

It is clear that the coronavirus pandemic has just made it incredibly difficult to script an endgame for the “Big Three” killer epidemics. The SDG goal is to end the epidemics of AIDS, TB and malaria by 2030. Is this still possible? The impact of COVID-19 on TB alone is unimaginable, as I wrote in my previous post. How are global leaders and agencies dedicated to AIDS, TB, and Malaria reacting to the pandemic? I interviewed several experts.

What is the anxiety?

“For communities suffering heavily from HIV, TB and malaria, COVID-19 represents a double threat,” said Peter Sands, Director of the Global Fund. “First, people who are immunocompromised or already have lung problems may be even more vulnerable if they become infected with COVID-19. Second, COVID-19 may disrupt programs to prevent and treat HIV,TB and malaria, with a consequent impact on mortality and infection rates. So we need an effective response to COVID-19 that takes account of this knock-on impact,” he added.

Winnie Byanyima, Director of UNAIDS, expressed grave concerns to me about the impact of COVID-19 on people living with and affected by HIV, including people living with TB. “We know from experience that pandemics impact hardest on the most marginalized. We also know that the majority of people currently in the path of COVID-19, those who live in low- and middle-income countries, live in poverty, which presents additional barriers to accessing services. And we know that in too many of these countries publicly provided and financed health care systems have been hollowed out rendering many public health responses difficult to implement,” she said.

 “We are super worried. COVID-19 could be a disaster for malaria,” said Pedro Alonso, Director of the WHO Global Malaria Programme. “We know when health systems get disrupted, malaria becomes the number one killer. We saw this with Ebola in West Africa and DRC, and in Nigeria with civil war. With malaria, we will see the impact of COVID-19 straight away. If people stop going to health facilities and don’t get bed nets, we will see a massive increase in malaria mortality, mostly in kids and pregnant women,” he added.

Joanne Liu, former president of MSF, echoed these concerns. “We learned from Ebola, that when the world’s attention is on one disease, people die of easily treatable and preventable diseases,” she said. She worries that, for a while, TB, HIV and malaria patients will get ‘second-class citizen’ treatment.

Saving someone from a pandemic but at the cost of allowing them or others to succumb to hunger or malaria is cruel. The need of the hour is to continue essential clinical services while minimising the real risk of further spreading the novel coronavirus.

What are AIDS, TB & Malaria agencies doing?

All major agencies have been quick to raise alarm, rally their partners, and put out urgent information notes on impact of COVID-19 on TB, HIV and Malaria. These information notes are clear: countries must do everything possible to ensure continuity of TB, malaria and AIDS care, even as the pandemic rages on.

“We need to act rapidly to ensure that those with TB can access the prevention and care they urgently need in this time of the COVID-19 crisis,” said Tereza Kasaeva, Director of the WHO Global TB Programme. “It is important the delivery of TB prevention, diagnosis, treatment and care services is people-centered. Adequate stocks of TB medicines should be provided to all patients to take home to ensure treatment completion without having to visit treatment centers unnecessarily to collect medicines. Use of digital health technologies should be intensified to support patients and programmes through improved communication, counselling, care, and information management, among other benefits,” she added.

“We must ensure programs and care for people is not interrupted or affected,” said Lucica Ditiu, Director of the Stop TB Partnership, which has put our several useful resources for dealing with COVID-19 and TB, including a framework to re-imagine TB care delivery.

The Global TB Caucus is the largest parliamentary network in the world dedicated to infectious diseases. “Parliamentarians are very concerned about the impact of both TB and Covid-19, and are focusing on how they can use their role to strengthen vulnerable health systems and improve critical public health infrastructure,” said Sarah Kirk, Head of the TB Caucus Secretariat.

“We need innovative ways of no-contact delivery and observation of medicines. Countries and donors also need to work in a coordinated manner to protect the drug-supply chain as well as ensure food security,” said Ngozi Erondu, an infectious diseases epidemiologist at Chatham House. She is concerned that most health care systems in Africa have no capacity for the surge of severely ill patients that we could see if COVID-19 impacts Africa.

At this time, our key message is “Do not scale back your planned malaria prevention, diagnostic and treatment activities. If someone living in a place with malaria develops a fever, he or she should seek diagnosis and care as soon as possible,” said Pedro Alonso of WHO.

“Through concerted action over the last two decades, more than 24 million people living with HIV (PLHIV) are now on antiretroviral treatment (ARVs). These gains must be protected. WHO is working to ensure that all PLHIV in low and middle-income countries have access to the right information about how to prevent COVID-19 infection, as well as to testing and supportive care if needed,” said Meg Doherty, Director of the Department of HIV, Hepatitis and STI programmes at WHO. “Immediate global and local action is needed to mitigate the spread of the coronavirus – particularly in countries with fragile health systems – and to maintain essential prevention, harm reduction and health services for PLHIV, provided they can be delivered safely,” she added.

