Introduction

As we make efforts to grapple with HIV, the novel COVID-19 pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been an unprecedented threat to global health, challenging the robustness of health systems and the overall economy as a whole. Since the first case was reported in Wuhan, China, in 2019, infections are approaching 200 million and has claimed more than 4 million lives as of July 22, 2021 [1]. Older age and the presence of chronic co-morbidities like hypertension, diabetes, obesity, chronic respiratory disease, chronic kidney disease, cardiovascular disease, and malignancies are currently linked with a higher risk of severe disease and mortality [2,3,22] and could be considered as a priority group for COVID-19 vaccination. Therefore, we urgently need studies that analyze the efficacy and safety of vaccines in these immunosuppressed patients, in patients without ART, in women, and in different races. In addition, we should also know the duration of the immune response since some PLWH may need additional doses of vaccines.

Finally, since there is evidence that HIV adenovirus-based vaccines, trials increased the risk of acquiring HIV [60,61,62], further information is also needed to better understand the appropriateness of using the adenovirus type 5 vectored vaccines among HIV most-at-risk groups.

Impact of SARS-CoV-2 Pandemic in HIV Most-at-Risk-Groups and PLWH

Aside the direct risks to physical health, the psychological impact of COVID-19 could also be detrimental to mental well-being as elevated levels of stress and anxiety are further exacerbated by the ongoing uncertainty of the situation [63]. Key populations among PLWH experience particular forms of exclusion, criminalization, inequality, and discrimination that render them particularly vulnerable to COVID-19 [64]. This burden can affect the physical, emotional, and social well-being of PLWH and interfere with the reception of effective healthcare and access to HIV treatment [65].

A survey of older PLWH in Miami, USA, found that participants reported increased stress associated with their sense of social isolation and fragile economic situation [66]. PLWH who reported higher levels of anxiety and depression also reported losing their jobs during the pandemic [67]. Another study has described that psychological stress might be a predictor of COVID-19 burden (financial and social burden) and COVID-19 risk (health factors associated with an increased risk of severe health outcomes due to COVID-19) [67]. Additionally, COVID-19 burden and COVID-19 risk were predictors of depression and sleep problems [68]. LGBT people reported an elevated risk of domestic and family violence, increased social isolation, difficulties in accessing crucial HIV treatment, and gender-affirming health services [67, 69].

The impact of COVID-19 on sexual behavior among gay and bisexual men living with HIV has been described in three studies which reported changes in sexual behaviors, including avoiding close physical contact and reducing or ceasing sex with casual partners [70, 71]. There is also a reported increase in recreational drugs such as marijuana and methamphetamine (up to 8%), and alcohol consumption and binge drinking [70,71,72].

Impact on Health Services, Access to Diagnosis, and Treatment

In addition to the health emergency caused by the COVID-19, the pandemic has threatened the excellence in ART delivery in well-resourced countries which could potentially result in reduction in adherence and decreased health care retention [73, 74]. It is estimated that a significant proportion of HIV-infected patients could not access usual care because many HIV/AIDS prevention and control centers around the world have been converted into COVID-19 treatment centers and the perceived fear of contracting COVID-19 has made this group situation more vulnerable [75].

Vital HIV care resources including healthcare personnel have been channeled into curbing the COVID-19 pandemic [76]. A high percentage of community-based testing services have stopped or dramatically decreased their activity [77] and many HIV care centers worldwide were repurposed for the fight against COVID-19 denying PLWH the possibility of accessing crucial ART. [75]

During these periods, drug guarantee and distribution strategies were adopted by several countries; however, there are still uncertainties regarding the situation of assistance to PLWH in countries where the economy was highly affected. A study evaluating the impact of the pandemic on care for this population as well as on the provision of treatment found that no country, among the 19 participants, reported the closure of HIV care services; however, the functioning was normal in 6 countries (31.6%) and in 11 of them (57.9%) care was shared between HIV and COVID-19. Furthermore, the rechanneling of health professionals, especially HIV specialists, to the COVID-19 response caused the exhaustion of many HIV care teams [77].

