Intersecting epidemics

[Full title: Intersecting epidemics: COVID-19 and HIV in sub-Saharan Africa. A systematic review (2020-2022)]

[Find the meaning and references behind the names: Art, Valeria, April]

JOURNAL OF PUBLIC HEALTH IN AFRICA 00: JPHA-14-9-2658, 0000 Abstract. There has been significant progress with regards to winning the fight against HIV globally, particularly due to the introduction of antiretroviral therapy (ART). COVID‑19 threatened to derail gains in the fight against HIV. As we have started to see with studies on COVID‑19 and HIV, there is a need to ‘provide an in‑depth view’ in understanding the dynamics between the two epidemics, especially in sub‑Saharan Africa. We, therefore, undertook a systemic review of existing literature to synthesize the effects of COVID‑19 on the utilization of HIV services in sub‑Saharan Africa, the literature on the risks associated with HIV during the COVID‑19 pandemic, and lastly, the innovations and strategies adopted to continue receiving treatment in sub‑Saharan Africa. We conducted a systematic review of studies published between 2020 and April 2022. We searched for relevant sub‑Saharan studies in the following databases: PubMed, Google Scholar, J‑STOR, and Science Direct. The review followed the Preferred Reporting Items for Systematic Reviews and Meta‑Analyses (PRISMA) guidelines. The search identified 647 papers, and after screening, 41 were in line with the inclusion criteria and were included in the review. There was evidence of the negative effects of COVID‑19 on reducing HIV testing, ART treatment, and HIV prevention services. There is evidence pointing to the need for people living with HIV to be prioritized for COVID‑19 vaccinations. Innovations and strategies implemented to mitigate the effects of COVID‑19 on HIV services include community‑based ART distribution, multi‑month ART dispensing, the use of digital technologies, and the use of the already existing HIV infrastructure to fight COVID‑19. It is still imperative that future studies explore the predictors of utilization of HIV services in the advent of COVID‑19 Introduction More than forty years since the start of the HIV epidemic, about 79.3 million people have become infected with HIV globally. The HIV epidemic has claimed approximately 36.3 million lives from AIDS‑related illnesses over the past four decades (1). There has been significant progress in fighting HIV, particularly due to the introduction of antiretroviral (ARV) therapy. However, in the year 2020; around 1.5 million people who were newly infected with HIV globally, showing the need of continued efforts to fight the spread of the disease. Eastern and Southern Africa contributed approximately 670,000 of these new infections; whilst West and Central Africa added nearly 200,000 new infections. Henceforth, more than 50% of the new HIV infections came from Sub‑Saharan Africa. By the year 2020, more than 27 million people globally were on antiretroviral therapy (ARV) (1). Around sixty‑seven percent of these people living with HIV are in Sub‑Saharan Africa; with almost 16 million residing in Eastern and Southern Africa and 3.5 million in Central and West Africa. The coming in of COVID‑19 posed a new threat to the fight against the HIV epidemic; particularly in Sub‑Saharan Africa which carries the greatest burden of the disease. Recent studies have documented intensified risk amongst people living with HIV after contracting COVID‑19 (2,3). There were also COVID‑19 lockdowns and restrictions pronounced by governments as response measures to reduce the spread of the disease. Unfortunately, that has disrupted access to Sexual Reproductive Services (4,5). Consequently, HIV treatment has been disrupted as more priority was given to reducing the spread of COVID‑19 In the advent of the new pandemic, scholarly studies linking HIV and COVID‑19 are needed particularly in highly affected regions like Sub‑Saharan Africa which constitutes approximately 67% of people living with HIV. As literature Intersecting epidemics: COVID‑19 and HIV in sub‑Saharan Africa. A systematic review (2020‑2022) TALENT TAPERA 1 , CLIFFORD ODIMEGWU 1 , REBAONE PETLELE 1 , MATSHIDISO VALERIA SELLO 1,2 , ARMSTRONG DZOMBA 3 , OLUWATOYIN ALADEJEBI 1 and MILLION PHIRI 1,4 1 Demography and Population Studies Programme, Schools of Public Health and Social Sciences, University of The Witwatersrand, Johannesburg; 2 Centre for Social Development in Africa, University of Johannesburg; 3 MRC/Wits Rural Public Health and Health Transitions Research Unit‑Agincourt, Johannesburg, South Africa; 4 Department of Population Studies, School of Humanities and Social sciences, University of Zambia, Lusaka, Zambia Received XXXXX; Accepted XXXXX DOI: 10.4081/jphia.2023.2658 Correspondence to: Talent Tapera, Demography and Population Studies Programme, Schools of Public Health and Social Sciences, University of The Witwatersrand, Johannesburg, South Africa E‑mail: talent.tapera@gmail.com Key words: COVID‑19, HIV, sub‑saharan Africa, public health ORIGINAL ARTICLE

[Find the meaning and references behind the names: Main, Sahara]

TAPERA et al : INTERSECTING EPIDEMICS: COVID‑19 AND HIV IN SUB‑SAHARAN AFRICA. A SYSTEMATIC REVIEW (2020‑2022) 2 on HIV and COVID‑19 is relatively new, in‑depth view from systemic review are a crucial need. There is, thus, a greater need to gain insight into knowledge that has been discovered recently concerning COVID‑19 in terms of risk among people living with HIV, utilization of HIV services and innovations for continuity of HIV services. Gaining insight into the intersections between HIV and COVID‑19 in Sub‑Saharan Africa will help to inform the development of evidence‑based interventions for the region in responding to the two epidemics Therefore, this systematic review was undertaken with the aim of gaining in‑depth understanding of the effects of COVID‑19 on utilization of HIV services. It also explored on the risks associated with HIV during the COVID‑19 pandemic as well as innovations and strategies adopted to continue receiving treatment. Specifically, the review employed a qualitative approach to systematically describe and review existing literature linking HIV and COVID‑19. It explored the risk of HIV and COVID‑19 comorbidity in sub‑Saharan Africa, examining the utilization of HIV services and evaluating innovations and strategies adopted for the continuity of such services Materials and methods Protocol and registration. The protocol was registered with the PROSPERO international prospective register of systematic reviews under registration number CRD 42021278730. The final review was reported following the PRISMA 2020 statement (6) Summary of methods. This is a qualitative systematic review of literature linking HIV and COVID‑19 in sub‑Saharan Africa. The inquiry underwent three main phases of adapting the framework for conducting reviews as presented by Arksey and O'Malley (7). The first phase involved identifying the research question whilst perusing relevant literature. Secondly, the researchers went through the process of selecting the literature that matched using inclusion and exclusion criteria. The third phase involved collating, summarizing it into themes, and reporting the results Eligibility criteria. The inclusion and exclusion criteria which was developed for this review aimed to identify researches accurately and then pick out the relevant studies Inclusion criteriaStudy design. The review included clinical and non‑clinical studies which used focus group discussions to interrogate data and make sense of the emerging information. It also included cross‑sectional studies, cohort designs, technical reports and systemic reviews in examining in full or in part; the relationship between COVID‑19 and HIV Outcomes. Three main outcomes were synthetized in this review. Firstly, the research synthesized knowledge about COVID‑19 and HIV comorbidity risk. Secondly, it explored on the utilisation of HIV services during COVID‑19 restrictions and lockdown periods. Thirdly, it explored the innovations and strategies implemented to ensure continuity of services during lockdown periods Study setting. The review focused on studies conducted in Sub‑Saharan Africa. These included southern, western, eastern and central African countries which are south of the Sahara Desert Time. The review was limited to studies published between January 1, 2020, and April 30, 2022, in the databases consulted. Data was collected between August 2022 to November 2022 Language. Only studies published in English were included Exclusion criteria. Theoretical studies and researches outside sub‑Saharan Africa were excluded Search strategyElectronic databases. The electronic databases which were searched included PubMed, Google Scholar, J‑STOR and Science direct databases. Geographical restriction was applied to Sub‑Saharan Africa region whilst language choice was confined to English. The PubMed search query is presented in Table I Study selection. An extensive title screening was performed first. During the title screening, researchers uploaded the literature search in Mendely Desktop version 1.19.4 (8). Secondly, deduplication of studies from the Mendeley library was done to ensure that the researchers remained with unique studies. Thirdly, abstract screening was conducted. Through Abstract screening, the inclusion was determined to the full text review. At the last stage of full text review, the researchers remained only with studies that met the inclusion criteria Ethics and dissemination. This systematic review was exempted from ethics approval because the work was carried out on published scholarly documents that already existed. The study will also contribute to a DPhil thesis in Demography and Population studies at the University of Witwatersrand, Johannesburg, South Africa Data extraction. Our search retrieved 671 publications. The identification of studies flow chart is presented in Fig. 1. The final Mendeley database was shared for abstract screening; using three independent reviewers. These three extracted the data in the targeted search engines. As a guide, researchers used a systematised data extraction sheet. This data extraction sheet captured information such as the reference, aim and location. The Mendeley referencing software was used to identify and remove duplicates, of which 264 duplicates were removed. The remaining 410 studies went for title and abstract screening. Through this screening 224 studies were excluded. The main reasons why these were excluded included, no focus on HIV although they had Covid‑19 effects, no focus on sub‑Saharan African countries and Some showing other comorbidities of Covid‑19 and TB, Malaria, hypertension and not HIV. Of the 41 studies that were selected for full text screening, the 41 were included for the review. Regarding assessment of individual reviews, two researchers independently assessed the reviews for quality. The measurement tool that was used to asses was the Assess Systematic Reviews 2 (AMSTAR 2).

