Impact of the COVID-19 pandemic on TB services at ART programmes in low- and middle-income countries: a multi-cohort survey

Abstract

Introduction: COVID-19 stretched healthcare systems to their limits, particularly in settings with a pre-existing high burden of infectious diseases, including HIV and tuberculosis (TB). We studied the impact of COVID-19 on TB services at antiretroviral therapy (ART) clinics in low- and middle-income countries.

Methods: We surveyed ART clinics providing TB services in the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium in Africa and the Asia-Pacific until July 2021 (TB diagnoses until the end of 2021). We collected site-level data using standardized questionnaires.

Results: Of 46 participating ART clinics, 32 (70%) were in Africa and 14 (30%) in the Asia-Pacific; 52% provided tertiary care. Most clinics (85%) reported disrupted routine HIV care services during the pandemic, both in Africa (84%) and the Asia-Pacific (86%). The most frequently reported impacts were on staff (52%) and resource shortages (37%; protective clothing, face masks and disinfectants). Restrictions in TB health services were observed in 12 clinics (26%), mainly reduced access to TB diagnosis and postponed follow-up visits (6/12, 50% each), and restrictions in TB laboratory services (22%). Restrictions of TB services were addressed by dispensing TB drugs for longer periods than usual (7/12, 58%), providing telehealth services (3/12, 25%) and with changes in directly observed therapy (DOT) (e.g. virtual DOT, 3/12). The number of TB diagnoses at participating clinics decreased by 21% in 2020 compared to 2019; the decline was more pronounced in tertiary than primary/secondary clinics (24% vs. 12%) and in sites from the Asia-Pacific compared to Africa (46% vs. 14%). In 2021, TB diagnoses continued to decline in Africa (-8%) but not in the Asia-Pacific (+62%) compared to 2020. During the pandemic, new infection control measures were introduced or intensified at the clinics, including wearing face masks, hand sanitation and patient triage.

Conclusions: The COVID-19 pandemic led to staff shortages, reduced access to TB care and delays in follow-up visits for people with TB across IeDEA sites in Africa and the Asia-Pacific. Increased efforts are needed to restore and secure ongoing access to essential TB services in these contexts.

Keywords: COVID-19; HIV clinic; antiretroviral therapy; differentiated service delivery; low- and middle-income countries; tuberculosis.

Figure 1

Map of the 46 participating countries and antiretroviral therapy (ART) clinics in the African and the Asian‐Pacific regions of the global International epidemiology Databases to Evaluate AIDS (IeDEA) consortium.

Figure 2

Impact of the COVID‐19 pandemic on health services at 46 ART clinics, overall and by region. Abbreviation: TB, tuberculosis.

Figure 3

Absolute number of tuberculosis (TB) diagnoses at ART clinics per year between 2017 and 2021. Percentages of the black line (total) indicate the changes from one year to the next in percentage. See also Table S3 with absolute numbers and percentages for each category.

Figure 4

Overview of infection control measures that were newly implemented, intensified, already resisting or not implemented at the ART clinics during the COVID‐19 pandemic (as of July 2021), by World Health Organization (WHO) categories for infection control measures.