“Our staff in the field are working tirelessly to establish emergency systems to ensure continuity of ARVs. We are working to empower communities to design locally inspired COVID-19 prevention measures and will support communities to share these across countries. In the short term, we are working with others to bring about a debt repayments moratorium and to mobilize resources to help people in low- and middle-income countries cope with the economic impact during the lock downs,” said Winnie Byanyima of UNAIDS.

Using TB, HIV and Malaria infrastructure for COVID-19

Since decades of effort and investment has gone into building TB, HIV and malaria programs in many countries, it stands to reason that this infrastructure could come in handy for dealing with the COVID-19 crisis.

In fact, this month, the Global Fund announced new guidance to enable countries to strengthen their response to COVID-19, by using existing grants in a swift and pragmatic way. According to Peter Sands, 21 countries have already received support from this mechanism.

“The infrastructure countries have put in place for TB has dual-use purposes for addressing other respiratory diseases. Health workers trained to respond to TB understand infection control, contact tracing and other measures we need for ending the COVID-19 pandemic. The diagnostic platforms widely used for TB in developing countries, called GeneXpert, can now be used to test for COVID,” said Jose Luis Castro, Director of the International Union Against Tuberculosis and Lung Disease.

But he acknowledged the risks with this approach. “The downside is that the TB infrastructure is already stretched, so shifting priorities now could leave significant gaps that cause TB to rise significantly this year,” said Castro.

Yogan Pillay, Deputy Director-General for Health in South Africa, echoes this. “Our response to COVID-19 is a double edged sword - on the one hand, it draws resources, focus and energy from HIV and TB (every day, more people contract TB and die from it than COVID-19). On the other hand, infection control efforts might reduce TB transmission. The COVID-19 response will benefit from the GeneXpert platform, but we must ensure that it does not displace TB diagnostics,” he said.

We must find new resources for COVID-19

“As the world increases its response to COVID-19, we must not do so at the expense of the focus on TB and HIV. The consequence will be a setback on our control efforts for two diseases that will still be with us even more profoundly after the COVID-19 pandemic has been hopefully relegated to the pages of history books,” said Emilio Emini, Director of HIV and TB at the Bill & Melinda Gates Foundation.

Stephen Lewis, Co-Director of AIDS Free World, shares the same concern. “There will be an inevitable clash over resources as governments take money from the AIDS and TB envelopes to combat the coronavirus,” he said.

This, then, is the tough choice for the TB, HIV, malaria community. On the one hand, they are uniquely placed to leverage their funding, deep expertise, advocacy track record, technologies, and field force to tackle the COVID-19 pandemic. On the other hand, if their valuable resources are diverted and depleted, will these programs collapse and lose all the gains they have worked so hard for?

Everyone in the TB, HIV, and malaria community must find a way to unite, and prevent disaster for millions of people who are relying on these programs. Even as they use their existing resources to fight COVID-19 in the short-term, they must unanimously advocate for new funding to fight COVID-19 in the longer term.

It will be hard but not impossible. The COVID-19 pandemic has taught world leaders a hard lesson - ignore health and it comes back to haunt you. Political leaders must use the pandemic crisis to invest in universal health coverage and stronger public health systems. Otherwise, the next pandemic will be worse.

It is not enough just to respond to outbreaks. We must do our best to prevent them. To do that, we must address the root cause of health insecurity: the lack of access of the most vulnerable people to essential health services. Ultimately, it’s the absence of universal health coverage that is the greatest threat to health security

“The support of the international community in the fight against AIDS, TB and malaria must not be diminished,” said Jane Philpott, former Canadian Minister of Health & Minister of Indigenous Services. “High-income countries, such as Canada, have played a critical role in support of the Global Fund for AIDS, TB and Malaria. These countries will all be under extraordinary fiscal pressure in the years ahead. But the global effort to sustain the Global Fund remains essential. It will save millions of lives and strengthen health systems for the good of all,” she added.

As Stephen Lewis, a former UN Special Envoy for HIV/AIDS in Africa, emphatically put it: “The coronavirus pandemic rivals climate change in the struggle to save humankind. Every major multilateral entity, from the G7 to the G20 to the World Bank to the IMF, must ante up the billions of additional dollars required to rescue the lives of millions.”

To this list, I would add the 2,153 billionaires on the Forbes list. They have an obligation to help end the COVID-19 pandemic, since it is in their best interests to avert a global economic meltdown. Indeed, some have already stepped up. The world could use many more.

Note: Post updated at 9.56 AM on March 29 with quote from Dr Jane Philpott.