[Find the meaning and references behind the names: June]

JOURNAL OF PUBLIC HEALTH IN AFRICA 00: JPHA-14-9-2658, 0000 3 Characteristics of articles reviewed. Regarding the first pillar of the systemic review, we reviewed 21 studies (described in Table II) that were focused on effects of COVID‑19 on HIV services in sub‑Saharan Africa. These studies provided insights from the following 20 countries Burkina Faso, Ethiopia, Nigeria, Uganda, Kenya, Rwanda, Cameroon, Zambia, South Africa, and Botswana, Tanzania, Angola, Burundi, Ivory Coast, Democratic Republic of Congo (DRC), Eswatini, Ethiopia, Mozambique, South Sudan, Malawi, and Zimbabwe. Commons studies in this pillar were primary studies, desk reviews and modelling studies. Regarding the second pillar, we reviewed 11 studies (described in Table III) for COVID‑19 and HIV risk amoung people living with HIV. These mainly came from Zambia, Nigeria and South Africa. Common studies under this pillar were primary studies and desk reviews. In the last pillar, 9 studies (described in Table IV) with data and perspectives on innovations for continuity of HIV services during the COVID‑19 pandemic from Ivory Coast, Democratic Republic of Congo (DRC), Eswatini, Ethiopia, Liberia, South Africa, Togo, Uganda and Zambia. Common studies under this pillar were desk reviews Results Effect of COVID‑19 on HIV services utilization. Studies on the effect of COVID‑19 are presented in Table II HIV testing. HIV testing presents an entry point to ensuring that all people living with HIV are put on lifelong antiretroviral treatment (ARV) in order to live healthier lives. However, HIV testing services were among the services most impacted by COVID‑19 in Sub‑Saharan African countries (9‑11). In Homa bay and Kisumu counties of western Kenya, it was noted that both HIV testing and partner notification for clients in the community were affected. This occurred because home testing was halted due to COVID‑19 restrictions (9). Moreover, health care workers who used to follow up eligible clients for HIV testing in the community had to refer them for the services at the facility. This would then factor in issues of distance, affordability of transport or fear of contracting COVID‑19. In south‑western Uganda, HIV testing was negatively impacted in two major ways. COVID‑19 restrictions of movement prevented access to services and also the issue of stigma related to the disease amongst health care workers. Moreover, in 11 sub‑Saharan countries; data covering over twelve months showed a temporary lapse of HIV services which then improved as measures to ensure continuity of HIV testing and treatment services were instituted (12). This concurred with studies in 65 South African primary health facilities where an estimated 48% decrease in HIV testing was observed in April 2020. It was associated with COVID‑19 lockdown (13). A similar finding showed reduction of HIV testing in Zambia, Malawi and South Africa. Recovery of HIV testing services was only realised after the easing of lockdown restrictions (11). Between April and June 2020, there was a significant reduction in HIV testing volumes by 50% in South Africa, 35% in Malawi and 22% in Zambia (11) HIV treatment services. Considerable gains have been realised in HIV treatment across the globe. HIV treatment services ranging from Art refills and viral load monitoring among others have been severely affected by the advent of COVID‑19 (9,14). In western Kenya, the time frame of viral testing process increased from 1 to 2 weeks to several months due to diversion of laboratory facilities for COVID‑19 prioritisation (9). There have been reduced opportunities for client and health care worker clinic interactions as clients were referred direct to pharmacies for drug collection (9). In Burkina Faso, Nigeria and Ethiopia; health care providers noted that 18% of people living with HIV faced difficulties in accessing HIV treatment services (14). More so; in Nigeria, Kenya, Tanzania and Uganda, a temporary decrease in HIV clinic visits was recorded (15). Issues concerning food security among people living with HIV were also noted as affecting adherence to treatment (15). Similarly, as restrictions eased; ART initiations gradually improved towards pre‑lockdown levels in Rwanda, Table I. PubMed search query Concept Key search items Subject headings COVID‑19 ‘COVID‑19’[All Fields] OR ‘COVID‑19’[MeSH Terms] OR ‘COVID‑19 Vaccines’ Covid‑19 [All Fields] OR ‘COVID‑19 Vaccines’[MeSH Terms] OR ‘COVID‑19 serotherapy’ [All Fields] OR ‘COVID‑19 serotherapy’[All Fields] OR ‘COVID‑19 Nucleic Acid Testing’[All Fields] OR ‘covid‑19 nucleic acid testing’[MeSH Terms] OR ‘COVID‑19 Serological Testing’[All Fields] OR ‘covid‑19 serological testing’ [MeSH Terms] OR ‘COVID‑19 Testing’[All Fields] OR ‘covid‑19 testing’[MeSH Terms] OR ‘SARS‑CoV‑2’[All Fields] OR ‘sars‑cov‑2’[MeSH Terms] OR ‘Severe Acute Respiratory Syndrome Coronavirus 2’[All Fields] OR ‘NCOV’[All Fields] OR ‘2019 NCOV’[All Fields] HIV ‘hiv’[MeSH Terms] OR HIV[Text Word] HIV HIV testing ‘hiv testing’[MeSH Terms] OR HIV testing[Text Word] HIV Testing HIV treatment ‘anti‑retroviral agents’[All Fields] OR ‘anti‑retroviral HIV treatment agents’[MeSH Terms] OR Antiretroviral[Text Word]) AND (‘therapy’[Subheading] OR ‘therapeutics’[MeSH Terms] OR therapy[Text Word])

TAPERA et al : INTERSECTING EPIDEMICS: COVID‑19 AND HIV IN SUB‑SAHARAN AFRICA. A SYSTEMATIC REVIEW (2020‑2022) 4 Kigali (13). There was an observed association between place of residence and ART collection (13) In a study that focused on people living in slum dwellings across Nigeria and Kenya, findings showed that there were barriers to HIV related services that included increased cost of health care, reduced household income and fear of COVID‑19 infection. The affected services included screening for hypertension, HIV related issues as well as tuberculosis among others (16). In 65 South African primary health facilities, there was a notable median decrease from 571 ART initiations a week before COVID‑19 lockdown restrictions to 375 a week post lockdown period. However, the same study noted no significant changes in the number of ART refill collection visits Regarding the proximity of residences to health facilities, people living with HIV who resided within Kigali utilised their ART refill appointments in comparison with 35% who stayed outside Kigali (17). Being diagnosed in World Health Organisation clinical stage 1 was then associated with meeting the ART refill appointment at 48%; with 56 and 22% for patients in clinical stages 3 and 4 respectively (17). The effect of access to isoniazid‑preventive therapy (TPT) during the COVID‑19 period has been documented (18). TPT is particularly important in preventing tuberculosis in people living with HIV. In Uganda, a decline in the initiation of TPT by 75% in the first two weeks of April 2020 was recorded (18). More so, there was a recorded diversion of HIV and TB commodities production in preference of COVID‑19 items (19,20) Figure 1. Identification of studies flow chart.

