It is not news that the COVID-19 pandemic has caused unprecedented disruption to public health – and as managing the pandemic ostensibly takes top priority for health systems worldwide, the ramifications for management of other diseases is a real concern. This concern has been raised in a modelling study released by The Lancet Global Health earlier this week, estimating the pandemic’s impact on three conditions: HIV, tuberculosis, and malaria.
“In high-burden settings, deaths due to HIV, tuberculosis, and malaria over five years could increase by up to ten percent, twenty percent, and 36 percent, respectively, compared with if there was no COVID-19 pandemic,” the study said. Study authors noted the disruption of the pandemic to routine health services; provision of therapies; and preventative campaigns could carry ominous portents for the response to the diseases and compromise the progress made against them thus far.
The study outlines that “the greatest impact on HIV was estimated to be from interruption to antiretroviral therapy [ART], which could occur during a period of high health system demand. For tuberculosis, the great impact would be from reductions in timely diagnosis and treatment of new cases, which could result from any prolonged period of COVID-19 suppression interventions. The greatest impact on malaria burden could be as a result of interruption of planned net campaigns.”
The potential consequences of the disruption to tackling HIV, tuberculosis, and malaria are grim. “Disruptions could lead to a loss of life-years over five years that is of the same order of magnitude as the direct impact from COVID-19 in places with a high burden of malaria and large HIV and tuberculosis epidemics,” the researchers caution. Dr Mikashmi Kohli, Postdoctoral Fellow in the Department of Epidemiology, Biostatistics and Occupational Health, at McGill International TB Centre, told me by email
“This pandemic has led to a divide in the healthcare system. There is a clear dichotomisation that is being seen – COVID and non-COVID patients. This is causing major disruptions for other diseases such as TB, HIV and malaria.
“The COVID-19 pandemic and actions taken in response to it could undo…some of the advances made against major diseases such as HIV, TB, and malaria over the past two decades, compounding the burden caused by the pandemic directly”, said Professor Timothy Hallett of Imperial College London, UK, co-leader of the research. “In countries with a high malaria burden and large HIV and TB epidemics, even short-term disruptions could have devastating consequences for the millions of people who depend on programmes to control and treat these diseases.”
India is a place with a large burden of those three diseases. It is home to the world’s third-largest HIV epidemic, being home to home to 2.1 million people living with HIV and losing 69,000 lives to AIDS in 2017.
Government figures indicated that India had an estimated tuberculosis incidence of 2.7 million in 2018. The country accounts for 25 percent of the global tuberculosis burden, while also accounting for a significant proportion of ‘missing cases’ (i.e. cases that are undetected). As such, it lags behind significantly on tuberculosis reduction targets both in terms of cases and mortality.
In the case of malaria, as previously reported by Health Issues India, “together with sub-Saharan Africa, India accounts for 85 percent of the world’s malaria burden. Of deaths, India is one of twenty countries accounting for almost 85 percent, the others belonging to the African region.”
Such concerns have been raised at length. In the example of HIV, the World Health Organization (WHO) has warned of compromised access to vital HIV medicines. Earlier this month, UNAIDS cautioned that the world – already off-track in the global fight against HIV/AIDS – stood to lose even more precious ground in the fight as a consequence of the pandemic.
In the example of malaria, Malaria No More UK (MNM) has warned that “current investments in tackling malaria prevent almost 100 million cases of malaria a year and save close to 600,000 lives. But If we do not sustain efforts to prevent, detect and treat malaria during this time of crisis posed by the COVID-19 pandemic, we risk reversing the hard-won gains that have been made over many years, compromising the health and well-being of millions of people, particularly those most vulnerable to the disease: pregnant women and children.”
Citing WHO and Imperial College London reports, MNM warned “severe disruption to insecticide-treated net campaigns and other core malaria prevention and treatment activities due to COVID-19 could lead to a doubling in the number of malaria deaths in sub-Saharan Africa unless we act now. This would represent a return to mortality levels last seen twenty years ago – and children and pregnant [women] are likely to be hardest hit.”
In the example of tuberculosis, the Stop TB Partnership warned earlier this year that “while stringent COVID-19 responses may only last months, they would have a lasting impact on TB [tuberculosis] in high-burden settings, through their effect mainly on TB diagnosis and treatment. Globally, a three-month lockdown and a protracted 10-month restoration could lead to an additional 6.3 million cases of TB between 2020 and 2025, and an additional 1.4 million TB deaths during this time.
“As such, global TB incidence and deaths in 2021 would increase to levels last seen in between 2013 and 2016 respectively – implying a setback of at least five to eight years in the fight against TB, due to the COVID-19 pandemic.”
As far as the Indian context goes, Dr Kohli told me that “for a country like India where there are about 1300 deaths each day due to TB, two important factors are responsible for this healthcare disruption: the harsh and unplanned lockdown in the country where migrants were forced to leave the cities and the diagnostic services (both human resource and infrastructure) at health clinics and hospitals are focussed solely on COVID-19. TB patients are supposed to take their medicines using the DOTS services, but with the lockdown, patients do not have access to proper and timely medicines and this could further worsen the situation by increasing the transmission rates. The same would apply even for HIV where inadequate or no access to testing and antiretrovirals will affect the patients’ health.
“There is a need for proper planning and strengthening the healthcare system where both the pandemic and these other treatable diseases can be managed simultaneously. We now have diagnostic tools which are muti-disease platforms so focusing just on COVID-19 , while forgetting about patients suffering from these manageable diseases will only lead us in the direction of a failure.”
The Lancet modelling study amplifies the concerns about how existing progress against HIV, tuberculosis, and malaria could be undone and how future progress will be compromised. Researchers highlight that “maintaining the most critical prevention activities and healthcare services for HIV, tuberculosis, and malaria could substantially reduce the overall impact of the COVID-19 pandemic.” The study elaborates that
“The indirect impact of the pandemic might be largely avoided through maintenance of core programme elements and recovery campaigns. For HIV, individuals receiving ART should continue to access treatment even in periods of highest health system demand (eg, via multimonth prescriptions or dispensing away from health facilities. For tuberculosis, routes for individuals to seek care and diagnosis must be provided despite interventions that promote social distancing. For malaria, preventative measures must be prioritised, ensuring LLINs [long-lasting insecticidal nets] and prophylactic treatments, such as mass drug distribution or seasonal malaria chemoprevention, are conducted at scale as soon as possible.”
A fundamental truth underlined by the study is that health systems were ill-prepared for the magnitude of the COVID-19 pandemic and the disruption it engendered. For chronically under-resourced and underfunded health systems such as that of India, the impact is acutely felt. As Professor Sarang Deo of the Indian School of Business told me in a recent interview, “I don’t think there was any country that would have been fully prepared [for the pandemic] – least of all a developing country like India, where doctors are in short supply, hospital beds in ICUs are in short supply. From a sheer quantum of capacity of any resource, even good health systems were not prepared.”
The study authors note “a major focus in the longer term is likely to be improving the resilience of the health system to cope with shock events such as pandemics, and the changes necessary could be far-reaching.” The challenges are enormous, but grappling with them is vital. Undertaking modelling analyses such as that by The Lancet Global Health – even as the authors note multiple uncertainties in producing their analysis – will be instrumental in guiding stakeholders at multiple levels, to provide continuity of care and avert the situation of one disease’s management precluding the management of others.
As Dr Kohli states, “we can’t just think unilaterally. It has been a problem of a broken healthcare system and it is imperative to start fixing that.”
“Potential impact of the COVID-19 pandemic on HIV, tuberculosis, and malaria in low-income and middle-income countries: a modelling study” can be accessed here.