Three lessons learned from the human immunodeficiency virus (HIV) pandemic were published by an international group of public health researchers in April 2020 in response to the coronavirus disease 2019 (COVID-19). These included anticipation of health inequalities, engagement in multidisciplinary efforts, and creating an environment to support effective behavioral changes. However, the context of these lessons has changed since their original publication.
Study: Living with COVID-19 and preparing for future pandemics: revisiting lessons from the HIV pandemic. Image Credit: DimaBerlin / Shutterstock.com
In April 2020, there was little access to COVID-19 testing and a lack of drugs and vaccines specific to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
The information that was available on the different viral, immunological, and environmental factors that increased the risk of infection was insufficient for the widespread implementation of non-pharmaceutical interventions. Additionally, information on aerosol transmission, asymptomatic carriers, test sensitivity and specificity, predictors of severe illness, and emerging viral variants was unknown.
Antigen and antibody tests, along with the development of effective messenger ribonucleic acid (mRNA) and viral vector vaccines, eventually became available to prevent severe COVID-19. Significantly, the rate at which these therapeutics were developed significantly differs from the rate at which HIV medications, preventive measures, and diagnostics were eventually established.
As of November 11, 2022, over 6.6 million deaths due to COVID-19 have been reported globally, with excess mortality likely two to four times higher. Continual mutations have exacerbated the persistence of this pandemic in SARS-CoV-2 that have led to the emergence of the Alpha, Beta, Delta, and Omicron variants, as well as numerous Omicron subvariants, each of which have caused consecutive waves of the pandemic.
In light of recent advancements made since the start of the COVID-19 pandemic, a recent The Lancet HIV study revisits the three aforementioned lessons from HIV.
Lesson 1: Anticipate health inequalities
It was advised that the global response to COVID-19 must reduce and anticipate the unequal burden of severe disease, infection, and deaths among vulnerable populations, which includes people living in low- and middle-income countries (LMICs). LMICs were reported to account for 85% of the 15 million excess deaths between January 2020 and December 2021; however, the extent of this discrepancy remains unknown.
Social and economic disadvantages increased health inequalities within and between countries. For HIV, the interaction between the virus and social health determinants can worsen health outcomes and increase comorbid conditions for marginalized and disempowered communities.
Furthermore, policies and interventions to combat the pandemic can also increase health inequalities, as people who can adopt new behaviors or accept new technologies are at an advantage compared to those who are less able to make such changes.
The COVID-19 pandemic also caused disproportionate infection rates, hospitalizations, and deaths in people with disabilities, marginalized ethnic and racial groups, people with higher clinical risk factors, and socioeconomically disadvantaged communities. Additionally, restrictions to social and economic activities in response to the pandemic adversely affected those worse off at the beginning of the pandemic.
COVID-19 inequalities between nations were also evident. A prominent example of this was the competition among high-income countries (HICs) to provide effective and safe vaccines for their population. This resulted in a shortage of vaccines for many LMICs, thus forcing these nations to resort to low-efficacy and low-cost vaccines.
Inequities in access to tools for combatting COVID-19 can result in the emergence of new SARS-CoV-2 variants that can evade both natural and vaccine-induced immunity. Although the COVID-19 Vaccine Global Access facility intended equal access to vaccines, HICs sabotaged international cooperation that would have led to affordable vaccine prices, globalized manufacturing capacities, and facilitated an early return to pre-pandemic life.
The intersection of HIV and COVID-19 in southern Africa was one example of the impact of inequitable access to life-saving diagnostics, vaccines, treatments, and essential health services.
Lesson 2: Create an enabling environment
Strong political leadership, avoidance of marginalization and stigmatization, and meaningful community engagement are important for controlling the COVID-19 pandemic. Some good practices were observed in Zimbabwe, for example, at the start of the pandemic.
However, some political leaders in other countries withheld information, were misinformed, and were in denial about COVID-19. This affected the initial response to the pandemic, infection rates, uptake of vaccinations, and death. More specifically, right-wing political ideologies and levels of national identity increased resistance to public health measures.
Nevertheless, several examples of engagement at the community level led to improved uptake of COVID-19 information and services. The effect of misinformation and understanding of mechanisms plays a vital role in mitigating future pandemics.
Surveys in South Africa found moderate levels of agreement with false COVID-19 statements among the population. However, such agreement was primarily associated with women, older people, unemployment, less education, and those residing in east Africa.
Several studies also indicated that misinformation and the absence of accurate health information increased among people with poor living conditions, the influence of religion and culture, poor health literacy, and political instability.
Moreover, everchanging public health policies and recommendations due to the evolving pandemic led to the mistrust of scientists, governments, and public health officials. This also impacted the uptake of vaccines in many countries.
The emergence of discrimination and racism towards people from east Asia occurred with the spreading of the term “China virus” through social media and national leaders. Additionally, the removal of blanket restrictions in many countries led to increased judgment, fear, and blame of this population.
Concerns about such stigmas must also be addressed for the monkeypox virus, which is emerging as a potential pandemic, with most cases reported in men who have sex with men.
Lesson 3: A multidisciplinary approach is essential
A multidisciplinary and integrated approach is needed to combat the COVID-19 pandemic by addressing interactions between human behaviors, viral pathogens, social contexts, and emerging protective tools and technologies. National policies must include population-level coverage of safe practices, information from various disciplines, and the evaluation and monitoring of strategies that affect behaviors at the population level.
Limited access to effective and safe vaccines, effective treatments, and quality diagnostic testing early in the pandemic led to more adherence to non-pharmaceutical interventions. Information from social and behavioral scientists with expertise in this area, along with community members, would parallel information from biomedical scientists with expertise in therapeutic and vaccine development. However, in many countries, COVID-19 scientific advisory councils consisted of people with biomedical competencies who understood a novel respiratory virus but provided guidance on topics they had little expertise.
Furthermore, context-specific and tailored COVID-19 responses are required to strengthen health systems, especially in LMICs.
It was also advised to not take a vertical response to COVID-19. The heightened focus on COVID-19 led to a reduction in people seeking tuberculosis treatment and global spending on its diagnosis, prevention, and treatment in 2020.
Therefore, the development of more potent integrated services across multiple sectors to understand the long-term consequences that have been intensified by the COVID-19 pandemic is needed.
The current study recognized that the analogy comparing COVID-19 to the HIV epidemic was relevant to a certain point. The spread of SARS-CoV-2, for example, was much more rapid and widespread as compared to that associated with HIV.
A better application of these lessons thus requires bringing together perspectives in national discussions that consider both priorities and trade-offs, in addition to the incorporation of multidisciplinary evidence. This would prevent the repetition of mistakes and help in the establishment of effective responses to the next pandemic.
- Auerbach, J. D., Forsyth, A. D., Davey, C., & Hargreaves, J. R. (2022). Living with COVID-19 and preparing for future pandemics: revisiting lessons from the HIV pandemic. The Lancet HIV. doi:10.1016/S2352-3018(22)00301-0.