JOURNAL OF PUBLIC HEALTH IN AFRICA 00: JPHA-14-9-2658, 0000 5 Table II. Utilization of HIV services in the advent of COVID‑19 in sub‑Saharan Africa Socio Author/year Study Focus/Aim of demographic Sample (Refs.) Title location Study profile Methodology size Findings Gaps Lagat et al Impact of the W estern The study was Males, Retrospective 2089 • Partner notification and HIV testing The study relies 2020 (9) COVID‑ 19 Kenya aimed at Females programmatic data Female for clients in the community was mostly on Pandemic on investigating indexes af fected as home testing was halted programme data and HIV T esting the impact of due to Covid‑19 restrictions service provider and Assisted Covid‑19 on • T urn‑around of viral results increased perceptions without Partner clinics providing from 1 to 2 weeks to several months interviewing the Notification assisted partner due to diversion of laboratory results clients aimed at Services, notificati on HIV for Covid‑19 receiving the W estern services in • Reduced opportunities for client and services Kenya western Kenya health care worker clinic interactions as clients were referred direct to pharmacy for drug collection Ponticiello et al ‘Everything South‑ To describe the Males and Qualitative 20 • In south‑western Uganda, HIV testing The study sample of 2020 (10) is a Mess’: western impact of Female ≥18 in‑depth was negatively impacted in two ways 20 was relatively too How COVID‑19 Uganda COVID‑19 years Interviews which include Covid‑19 restriction small to generalise is Impacting on uptake of and preventing access of services the study Engagement HIV testing in • It was noted that there was Covid‑19 with HIV south‑western related stigma among the health care Testing Services Uganda workers in Rural south‑ western Uganda Assefa et al Reported Burkina To assess the Health Care Telephone 900 • Health Care Providers noted that 18% Health service was 2021 (14) Barriers to Faso, ef fects of Providers Survey health of clients had difficulty in accessing interruption Healthcare Ethiopia, Covid‑19 Community Care HIV treatment through self‑reports Access and and Nigeria pandemic Members Providers only may introduce Service Uganda on healthcare 1797 some level of bias Disruptions services from the Community Caused by perspectives of members COVID‑19 in healthcare Burkina Faso, providers Ethiopia, and (HCPs) and Nigeria: A community Telephone members Survey

TAPERA et al : INTERSECTING EPIDEMICS: COVID‑19 AND HIV IN SUB‑SAHARAN AFRICA. A SYSTEMATIC REVIEW (2020‑2022) 6 Table II. Continued Socio Author/year Study Focus/Aim of demographic Sample (Refs.) Title location Study profile Methodology size Findings Gaps Bell et al Predicting To predict Men, W omen Retrospective ‑ • A decline in new HIV case HIV data on 2020, (18) the Impact the impact of Study identification by 75% in April 2020 impact of Covid‑19 of COVID‑19 covid‑19 on • A decline in the initiation of on services was for and the the disease isoniazid‑preventive therapy to a relatively short Potential burden prevent tuberculosis in people living period of time Impact of the with HIV by 75% in April 2022 (2 weeks), hence the Public Health situation could Response on have subsequently Disease Burden changed in shorter in Uganda periods of time as well Umviligihozo Sub‑Saharan Uganda, To document Men, W omen Review of ‑ • Interruption of pre‑existing et al 2022, (19) Africa Kenya, public health publicly programmes such PrEP for prepared ness Rwanda, interventions available prevention of HIV programmes and response Camero on, implemented in information to the Zambia, seven sub‑ COVID‑ 19 South Saharan pandemic : A Africa, and African perspective of Botswana countries early career on preparedness Africans and response to the Covid‑19 outbreak Dear et al Transient Nigeria, To observe Men, W omen Cohort study 2666 • A temporary decrease in HIV The participants that 2021, (15) Reductions Kenya, transient clinic visits were enrolled had a in Human Tanzania decreases in unique access to care Immunodeficiency and human during thepandemic, Virus (HIV) Clinic Uganda immuno hence the study Attendance and deficiency findings may not be Food Security virus (HIV) clinic representative of the During the visit adherence general population Coronavirus and food Disease 2019 security among (COVID‑19) persons living with

[Find the meaning and references behind the names: Ahmed, Harris]

JOURNAL OF PUBLIC HEALTH IN AFRICA 00: JPHA-14-9-2658, 0000 7 Table II. Continued Socio Author/year Study Focus/Aim of demographic Sample (Refs.) Title location Study profile Methodology size Findings Gaps Pandemic for HIV early in the People Living pandemic, with HIV in 4 and an increase African in viral suppressi Countries on later in the pandemic Harris et al Ef fects of the Angola, To document Men, W omen Retrospective 1059 • In 1 1 sub‑Saharan countries data The study included 2021, (12) Coronavirus Burundi the ef fect of cohort study supported tracked over 1 year showed a selected health Disease 2019 Camero, Covid‑19 on health transient ef fect on HIV services facilities and may Pandemic on on, Cote HIV services facilities which was then followed by a not be representative Human d'Ivoire, recovery in important measures of all health Immunodeficiency DRC, related to the HIV testing and facilities in the Virus Services: Eswatini, treatment 11 countries Findings from 1 1 Ethiopia, Sub‑Saharan Kenya, African Countries Mozambique, South Sudan and Zambia Ahmed et al Impact of the Bangladesh, To compare Men, W omen Qualitative 860 • Perspectives showed that among The study is based 2020, (16) societal response Kenya, access to stakeholder community slum dwellers, barriers that include on perspectives of to COVID‑19 on Nigeria Health engagements leaders, increased cost of health care, the stakeholders access to and Pakistan care for residents reduced household income, fear of healthcare for non‑ non‑Covid‑19 and health Covid‑19 infection were COVID‑ 19 health conditions care among the reasons that impacted issues in slum in the pre and workers access to services during the communities of post Covid‑19 Covid‑19 era Bangladesh, Kenya, periods in • The af fected services included Nigeria and slum screening for hypertension, HIV , Pakistan: results communities tuberculosis among others ofpre‑COVID and COVID‑19 lockdown stakeholder engagements

