The impact of COVID-19 non-pharmaceutical interventions on HIV care continuum in China: An interrupted time series analysis

Abstract

Background: China implemented strict non-pharmaceutical interventions to contain COVID-19 at the early stage. We aimed to evaluate the impact of COVID-19 on HIV care continuum in China.

Methods: Aggregated data on HIV care continuum between 1 January 2017 and 31 December 2020 were collected from centers for disease control and prevention at different levels and major infectious disease hospitals in various regions in China. We used interrupted time series analysis to characterize temporal trend in weekly numbers of HIV post-exposure prophylaxis (PEP) prescriptions, HIV tests, HIV diagnoses, median time intervals between HIV diagnosis and antiretroviral therapy (ART) initiation (time intervals, days), ART initiations, mean CD4+ T cell counts at ART initiation (CD4 counts, cells/μL), ART collections, and missed visits for ART collection, before and after the implementation of massive NPIs (23 January to 7 April 2020). We used Poisson segmented regression models to estimate the immediate and long-term impact of NPIs on these outcomes.

Findings: A total of 16,780 PEP prescriptions, 1,101,686 HIV tests, 69,659 HIV diagnoses, 63,409 time intervals and ART initiations, 61,518 CD4 counts, 1,528,802 ART collections, and 6656 missed visits were recorded during the study period. The majority of outcomes occurred in males (55·3-87·4%), 21-50 year olds (51·7-90·5%), Southwestern China (38·2-82·0%) and heterosexual transmission (47·9-66·1%). NPIs was associated with 71·5% decrease in PEP prescriptions (IRR 0·285; 95% CI 0·192-0·423), 36·1% decrease in HIV tests (0·639, 0·497-0·822), 32·0% decrease in HIV diagnoses (0·680, 0·511-0·904), 59·3% increase in time intervals (1·593, 1·270-1·997) and 17·4% decrease in CD4 counts (0·826, 0·746-0·915) in the first week during NPIs. There was no marked change in the number of ART initiations, ART collections and missed visits during the NPIs. By the end of 2020, the number of HIV tests, HIV diagnoses, time intervals, ART initiations, and CD4 counts reached expected levels, but the number of PEP prescriptions (0·523, 0·394-0·696), ART collections (0·720, 0·595-0·872), and missed visits (0·137, 0·086-0·220) were still below expected levels. With the ease of restrictions, PEP prescriptions (slope change 1·024/week, 1·012-1·037), HIV tests (1·016/week, 1·008-1·026), and CD4 counts (1·005/week, 1·001-1·009) showed a significant increasing trend.

Interpretation: HIV care continuum in China was affected by the COVID-19 NPIs at various levels. Preparedness and efforts to maintain the HIV care continuum during public health emergencies should leverage collaborations between stakeholders.

Funding: Natural Science Foundation of China.

Keywords: COVID-19; China; HIV; Interrupted time series analysis; Non-pharmaceutical interventions (NPIs).

Figure 1

Definition of indicators of HIV care continuum. PEP= post-exposure prophylaxis. ART= antiretroviral therapy. Median time intervals= median time intervals between HIV diagnosis and ART initiation (days). CD4 counts= mean CD4 counts at ART initiation (cells/μL). Missed visits=Missed visits for ART collection.

Figure 2

Weekly numbers, trends and fitted Poisson segmented regression models for eight indicators of HIV care continuum in China from 1 January 2017 to 31 December 2020, accounting and not accounting for seasonality. PEP prescriptions (A), HIV tests (B), HIV diagnoses (C), median time intervals (D), ART initiations (E), CD4 counts (F), ART collections (G) and missed visits (H). PEP= post-exposure prophylaxis. ART= antiretroviral therapy. Median time intervals= median time intervals between HIV diagnosis and ART initiation (days). CD4 counts= mean CD4 counts at ART initiation (cells/μL). Missed visits=Missed visits for ART collection. The legend is located on subfigure A.