Estimating the effect of COVID-19 pandemic restrictions on self-reported antiretroviral therapy use and late refill visits among people living with HIV in rural South Africa

Abstract

Background: People living with HIV require reliable access to and adequate supply of antiretroviral therapy (ART) for viral suppression. The Deliver Health Study, a randomized trial conducted during the COVID-19 pandemic, found that home-delivered ART significantly increased viral suppression compared to clinic-based care. The effect of changing COVID-19 alert levels on self-reported ART use has not been quantified. Setting: KwaZulu-Natal, South Africa. Methods: Adults living with HIV were followed in the Deliver Health Study during October 2019-December 2020. We used difference-in-differences (DiD) to estimate the effect of changing COVID-19 alert levels during three distinct periods on self-reported missed ART doses (missed 0 vs. 1 doses in past week) for participants receiving home-delivered vs. clinic-based refills. We additionally estimated the effect of changing COVID-19 alert levels on late clinic ART refill visits (late vs. on-time). We used relative risk regression for both binary outcomes. Results: Of 155 participants, 46% were women and median age was 36 years. The mean number of missed weekly doses was 0.11, 0, and 0.12 in the home-delivery group and 0.09, 0.08, and 0.18 in the clinic group during periods 1, 2, and 3, respectively. There were no differences in relative risk (RR) of self-reported daily ART use between refill groups when comparing across periods (DiDperiod 2 vs. 1=1.05; 95% confidence interval [CI]: 0.97, 1.13 and DiDperiod 3 vs. 2=0.99; 95% CI: 0.91, 1.08). In the clinic group, the risk of late refill visits was significantly higher during COVID-19 restrictions (vs. before alert level 5 implementation) and even after the COVID-19 alert level was downgraded to level 1 (RRperiod 2 vs. 1=1.83, 95% CI: 1.34, 2.51 and RRperiod 3 vs. 2=1.71; 95% CI: 1.43, 2.04). Conclusion: The COVID-19 pandemic did not differentially impact self-reported ART adherence by method of ART refills, but the risk of late clinic refill visits was significantly higher during COVID-19 restrictions and sustained after restrictions were loosened.