TAPERA et al : INTERSECTING EPIDEMICS: COVID‑19 AND HIV IN SUB‑SAHARAN AFRICA. A SYSTEMATIC REVIEW (2020‑2022) 8 Table II. Continued Socio Author/year Study Focus/Aim of demographic Sample (Refs.) Title location Study profile Methodology size Findings Gaps Thirumalaisamy COVID‑19 and Sub‑ To bring the Male, Female Desk review ‑ • The study predicted an intensification The study is a et al 2021, (26) syndemic Saharan ef fects of of the burden of HIV infections, desk review challenges in Africa Covid‑19 on malaria and tuberculosis if Covid‑19 ‘Battling the Big Sub‑ Africa with cases are not curtailed Three’: HIV , TB already high and malaria incidences of HIV , TB and Malaria Chanda‑Kapata Tuberculosis, Saharan To reflect on the Male, Female Desk review ‑ • Covid‑19 led to diversion of The study is a desk et al 2022, (20) HIV/AIDS and Africa COVID‑19 diversion of resources from HIV , review Malaria Health related Malaria and TB services Services in sub‑ disruptions on Saharan Africa‑A the Tuberculosis, Situation Analysis HIV/AI DS and of the Disruptions Malaria routine and Impact of the health services COVID‑19 across Africa Pandemic Coker et al Things must not Sub‑Saharan To highlight the Children Desk review ‑ • The study noted the highly The study is a desk 2021, (21) fall apart: the Africa impacts of likelihood of pandemic restrictions review ripple ef fects of Covid‑19 on and service disruptions as impacting the COVID‑19 children children living with HIV services pandemic on in sub‑Saharan such as psychosocial support, leading children in sub‑ Africa to poor adherence, deterioration of Saharan Africa mental health, and greater HIV ‑ related morbidity and mortality for children Britta et al Understanding South To Zimbabwe, Male, Females Use of a ‑ • A three‑month interruption for 40% The model did not 2020, (25) the impact of Africa, and explore mathematical of those on AR T could cause a take into interrupti ons to Malawi, the impact of model to examine similar number of additional deaths consideration any HIV services Uganda disruptions on how impact is as those that might be saved from interaction during the HIV outcomes af fected by model COVID‑19 through social distancing between HIV , or COVID‑19 assumptions • An interruption for more than AR T status and pandemic: A 6‑months could cause the 90% of covid‑19 infection

[Find the meaning and references behind the names: Pir, Peer]

JOURNAL OF PUBLIC HEALTH IN AFRICA 00: JPHA-14-9-2658, 0000 9 Table II. Continued Socio Author/year Study Focus/Aim of demographic Sample (Refs.) Title location Study profile Methodology size Findings Gaps modelling study individuals on AR T for nine hence people living number of HIV deaths to exceed with HIV are not the number of COVID‑19 deaths assumed to be more or less likely to acquire or die of Covid‑19 Dorward et al The impact of South Africa T o measure the Males, Females Interrupted time ‑ • In South Africa, lockdown was The study did not 2021, (13) the COVID‑19 impact of the series analysis associated with an estimated 47.6% take into account lockdown on 2020 national decrease in HIV testing in April, influences of viral HIV care in 65 COVID‑19 2020 load to complete the South African lockdowns on • AR T initiations decreased from a HIV care continuum primary care HIV testing and median of 571 per week before clinics: an treatment in lockdown to 375 per week after interrupted time KwaZulu ‑Natal, lockdown series analysis South Africa • However , there was no marked change in the number of AR T collection visits • As restrictions eased, HIV testing and AR T initiations gradually improved towards pre‑lockdown levels Jewell et al Potential ef fects Sub‑Saharan T o predict the Males, Females The study used ‑ • A 6‑month interruption of supply The model outputs 2020, (48) of disruption to Africa potential ef fects five models of of antiretroviral therapy (AR T) drugs were depended on HIV programmes of disruption to HIV epidemics across 50% of the population of the data that was in sub‑Saharan HIV programmes [Goals, Optima people living with HIV who are on available which may Africa caused by in sub‑ Saharan HIV , HIV treatment would be expected to lead e not have been COVID‑19 Results: Africa caused by Synthesis, an to a 1·63 times increase in HIV ‑ always compete from multiple COVID‑19: results Imperial College related deaths over a 1‑year period mathema tical from multiple London model, and compared with no disruption models mathema tical Epidemiological • Interruption to condom supplies models Modeling software and peer education would make (EMOD)] to estimate populations more susceptible to the ef fect of various increases in HIV incidence

[Find the meaning and references behind the names: Sar, Pierre]

TAPERA et al : INTERSECTING EPIDEMICS: COVID‑19 AND HIV IN SUB‑SAHARAN AFRICA. A SYSTEMATIC REVIEW (2020‑2022) 10 Table II. Continued Socio Author/year Study Focus/Aim of demographic Sample (Refs.) Title location Study profile Methodology size Findings Gaps potential disruptions to HIV prevention, testing, and treatment serviceson HIV ‑ related deaths and new infection Davey et al Contracting HIV South Africa T o document Male, Female Desk review ‑ • HIV preexposure prophylaxis The study is a desk 2020, (23) or Contracting the risks and (PrEP) in pregnancy had been halted review SAR‑Co V‑2 benefits of in various areas in light of the (COVID‑19) in contracting potential risk of Coronavirus Pregnancy? HIV or Covid‑19 exposure amongst pregnant women. Balancing the in pregnancy • However , it has been ar gued that Risks and Benefits benefits outweigh the risks in this population. Advocacy was made for continued PrEP enrolment, drug provision and adherence counselling in HIV infected and uninfected; patients pregnant and breastfeeding women at high risk of HIV acquisition in South Africa. It was concluded that continuing with our retention and prescription was ideal Pierre et al Attendance to Rwanda To document Male, Female Retrospective 382 • There was an association between The study is a single 2020, (17) HIV Antiretro attendance on study place of residence and attendance centrer study , hence viral Collection HIV related Peoplestaying within Kigali attended it may be difficult Clinic collections during scheduled AR T collection clinic to generalise Appointments the Covid‑19 appointments during the During COVID‑19 lockdown lockdown period compared to 35% Lockdown. A among those living outside Kigali Single Centre • There was an association between Study in Kigali, WHO clinical stage and attendance Rwanda status. 48% in WHO clinical stage 1

JOURNAL OF PUBLIC HEALTH IN AFRICA 00: JPHA-14-9-2658, 0000 11 Table II. Continued Socio Author/year Study Focus/Aim of demographic Sample (Refs.) Title location Study profile Methodology size Findings Gaps attended scheduled AR T collection clinic appointments during the lockdown period compared to 56% and 22% among those in WHO clinical stage 3 and 4 respectively Stover et al Estimation Malawi, To Male, Female Study applied an ‑ • Disruptions to primary prevention The authors admit 2020, (27) of the Potential Mozam bique, comparat ively existing HIV programmes such as male that the assumption Impact of Uganda, analyse the simulation circumcision, HIV behaviour change of no casual or COVID‑19 Zimbabwe ef fects of 3 and model programmes and condom commercial Responses 6‑month distribution would have small but sexduring the stay‑ on the HIV disruptions transitory ef fects on new infections at‑home period may Epidemic: in health that might be more than of fset by over ‑estimate the Analysis services as a reductions in commercial and reduction in using the result of multi‑partner sex due to lock downs incidence Goals Model COVID‑19 Snyman et al COVID‑19 in Africa To highlight Male, Female Desk review ‑ • The impact of HIV on Covid‑19 The study is a desk 2021, (29) Africa: pre‑ the ef fect infection is not yet completely review existing immunity preexposure to understood but evidence suggests that and HIV other human uncontrolled HIV negatively impacts coronavi ruses Covid‑19 clinical outcomes might have on SARS‑CoV ‑2 infection and disease course and the possibility of cross‑reactivity when performing diagnostic testing or surveilla nce for SARSCo V‑2 using immunoassay

[Find the meaning and references behind the names: Fernandez, Rose]

