Maintaining Continuity of HIV Care during the COVID-19 Pandemic: an interview with Dr. Yacouba Doumbia

May 8, 2020

The interview below was originally conducted in French, and has been translated and abridged.  The final write up was reviewed and approved by Dr. Doumbia.

Imagine a medicine that you must take every day to stay healthy. Now imagine that your stock of this medicine is about to run out. To get more, you have to travel many miles and come in contact with many people who may be carriers of a new threat to your health. This is an over-simplified, yet very real scenario for many people living with chronic illnesses during the coronavirus pandemic.

Coronavirus is having a ripple effect on healthcare delivery across the world. In response, health systems (and social systems) make adjustments—i.e. redirecting resources, implementing quarantine and stay-at-home measures—and these adjustments too, have subsequent impacts on health and health care delivery.

In Côte d’Ivoire, where HAI has collaborated with the Ministry of Health since 2007, about half a million people are estimated to be living with HIV. Adherence to effective antiretroviral treatment (ART) can increase immune system functioning among PLHIV and reduce the risk of coronavirus infection. Unfortunately, at the moment this at-risk population is facing the hypothetical posed at the beginning of this post in a very real way. How can I stay adherent to ART, while avoiding coronavirus exposure and co-infection?

Dr. Yacouba Doumbia is a Senior Technical Advisor in HAI’s Côte d’Ivoire office. Under HAI’s CDC/PEPFAR-funded Project LINKS, Dr. Doumbia is responsible for implementing, monitoring, and improving HIV prevention activities in collaboration with Regional and District Health Departments across 6 regions of northern and eastern Côte d’Ivoire. Dr. Doumbia and his team are also helping to roll-out adjusted guidelines for HIV prevention, care, and treatment in Côte d’Ivoire during the coronavirus pandemic.

Dr. Yacouba Doumbia is a Senior Technical Advisor in HAI’s Côte d’Ivoire office. Under HAI’s CDC/PEPFAR-funded Project LINKS, Dr. Doumbia is responsible for implementing, monitoring, and improving HIV prevention activities in collaboration with Regional and District Health Departments across 6 regions of northern and eastern Côte d’Ivoire. Dr. Doumbia and his team are also helping to roll-out adjusted guidelines for HIV prevention, care, and treatment in Côte d’Ivoire during the coronavirus pandemic.

QAs of this morning, there have been over 300 positive cases of COVID-19 in Côte d’Ivoire.  How has the presence of coronavirus in Côte d’Ivoire had an impact on HIV care and people living with HIV?

In my view, the COVID-19 epidemic has a significant impact on people living with HIV. I think there are two primary concerns. The first is related to the offer of services. The epidemic has created widespread panic [psychose] both in the general population, as well as among health providers, because it is a new infection with a lot of conflicting information. Consequently, health providers are reticent to approach patients normally, without protective precautions in place. Unfortunately, due to the very rapid evolution of the infection here [in Côte d’Ivoire], health providers weren’t sufficiently prepared, both in terms of [availability of] protective materials and their ability to immediately follow preventive guidelines [in the absence of such materials]. Providers, thus, felt concerned about how to meet the dual obligation of providing care while also protecting their own health. So that created some mistrust and hesitance [to continue to provide care] at the beginning.

The second concern is related to [people living with HIV] themselves. With the travel restrictions in place, and the reorientation of priorities, PLHIV are concerned about making the trip to the health facility. For some, they are afraid of the hospital itself. In the eyes of many here, the hospitals are seen as ‘contaminated places’. These two aspects are really impacting PLHIV and HIV care.

QIt seems that misinformation and fear of the unknown has a major impact.  How has HAI worked to overcome that problem?

Right at the beginning, we recognized that PLHIV, along with people with TB, are high-risk populations during the COVID-19 pandemic, as [COVID-19] is more threatening to the lives of those with co-morbidities. At the health facility level and also at HAI, we quickly put in place a contingency plan.  In this plan there are a series of measures to put in place, including multiple scenarios.  For each scenario, we outlined specific response activities. […]  That doesn’t mean we changed HIV care guidelines, rather we just made systems adjustments in response to this exceptional situation.  For example, regarding HIV screening, we helped establish and implement guidelines for how to triage, counsel, screen patients with patients with symptoms [associated with COVID-19].

