Jury Still Out on Whether Telehealth Is a Plus or Minus for HIV Amid the COVID-19 Pandemic

A year of the COVID-19 pandemic has set loose a new wave of innovation across the healthcare system, creating exciting opportunities yet novel challenges in the delivery of care. Care and treatment of people with HIVis no exception, according to a new review, which says that the rapid implementation of telemedicine has been viewed favorably by providers offering HIV care yet has conflicting results on how well it facilitates patient retention.

While some research suggests that the number of patients engaged in care has remained constant throughout the pandemic, other research points to the opposite. One clinic in particular found that between February and August 2020, the number of patients lost to follow-up — defined as those not receiving care for at least one year — increased from 34 to 59.

Prior to COVID-19, adoption of telemedicine remained suboptimal because of regulatory and reimbursement restrictions. With the arrival of the pandemic, the federal government removed certain restrictions and others followed suit. Telehealth also got a major boost when many payers started to reimburse in-person and telehealth visits at the same rates. Guidance from the government put an emphasis on telemedicine visits rather than in-person visits for routine or non-urgent care.

“The COVID-19 pandemic has revolutionized the practice of ambulatory medicine,” say lead author Jehan Z. Budak, M.D., of the University of Washington and her colleagues. “We have entered an era in which we need to build telemedicine models that empower [people living with HIV] and improve access to care. In fact, the pandemic has facilitated differentiated care delivery in the U.S.”

Zehan Budak, M.D.

Their review, titled “The Impact of COVID-19 on HIV Care Provided via Telemedicine—Past, Present, and Future,” was published online in late February in Current HIV/AIDS Reports.

On the one hand, telemedicine visits allow for a more tailored approach to care that can decrease travel times, expenses, and time away from work, as well as help those who fear the stigma of attending a clinic. On the other hand, patients have cited concerns over privacy, data breaches, billing, and insurance challenges.

Budak and her co-authors discuss the “digital divide” between advantaged and disadvantaged populations. Communication by telephone may serve as a safety net, they say. “Some individuals have difficulty with video visits, often due to absence of broadband connectivity, inexperience with the technical hardware or software required, or lack of a private space in which to join a visit,” they say in the article. “Many such individuals thus rely on telephone visits to stay engaged with care; as such, telephone visits have become a crucial safety net for many patients to stay connected.”

With more patients perhaps being lost to follow-up, there are also concerns over viral suppression rates dropping, giving cause to the notion that the pandemic has exacerbated gaps already prevalent in the HIV care continuum.

“Importantly, connecting to a visit via telemedicine does not supplant the wraparound services often needed to help an individual achieve virologic suppression,” write the researchers, who added that more data on virologic suppression and retention in care in the age of telemedicine are required.

While the pandemic led to an acceleration of telemedicine adoption for prescribing pre-exposure prophylaxis (PrEP), a daily pill that can be taken to prevent HIV, practices have seen some negative effects on PrEP; for example, data from a Boston community health center that specializes in sexual health show a 191% increase in PrEP refill lapses between January and April 2020 and that the number of people newly starting PreP fell by 72%.

But the tailing off of PrEP has to be put in some context, note Budak and her co-authors. While visits and prescriptions have dropped drastically, many patients have stopped taking PrEP because of the social distancing resulting from the pandemic. “Physical distancing and stay-at-home orders may have contributed, as a survey study found that of individuals who stopped PrEP voluntarily, 85% stopped due to low perceived risk,” they observed.