TAPERA et al : INTERSECTING EPIDEMICS: COVID‑19 AND HIV IN SUB‑SAHARAN AFRICA. A SYSTEMATIC REVIEW (2020‑2022) 12 Table II. Continued Socio Author/year Study Focus/Aim of demographic Sample (Refs.) Title location Study profile Methodology size Findings Gaps Mwananyanda Covid‑19 deaths Zambia To measure the Male, Female Cross • The five most common comorbidities The study was et al 2021, (49) in Africa: fatal impact of sectional among people who died of Covid‑19 limited by the prospective Covid‑19 in an study were tuberculosis (22; 31%), completeness and systematic urban African hypertension (19; 27%), HIV/AIDS accuracy of medical postmortem population (16; 23%), alcohol misuse (12; 17%), chart data surveilla nce study and diabetes (9; 13%) Fernandez et al HIV treatment/ Sub‑Saharan To assess the Male, Female Cross sectional 740,1 12 • The proportion of AR T clients who 2021, (50) retention in sub‑ Africa potential loss study were lost to follow up rose from Saharan Africa to follow‑up 4.9 and 5.3% between quarter 1 and before and during (L TFU) across Quarter 2 of 2020 in 18 countries of the Covid‑19 PEPF AR Sub‑Saharan Africa pandemic countries in SSA before and during the pandemic in order to determine the impact of COVID‑19 on HIV clinical treatment Murewanhema HIV and Sub‑ Sub‑Saharan To discuss the W omen Desk review ‑ • W omen from SSA remain at The study is a desk 2020, (22) Saharan African Africa factors that substantial risk of HIV acquisition, review W omen in the put women from especially the younger ones between COVID‑19 Era Sub‑Saharan 15 and 24 years of age. Factors that and beyond Africa at predispose them to an increased risk dif ferential risk of HIV infection may be aggravated of HIV acquisiti by the COVID‑19 pandemic on, and the possible impacts of the COVID‑19 pandemic on HIV care and prevention

JOURNAL OF PUBLIC HEALTH IN AFRICA 00: JPHA-14-9-2658, 0000 13 Table III. Risk of COVID‑19 among people living with HIV in Sub‑Saharan Africa Socio Author/year Study Focus/Aim of demographic Sample (Refs.) Title location Study profile Methodology size Findings Gaps Nepomuceno Vulnerable Sub‑Saharan To highlight Males, Retrospective ‑ • HIV infected patients are The study pillars on et al 2020, (32) groups at Africa the potential Females potentially at greater risk of inferring to previous increased risk risk profile for dying due to Covid‑19, finding; for example, of COVID‑19 Covid‑19 in considering that it is so on the risk of influenza in sub‑ high HIV because of influenza on the HIV population Saharan prevalence • HIV infected populations No actual data was Africa: The settings of are potentially a vulnerable collected on therisk of case of the Sub‑Saharan group at increased risk of Covid‑19 in sub‑Saharan HIV population Africa Covid‑19 Africa Himwaze et al Post‑mortem Lusaka, To define the Males, Descriptive 29 • Among the 29 autopsies, The study sample of 2021, (33) examination of Zambia gross Females, post‑mortem common co‑morbidities 29 is relatively small to Hospital pathology and Aged 15‑85 examination study included HIV were 28% (8/29) generalise the findings Inpatient histological of inpatient elsewhere COVID‑19 features of Covid‑19 related Deaths in COVID‑19 deaths Lusaka, Zambia‑A Descriptive Whole‑body Autopsy Series Bell et al 2021, Relative Sub‑Saharan To examine the Men, Retrospective 1,523,1 87 • In South Africa and Lesotho, The data analysis (34) Burdens of African disease burden of W omen Study (all mortality) tuberculosis, HIV/AIDS, and may be marred with the COVID‑19, countries Covid‑19, Malaria, malaria individually some completeness Malaria, Tuberculosis, dominated COVID‑19 issues as COVID‑19 Tuberculosis, and HIV/AIDS mortality until age 65 to 69 mortality data is and HIV/AIDS years, after which COVID‑19 incomplete Epidemics in dominated HIV/AIDS Sub‑Saharan Africa Mandala et al SARS‑CoV ‑2 Sub‑Saharan To find out if Men, W omen Desk review ‑ • There is need of prioritising It is a desk review 2021, (31) and HIV ‑1: Africa people living COVID‑19 vaccination for Should HIV ‑ with HIV those living with HIV ‑1 in 1‑Infected should be a Sub‑Saharan Africa (SSA) Individuals in priority group

TAPERA et al : INTERSECTING EPIDEMICS: COVID‑19 AND HIV IN SUB‑SAHARAN AFRICA. A SYSTEMATIC REVIEW (2020‑2022) 14 Table III. Continued Socio Author/year Study Focus/Aim of demog raphic Sample (Refs.) Title location Study profile Methodology size Findings Gaps Sub‑Saharan for the COVID‑19 Africa Be Vaccines Considered a Priority Group for the COVID‑19 Vaccines? Boulle et al Risk Factors South To examine risk Men, Populati 3,460,9 • HIV was associated with The study lacked data 2020, (3) for Coronavirus Africa factors for W omen on cohort 32 COVID‑19 mortality for other risk factors Disease 2019 COVID‑19 study • Current and previous such as socioecono (COVID‑19) death in sub‑ diagnosis of tuberculosis mic status and smoking Death in a Saharan Africa were associated with Population and the ef fects of Covid‑19 deaths Cohort Study human from the W estern immunodeficiency Cape Province, virus (HIV) and South Africa tuberculosis on COVID‑19 outcomes are unknown Venturas et al Comparison of South To ascertain HIV positive Retrospective 384 (108 HIV ‑ • In comparison of HIV The referred to only 2021, (36) outcomes in data whether people and HIV analysis Positive and negative and HIV hospitalized cases HIV ‑positive and living with HIV negative 276 HIV ‑ positive clients, although HIV ‑negative Africa have worse adults negative the median 4 C score was patients with outcomes higher in HIV positive COVID‑19 compared to patients, there was no HIV negative significant dif ference with patients with regards to mortality Covid‑19 • More so, although not staticallysignificant; HIV ‑ positive patients who died were younger than their HIV ‑ negative counterparts

[Find the meaning and references behind the names: Low]

JOURNAL OF PUBLIC HEALTH IN AFRICA 00: JPHA-14-9-2658, 0000 15 Table III. Continued Socio Author/year Study Focus/Aim of demog raphic Sample (Refs.) Title location Study profile Methodology size Findings Gaps Anjorin et al Comorbidities Africa To explore of Male, Female Deskreview ‑ • W ith regards to HIV the study The study is a desk 2021, (51) and the the impact of also ascertained that there is review COVID‑19 dif ferences in currently no epidemiological pandemic the epidemiology relationship between HIV and dynamics in of key COVID‑19. However , Africa comorbidities people living with HIV have as they relate been regarded a vulnerable to Covid‑19. group for covid‑19 Govender et al Systemic South To evaluate Male, Female Cross‑sectional 131 HI • HIV ‑1 controllers and The study did not have 2020, (52) DPP 4/CD 26 Africa soluble DPP 4 study infected progressors may have data for BMI and is associated (sDPP 4) levels and 20 HIV ‑ implications for risk and glucose for the clients with natural and activity in uninfected treatment of COVID‑19 in sampled HIV ‑1 control: plasma of 131 people living with HIV . Implications HI infected for COVID‑19 and 20 HIV ‑ susceptibility uninfected South African individuals Phiri et al Spread of Zambia To understanding Male, Female Cross‑sectional ‑ Areas with high rates of human The data on age groups 2021, (28) COVID‑19 in the association study immuno‑deficient virus (HIV) and socioeco nomic Zambia: An of COVID‑19 infection had relatively high situation was not assessment of cases with chances of having many available environmental environmental COVID‑19 cases when and and socioeconomic compared to areas with low socioeconomic factors in Zambia HIV rates factors using a classification tree approach Chanda et al COVID‑19 Zambia To find out if Male, Female Cross‑sectional 443 HIV infection was not Data complet eness 2021, (53) Severity and COVID‑19 Among study independently associated with was a limitation COVID‑19‑ Severity and Hospitalised worse outcomes among because clinicians who Associated COVID‑19‑ patients hospitalised for were responsi ble for Deaths Among Associated COVID‑19 in Zambia data collection were Hospitalized Deaths we also responding to other

