Our study provided strong indications that the decrease in HIV diagnoses in Belgium in 2020 was linked to the COVID-19 pandemic and the imposed containment measures. Indeed, the decline of HIV diagnoses was most pronounced during the first lockdown in April–May. In the following months, with the exception of June, the number of diagnoses remained significantly lower than in previous years. In contrast, HIV care indicators such as viral suppression and ART coverage remained good though a slight increase in HIV care interruption was observed in 2020.
As also observed in other countries, the decrease in HIV diagnoses in Belgium largely coincided with a reduction in testing activities [1, 10]. This reduction was reported in health care facilities and in community based testing services which target specific key populations [4]. The amount of tests performed depends on the available and accessible offer and the clients’ or patients’ demand, which in turn is also influenced by (self-perceived) risk of HIV infection.
During the months of March to May 2020, whilst access to testing facilities was very limited leading to a decrease in test offer, the ratio of diagnoses per test was higher than the annual average of previous years. This suggests a restriction of testing towards those at high risk or with suggestive clinical symptoms. Between June and September, access to testing normalised with a similar number of tests per month as in previous years. The ratio of diagnoses per test was very low in the summer months, suggesting an extension of testing to less urgent or less specific indications, which were postponed during the lock-down period.
Several studies suggest that HIV transmission may have been reduced by the decrease in sexual interactions with casual partners due to the restriction of physical and social contacts during the periods of strict confinement [11]. An online survey among MSM in Belgium showed a sharp drop in the number of casual sex partners during the first lock-down period from March to May 2020 [12]. Similar results were observed in studies in the Netherlands [13], United Kingdom [14, 15] and Australia [16].
A first observation that is in line with those studies showing a lower risk of HIV transmission in this period is the halving of the number of acute HIV diagnoses from March 2020 to the end of the year compared to the previous year. Diagnoses during the acute phase of HIV infection have decreased significantly more than the HIV diagnoses in general, while during acute infection a large majority of patients present with clinical symptoms, which may draw clinicians’ to this differential diagnosis, as opposed to established HIV infection. However, it cannot be excluded that some diagnoses of acute infections may have been missed as HIV acute infection may mimic COVID-19 symptoms [17].
A second observation in the same direction is the decrease in the purchase of PrEP pills and the number of PrEP purchasers from April 2020 onwards, meaning that some users have reduced or suspended their PrEP use, and very few initiated PrEP. Studies among PrEP users indicated that they tailor their PrEP use according to their risk exposure [18,19,20]. Continued use of PrEP during periods of lockdown was found to be associated with having sex with casual partners [12]. It can therefore be assumed that PrEP use patterns were adapted by users according to the perceived needs, potentially allowing PrEP to continue playing its role in reinforcing combination prevention.
HIV diagnoses among heterosexuals are still mainly reported in people of sub-Saharan African origin followed by people of other non-Belgian nationalities. Among non-Belgians, the decrease in HIV diagnoses was mainly observed during the COVID-19 lockdown periods when travel restrictions were in place. The pandemic has had a major impact on international migration flows to Belgium (-15.5% international immigrations in 2020 compared to 2017–19 [21]) and in consequence, most likely, on the number of non-Belgian PWH whose diagnosis was confirmed after arrival in Belgium.
In parallel to the decrease in the overall number of HIV diagnoses, there was a decrease in the number of late diagnoses. On the one hand, travel restrictions and reduced migration during the lockdown periods may have had an impact on the number of late diagnoses among non-Belgians, although this number decreased only minimally compared to previous years. On the other hand, limited accessibility to testing facilities also played a role and may have increased the delay in diagnosis for some people, as reported in the Netherlands where more advanced disease was observed at entry in clinical care after the lockdown periods [22]. Though no rebound with an increase in late diagnoses post lock-down was noticed in Belgium until end 2020, which is a preliminary reassuring signal. The trend in late diagnoses in the following year will be monitored to reappraise the extent to which HIV diagnoses were missed in 2020.
As a result of the social and physical distancing, as well as shift from the infectious diseases dedicated staff to COVID-19 care, the organization of the HIV-care had to be adapted during the periods of lockdown, with an impetus for alternative strategies such as telemedicine [5, 23]. This adaptation of care is illustrated by the reduced number of viral load tests performed during the months of March to May, linked to the postponement of these tests in clinically stable patients. A similar trend was observed in a monocentric study in Belgium [23]. Nevertheless, the antiretroviral treatment coverage remained high in 2020 and very effective in controlling the viral load of HIV-positive patients in care. The feasibility and positive experience of this digital switch supports its use in future routine HIV care.
Similarly, prevention services had to be adapted during lock-down: renewal of the PrEP prescriptions could be done remotely by the physician allowing the collection of the PrEP pills at the pharmacy. Field prevention and support organizations reinvented their action package to adapt to the pandemic by informing PWH about COVID-19 vaccines and providing support in making vaccine appointments. The link with the community was maintained by switching to online prevention, support and sharing groups and supportive phone calls. Testing was supported through the distribution of HIV self-tests (T. Martin, Director Plateforme Prévention SIDA, personal communication, April 19, 2022). Harm-reduction services also had to adapt their service offer during the lock-down periods by limiting or stopping the public reception, introducing online support, adjusting syringe exchange programs and providing information and education on COVID-19 prevention [24].
Finally, structural inequalities related to poverty and migration may have been exacerbated during the COVID-19 pandemic, potentially limiting access to health services for vulnerable populations even more than before [25,26,27]. Our results show indeed a slight increase in HIV care interruption in 2020. The results of a study conducted among PWH revealed that the negative impact of COVID-19 was more important in the most vulnerable PWH. The reported reasons include an increased fear of COVID-19 infection, greater sense of isolation for PWH living alone, deterioration of financial situation especially for those in the informal economy, and increased uncertainty of legal status for asylum seekers. For some, this led to weight gain and bad habits such as alcohol use and other addictions (Thierry Martin, Director Plateforme Prévention SIDA, personal communication, April 19, 2022). Therefore it is essential, particularly during a pandemic period, that prevention and testing facilities as well as care are inclusive and accessible to all affected populations.
