Déjà vu, all over again: HIV and COVID-19
A recent article in the New York Times ("How Much Worse the Coronavirus Could Get, in Charts" by Nicholas Kristof and Stuart A. Thompson) included some nice interactive charts with various scenarios for the COVID-19 epidemic in the United States. As I read the article and experimented with the interactive charts, I remembered the time five years ago when I first learned about UNAIDS Fast Track strategy for ending the HIV epidemic by 2030. There are many similarities between the two epidemics and the global response to them. I’m sure an epidemiologist would say, “Of course, there are similarities. What would you expect? They’re both epidemics!” But for those of us who are not epidemiologists, here’s a list:
Modeling and projections can never be perfect, but they can certainly help us face reality. When I first learned about Fast Track, I was shocked to see scenarios where HIV made a resurgence in the 2020s. When I looked at the COVID-19 models, it was sobering to see a scenario in which a million people die in the US.
Epidemics are global in the 21st century, just like everything else. HIV was initially seen as isolated, affecting only certain groups of people, but by 2000 it had become apparent that it was a global pandemic, requiring a global response that came in the form of institutions like UNAIDS, the Global Fund, and PEPFAR. The COVID-19 epidemic began in China but it quickly spread, reaching over one hundred countries within a few months. And it’s not just the epidemic itself, but its effect on the global economy, where every country is connected, directly or indirectly, to every other country. Like it or not, we are all in this together.
Acting early and aggressively is vitally important. The key to the Fast Track strategy was to ramp up the global HIV response from 2016-2020, which would save many lives and much money during the 2020s. The key to the COVID-19 response is an immediate, aggressive response, to use the language of the NYT article. I hope we are more successful with COVID-19 than we were with Fast Track funding.
Reliable testing and data are critical. Representative Nancy Pelosi said that the three key elements of the bill recently passed by the United States House of Representatives are “testing, testing, and testing.” The analogous phrase in the HIV epidemic is “Know your status.”
There are often non-medical barriers that keep people from getting tested. In the case of HIV, one of the key barriers is societal stigma. In the case of COVID-19, it is the economic risk, especially in the United States where many workers don’t have paid sick leave.
Epidemics always hurt the vulnerable and marginalized. In the case of HIV, it is key populations like men who have sex with men, and people who inject drugs, as well as women and girls in some societies. In the case of COVID-19, it involves people who are on the economic margins, like hourly workers in service industries.
Often, community responses are the key. One of the lessons of four decades of the HIV epidemic is that community responses are often the most effective - when people you know encourage you to get tested or support you during treatment, the results are often the most successful. In the case of COVID-19, we will see this, for example, when communities help look after children whose schools are closed or help deliver food to the elderly so they don’t need to go out.
Success requires political will. The NYT article mentioned the importance of political will in addressing the COVID-19 epidemic. In the case of HIV, the political will was there in the 2000s and through the early 2010s, but lack of political will has often been cited for the global failure to meet the funding requirements of the Fast Track strategy in the last several years.
Success also requires societal will. Political will matters, but I think there is also a need for societal will. During the 2000s, there was a widespread understanding that we had some sort of collective obligation to end AIDS. With COVID-19, there is a rapidly growing recognition of the need for maintaining a social distance and for stopping large gatherings. There’s a sense that, if this is what we need to do, then we can and will do it.
It’s interesting to note that President Trump selected Ambassador Deborah Birx to be the coordinator of the United States response to COVID-19. She has been the head of PEPFAR since 2014, leading the American response to the global HIV epidemic. She certainly brings a lot of experience from one epidemic to another.
In the words of Yogi Berra, an American baseball player known for interesting turns of phrase, “It’s déjà vu, all over again.”