TAPERA et al : INTERSECTING EPIDEMICS: COVID‑19 AND HIV IN SUB‑SAHARAN AFRICA. A SYSTEMATIC REVIEW (2020‑2022) 16 Table III. Continued Socio Author/year Study Focus/Aim of demog raphic Sample (Refs.) Title location Study profile Methodology size Findings Gaps Patients with related Patients ur gent demands HIV Infection with HIV Zambia, March‑ Infection December 2020 Osibogun et al Outcomes of Nigeria To identify Male, Female Retrospe 2184 • Compared to patients without Documented 2021, (35) COVID‑19 comorbidities ctive analysis laboratory these comorbidities, patients comorbidities were patients with that predict confirmed with hypertension were 2.21 basedon self‑reporting comorbidities death among a cases of times more likely to die from which could result in in southwest lar ge sample of COVID‑19 COVID‑19, patients with underest imation Nigeria COVID‑19 diabetes were 3.69 times more, patients from those with renal disease were Nigeria 12.53 times further , those with cancer were 14.12 times more likely to die while those with HIV were 12.21 times were more likely to die of COVID‑19

[Find the meaning and references behind the names: Gani]

JOURNAL OF PUBLIC HEALTH IN AFRICA 00: JPHA-14-9-2658, 0000 17 Table IV . Innovation for continuity of HIV services during the advent of COVID‑19 Socio Author/year Study Focus/Aim of demographic Sample (Refs.) Title location Study profile Methodology size Findings Gaps Acceleration of Sub‑Saharan The study sought Male, Females Retrospective ‑ • In response to Covid‑19 HIV The data used for this dif ferentiated African to summarise four analysis of service delivery in response to synthesis were service countries ways in which publicly COVID‑19, the following limited to delivery for dif ferentiated available data countries increased Multi month what was publicly HIV treatment service delivery dispensing of AR Vs to reduce available and were in sub‑Saharan (DSD) for HIV clinic consultations: Cote D' likely incomplete Africa during treatment has Ivoire,Democratic Republic of COVID‑19 been accelerated Congo (DRC), Eswatini, during COVID‑19 Ethiopia, Liberia, South Africa, in policy and Togo, Uganda and Zambia implementation in • Cote d'Ivoire,Eswatini, Sub‑Saharan Ethiopia, Kenya, Lesotho, Africa Mozambique, South Africa, South Sudan, Tanzania, Uganda and Zimbabwe emphasized community‑based models for AR T delivery within their HIV guidance during COVID‑19 • In HIV guidance in response to COVID‑19, a few countries (Cote D'Ivoire, Liberia and South Africa were the countries that emphasized the need to align refills for all medications among people living with HIV . Zakumumpa Dispensing Eastern The study Health team qualitative 99 Five broad strategies for Patients who et al 2021, (42) antiretroviral Uganda sought out to leaders, AR T case‑study distributing antiretroviral participated in the during Covid‑19 explore health‑ clinic managers, of eight during ‘lockdown’ emer ged in study may be lockdown: system representatives districts our analysis: accelerating representative of re‑discovering resilience at the of PEPF A R purposi • home‑based delivery of those who had community‑based sub‑national implem enting vely antiretroviral, extending means to overcome AR T delivery level in Uganda or ganis ations, selected multi‑month dispensing the transport barriers models in with regard to recipients of from three to six

TAPERA et al : INTERSECTING EPIDEMICS: COVID‑19 AND HIV IN SUB‑SAHARAN AFRICA. A SYSTEMATIC REVIEW (2020‑2022) 18 Table IV . Continued Socio Author/year Study Focus/Aim of demographic Sample (Refs.) Title location Study profile Methodology size Findings Gaps Uganda strategies for HIV care months for stable dispensing • patients; leveraging the antiretroviral Community Drug Distribution during Covid‑19 Points (CDDPs) model for AR T lockdown refill pick‑ups at outreach sites • in the community; increasing reliance on health information systems, including geospatial technologies, to support • AR T refill distribution in unmapped rural settings. District health teams reported leveraging Covid‑19 outbreak response funding to deliver AR T refills to homesteads in rural communities Nyoni 2020, COVID‑19‑ Sub‑Saharan To document Males, Females Desk review ‑ • T reatment supporters cost The study is a desk (43) Compliant Africa COVID‑19‑Com ef fective means of having review Strategies for pliant Strategies community based AR T Supporting for Promoting • Using digital health Treatment AR T Adherence interventions to provide Adherence • Cash transfers proved more Among People ef fective than food distribution Living with for nutritional programmes HIV in Sub‑ among people living with HIV Saharan Africa Amimo What does the Sub‑Saharan To examine the Male, Female Desk review ‑ • The current measures to control The study is a desk 2020, (45) COVID‑19 Africa potential COVID‑19 neglect important review pandemic implications of and complex context‑specific mean for HIV , COVID‑19 on epidemiological, social, and tuberculosis, the control of economic realities in Africa and malaria major epidemic COVID‑19 responses at country control? diseases in level should include measures to Africa (HIV , protect vulnerable and under ‑ TB and Malaria) served segments of society

[Find the meaning and references behind the names: Good]

JOURNAL OF PUBLIC HEALTH IN AFRICA 00: JPHA-14-9-2658, 0000 19 Table IV . Continued Socio Author/year Study Focus/Aim of demographic Sample (Refs.) Title location Study profile Methodology size Findings Gaps Brault 2021, Leveraging Sub‑Saharan To prof fer the Male, Female Desk review ‑ • Existing infrastructure for The study is a desk (44) HIV Care Africa deployment of fighting HIV/TB/Malaria review Infrastructures an integrated such as PEPF AR and Global for Integrated service delivery Fund need to pivot towards Chronic Disease model to fight integrated care inclusive of a and Pandemic covid‑19 and wider swathe of Management other pandemics non‑communicable diseases and in Sub‑Saharan pandemic threats Africa Golin (2020) PEPF AR's Sub‑Saharan To review Male, Female Desk review ‑ • Utilising the adaptive, data‑ The study is a desk response to Africa PEPF AR's driven programme approaches review the conver gence COVID‑19 in facilities and communities of the HIV and technical established and supported by COVID‑19 guidance and PEPF AR provides the pandemics in provides opportunity to strengthen the Sub‑Saharan country‑specific COVID‑19 response while Africa examples of protecting theimmense gains programme spanning HIVprevention, adaptions in sub‑ testing and treatment Saharan Africa W ilkinson The time is now: Sub‑Saharan To document the Male, Desk review ‑ • Expanding access to The study is a desk 2020, (38) expedited HIV Africa need for Female dif ferentiated service delivery review dif ferentiated expediting to people living with HIV is a service delivery dif ferentiate good way to disrupt the ef fects during the service delivery of Covid‑19 on HIV treatment COVID‑19 in the advent of access pandemic covid‑19 Grimsrudm, Silver linings: Sub‑Saharan To prof fer Male, Female Desk review ‑ • Strategies for expedited The study is a desk 2021, (39) how COVID‑19 Africa strategies on dif ferential service delivery review expedited how to expedite 19 include expanding into dif ferentiated expedited and community based services service delivery dif ferentiated for HIV service delivery

