As of February 2015, the World Health Organization had reported 22,859 suspected, confirmed, and probable Ebola Virus Disease (EVD) cases in Guinea, Sierra Leone, Liberia, Mali, the United States, Spain, Nigeria, and Senegal and had declared the outbreak to be a public health emergency of international concern. ¹ War and instability have plagued the region since the 1980s, resulting in the countries with the highest caseloads of EVD being among the least developed nations worldwide. Containing Ebola in the regions affected is of paramount importance and rightfully remains the world’s primary public health priority.

Meanwhile, the crippling Ebola outbreak and the resulting collapse of the already fragile health care delivery system have led to the disruption of other essential health services, including those designed to treat persons living with HIV. As the EVD response displaces previous health care priorities, it is critical to consider the broader impact of this shift. This outbreak has channeled most health resources of already weak health systems to fight Ebola. Unfortunately, to date, international recommendations on service delivery during humanitarian emergencies have largely focused on specific types of disasters, namely, armed conflict, natural disasters, or political instability, and little has been reported on the delivery of HIV clinical services in the context of a disaster.Reference Griffiths and Ford ²

The life-saving, life-extending, and prevention benefits of HIV care and treatment, including prevention of mother-to-child transmission (PMTCT), are well recognized and understood. Adult HIV prevalence rates in Sierra Leone, Guinea, and Liberia are 1.5%, 1.7%, and 0.9%, respectively. Although tens of thousands of West Africans are currently receiving HIV treatment, antiretroviral therapy (ART) coverage in these countries remains low (24% in Liberia, 17% in Sierra Leone, and 24% in Guinea). ³ Antenatal care, often the entry point for PMTCT and related testing and counseling services, is also underutilized in the region. ^{4 - 6} Even before the Ebola outbreak, Guinea covered fewer than 50% of pregnant women with antiretroviral drugs to prevent mother-to-child transmission. ³

West African countries have made important progress against HIV in recent years, yet challenges—stigma, attrition, low coverage, inadequate equipment, poor staffing, poor adherence, limited access to HIV tests, opportunistic infections, poor infrastructure, and irregular drug supply—remain. ^{3 ,} Reference Jespersen, Hønge and Oliveira ⁷ It is likely that the insecurity, fear, and appropriate governmental responses associated with the EVD outbreak are further subverting the already limited clinical and community HIV service delivery. Clinical services are further stymied by dwindling numbers of health care workers. Both Liberia and Sierra Leone, respectively, have 0.1 and 0.2 physicians/10,000 population, which is among the lowest physician coverage levels worldwide. ⁸ Prior to the Ebola outbreak, these limited human resources for health contributed to the fragile health infrastructure. The weak health systems are further compromised by the unprecedented number of health care workers who have been exposed to and infected with Ebola in this context: 822 health care workers infected and 488 dead as of February 2015 per the WHO. ¹ Recent rapid assessments have shown a decline in the number of people using health facilities, where respondents have cited fear of being exposed to the Ebola virus as a key factor. ⁹

The effects of additional strain on a health care system that is already above capacity are predictable. Reports from Liberia suggest that the ongoing Ebola outbreak has led to disruptions in access to HIV care and treatment and other needed clinical HIV services. According to Liberia’s National AIDS program, more than 60% of HIV care facilities have closed. ¹⁰ The Liberia Network of People Living with HIV reports that the current emergency has halted its national HIV response services and interrupted access to life-saving antiretroviral therapy. ¹¹ In Sierra Leone, the Deputy Director of the National HIV/AIDS Secretariat recently disclosed that the outbreak of Ebola has greatly threatened the prevention and control of HIV. ¹² The Network of HIV Positives in Sierra Leone (NETHIPS) advocacy group reports that counseling, support groups, stigma-reduction training, and treatment adherence activities have declined as a result of this outbreak.Reference Fofana ¹³ UNAIDS reports a decrease in the number of functioning ART sites in Sierra Leone, with 2 sites placed under temporary quarantine. ⁸ Liberia and Sierra Leone have declared a national state of emergency, with associated school closures and quarantine. Although data are limited on the effects of quarantine thus far, such restrictions on movements certainly further compromise access to health services.

