Lessons learned, mistakes repeated: From HIV/AIDS to COVID-19

COVID-19 is often described as unprecedented but 40-year-old lessons from HIV/AIDS can guide the public-health response in significant ways.

Many infectious-disease practitioners pivoted from HIV to COVID at the beginning of the pandemic. Two years later, some of them share their views on what we’ve learned, where we’ve repeated mistakes from the past, and how we can move forward most effectively in the next phase of the pandemic.

Lesson #1: Early access to medical treatment is the only way to stop viral spread across the globe

“We had a window,” says Chris Beyrer, professor of public health at Johns Hopkins. In the 1990s, Beyrer witnessed as HIV “got out of control” in portions of Africa that couldn’t access antiretroviral drugs because of the cost. Only after the U.S. created the PEPFAR program – the President’s Emergency Plan for AIDS Relief, established in 2003 – did people in low-income countries receive treatments. By then, it was too late to contain the virus. Currently, one in five adults in South Africa is HIV-positive.

Beyrer is one of many who say the same mistake is being made with COVID. The numbers are stark: As Western nations respond to Omicron by administering third shots – and some jurisdictions begin administering fourth shots – only eight per cent of people in low-income countries have received one dose.

This affects people not only in Africa: high rates of community spread – especially among immunosuppressed people, such as those with untreated AIDS – create the optimal conditions for viral mutation. It is hypothesized that Omicron emerged through this mechanism.

Lesson #2: Illness is a reflection of the health of society – not just individuals

By examining which populations are hit hardest by a disease, public-health officials can identify gaps in policy as well as harmful cultural norms. The prevalence of AIDS in females in South Africa alerted public-health professionals that sexual violence was a serious problem in certain communities. Rebecca Martin, director of the Emory Global Health Institute at Emory University in Atlanta, says this discovery led to programs such as PEPFAR’s Dreams that empower women through education and economic independence.

Similarly, says Beyrer, policymakers can use COVID numbers as a roadmap highlighting weaknesses in the social safety net, with the virus disproportionately affecting people in long-term care homes as well as minority and low-income communities. Early in the pandemic – especially when data about disproportionate deaths in minority communities was coupled by the murder of George Floyd by police – it seemed these insights might lead to fundamental shift in health-care policy, Martin says. Increasingly, though, the conversation has turned away from the “social determinants of health,” including poverty, pollution, and access to primary care. Martin sees this as a lost opportunity – another place where the lessons of HIV/AIDS were not heeded.

Lesson #3: Trust in public-health interventions is developed over time, through mutual respect

Communities are “wary” of outside experts descending on them, dictating what they must do with their health and their bodies, Martin says. Relationships need to be developed over time, “not just during a crisis,” so people can see the consistent, everyday benefits of public-health measures. Such relationships not only build trust, they also build infrastructure: supply chains, laboratories that sequence viral genomes, communications networks of doctors and nurses who share real-world experience about best practices.

All of these systems were created through community engagement, finding local partners to develop solutions that meet the needs of the population. “Local communities need to be in charge of decision-making around their health,” Martin says. PEPFAR recognized this, too, making a “strong policy switch” three years ago to take a supportive role, rather than bringing pre-made policies to people across the globe.

Lesson #4: Harm-reduction strategies limit infection while allowing for vital social interactions

Harm reduction is a public-health approach that developed in the 1980s, when the AIDS epidemic first hit. Since then, it’s become predominant in some public-health circles. At its core, harm reduction “abolishes the all-or-nothing approach to risk and disease,” write Eric Kutscher and Richard Greene in an article published in JAMA. More colloquially, Greene says it’s a way to “learn how to feel joy in a world that is not no-risk.”

Greene and Kutscher have been on the front lines of COVID as doctors in New York City. They’ve also been active in HIV prevention for decades, giving them a unique perspective on the pandemic.

“The LGBT community learned how to adapt, despite the threat of disease,” says Kutscher, who works at NYU Langone Health. That adaptability prepared the community for COVID. After the initial period of uncertainty – once scientific data provided evidence that transmissibility in outdoor settings was low – calls to abstain from in-person socialization reminded Kutscher of calls for gay men to abstain from sex. “It ignored basic human needs.” The response from the LGBT community, as observed by Kutscher and Greene, was to mitigate risk while still engaging in social activities.

Kutscher says the broader medical community is beginning to explore harm reduction in its COVID response, “but we’re not there yet.” That trend might accelerate now that Omicron has altered our ability to rely on vaccines.

“Normalcy was the promise,” Greene says. Vaccines were supposed to bring us back to our pre-COVID lives. But if vaccines can’t provide blanket protection – if they are only a part of the solution, but not the totality – people and policymakers might be ready to explore harm reduction as a guiding principle for personal behaviour and public policy, Greene says.

The strategy would include current measures – vaccines and mask-wearing – as well as rapid tests, antiviral treatments, better data on transmissibility “so people know the level of risk,” Kutscher says, and fundamental changes to the safety of spaces, such as increasing ventilation to lower the chances of transmission.

Ongoing efforts

For many people, COVID made us aware of the work of infectious-disease practitioners for the first time, but their work has been unrelenting and urgent for decades. The fundamental question they asked during HIV/AIDS is the one they’re asking now, Martin says: “How do you make sure you’re engaging all sectors of society to come up with solutions together.”