TAPERA et al : INTERSECTING EPIDEMICS: COVID‑19 AND HIV IN SUB‑SAHARAN AFRICA. A SYSTEMATIC REVIEW (2020‑2022) 20 Services for women and children. Children living with HIV have also been affected by the pandemic. Studies noted that restrictions and service disruptions caused by the pandemic impacted on children living with HIV. Services affected included; but were not limited to adherence counselling, psychosocial support and mental health support (21). On the other hand, women in sub‑Saharan Africa remain at substantial risk of HIV acquisition, especially younger ones between 15 and 24 years of age. Factors that predispose them to an increased risk of HIV infection may be aggravated by the COVID‑19 pandemic; including economic vulnerability due to the lockdown restrictions (22) HIV Prevention services. HIV preexposure prophylaxis (PrEP) in pregnancy had been halted in various areas because of the potential risk of Corona virus exposure for pregnant women (23). However, it was argued that the benefit completely outweighed the COVID‑19 risk. Henceforth, there was advocacy for continued PrEP use, and PrEP services among HIV infected or uninfected pregnant women as well as breastfeeding women that were at high risk of being infected by HIV (23) Modelling the impact on HIV services during COVID‑19 pandemic. Modelling studies also aided in projecting the impact of COVID‑19 on HIV services (24,25). Studies predicted an intensification of the burden of HIV infections and tuberculosis cases if COVID‑19 cases are not curtailed (26). In one modelling study carried out in South Africa, Zimbabwe, Uganda and Malawi; an interruption of 3 months for 40% of those on ART would in turn lead to similar additional number of recorded deaths. Moreso, an interruption of 6 to 90% of the people living with HIV for a period of 9 months would in turn make the number of HIV deaths to exceed those of COVID‑19 (25). In another modelling study, a similar picture was found. An interruption of 6 months in ART supply in at least 50% of the population of people living with HIV would be expected to lead to a 1·63 times increase in HIV‑related deaths in sub‑Saharan African countries (25). More so; with regards to HIV prevention programmes, the interruption in condom supplies and peer education would make populations more susceptible to HIV transmission and new infections (25). In addition, it was predicted that disruptions to prevention programmes would have temporary negative effects to the increase of new infections (26). Primary prevention programmes include; but are not limited to condom distribution, voluntary medical male circumcision and other HIV behavior change programmes (27) Risk of COVID‑19 among people living with HIV in Sub‑Saharan Africa. HIV and COVID‑19 comorbidity studies which were reviewed are presented in Table III HIV and COVID‑19 comorbidity. Current studies have reported no epidemiological relationship between HIV and COVID‑19. However, people living with HIV are regarded as a vulnerable group for COVID‑19; hence the need to ensure that they are vaccinated to guard against fears of heightened risk (28). The impact of HIV on COVID‑19 infection is not yet well understood, but the available evidence points to the Table IV . Continued Socio Author/year Study Focus/Aim of demographic Sample (Refs.) Title location Study profile Methodology size Findings Gaps for HIV during the Covid‑19 pandemic Stover , The risks and Sub‑Saharan To apply HIV Male, Female Desk review ‑ • Maintaining these HIV services COVID‑19 is a new 2021 (30) benefits of Africa simulation could lead to additional disease, so models providing models (Goals, COVID‑19 deaths of 0.002 are also new and HIV services HIV Synthesis, to 0.15 per 10,000 clients relatively untested in during the Optima HIV and projecting into the COVID‑19 EMOD) in order future pandemic to estimate the benefits of continuing HIV services

[Find the meaning and references behind the names: Job]

JOURNAL OF PUBLIC HEALTH IN AFRICA 00: JPHA-14-9-2658, 0000 21 fact that uncontrolled HIV may negatively affect COVID‑19 clinical outcomes (29). In South Africa, a study ascertained that HIV‑1 controllers and progressors may have significant implications for the risk and treatment of COVID‑19 among people who are living with HIV (30). As such, it has been recommended that there is need to make people living with HIV a priority group for COVID‑19 vaccination (31) HIV infected people are potentially at greater risk of dying due to COVID‑19; considering their susceptibility to influenza (32). Thus, HIV infected populations are a vulnerable group to negative COVID‑19 outcomes. In Zambia, findings of a study looking at 29 autopsies showed that 28% (8/29) of the deaths had co‑morbidities that included HIV (33). In a related study carried out in Lesotho and South Africa, HIV, tuberculosis and malaria were the predominant factors of COVID‑19 mortality (34). In a population cohort study of 3 460 932 participants, HIV was associated with COVID‑19 related mortality (3). Moreover, current and previous diagnosis of tuberculosis were associated with COVID‑19 deaths (3). In a study in Zambia, HIV was among the top five comorbidities among the people who died of COVID‑19. In another study conducted in Nigeria, there was comparison of patients without comorbidities and those with HIV. The study found out that patients with comorbidities were 12 times more likely to die from COVID‑19 (35). In comparison to HIV negative and HIV positive clients, it was discovered that although the median 4 C score was higher in HIV positive patients; there was no significant difference with regards to mortality (36). In addition, although it was not statistically significant; the study found out that people living with HIV who passed on were younger than those who were HIV‑negative (37). In Zambia, areas with higher HIV infection rates had greater chances of having higher COVID‑19 infection rates (28) Risk of offering HIV services during the COVID‑19 pandemic. Other studies have also documented the dangers of continuing to offer services during the COVID‑19 pandemic. In terms of risk, it was modeled that maintaining HIV services would also in some way lead to additional COVID‑19 deaths which were occurring at 0.002 to 0.15 per 10,000 clients (30) Responses to the effect of COVID‑19 on HIV in Africa. Innovations for continuity of HIV services during the advent of Covid‑19 are presented in Table IV Community ART delivery. Expanding access to differentiated service delivery to people living with HIV was a good way of disrupting the impact of COVID‑19 on access to HIV treatment services (38). Strategies for expedited differential service delivery include expanding into community based services (39). Some strategies which were COVID‑19 compliant included proffering treatment adherence, having treatment supporters and providing cost effective means of community‑based ART [47]. In response to COVID‑19, HIV service delivery increased in the dispensing of ART to Ivory Coast, the Democratic Republic of Congo, Ethiopia, Eswatini, South Africa, Liberia, Togo, Zambia and Uganda (40). Home‑based delivery of antiretroviral (ARV) drugs was a strategy utilised in Uganda. It leveraged the Community Drug Distribution Points model for ART refill at designated pick up points in the communities (41) Multi‑month ART dispensing. In the Ivory Coast, Ethiopia, Eswatini, Kenya, Mozambique, Lesotho, South Africa, South Sudan, Uganda, Tanzania and Zimbabwe; community‑based models for delivering ART in the community were prioritised. These countries combined it within their HIV guidance during COVID‑19 (42). More so, South Africa, Ivory coast and Liberia prioritised the need to align refills for all medications among people on ART (40). In addition, Uganda went to the extent of increasing multi‑month dispensing from three to six months for stable clients (42) Digital interventions. The use of digital health interventions to provide psychosocial support to people living with HIV was another innovation introduced during the pandemic. Cash transfers have also proved to be more effective than food distribution for nutritional programmes among people living with HIV (43). In Uganda, there was notable use on health information systems. Their use included employment of geospatial software in order to enhance ART refill distribution in areas which had not been mapped such as rural areas (42) Utilizing existing HIV infrastructure to fight COVID‑19. Existing infrastructure for fighting HIV, TB or malaria which was provided by donors such as PEPFAR and Global Fund need to be utilised in responding to pandemics such as COVID‑19(44). Infrastructure provided by the programmes enhanced the practice of being adaptive and a strong emphasis on data‑driven programme approaches which gives an opportunity to strengthen the COVID‑19 response activities (41) Protecting vulnerable populations. Measures to control COVID‑19 that were instituted portray realities in Africa, especially through protecting vulnerable population (44,45). Hence it was recommended that COVID‑19 responses should include measures that protect vulnerable population in the society such people living with disability and children among others (45) Discussion On the 11 th of March 2020, the World Health Organisation (WHO) declared COVID‑19 a global pandemic (46). This systematic review of the intersection of COVID‑19 and HIV was prompted by compelling reports which surfaced in the public health space pertaining the impact of COVID‑19 on HIV service provision. Governments worldwide initiated a multitude of strategies to reduce the spread of COVID‑19 in communities, but these had unintended and unwanted repercussions for society. Health care was one such activity which was negatively affected. Lockdowns resulted in severe loss of economic activity, job losses, closure of manufacturing industries, halts placed on import and exports which resulted in a shortage of medical equipment, products and stock‑outs on vital medication in clinics. Questions arose pertaining the impact of COVID‑19 on what was an already ailing health system in many developing countries, including those in sub‑Saharan Africa.