For this reason, recommendations for management and prevention of COVID-19 among PLWH emphasize the need for continuity of HIV care, including uninterrupted access to ART, routine vaccinations, and the use of telematic means to access care, as long as it follows the general COVID-19 preventive guidelines. Also, continuous monitoring of the impact of the pandemic on this population is encouraged, so that it is possible to systematize evidence to support the reorganization of assisting services for PLWH. Regarding prevention services, the pandemic has challenged the functioning of HIV prevention services, such as free access to condoms and HIV pre-exposure prophylaxis (PrEP) and calls for innovative approaches going forward [78].

In Europe, some HIV prevention and diagnosis services have incorporated self-sampling and self-testing approaches [77]; nevertheless, applicability of these strategies may not be easy as they require good information technology and mailing systems, which is not the case in many LMIC. On the other hand, steady access to clinical care may be facilitated by means of telemedicine. But again, in light of the COVID-19 pandemic, as it has been described from an experience in the USA that it is likely that economic, geographic inequities, and the digital divide will prevent some PLWH from accessing care via this route due to lack of necessary technology (e.g., computer, smartphones) or stable internet access, especially among older PLWH [79].

Conclusions

In this review, we have highlighted some aspects of the SARS-CoV-2/HIV co-infection from both a public health and clinical perspective. Although at the beginning of the COVID-19 pandemic, the lack of integrated epidemiological surveillance and programmatic data prevented to have a clear picture of the overlap** distribution of both infections and its determinants, from a public health perspective, currently available data confirms the role of common structural determinants in both their acquisitions and clinical impact. Public health weakness, drug use, mental health, stigma, social marginalization, and other structural determinants they all disproportionally increase the exposure to both HIV and SARS-CoV-2.

From a clinical perspective, data suggest that PLWH under effective ARV treatment are not at higher risk of acquiring SARS-CoV-2. Moreover, there is no current evidence suggesting that TDF could reduce the risk of SARS-CoV-2 infection or severe COVID-19 outcomes in PLWH, and both clinical and radiological features of COVID-19 in PLWH are similar to those without HIV infection. Nevertheless, HIV-associated co-morbidities, low CD4 (< 200 cells) cell counts, and in particular unsuppressed HIV viraemia are associated with poorer COVID-19 clinical outcomes and death among PLWH. In such a context, PLWH should be considered a priority target group for SARS-CoV-2 vaccinations and further information is needed to identify potential advantages or disadvantages of the different commercially available vaccines and vaccination schedules to be used into this population.

The SARS-CoV-2 pandemic has not only impacted PLWH, particularly disrupting access to ARV treatments, but also HIV most-at-risk groups—including men who have sex with men (MSM), sexual workers (SW), and people using drugs (PUD)—decreasing access to HIV prevention and early diagnosis and linkage programs. Under the current uncertain epidemiological scenario, both clinical services offering medical care to PLWH and community programs offering services to vulnerable groups should be adapted to the evolving COVID-19 pandemic and the corresponding mitigation scenarios to prevent disruption of the HIV continuum of care among these populations. Systematization of SARS-CoV-2 testing among PLWH is basic not only to better understand the epidemiological co-infection pattern, but also to identify PLWH co-infected with SARS-CoV-2 with worse prognostic factors, as soon as possible. Integration of SARS-CoV-2 testing strategies in HIV testing programs should therefore be considered. With this regard, alternative approaches like telemedicine, self-sampling, and self-testing technologies have been used in both developed and LMIC with promising results and they should be scaled up.

Integrated information systems including epidemiological, microbiological, clinical, vaccination, and mortality data should be reinforced and maintained to monitor the impact of COVID among PLWH and HIV most-at-risk-groups. The use of PLWH longitudinal clinical data, population-based SARS-CoV-2 diagnosis data as well as ecological approaches to include structural indicators, seems crucial to increase the knowledge and practices towards SARS-CoV-2/HIV coinfection from both a clinical and public health perspective.