The COVID-19 pandemic has significantly disrupted healthcare services worldwide, including those specifically tailored for individuals living with HIV. Many health facilities, particularly in areas severely impacted by COVID-19, shifted their focus to managing the pandemic. As a result, routine HIV services, such as testing, treatment initiation, and follow-up appointments, were postponed or canceled. This disruption has led to increased anxiety among individuals living with HIV, as they were unsure about the continuity of their care. In some regions, the diversion of resources to combat COVID-19 has resulted in reduced access to essential services, particularly in low- and middle-income countries where healthcare systems are already strained.

Challenges in Accessing Antiretroviral Therapy During the Pandemic

Access to antiretroviral therapy (ART) is crucial for individuals living with HIV to maintain their health and prevent the transmission of the virus. However, during the COVID-19 pandemic, many people faced challenges in obtaining their medications. Lockdowns and movement restrictions made it difficult for individuals to visit healthcare facilities for refills. Additionally, supply chain disruptions affected the availability of ART in some regions. To address these challenges, some countries implemented innovative solutions, such as multi-month dispensing of medications and the use of community health workers to deliver ART to patients’ homes. Nevertheless, these adaptations were not universally available, leading to disparities in access to vital treatment.

Mental Health Implications for Individuals with HIV Amid COVID-19

The pandemic has taken a toll on the mental health of many individuals, including those living with HIV. The isolation resulting from lockdowns, combined with the heightened anxiety surrounding COVID-19, has exacerbated feelings of stigma and discrimination often experienced by those with HIV. Many individuals reported increased feelings of depression and anxiety due to their concerns about health and the potential consequences of contracting COVID-19. Access to mental health services became more challenging as face-to-face appointments were limited. Some organizations have turned to teletherapy and virtual support groups to provide necessary mental health resources, but barriers such as technology access and digital literacy persist for some populations.

Telehealth: A New Avenue for HIV Care During Lockdowns

The pandemic accelerated the adoption of telehealth services across various healthcare sectors, including HIV care. Telehealth has provided a valuable alternative for individuals who faced barriers to in-person appointments during the pandemic. Through virtual consultations, healthcare providers could continue monitoring patients’ health, prescribing medications, and offering counseling services. This shift has proven particularly beneficial for those in remote areas or those with mobility challenges. However, while telehealth has expanded access for many, it also highlighted the digital divide, with some individuals lacking reliable internet access or devices necessary for virtual appointments. Ensuring equitable access to telehealth services remains a critical challenge.

Lessons Learned: Strengthening HIV Support Systems in Future Pandemics

The COVID-19 pandemic has underscored the need for resilient healthcare systems that can adapt to emergencies while maintaining essential services for vulnerable populations, including individuals living with HIV. Moving forward, it is vital to integrate HIV services into broader health emergency response plans. This includes ensuring that HIV care is recognized as essential during pandemics and that resources are allocated accordingly. Stakeholders must also prioritize the development of telehealth infrastructure and training to ensure that individuals can access care remotely when needed. Finally, fostering community engagement and support networks will be crucial to combat stigma and ensure that people living with HIV receive the comprehensive care they need, regardless of the challenges posed by future health crises.

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The U.S. Centers for Disease Control and Prevention (CDC) suggests getting tested:

• all people from 13 to 64 years old;
• pregnant women at the first visit to a gynecologist and additionally in the third trimester if they are at increased risk;
• everyone who comes to be checked for other sexually transmitted diseases;
• annually for sexually active men who have sex with other men, if the man or his partner has had sexual contact with another person since the last test;
• annually for people at high risk.

What is an elevated risk? The U.S. Centers for Disease Control and Prevention (like most other organizations) believe that the risk is elevated in

• men who have sex with other men;
• people who have had vaginal or anal sex with an HIV-positive person;
• those who have had more than one partner since their last test;
• those who inject illegal substances and share the necessary items with other users of illegal substances;
• those who have sex for money;
• those who have been diagnosed with another sexually transmitted disease;
• those who have been diagnosed with hepatitis or tuberculosis;
• those who have had sex with someone who could report that at least one of the above items is true.

The U.S. Preventive Services Task Force recommends that all people aged 15 to 56 (and all others at increased risk) should be tested for HIV. But the question is: at what interval should you be tested? The group suggests repeating testing if a person has risk factors. In addition to those specified by the CDC, the group also includes people who receive medical care in medical centers with many patients with HIV, as well as in correctional facilities and homeless shelters.