[Find the meaning and references behind the names: Dip]

TAPERA et al : INTERSECTING EPIDEMICS: COVID‑19 AND HIV IN SUB‑SAHARAN AFRICA. A SYSTEMATIC REVIEW (2020‑2022) 22 This systematic review found a wealth of studies had been conducted on an array of themes related to HIV and COVID‑19. Studies included in the review were used to answer research questions which aimed to examine the risks associated with HIV and COVID‑19, the impact COVID‑19 would have on HIV related services and inquire on what systems were in place to mitigate the regression on the gains which had been made in the prevention of HIV infections, provision of ART and the uninterrupted delivery of psychosocial care for people living with and affected by HIV/AIDS Findings suggest that COVID‑19 had a significant impact on the ability to deliver HIV testing services and support as we know it. Sub‑Saharan African countries are the most affected by the HIV/AIDS epidemic but regulations during the peak of COVID‑19 transmission resulted in a break in services. The results from our review show that referrals to testing had dwindled or stopped as health facilities were prioritising COVID‑19 related illnesses (9). Our review also shows that lockdowns restricted movements of individuals who were uncertain about the availability of health care services in general, but HIV testing was negatively reduced due to these containment measures implemented by governments. Fear also played an important component in the reduction of clients who were tested and initiated onto ART as community members were afraid of being infected with COVID‑19 in the health care facility. The studies reveal a drop in the rate of HIV testing during this period. Community health service provisions have been noted to be a good way of creating an enabling environment for the improved utilisation of HIV services (47‑53). This review has found evidence that community HIV testing activities were halted in the advent of COVID‑19 restrictions. This therefore paused a significant effect with regards to slowing down treatment of the HIV positive clients Access to ART was equally affected by the COVID‑19 pandemic. The researchers noted that utilisation of HIV treatment services such as ART refill, viral load monitoring and access to TB preventative treatment was not spared by COVID‑19. Factors such as curtailing of movements, stigma, diversion of HIV resources to COVID‑19 cumulated to limited access of ART services; particularly in the peak of the pandemic in period 2020‑2022. Studies which were reviewed in this research demonstrated how adherence to ART had taken a dip and therefore drastic measures were taken by public health professionals through mechanisms such as dispensing ART medication for a 6‑month period to avoid any defaulters. A differentiated model of delivery was seen in some of the studies reviewed, where treatment was dispensed outside the traditional clinic or hospital facilities. Initiatives such as home deliveries of medication were also noted as strategies initiated as a response to the gap in access to ART seen across already compromised public health care. This review again highlighted innovative solutions which were quickly initiated. They included the use of technology to provide non‑contact counseling services which proved to be helpful when social distancing was encouraged. With the drastic impact on household food security in poor households, governments resorted to cash transfers to ensure that the dire economic impact of the pandemic lockdowns could be cushioned. Previous studies had shown the importance of food for ART adherence and that the reduced household income was a threat to ART maintenance Another component of our investigation was to gauge the extent of vulnerability of HIV positive individuals towards morbidity and mortality related to COVID‑19 infection. Our findings suggest that HIV/AIDS increased the likelihood of adverse COVID‑19 outcomes. Comorbidities such as tuberculosis, hypertension and diabetes were seen to pose an increased risk of mortality, but our findings show that the risk is highest amongst those who are HIV positive. This expedited the need to dispel myths and misconceptions about COVID‑19 vaccines, it is vital for government campaigns to provide targeted messaging to encourage those most vulnerable to mortality to be vaccinated Our review has some limitations. Due to the heterogeneity of included studies, a meta‑analysis could not be conducted. Lastly, we only selected studies published in the English language. It is therefore possible that studies in other languages; particularly from French speaking nations in West Africa, were missed Conclusions Our study has demonstrated that there is a relationship between COVID‑19 and HIV. During the peak of transmission, HIV/AIDS related services were heavily compromised; which prompted the health system to adjust traditional service provision. Decades of systematic effort and gains towards the prevention, care and treatment of HIV/AIDS suffered. The results from this systematic review presented sufficient evidence that individuals who were HIV positive were more vulnerable to mortality related to COVID‑19 infection than those who were HIV negative. Our findings suggest that government interventions and mass campaigns should continue to target and encourage individuals with comorbidities to receive a COVID‑19 vaccinate in order to reduce their risk of mortality. Governments should continue to leverage on differentiated health care services; not only in response to COVID‑19 and HIV, but in order to promote an efficient service delivery such as the community‑based pick‑up points which reduce the likelihood of those lost due to travel barriers to follow up. Many under‑resourced public health facilities are plagued with overcrowding. Implementing COVID‑19 innovations such as telephonic psychosocial services, home deliveries for older persons and those living with disabilities, accessing mobile services which can also provide youth‑friendly sexual and reproductive health services in school will alleviate the burden on health facilities. With the evidence provided, many lessons are available for the governments to adapt in the provision of holistic services Acknowledgments The authors would like to thank the Demography and Population Studies team at the University of Witwatersrand for their continued mentorship in the systemic review process Funding This research did not receive any funding in either public, commercial, or not‑for‑profit sectors. The authors do not have

[Find the meaning and references behind the names: Liu, Hoffmann, Sharma, Kelly, King, Wang, Martin, Shamseer, Mkhize, Hansen, Smith, Abdullahi, Azeem, Joseph, Sam, Med, Green, Chen, Lewis, Bhaskaran, Jan]

JOURNAL OF PUBLIC HEALTH IN AFRICA 00: JPHA-14-9-2658, 0000 23 financial interests that are directly or indirectly related to the work submitted for publication Availability of data and materials Data and materials are available from the corresponding author upon request Contributions TT, conceived the idea for this paper; TT, MP, RP, MVS, AD, OA, CO, contributed screening and data extraction. All authors contributed to the subsequent interpretation, edits and final decision to submit the manuscript Conflict of interest The authors declare no potential conflict of interest Accepted: 14‑05‑2023; submitted: 19‑04‑2023 References 1. UNAIDS. Global HIV & AIDS statistics‑2020 fact sheet [Internet]. 2020 [cited 2021 Jan 24]. Available from: https://www unaids.org/en/resources/fact‑sheet 2. Williamson EJ, Walker AJ, Bhaskaran K, Bacon S, Bates C, Morton CE, Curtis HJ, Mehrkar A, Evans D, Inglesby P, et al : OpenSAFELY: Factors associated with COVID‑19 death in 17 million patients. 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[Find the meaning and references behind the names: Lee, Ali, Martins, Mohamed, Ebrahim, Idris, Gill, Raji, Julius, Wong, Wright, Aliyu, Omer, Cohen, Lawal]

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