Dr Becky Metcalfe’s work changed radically after the UK went into lockdown last March. A consultant in sexual health and HIV at the Sandyford clinic in Glasgow, she was working with the city’s homeless population of drug users. Overnight, support services for her patients were withdrawn. “The addiction services, the third-sector support services, the charity-funded organisations – they all stopped doing face-to-face,” she says.
Metcalfe’s area has close to 1,000 patients using pre-exposure prophylaxis, or “PrEP”, a pill taken by at-risk individuals which can prevent HIV. Where Metcalfe works, PrEP users are tested for HIV every three months: if they test positive, the clinic works with them to trace everyone with whom they’ve come into sexual contact or shared needles. That strategy has helped to control an outbreak of HIV among Glasgow’s homeless population which began in 2015 – but the sudden closure of face-to-face services meant this regular testing vanished. That was potentially devastating, says Metcalfe.
UNAIDS, the joint UN programme which aims to eradicate HIV, says the disruptions to these kinds of services caused by Covid might have set back the fight against the disease “by ten years or more”. Given how tantalisingly close scientists and campaigners were to winning the war against HIV – UNAIDS’ goal is to end the global Aids epidemic by 2030 – that is deeply frustrating.
Meanwhile, governments around the world have drawn on research and clinical networks established by the global HIV community in its fight against Covid. It’s hardly surprising: HIV is still one of the worst pandemics in history – since it emerged 40 years ago, it has infected 77.5 million people worldwide, killing close to 35 million. The question, once the Covid pandemic recedes, is whether the HIV community can in turn draw on the advances made during this pandemic to get their own fight back on track.
Dr Anthony Fauci, director of the US National Institute of Allergy and Infectious Diseases and the chief medical advisor to the president, has hailed the speed and efficiency with which the US Covid-19 Prevention Network (CoVPN) helped to identify a Covid vaccine, calling their work “elegant science”. He helped to establish the network last year, merging three HIV-focused clinical trials networks – the HIV Vaccine Trials Network, the HIV Prevention Trials Network and the Aids Clinical Trials Group. The networks were practised at identifying potential vaccines: within months of its formation, CoVPN’s trials had helped to create the Moderna and Janssen vaccines. CoVPN is only one example of a set of HIV clinical trials networks that have been commandeered for the fight against Covid.
Moving all that capacity to a different focus has “of course” derailed HIV research, says Professor Sharon Lewin, a leading virologist who has been at the forefront of the fight against HIV since the mid-nineties. But she is optimistic too. As director of the University of Melbourne’s Peter Doherty Institute for Infection and Immunity, and a member of Victoria’s Covid Advisory Group, she’s had a front-row view of the Covid epidemic.
There’s no question advances made by Covid researchers will be beneficial to the fight against HIV, she says. “Let’s say we manage Covid. What do we do with all that infrastructure? We have to use it to deal with all the other challenges. And HIV is still there.”
Vaccine technology has also taken leaps forward over the course of the Covid pandemic: mRNA vaccines, which “instruct” immune cells in how to produce antigens, had been talked about in HIV “for decades”, she says. “They looked really good in monkey models, but no one had cracked how to best deliver it to humans. And now we’ve worked out how to deliver it, how to manufacture it, how to distribute it, how to make it cheaper and what the side effects are.”
At the same time, viral vector vaccines, such as the AstraZeneca vaccine, use an engineered version of the target virus to deliver instructions to the body’s immune system. They have been the subject of small-scale studies in HIV, says Lewin. “Now we know so much about their side effects and how to dose them – that will definitely benefit HIV vaccine research, as well as cure research.”
It’s less certain whether the social strategies seized on by governments to limit Covid transmission will be as effectively applied. In the wake of national Covid measures, the logic behind Metcalfe’s test-and-trace programme in Glasgow is all too familiar: regular testing and rapidly making contact with sexual partners of those who test positive for HIV are two of the main strategies used by campaigners to control transmission of the disease. Deborah Gold, chief executive of the National Aids Trust, says campaigners have been trying to persuade governments to make HIV testing more widely available for years – but have largely been ignored.
Covid has proved testing should become “much more routine”, says Gold. “Every time you’re having your blood screened, it should be screened for HIV as well. That’s not the case at the moment.”
“Once you know you have HIV, you can get access to treatment which is going to save your life, [help you] live a long and healthy life and also prevent you from passing HIV on to others,” she says. “Getting on top of testing means you’ll get on top of transmission.”
In the fight against both diseases, Gold adds, governments have also failed to recognise that pandemics thrive on inequality. “People don’t acquire HIV or Covid in circumstances of their own choosing, and we know that pre-existing inequalities that are baked into society are also baked into how epidemics work.
“The lesson from HIV, which I’m not sure has been necessarily learned in terms of Covid, is that you can’t fight that without collaborating in a really positive way with those communities who are most at risk and having them drive the fight against the pandemic.”
Metcalfe’s story has a happy ending: she and her colleagues borrowed a van and set up a mobile clinic offering screening and PrEP, which they took to the hostels in Glasgow where the homeless population had been housed during lockdown.
The idea has been so successful that they are looking forward to getting their own van in August, so they can continue their work in areas where HIV testing services have yet to resume.
For the rest of the HIV community, the effects of Covid may take longer to overcome. But Lewin is hopeful that governments have learned lessons in the last two years which they can apply to other pandemics that are present – namely HIV – and those yet to come.
“Covid is an opportunity to reinvigorate interest in HIV because people have realised the importance of public health, resilience, the need for science, virology, immunology capacity in low-income countries, vaccine manufacturing and public health systems,” she says. “Even in high-income countries, it’s shone a light on this infrastructure that we need to manage with infectious diseases.”