Lessons from HIV in war against Covid-19

For those who remember how HIV/Aids swept across countries in the 90s, the Covid-19 outbreak reads like a familiar script. Many have likened the attention the world has given Covid-19 to that of HIV/Aids. But now that HIV is no longer killing as many people as it did in the last century, there are lessons the world can learn from this.

After all, there are many similarities between the two viruses.

In 1981, American epidemiologists reported deaths among young men who had sex with men, describing the disease as a mysterious immune-wrecker. Two years later, researchers would identify it as HIV. Before it was named, the World Health Organization reported that Covid-19, caused by the virus Sars-Cov-2, started in December 2019 in China as a cluster of pneumonia cases with an unknown cause.

By 1999, Africa was the hardest hit by HIV deaths, with the United Nations records showing the continent accounted for nearly three in every four (76 per cent) of the total 16 million deaths.

Thankfully, Africa has reported very few deaths compared to European countries. As of yesterday, 158 people had tested positive for Covid-19 and six had died in Kenya.
Kenya has been a gallant warrior against HIV. According to the National Aids Control Council, 1.6 million people had HIV as at 2018, representing 4.7 per cent of the entire population. This was a remarkable drop from the 7.4 per cent in 2004.

Quick acknowledgment of a pandemic

Nelson Otwoma, chairperson of the National Empowerment Network of People Living with HIV/Aids in Kenya (Nephak), says for Kenya to survive Covid-19, the country can learn to acknowledge the seriousness of a disease.

Otwoma, who survived the deaths caused by Aids in the 1980s, tells HealthyNation that he shudders at the current pattern where people downplay the seriousness of Covid-19 just like they downplayed HIV.

“The government and the people took a back seat in those years and theories were span that it was caused by homosexual sex,” says Otwoma.

The world would have had a fighting chance to stop HIV from becoming a pandemic that had infected 1.3 million Kenyans, 37.9 million people across the globe with HIV/Aids by 2018. Of these, 36.2 million were adults and 1.7 million were children, according to data from UNAids.

In South Africa, for instance, President Thabo Mbeki shocked the world when he publicly rejected the accepted scientific studies that Aids was caused by a virus. Mbeki was under the influence of a group of maverick scientists known as Aids denialists, most prominent among Peter Duesberg.

By 2005, more than 900 people were dying in South Africa of HIV, according to the UN as he rejected offers of free drugs, grants and his government dragged its feet on treatment. A 2008 research by Harvard University shows that Mbeki’s government was directly responsible for the avoidable deaths of over 300,000 people in South Africa.

Otwoma recalls this and his fears are valid: Italy has shown the world how a virus’ itinerary can be made deadlier when authorities and people downplay a disease.

Health Cabinet Secretary Mutahi Kagwe has also raised concerns about Kenyans’ apathy towards Covid-19 and he warned it would cost the country more lives. One example is Kilifi’s deputy governor who is accused of refusing to self-quarantine even though he had been exposed to Covid-19.

While the Italian situation cannot be compared to Kenya in terms of magnitude, Kenya’s government also dragged its feet in acknowledging the presence of the virus in the country.

In 1984, Kenyan doctors diagnosed their first Aids case, but the government did not release national statistics on the virus until 1986. It has not been quantified, but historical accounts such as Dr Joyce Nyairo’s book Kenya@50: Trends, Identities and the Politics of Belonging records that there were many HIV deaths in this period.

When there was consensus, deaths were stopped due to testing.

Testing and treatment

Dr Patrick Oyaro, a public health expert whose work on epidemiology has been around HIV, tells HealthyNation many people died of Aids because they were tested late, therefore, were not put on antiretroviral drugs on time.

He says the Covid-19 response should learn about the importance of prioritising diagnosis and treatment the way researchers did for HIV/Aids.

“Unlike Covid-19, the progress of HIV until it is in the full blown Aids stage takes time. But, when it is tested and detected early, the ghastly final stage can be prevented through medication,” says Dr Oyaro.

The success rate of minimising HIV cases was due to persistent and constant monitoring of scientific evidence.

In October 2015, the Health ministry recommended that anyone testing positive for HIV should be put on treatment immediately. Before that, patients were only introduced to antiretroviral therapy when tests on their immune system, determined by their CD4 count, suggested they were getting sick. The directive led to a reduction in the deaths of HIV tremendously.

Considered an essential tool to track the spread of the disease, the World Health Organization (WHO) has repeatedly urged governments and health agencies to make testing for Covid-19 a top priority in their response to the pandemic.

Prof Omu Anzala, a virologist, says testing for Covid-19 is currently done on viral genetic material taken from the nose and throat swabs of a patient.

Africa CDC director, Dr John Nkengasong, tells HealthyNation inability to set up the testing for Covid-19 could be contributing to a gross underreporting of the positive cases.

Testing for HIV controlled the disease because those found positive were immediately put on treatment. By doing so, the viral load in their system was suppressed. Through testing, Covid-19 can also be suppressed by limiting the number of those sick among us.

Suppression refers to reducing the infectivity (RO) of a pandemic. This is by aggressively testing and then isolating those who are positive so that they are not able to infect others.

Studies show that if left unchecked, the infectivity of Covid-19 is between two and three, meaning every infected person infects two to three others.

