Understanding the impact of interruptions to HIV services during the COVID-19 pandemic: A modelling study

Background: There is concern that the COVID-19 pandemic could severely disrupt HIV services in sub-Saharan Africa. However, it is difficult to determine priorities for maintaining different elements of existing HIV services given widespread uncertainty. Methods: We explore the impact of disruptions on HIV outcomes in South Africa, Malawi, Zimbabwe, and Uganda using a mathematical model, examine how impact is affected by model assumptions, and compare potential HIV deaths to those that may be caused by COVID-19 in the same settings. Findings: The most important determinant of HIV-related mortality is an interruption to antiretroviral treatment (ART) supply. A three-month interruption for 40% of those on ART could cause a similar number of additional deaths as those that might be saved from COVID-19 through social distancing. An interruption for more than 6-90% of individuals on ART for nine months could cause the number of HIV deaths to exceed the number of COVID-19 deaths, depending on the COVID-19 projection. However, if ART supply is maintained, but new treatment, voluntary medical male circumcision, and pre-exposure prophylaxis initiations cease for 3 months and condom use is reduced, increases in HIV deaths would be limited to <2% over five years, although this could still be accompanied by a 7% increase in new HIV infections. Interpretation: HIV deaths could increase substantially during the COVID-19 pandemic under reasonable worst-case assumptions about interruptions to HIV services. It is a priority in high-burden countries to ensure continuity of ART during the pandemic. (C) 2020 The Authors. Published by Elsevier Ltd.