The response to the ‘Big Three’ – HIV, malaria, and tuberculosis – has been hard-hit by the COVID-19 pandemic. Experts have warned that a surge in deaths due to the ‘Big Three’ could ensue, as the pandemic hits access to vital medicines and other treatments and disrupts much-needed prevention campaigns.
To discuss the effect of COVID-19 and the Big Three, I spoke with Urban Weber of the Global Fund to Fight AIDS, Tuberculosis and Malaria. Mr. Weber has worked with the Global Fund to Fight AIDS, Tuberculosis and Malaria in Geneva, Switzerland since 2003. For the last eight years, he heads the department “High Impact Asia”, covering Bangladesh, Cambodia, India, Indonesia, Myanmar, Pakistan, Philippines, Thailand, and Vietnam. His team manages grants for the prevention and treatment of the three diseases with an annual budget of some 800 million USD.
Our conversation has been edited for length and clarity.
- You and the Global Fund at large have spoken out about how the COVID-19 pandemic has hit the response to the ‘Big Three’ infectious diseases – HIV, malaria, and tuberculosis. How have the efforts against these diseases been affected and how is the Global Fund working to counteract the disruption to such efforts?
This is the biggest concern that we are having at this point, but maybe it is important to distinguish between getting a comprehensive picture and anecdotal evidence. The Global Fund in most of the cases follows a semi-annual reporting cycle, which means that the countries usually report at the end of the year and then at the end of the first six months of the year with a certain delay. The cutoff date for the next reporting was at the end of June, so the current reporting we have is from the end of December – before the COVID crisis was hitting. Right now, we are gradually receiving comprehensive information from the individual grants, so we’ll have a more detailed picture some time later in the summer.
Right now, we can speak about anecdotal evidence that we are receiving from individual countries that are, however, hit in different ways and at different speeds by the pandemic. Such evidence would suggest that in the field of tuberculosis, countries are currently seeing a significant downturn in notifications. Consequently, fewer patients are enrolled on treatment and much of that is linked to two elements. One would be the lockdown situation, meaning patients simply cannot move despite having symptoms that would suggest they should seek professional medical care. The second thing is testing capacity in the laboratories. We’re facing a competitive situation where either tests for tuberculosis or tests for the coronavirus are made.
Where resources are being shifted towards coronavirus, other disease programmes could see a downturn. In concrete terms, for instance, India – which has one of the most sophisticated electronic notification systems in the entirety of Asia – has seen downscaling of tuberculosis notification from 7,000 cases a day to 5,000. In Pakistan, we are seeing a similar or worse downturn in notifications.
On malaria, we are seeing that bednet distribution campaigns are being delayed because of lockdowns, thus impacting prevention campaigns resulting in potentially increased transmission. People infected with malaria are dying relatively quickly, especially when we speak about children under five. On HIV, we are seeing a reduction in prevention campaigns, again related to lockdowns. So what we are seeing, based on anecdotal evidence, is a fairly widespread interruption of services mostly related to side effects of lockdowns.
When it comes to the effects of the virus itself, we have much less information but we expect such information to come through in the coming months. One of the effects is the toll the virus takes on the healthcare workforce, through absence because of sickness or ultimately through mortality. Health care work force losses in the countries we serve tend to be more severe compared to our donor countries, simply because in the former, there are fewer health worker per population.
What we’re doing to mitigate against that is allowing the countries to use flexibilities under the current grant agreements that they have. Countries may use grant savings and direct them towards COVID responses. We also make available additional funding, for which countries can apply.
Globally, more than 90 countries have used these instruments already. In Asia, US$49 million in savings were used, as well as US$46 million of additional funding was approved Most of the money goes to personal protective equipment (PPE), infection control and diagnostics so that countries can increase their testing capacity. Of course, where there is a need to protect the existing disease programmes, we allow that to happen. We are ready to cover the bill.
