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Loss of viral suppression by 31% in SF is deleterious to the individual and hinders treatment-as-prevention: the COVID-19 pandemic is threatening the goals of the US EHE initiative.
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After institution of a shelter-in-place ordinance for COVID-19 in San Francisco, viral suppression rates fell substantially compared with pre-COVID-19 in a large HIV clinic serving vulnerable populations. The odds of viral nonsuppression are now 31% higher than before the pandemic. This destabilization occurred despite our population attending telemedicine visits at a higher rate than expected, given the 60% drop in ambulatory care visit volume nationwide [7]. Telehealth visits, while offering greater patient convenience, may lead to less access to clinic-based social support services essential to achieving viral suppression among vulnerable groups [8].
Concomitant with this explanation, homeless individuals at Ward 86 had higher odds of unsuppressed viral loads post-COVID-19 vs. pre-COVID-19, despite higher visit attendance. The disproportionate economic impact of the shutdown on those with housing instability, coupled with depopulation of San Francisco shelters with COVID-19 outbreaks [9], are expected to destabilize viral suppression, despite ongoing or increased healthcare utilization by this group. Younger individuals had higher retention-in-care post-COVID-19, possibly related to comfort with telemedicine, but not higher viral suppression. Black individuals had persistent, unchanged disparities in viral suppression compared with white individuals, in spite of similar visit volume.
In conclusion, viral suppression rates fell during COVID-19 in an urban HIV clinic serving publicly insured patients. Telemedicine may facilitate retention-in-care in the context of shelter-in-place for those without a digital divide, but is unlikely to compensate for the loss in clinic-based social services and support for PWH with vulnerabilities. In our population, retention-in-care via telemedicine was not sufficient to keep suppression rates stable. Loss of viral suppression is deleterious to the individual and hinders treatment-as-prevention: the COVID-19 pandemic is threatening the goals of the US EHE initiative. Measures to counteract the effect of COVID-19 on HIV care outcomes are urgently needed [10,11].
COVID-19 Susceptibility and Outcomes Among People Living With HIV in San Francisco
- Data are accumulating regarding the impact of HIV infection on either susceptibility to COVID-19 infection or disease severity. There are reasons to think that people living with HIV (PLWH) may be more susceptible to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in urban centers in congregate living situations where social distancing is more difficult to achieve. In San Francisco, PLWH have higher rates of unstable housing at 8.0% compared with 1.0% among the general San Francisco population,1 with subsequently higher rates of living in single residency occupancy hotels, shelters, or tent encampments. There are also reasons to consider why PLWH could have more severe manifestations of COVID-19 than those without HIV. There is a higher rate of comorbidities among - - PLWH than those without HIV that predispose to severe COVID-19, including pulmonary disease,2 cardiovascular disease,3 and smoking.4
- Among 4252 COVID-19 tests performed among PLWH, 4.5% (N = 193) were positive for COVID-19, compared with a 3.5% (N = 9626) positivity rate among the 272,555 people without HIV tested for COVID-19 (P < 0.001).
Of the 183 interviewed, 24% reported known contact with someone diagnosed with COVID-19, and 42.6% reported an additional risk factor for COVID-19 disease severity (7.1% cardiovascular disease, 4.9% diabetes, 1.6% liver, and 4.4% lung disease, Table 2).
- The mean age of those infected with HIV/COVID-19 was 48 years (20-76), 38.9% White, 38.3% Latinx, 11.9% Black, and 91.2% were men. Only 54.6% of coinfected PLWH were housed, with the remainder marginally housed. The rate of severe illness with COVID-19 was not increased among PLWH.
- Our report, similar to the one conducted in Spain,6 does suggest an increased incidence of SARS-CoV-2 infection among HIV compared with people without HIV in San Francisco from the date community transmission was reported (March 5, 2020) to September 3, 2020 (4.5% vs. 3.5%, P 0.00004). This may be due to the fact that a number of HIV/COVID-19 coinfected patients in our study were in congregate living situations such as single residency occupancy hotels, homeless shelters, and long-term care facilities. Shared bathrooms and crowded spaces make social distancing challenging.
Viral suppression rates in a safety-net HIV clinic in San Francisco destabilized during COVID-19
The COVID-19 pandemic is expected to hinder US End the HIV Epidemic goals.
For the viral load outcome, the odds of viral nonsuppression were 31% higher during shelter-in-place [(aOR 1.31; 95% CI = 1.08-1.53) than before COVID-19 in adjusted analyses. Viral nonsuppression was also higher among homeless individuals during-COVID-19 (aOR 3.36; 95% CI = 2.74-4.12) vs. pre-COVID-19 (aOR 2.27; 95% CI = 1.91-2.71). Age less than 35 years and black vs. white race were each associated with higher odds of viral nonsuppression (aOR 1.29; 95% CI = 1.11-1.51 and aOR 1.60; 95% CI = 1.3-1.91, respectively), but these associations did not differ pre/post COVID-19 (P = 0.49 and 0.93, respectively;
Ward 86 is a safety-net clinic in San Francisco serving people with HIV (PWH) on publicly funded insurance; our population has a high prevalence of mental illness, substance use and unstable housing [2].
We evaluated viral suppression and retention-in-care before and after telemedicine was instituted, in response to shelter-in-place mandates, in a large, urban HIV clinic. The odds of viral nonsuppression were 31% higher postshelter-in-place (95% confidence interval = 1.08-1.53) in spite of stable retention-in-care and visit volume, with disproportionate impact on homeless individuals. Measures to counteract the effect of COVID-19 on HIV outcomes are urgently needed.
This analysis compares viral loads and retention-in-care, defined as no-shows for scheduled in-person/telephone visits, before and during shelter-in-place (1 December 2019-29 February 2020 vs. 1 April 2020-30 April 2020) [5].
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