Sharing Lessons Between Epidemics: What can we learn from the responses to HIV and COVID-19?

Recently, JSI’s consultant Arman Lorz spoke with colleagues Amy Cullum and Gretchen Weiss to examine the linkages between COVID-19 and HIV and how the COVID vaccine rollout can inform an anticipated HIV vaccine, as well as how 40 years of experience with the HIV epidemic is informing the COVID response. Following are excerpts from their conversation.

Arman: COVID-19 emerged as a pandemic last year, and June 5, 2021, marks 40 years since HIV was first officially reported. What similarities do you see across responses to these infectious diseases, and what one can learn from the other?

Gretchen: COVID-19 has had parallels with HIV every step of the way. In fact, many leaders in the HIV field are at the forefront of the COVID response, and what we’ve learned from decades of responding to HIV, including vaccine research, community engagement, and health communications, has been building blocks for the COVID response.

Amy: And the learning has been bi-directional. COVID will be instructive to not only HIV, but all of public health. The lessons are applicable to any new vaccine introductions. How we communicate complex, highly nuanced health information to the public is always critical.

Arman: How did the COVID-19 vaccine come about so quickly, while an HIV vaccine still eludes us?

Amy: We did have a head start since there had been other coronaviruses (e.g., SARS and MERS) so we knew to target the virus; if it weren’t for this, things would likely have progressed more slowly. Other key factors were clinical trial design, government investment in production of promising vaccines while trials were in process, and collaborations that accelerated the process.

Additionally, high rates of community transmission meant that Phase 3 efficacy trials reached their endpoints quickly. All of this contributed to the safe and effective COVID-19 vaccines we have today.

Gretchen: It has been difficult to develop an HIV vaccine for many reasons related to the unique nature of the virus. I’ll leave it to the scientists, like Tony Fauci, to explain why. Nevertheless, there have been other significant advances in HIV prevention, including daily oral PrEP (pre-exposure prophylaxis) and long-acting forms of HIV prevention, as well as the science behind the message that U=U, or undetectable equals untransmittable. As work on an HIV vaccine continues, we are focused on scaling up and delivering these prevention strategies equitably.

Arman: How do we allay people’s concerns about new vaccines?          

Gretchen: There are many different reasons for why people don’t get vaccinated. We need to thoroughly understand these reasons, the motivations behind them, and who is affected to develop effective messaging for different audiences. The messenger also really matters, as we’ve seen with COVID. Meaningfully involving community members throughout all facets of vaccine research, development, and delivery is essential to building vaccine confidence and ensuring equitable access.

We also see this with the uneven uptake of PrEP, which has contributed to and exacerbated disparities in new HIV infections. In communities of color, for example, concerns and questions about the COVID vaccine are similar to those affecting PrEP uptake, as well as the social determinants of health, systemic racism, mistrust of the health care system and other governmental bodies, and availability of health care services.

Amy: The internet is a tremendous source of misinformation, and the politicization of everything, including vaccines, also makes it difficult to help people overcome their concerns. There has been a barrage of information without evidence.

Arman: Adapting and focusing our messaging is critical. How can we do this better for both COVID and HIV?

Amy: We need to shift our thinking to recognize that if people are not getting services, it’s not their fault, it’s a problem with the health care and public health system.

People who experience the greatest health disparities across the board—whether we’re talking about HIV, diabetes, or COVID—are those who we most often fail to reach. Materials and messages must be culturally and linguistically appropriate. And you need non-stigmatizing communications and trusted messengers who can convey complicated information clearly.

Gretchen: One thing we talk about in HIV is that as individuals, we are not good at assessing our own risk. There are HIV risk-assessment tools for providers, case managers, other service providers, and individuals. Understanding risk informs HIV-prevention messaging and counseling and people’s behavior and choices. There are many parallels with COVID, such as how one’s perception of risk affects mask-wearing or the decision to get a vaccine and what information may be helpful to make a more informed decision. There is also an opportunity to draw on harm reduction principles when communicating prevention strategies, whether for HIV or COVID-19.

Arman: We see the effects of the social determinants of health in vaccine access and uptake. How might this look for the HIV vaccine?

Gretchen: I expect this would play out similarly for an HIV vaccine, as we have seen the effects of social determinants in all other aspects of our HIV response. Addressing the social determinants of health is a central component of the Ending the HIV Epidemic initiative, launched nearly a year before the COVID pandemic began. COVID has illuminated these issues.

Whether for HIV or COVID, we need to look holistically at health equity and social justice, working across sectors, such as housing, employment, transportation, and the legal/incarceration system. We can’t rely on the response to—or funding for—a particular virus or disease. Our health initiatives must be tied to broader movements for equity.

Amy: Hopefully we’ve all learned that we can’t make efforts to support healthier lives in just one part of the health care system. We need more emphasis and funding for primary care, focusing on prevention and the health of the whole person, integration of HIV, behavioral health, and other services. COVID has underscored the need to strengthen long-term care and support community-based services: who will give COVID booster shots (assuming they’re needed) to people who are homebound or not connected to the health care system when there is no more supplemental funding? For people without access, do we need to revive house calls?

Arman: We’ve seen through the 40-year curve of the HIV epidemic that things change, and often we end up with more questions than we can answer. I have one more question: there are many recommendations, but where do you think we must start?

Gretchen: We must sustain and increase support for HIV research, prevention, and care, as well as our overall public health infrastructure and workforce. Too often we see an influx of funding in response to an emergency, then a precipitous dropoff as the emergency fades from public view. We had a national initiative to eliminate syphilis in 1999; funding was allocated and after a few years reduced, and now we find ourselves in 2021 with all-time highs for reported cases of syphilis (as well as gonorrhea and chlamydia), and a 279% increase in congenital syphilis from 2015 to 2019. 

As COVID fades from the headlines, we must keep a spotlight on public health and the social determinants of health, so that whether it is an HIV vaccine, a new HIV prevention strategy, or advances in HIV treatment or any other public health issue, our system can ensure equitable access for all.

Amy: Some of the populations who have yet to be reached with the COVID vaccine are the same as those we hope to reach with HIV services, and, eventually, a vaccine. In reality these people, like everyone, need the full range of health services to maintain their health. The COVID-19 pandemic has reinforced the need to fund community-based health care and public health services to increase trust and access so that we can respond in an equitable way to whatever the future brings. 

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Gretchen Weiss is a senior consultant at JSI who has worked in the HIV field for more than 15 years. She supports state and local health departments, community-based organizations, and health care provider efforts to end the HIV epidemic in the United States.

Amy Cullum is a registered nurse and a JSI senior consultant who has worked in public health and health care preparedness since 2003. She has been involved in the COVID-19 response in New Hampshire since March 2020.

Arman Lorz is a consultant based in JSI’s Denver office. Since 2007 he has been working in various national HIV-related projects and works on a couple of COVID-19 and health disparities related portfolios.