- LMICs are especially hard-hit by HIV, malaria and tuberculosis and many LMICs struggle from the position of having health systems that were already underresourced. Now COVID-19 is overwhelming them. How do they move forward in tackling these pressing public health challenges?
We need to be mindful that in Asia, we have very different situations. Some countries might have a relatively weak health system, but are also not be very affected by COVID-19 at this point. So, for instance, Vietnam and Cambodia both imposed restrictions on the movement of people early on and introduced contact tracing and isolation – both of patients and contact persons – very early on and strictly. Their health system was never stretched because of COVID-19.
India has, by contrast, a very high number of cases at this point with almost 1.4 million infections on 26 July. However, relative to the size of the population, they have an infection rate per million that is far lower than many countries in the Americas. Other countries in the region such as Bangladesh and Pakistan have both a high absolute number of infections and infection rates per million of the population, as well as more difficulties in grappling with the situation.
All the countries must look into ways to protect their health workforce, as it will be very difficult for many of them to replace such workforce if they fall sick or die. Countries must also ensure the provision of treatment and care for patients and ensure they are isolated from the rest of the population to prevent uncontrollable community transmission. In that regard, Asia is probably in a better situation than other parts of the world as there is still a little more time for preparation. The World Health Organization has developed a wealth of technical guidance papers, and we recommend using them for the preparation of national COVID response plans.
- Do you see a lasting disruption in research into HIV, malaria, and tuberculosis treatments and the capacity to carry out prevention campaigns?
These are two very different areas.I don’t think that research into HIV, malaria and tuberculosis is affected at this point, as they are usually long-term research programmes aimed at providing better prevention material, better medications, or better diagnostic tests. On the other hand, the situation is very different for prevention campaigns. There is a lot of speculation here but, in countries that fail to bring their COVID-19 epidemics under control and where governments resort to introducing or reintroducing lockdown measures, prevention campaigns will be affected. It is difficult to predict and we will have to wait for the comprehensive monitoring later this year to assess the effect of COVID-19 on these issues.
- What is needed from the donor community to ensure that the disruption to addressing HIV, malaria and tuberculosis is mitigated and that hard-won progress is not lost?
A couple of considerations come to mind. One is that donors should consider COVID as a health security threat, in the sense that the pandemic cannot be stopped if it isn’t stopped everywhere. The transmission situation in Europe at this moment looks favourable, but we will have re-emergence of localised or even national COVID-19 epidemics if COVID is reintroduced from anywhere else in the world. Given our international connectivity, donors must be mindful that COVID is a health security threat.
For malaria, the donor community should be prepared to support instant mitigation: if bednet campaigns don’t happen, there will be an immediate loss of life. Infected patients, especially children under five, will die in a matter of days. The response against COVID and the response against malaria must happen in parallel. This is more of a problem for sub-Saharan Africa, where the malaria burden is significantly higher than in Asia.
You have a different story with regards to tuberculosis. If tuberculosis notification and therefore enrollment for treatment is reduced because of lockdowns, a higher transmission rate in underserved communities will be the result. At this point, however, most of the people will not fall sick or die immediately, so this provides the opportunity for catch-up plans. Many of them are right now under consideration. India is currently notifying and treating 5,000 tuberculosis patients a day when it should be 7,000 to 7,500 a day. The question is that – as soon as the lockdown situation is relaxed – how do we reach the unidentified patients? How can we multiply efforts in the second half or the fourth quarter of the year to make good on the patients who were not found at this moment in time?
The same thing would apply for HIV. Mortality is not increasing immediately, and similarly to TB, the catch-up plans would need to be very comprehensive and donors would need to commit to funding these additional efforts when lockdown restrictions are relaxed.
- Do you have anything you wish to add?
In a nutshell, it is important to realise that the world was on a good path of progress before COVID was hitting. We now face a situation where an external shock had an impact on disease programming. We need to be mindful that we have the tools to react on hand and we have a responsibility to use these tools. And from a donors’ perspective: to fund them.
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