An RO of less than one indicates that each infected person results in less than one new infection. When this happens, the outbreak will slowly grind to a halt.

When HIV was declared an epidemic, discrimination and stigmatisation were witnessed in the provision of care. Insurance companies refused to cover those who tested HIV positive and the drugs were very expensive. Most people died, denying them critical health care services, it endangered the health of others and undermined the overall response.

This stigma was a hindrance to testing and treatment. At the beginning of the Covid-19 outbreak, the virus was termed the “Chinese disease”. “In the early 1980s, Kenya did not take HIV testing seriously. Testing was only done at Kenya Medical Research Institute (Kemri) and once tested, one was given a tag number and told to report back to the chief in their village and through the tag number, they were able to trace all the contacts. This brought about the stigma that we still have in the country,” says Otwoma.

Use existing infrastructure and resources

While testing may be a priority, there is a global shortage of resources needed to respond Covid-19, including testing kits.

HIV/Aids response in Kenya found itself in this situation until the 2000s when generic medicine started being used. There was a challenge of human resources for health that could handle the needs of the other diseases in the health system as well as the HIV pandemic.

What did Kenya do?

Dr Oyaro says the government trained nurses and clinical officers, who were then put in charge of managing HIV and TB in hospitals. Clinical officers were found to be efficient in disease management because their training is heavy on assessing patients using what they observe and the nurses in keeping them on medication due to their training in walking with patients throughout their sickness.

This network, Dr Oyaro says, now includes biostatisticians and epidemiologists who ensure resources allocated for HIV are not mismanaged. “The government can not only borrow these professionals, but also try this method of riding on existing infrastructure,” says the public health expert.

To some level, Kenya is learning this. In a previous interview, Africa CDC Deputy Director Ahmed Ogwell told HealthyNation his agency, WHO and Kenya have trained lab technologists who are already working to diagnose Covid-19.

The tools that they will use are already in the health system: the Cobas 6800 or Cobas 8800 which are used in Kenya for viral load detection in HIV patients and the GeneXpert machines that now offer point of care to TB patients. Kenya Medical Supplies Authority’s, Dr Jonah Manjari, says the agency procured the Cobas Sars-Cov-2 to be mounted on the viral load machines.

The announcement comes barely a week after the Africa CDC announced that the US Food and Drug Administration had granted emergency use authorisation to Cepheid’s Covid-19 test that can provide accurate results in 45 minutes and is mounted on the GeneExpert.

Limiting community infections using community health workers

While HIV transmission is mostly sexual. It has comorbidities like TB that are spread in the community. When the research community realised this, they activated the use of community health volunteers who knew everyone in the village and would help with tracing the people to complete their treatment.

“During the HIV outbreak, the government restricted freedom of speech and the free flow of information, hence denying communities regular and up-to-date information and guidance and that’s what we are seeing with Covid-19. The community has been neglected and they are not part of this. This is a wrong move from the government and will affect how the pandemic is handled,” Otwoma tells HealthyNation.

He adds: “The government needs to know this is not a government affair. Take actions at the community level, talk to them on the safety measures.”

When schools are closed or people are asked to self-isolate, communities are needed to make sure that these people have food and medical supplies and that children are looked after.

Communities are able to monitor the response from the ground to see how it is affecting vulnerable groups and bring issues to the attention of the government and service providers, he says.

Health Director-General Patrick Amoth has said the Covid-19 outbreak has entered a new, more potent phase dictated by local or community transmission, the kind that occurs without air travel to affected countries.

A German study published online on March 8 showed that throat swabs of people with little or no symptoms had high level of Sars-Cov-2. Three other studies, including one published in the New England Journal of Medicine wrote: “The viral load that was detected in the asymptomatic patient was similar to that in the symptomatic patients, which suggests the transmission potential of asymptomatic or minimally symptomatic patients.”

Dr Oyaro, therefore, advises Kenya to learn from the HIV/Aids research community on tackling this through the use of community networks.

Dr Oyaro said: “Community health workers are the ones who would know where the elderly are, who travelled abroad and came back and this can help in contact tracing of Covid-19 just like it did in HIV.”

Collaboration for a vaccine, tests

While there has not been success yet, the research for a HIV vaccine has brought about unprecedented collaborations that have also improved the care for patients since the 1990s.

Labs such as Kenya’s KAVI Institute of Clinical Research and South Africa’s Sub-Saharan African Network for TB/HIV Research Excellence have contributed towards the production of the evidence that has led to the medical management of HIV in Africa.

Covid-19 needs new diagnostic tools and partnership in research.

Dr Nkengasong says CDC is not manufacturing their own vaccine at the moment and will collaborate with their western counterparts.

Last week, four scientists based in Kenya were incorporated into a global coalition of researchers from all continents in clinical trials aimed at finding solutions for Covid-19. The Covid-19 Clinical Research Coalition has more than 70 institutions from over 30 countries.

The researchers were Prof Yeri Kombe, the Kemri director-general; Philip Bejon, executive director of the Kemri-Wellcome Trust Research Programme; Anastasia Guantai from the University of Nairobi, and Fred Siyoi from the Pharmacy and Poisons Board.