Maintaining Essential Health Services for Tuberculosis, Malaria and HIV during the COVID-19 Pandemic in Low Resource, Non-U.S. Settings – CDC

Globally, health systems have been challenged by the overwhelming demands of the COVID-19 pandemic. Resources and staff are being diverted to test and provide treatment for people with presumed or diagnosed COVID-19, and supplies are limited. Some healthcare services are being compromised in order to meet the demands of caring for patients with COVID-19 and many people fear accessing healthcare facilities due to fear of acquiring the virus.
During the Ebola outbreak in West Africa in 2014–2015, increased morbidity and mortality in other diseases (e.g., measles, tuberculosis, malaria, HIV/AIDS were seen due to reduction in access to and utilization of healthcare services1. It is important to ensure continuity of essential health services in order to prevent illness and death from non-COVID-19 illnesses.  This will likely require adaptations to service delivery models and settings. In addition, infection prevention and control (IPC) measures to reduce the risk of exposure to COVID-19 among patients and HCWs should be integrated into all healthcare settings3.
The purpose of this document is to provide Ministries of Health, public health authorities, and partners with a framework for implementing strategies to reduce preventable illness and death during the COVID-19 pandemic, particularly in low-resource, non-U.S. settings. It includes specific guidance on tuberculosis (TB), malaria and HIV due to their high preventable burden.
Ministries of Health, public health authorities, and implementing partners should continue efforts to actively engage community leaders to promote behaviors that will prevent transmission of diseases. Ensure that people do not receive potentially contradictory messages or misinformation regarding care-seeking behavior for febrile illness. For example, some COVID-19 messages encourage people with fever and mild illness to stay home, but if a person has TB, malaria, or HIV, it is critical that they seek care early. Messages to people who may have febrile illness must be clear and tailored to them:
Stigma and fear around diseases like COVID-19, TB, malaria, and HIV hamper an effective public health response. Interventions that can help reduce stigma include:
To protect the progress made through global efforts and investments in HIV, malaria, and TB, it is important that programs ensure continuity of essential services.
Despite being preventable and curable, TB remains the world’s deadliest infectious disease, taking the lives of 1.5 million persons each year. The global community has made substantial progress in the fight to end TB, and it is critical that the progress made in TB prevention, care, and treatment is not reversed by the COVID-19 pandemic. Increased demand for healthcare services due to COVID-19 can challenge health facilities and healthcare systems, resulting in delayed TB diagnosis and treatment, and increased illness and death. Previous global and regional health emergencies, like Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS), and Ebola virus disease, negatively impacted TB care2,3,4.
COVID-19 and TB share some common clinical features. Patients with chronic respiratory diseases, including TB, are at increased risk of severe COVID-19 illness and death5,6,7. Exposure to both can occur simultaneously, and the presence of comorbidities can result in poor outcomes for both diseases. A positive test result for COVID-19 does not rule out the presence of TB disease. In high burden TB settings, implementation of simultaneous testing for both diseases is recommended by WHO for persons with respiratory symptoms.
Modeling analysis by WHO and partners suggests that if essential malaria interventions are greatly disrupted due to COVID-19, the number of malaria cases will significantly increase, and death rates could double. Ministries of Health and National Malaria Control Programs (NMCPs) should implement malaria prevention and treatment activities in a manner that also protects patients, health care providers, and public health officials from COVID-19.
Both COVID-19 and malaria may cause fever, therefore planning for continuous availability of rapid diagnostic tests (RDTs) in healthcare settings will help distinguish between the two diseases and allow better understanding of the burden of each and whether there are interactions between them. National COVID-19 Incident Management Teams should include a representative from the NMCP to support decision-making that could impact the implementation of malaria prevention and control programs. These should supplement country Ministry of Health guidance.