The British recommendation is to test people living in places where HIV is spread every year. If a person has other factors, they should be tested more often. Pregnant women are also offered a test.

The World Health Organization believes that people who have certain risk factors should be tested for HIV. The same applies to their partners. If the risk remains, they should be tested at least once a year.

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Every year the number of people with terminal stages of HIV infection (AIDS itself), which causes mortality, is growing. Therefore, in order to reduce the number of AIDS patients and prevent the spread of the infection among the population, timely detection and treatment of HIV-infected persons, especially in the early stages of the disease, is important, which is facilitated by their diagnosis by the manifestations of HIV/AIDS on the skin.

According to the WHO classification (2006), there are four stages in the course of HIV/AIDS with the following skin manifestations:

Clinical stage I:
Asymptomatic course.
Persistent generalized lymphadenopathy.

Clinical stage II:
Moderate unmotivated weight loss (up to 10%).
Herpes zoster.
Papular itchy dermatitis.
Seborrheic dermatitis.
Fungal lesions of the nails.

Clinical stage III:
Weight loss (>10%), chronic diarrhea, fever, anemia, severe bacterial infections (pneumonia, meningitis, gingivitis, etc.).
Oral candidiasis.
Hairy leukoplakia of the tongue.

Clinical stage IV:
Wasting syndrome (HIV cachexia).
Kaposi’s sarcoma.
Chronic viral infection.

After infection with the immunodeficiency virus, the disease is usually asymptomatic for a long time. Manifestations of the first clinical stage may include enlarged lymph nodes (generalized lymphadenopathy) without affecting the general condition of infected individuals.

With the development of the second clinical stage of HIV infection, characteristic changes occur on the skin and mucous membranes, which are manifestations of infectious and non-infectious dermatoses. For example, the earliest and most common sign of HIV infection is herpes zoster, a viral skin disease that in HIV-infected individuals is manifested by a significant number of blisters that occur against the background of redness and swelling of the skin, are accompanied by sharp pain, tend to widespread skin damage, often become suppurative, are difficult to treat, and can recur, leaving scarring of the skin.

One of the earliest manifestations of HIV infection can be papular pruritic dermatitis in the form of widespread (on the trunk, extremities) small nodular elements of pinkish-red color with a bloody crust in the center, accompanied by itching.

The first symptom of HIV infection can be seborrheic dermatitis of the face in the form of redness and flaking on the forehead, cheeks and nose in the form of a “butterfly”. In the future, dermatosis can spread to other areas (trunk, buttocks, thighs) with complications of pustular rash.

An early manifestation of HIV infection is fungal nail disease – onychomycosis. The nail plates become dull, thickened, and fragile. Due to immunodeficiency, all nail plates of both feet and hands are rapidly affected.

During the third clinical stage, every second HIV-infected person is diagnosed with oral candidiasis, which develops in the form of whitish layers on the mucous membranes of the tongue and cheeks and is characterized by resistance to fungicidal therapy.

One of the most characteristic manifestations of HIV infection is hairy leukoplakia of the tongue, which occurs on the lateral surfaces of the tongue in the form of single gray-white plaques up to 3 cm in diameter with thin keratotic processes (in the form of hairs) on their surface.

At the final (fourth) stage of HIV infection, which is actually called AIDS – acquired immunodeficiency syndrome, Kaposi’s sarcoma develops on the skin and mucous membranes, along with chronic viral infection (recurrent herpes of the face, genitals, etc.), in the form of plaques and nodules of deep dark bluish, brown or black color with a smooth shiny surface. The features of Kaposi’s sarcoma in AIDS patients are the location of the rash on the upper torso, upper extremities, face, and oral mucosa, as well as a tendency to rapid disintegration with the formation of ulcers and early metastasis to internal organs.

Thus, dermatologic manifestations of HIV/AIDS can include a variety of infectious and non-infectious dermatoses, which, in the context of immunodeficiency, acquire a severe clinical course. For the purpose of early detection and timely treatment of HIV-infected persons, knowledge of dermatological manifestations of HIV/AIDS is necessary not only for infectious disease specialists and dermatovenereologists, but also for general practitioners – family medicine and other medical specialists.