While it is difficult in the midst of this crisis to formally assess the impact of the Ebola outbreak on HIV clinical services, proactive efforts to protect the continuum of care for HIV are critical. Figure 1 depicts a conceptual framework developed to illustrate the effect of the Ebola outbreak on the delivery of HIV clinical services. The figure illustrates how the fragile health infrastructures that have been unable to contain the Ebola epidemic also contribute to interruptions in access to routine, life-saving drugs, commodities, and services, which are likely to result in increased HIV-related morbidity and mortality, treatment failure, ART resistance, and new infant HIV infections. Mounting food insecurity in the context of quarantine and closed borders is certain to amplify these negative health outcomes for people living with HIV.

Figure 1 Conceptual Framework of the Effect of the Ebola Outbreak on Delivery of HIV Clinical Services. Abbreviations: ANC, antenatal care; ART, antiretroviral therapy; DOTS, directly observed treatment, short-course; FP, family planning; PMTCT, prevention of mother-to-child transmission of HIV; TB, tuberculosis.

With the emergence of the current Ebola outbreak and the further weakening of already inadequate health services, authorities may not prioritize continuity of HIV care and treatment. We recommend the development and implementation of targeted approaches that help the countries most affected by the Ebola outbreak to sustain priority elements of HIV service delivery. Wherever possible, these approaches should integrate with the broader Ebola response. Particular attention should also be given to tuberculosis, which has parallelisms with HIV, given the significant potential for resistance and transmission during this outbreak.

PRIORITY #3: DETERMINE THE HIV STATUS OF CONFIRMED EVD PATIENTS

Clinical providers should determine the HIV status of admitted EVD patients and inquire about their ART use. Little is known about the effect of HIV on clinical outcomes for EVD patients. A retrospective study conducted during the Kikwit outbreak in 1995 revealed that the general population was screened for HIV infection, with a 2.9% antibody seroprevalence. A subset of EVD patients tested were all HIV negative. These data suggest that the AIDS pandemic did not drastically influence the clinical presentation or the severity of Ebola hemorrhagic fever cases in 1995.Reference Oleribe, Salako and Ka ¹⁴ However, as one can hypothesize that the compromised immunologic status among many living with HIV may have a detrimental effect on overall health outcomes, it is important to better understand how HIV affects the clinical outcomes of EVD patients specifically. Additionally, there have been anecdotal reports that the use of lamivudine improved the clinical outcomes of EVD patients.Reference Cohen ¹⁵

Given the unprecedented nature of this outbreak, innovation, flexibility, and adaptability will be needed to develop creative strategies to ensure continuity of critical HIV prevention and treatment services. Over the longer term, countries should consider adopting their existing policy frameworks to delineate their plan to protect the continuity of HIV treatment services in the context of a complex emergency.

Drawing from this framework, the priorities outlined above, and previous evidence about protecting the continuum of care during humanitarian emergency settings, additional considerations to maintain continuity of care for HIV patients are provided in Table 1.

Table 1 Additional Strategies to Protect HIV Clinical and Preventive ServicesFootnote ^a

^a Abbreviations: ART, antiretroviral therapy; EVD, Ebola virus disease; NGO, nongovernmental organization; PMTCT, prevention of mother-to-child transmission.

Failure to consider HIV during the Ebola response may unwittingly subvert the already limited services available and create an enabling environment for increased sexual and mother-to-child transmission of HIV. While insufficient investment in health system strengthening has likely contributed to the challenges in controlling the Ebola outbreak in West Africa,Reference Kieny, Evans, Schmets and Kadandale ¹⁶ if this outbreak does not include specific attention to HIV clinical services, including PMTCT, we are at risk of dismantling the progress made thus far regarding HIV care and treatment in West Africa.

As the international community attempts to curtail this horrific epidemic, our response must be one that is robust and integrative. It is extremely difficult to conduct studies in the midst of this crisis to assess the impact of the Ebola outbreak on HIV services. However, it is known that this epidemic has led to the collapse of an already weak health infrastructure. All sectorial initial assessments and resulting action plans should consider protecting the continuity of HIV care and treatment of individuals known to have or be exposed to HIV. Limiting the number of lives taken by this epidemic will mean limiting the number of deaths from all causes.