Impact of the COVID-19 Pandemic on Use of HIV Care, Antiretroviral Therapy Adherence, and Viral Suppression: An Observational Cohort Study From Uganda

Abstract

Introduction: Recent studies project thousands of additional AIDS-related deaths because of COVID-19-related disruptions in HIV care. However, the extent to which disruptions in care have materialized since the start of the pandemic is not well understood.

Methods: We use electronic health records to investigate how the pandemic has affected clinic visits, patients' antiretroviral therapy (ART) supply, and viral suppression for a cohort of 14,632 HIV clients from a large HIV clinic in Kampala, Uganda. We complement this with an analysis of electronically measured longitudinal ART adherence data from a subcohort of 324 clients.

Results: Clinic visits decreased by more than 50% after a national lockdown started. The risk of patients running out of ART on a given day increased from 5% before the lockdown to 25% 3 months later (Relative Risk Ratio of 5.11, 95% confidence interval: 4.99 to 5.24) and remained higher than prelockdown 6 months later at 13% (Relative Risk Ratio of 2.60; 95% confidence interval: 2.52 to 2.70). There was no statistically significant change in electronically measured adherence or viral suppression.

Conclusion: We document substantial gaps in HIV care after the start of the COVID-19 pandemic in Uganda. This suggests that measures to improve access should be explored as the pandemic persists. However, ART adherence was unaffected for the subcohort for whom we measured electronic adherence. This suggests that some clients may have stockpiles of ART tablets from previous prescriptions that allowed them to keep taking their medication even when they could not visit the clinic for ART refills.

Trial registration: ClinicalTrials.gov NCT03494777.

FIGURE 1.

ART adherence and days without personal ART supply over time. Numbers above the adherence line represent sample sizes for each month for the MEMS cohort. % of days without ART reflects the share of client days in a given month where ART supply was 0. This measure is based on pharmacy refill records and assumes clients took their pills as prescribed. The full Mildmay cohort includes all clients with at least 2 ART prescriptions between July 2019 and March 2020. The MEMS cohort is the subset for which we have MEMS cap data. Although the “lockdown” in Kampala was eased in June 2020, several restrictions were still in place by September 2020.

FIGURE 2.

Share of clients with suppressed viral load by month. Data are from all viral load tests conducted for the full Mildmay cohort from May 2018 to September 2020 (36,356 tests for 14,632 unique clients). The full Mildmay cohort includes all clients with an ART prescription between July 2019 and March 2020. This figure plots the share of viral load tests in each month that recorded a suppressed viral load (<200 copies/mL). We are not sure why there is a dip in September 2019, but this could be because one of the viral load machines was down and the remaining machine could have had higher sensitivity. Although the “lockdown” in Kampala was eased in June 2020, several restrictions were still in place by September 2020.