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HIV is transmitted only from person to person. Only humans can be infected with HIV. Once it enters the body, HIV very quickly penetrates blood cells – lymphocytes, which have receptors that have an affinity for HIV, the so-called “CD4+ T lymphocytes”. Some other blood cells (monocytes and macrophages), cells of the central nervous system, rectum, cervix, etc. also have such receptors. Due to the affinity of the virus surface proteins and cell receptors, HIV enters the cytoplasm of the cell. Then, thanks to the reverse transcriptase enzyme, the formation of proviral DNA takes place from viral RNA.

The viral DNA is “embedded” in the genetic material (DNA) of the host cell. After that, the host cell perceives the virus DNA as “native”. The virus becomes part of the cell and remains so until the cell dies. During its life, a cell infected with HIV produces new copies of the virus, releases them into the plasma, other biological fluids and secretions. This reproduction process is called viral replication. New copies of the virus come out of the infected cell, spread in the body, invade other cells, infect them and start reproducing new copies.

During the formation of new viruses, “mistakes” called mutations often occur. The variability of the pathogen leads to the fact that some drugs used to treat HIV infection lose their ability to act on the enzymes of the virus, i.e., the virus develops resistance or resistance to this drug. In order to avoid the development of drug resistance in the treatment of HIV infection, it is necessary to use a combination of several drugs at the same time.

Virus resistance in the environment

• In the environment, when lymphoid cells infected with HIV are dried, viral activity disappears within a few days.
• When cell-free fluid is dried with the addition of human plasma, the virus dies at a temperature of 23-27°C in 7 days.
• In a liquid medium at 23-27°C, the virus remains active for 15 days, and at 36-37°C – 11 days.
• In blood intended for transfusion, the virus survives for years, and in frozen serum, its activity persists for up to 10 years.
• HIV dies quickly when using disinfectants, ultraviolet radiation; when heated above 56°C, it loses activity in 30 minutes.

Swollen lymph nodes are one of the early signs of HIV infection. Lymph nodes the size of a pea or larger usually do not bother a person. Enlargement of the lymph nodes is not associated with acute illnesses and lasts for 3 months or more.

Increased size of the liver and spleen are often observed in people with HIV infection. A pronounced increase in the size of these organs can lead to an increase in the size of the abdomen. Liver enlargement associated with HIV infection is usually not accompanied by the appearance of yellow coloration of the skin and sclerae.

Impaired physical development is manifested by a slowdown in the rate of weight gain and height.

Impaired physical development in the progression of HIV infection leads to the development of wasting syndrome, which is characterized by a loss of more than 10% of body weight, fever and stool disorders for 30 days or more.

Skin lesions are often observed in HIV infection. They can be caused by allergies and various infectious pathogens (fungi, bacteria, viruses).
However, one of the symptoms of HIV infection is an increase (swelling) of the parotid salivary glands. This condition is usually not accompanied by fever and soreness.

The direct effect of HIV on the cells of the nervous system leads to the development of HIV encephalopathy.

The progressive dysfunction of the immune system in HIV infection leads to the fact that microorganisms and viruses – natural inhabitants of the environment (that do not cause disease in people with normal immune system function) – cause diseases in the patient, which are called opportunistic infections (opportunist – opportunist).

One of the manifestations of HIV infection is the appearance of tumors (Kaposi’s sarcoma, malignant lymphoma or lymphosarcoma).

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HIV affects the white cells in the blood, which leads to a weakened immune system. This increases the likelihood of developing diseases such as tuberculosis, infectious diseases, and some types of cancer.

HIV is transmitted through various body fluids of infected people, including blood, breast milk, seminal fluid, and vaginal secretions. Transmission does not occur through kissing, hugging, or sharing food. HIV can also be passed from mother to child.

HIV infection is treatable and preventable with antiretroviral therapy (ART). If untreated, HIV infection can progress to AIDS, often many years after infection.

HIV infection is a preventable disease.

The risk of HIV infection can be reduced by:

• using male or female condoms during sex;
• getting tested for HIV and sexually transmitted infections;
• having voluntary medical male circumcision;
• Participating in harm reduction programs for injecting drug users.

To prevent HIV infection, physicians can provide guidance on the use of medications and medical devices such as:

• antiretroviral drugs (ARVs), including oral DAAs and long-acting drugs;
• vaginal rings with dapivirine;
• long-acting injectable cabotegravir.

ARVs can also be used to prevent mother-to-child transmission of HIV.

People on antiretroviral therapy (ART) who have no evidence of the virus in their blood do not transmit HIV to their sexual partners. Ensuring access to testing and ART is an important part of HIV prevention.

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