After this, we quickly reached out to all of our community partners to give them information on COVID-19, so that they could disseminate this information and help avoid further panic.  We also furnished our partners with protective and hygienic materials—such as soap, waterless hand sanitizer, and masks—and we helped elaborate procedures for how to adjust their typical [patient follow up and HIV testing] activities in light of COVID-19.

QDoes that mean our community partners* are still conducting home visits?

Generally, we are advising them to conduct follow up activities by telephone wherever possible.  However, some home visits are still necessary.  Of course, due to the panic I mentioned before, many families are fearful of having community counselors in their homes. In response, we made sure that when our community partners are conducting home visits, that they are not only wearing appropriate protective equipment, but that they begin the visit by sharing information on COVID-19 with the entire household. By becoming messengers of COVID-19 information, they are able to respond to concerns that affect the whole household. Only afterwards does the counselor move on to offering care to the [known PLHIV] in the household.

 

* Through Project LINKS, HAI provides financial and technical support to 16 local nonprofit organizations responsible for community-based patient follow up activities and providing linkages to clinic-based care

 

 QWith the travel restrictions in place, how has HAI worked to keep our partners updated?

Every week on Thursday afternoons we have a zoom call with all our community partners during which each partner reports out on any difficulties they faced during the week, and the other partners can respond and provide advice.  The meetings help all the partners stay equally informed and share best practices across regions.

For example, during our meeting last week, we discussed all the strategies being implemented to ensure continuity of care and follow up of patients who live [far from their health facilities]. We followed this up by making sure that the community partners and health facilities are sharing information and implementing activities in a coordinated manner to avoid challenges. This means that, following an initial lapse [in patient follow-up activities] at the beginning, today nearly all patients are able to access care and treatment services.

 

 

 Q

Nearly all?

The main concern that we have now, is that due to the travel restrictions, the restocking of ARVs is becoming a challenge. In the contingency plan, it was suggested that patients receive several months worth of ARVs (at least 90 days) to prevent multiple health facility trips, but unfortunately the pandemic coincided with a moment where the stock of ARVs was not sufficient to take [the new guidelines] into account.  Under normal circumstances, when stocks are low in a certain region, we would organize a transfer from one region to another.  However, with the travel restrictions in place it is more difficult to organize these transfers.  However, we are on the telephone, working with multiple  district directors and others to organize the logistics of coordinated transfers of these medicines.  It’s difficult, but for the moment it seems to be an effective solution to the challenge.

 

Q

You mentioned patients who live far from their typical HIV care facilities.  Aside from the extended ARV prescriptions, how is their care changing?

For patients who are unable to travel to their health facility because of the travel restrictions, they are given information on health facilities located closer to their homes where they can continue care.  Once there, we connect with the manager at that site to coordinate information sharing with the patient’s home facility, so they can continue to track patient retention and adherence. We also request a weekly update on ARV stock at these sites so we can follow up and ensure transfers, as needed.

We are also working on a directory that will list the facilities and focal points for HIV care and community support for every locality across [all 6 regions where HAI works].  Once that is complete, it will be shared with every health facility, so that patients can be easily referred to new reference sites and providers can more effectively follow up on their care.

 

 

Since 2015, Project LINKS has supported Côte d’Ivoire’s Ministry of Health to identify and treat more than 40,000 PLHIV. HAI’s longstanding relationship with district and regional health departments and existing partnerships with active community-based organizations have facilitated a proactive and coordinated response to combatting fear and stigma and adjusting systems of care to ensure continuity of HIV service delivery during the active coronavirus pandemic.

As of the publication of this interview, the number of reported COVID-19 cases in Côte d’Ivoire has reached 1,602, and is growing daily.  Dr. Doumbia is joined by the whole HAI-Côte d’Ivoire team, the US Center for Disease Control and Prevention, Côte d’Ivoire’s Ministry of Health and Public Hygiene, and all our community-based organization partners in the response efforts.

 

Project LINKS is supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $35 million with 100% funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS, or the U.S. Government.

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