NMCPs should ensure continued access to ITNs and proper use of ITNs for populations at risk.  Nonetheless, plans to bring together large groups of people for ITN distribution should be reconsidered. If mass ITN distribution campaigns cannot be implemented as planned, consider:
Essential routine entomological monitoring activities, such as vector bionomics collection, indoor residual spraying (IRS) quality and residual efficacy evaluation, and ITN durability monitoring may be conducted with NMCP approval if COVID-19 precautions are followed. This includes:
In 2020, a WHO pulse survey on continuity of essential health services found that approximately half of countries reported partial to moderate disruptions in malaria diagnosis and treatment. It is therefore important that countries continue to encourage the general population to seek care early for fever and suspected malaria, particularly for children under age 5 and pregnant women, who are most at risk for adverse consequences of malaria, while taking into consideration physical distancing and COVID-19 policies and guidelines:
In certain situations (e.g., ongoing local COVID-19 transmission, RDT stockouts, lack of PPE), presumptive malaria treatment for febrile illness may be required to minimize increased malaria illness and death while preventing COVID-19 transmission.
Due to the COVID-19 pandemic, countries have seen delays in the production and supply of malaria commodities, most notably RDTs and antimalarial treatments. Malaria program staff should proactively plan for potential changes in commodity availability, unreliable logistics systems, increased lead time for procurements, and increased demand for RDTs and antimalarial drugs. To avoid facility level stock-outs, countries should allow health care facilities to maintain 1 to 2-month longer supply stock than usual.
High-quality, timely routine health information—such as numbers of outpatient consultations, fevers, and malaria cases—is critical to monitoring both malaria and COVID-19 illness in the population. To help ensure timely availability of surveillance data for decision-making, countries should:
Currently available data suggests that PLHIV who acquire SARS-CoV-2 infection are at greater risk for severe COVID-19 disease than the general population. WHO report suggests that HIV is an independent risk factor for severe or critical illness at hospital admission and in-hospital mortality. Individuals with advanced HIV disease (e.g., CD4 count <200 cells/mm3) appear to be at greater risk for SARS CoV-2, and individuals with HIV and severe COVID-19 may be at greater risk for death. In addition, some PLHIV may have additional comorbidities, such as obesity, diabetes and hypertension, that put them at risk for severe illness from COVID-19. CDC and WHO have identified PLHIV as a group at higher risk for severe COVID-19 and vaccine receipt is recommended.
For PLHIV who have suspected, probable, or confirmed COVID-19, care and treatment for HIV should:
The US President’s Emergency Plan for AIDS Relief (PEPFAR) regularly updates and provides detailed, publicly available technical guidance for its HIV programs in the context of COVID-19. This technical guidance focuses on:
HIV viral suppression is critically important, and thus many considerations for HIV service delivery in the context of COVID-19 center on providing uninterrupted ART.
Conduct HIV care and treatment services in dedicated spaces that are physically separated from areas where patients with COVID-19 are being managed. PLHIV with COVID-19 should be managed in the areas dedicated to COVID-19 care.
Certain vulnerable populations may require focused attention to ensure uninterrupted service delivery. Children, adolescents, and pregnant and breastfeeding women should be included in differentiated HIV service delivery models. The same applies for patients with advanced HIV disease and/or high VLs who may require more frequent clinical evaluation. For some, this may be conducted virtually or outside a facility-based setting. It is also important to prioritize efforts to continue critical services for key populations (who may be at increased risk for both HIV and SARS-CoV-2  infection), such as treatment for substance use disorder, including medications for opioid use disorder, and access to clean/sterile injection supplies such as needles and syringes. Programs may also wish to be vigilant for increasing mitigation efforts to address food and economic insecurity among PLHIV in the context of COVID-19.
Although HIV testing may be affected by reductions in facility utilization and community testing activities, it should be prioritized:
Active patient tracking and tracing to ensure linkage to care once diagnosed, and for patients late to appointments or medication pick-ups or lost to follow up, should rely primarily on phone calls before resorting to in-person tracking in communities. All persons involved in tracking patients in the community should be provided with proper PPE and follow IPC procedures.
Routine viral load (RVL) monitoring may be affected by staffing or facility limitations, and/or concurrent use of HIV diagnostic instruments for SARS-CoV-2 testing. PEPFAR guidance suggests:
Disclaimer:
CDC operational considerations documents and/or resources are developed in partnership with global partners and specifically designed as reference guides in non-U.S. settings. CDC guidelines are intended for a U.S. audience and not meant to supersede guidance issued by the World Health Organization or any country.
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