Members of GMHC's Testing Center team at AIDS Walk New York 2022. Photo: Daphne Salgado

NYC HIV Chief Assesses COVID-19’s Impact on HIV

How has the COVID-19 pandemic affected HIV testing and treatment in New York City? To find out, GMHC talked to Dr. Sarah L. Braunstein, the NYC Department of Health and Mental Hygiene’s Assistant Commissioner for the Bureau of Hepatitis, HIV and STI.

“COVID-19 definitely affected HIV prevention, testing and care,” Braunstein said, and the impact “is multi-fold and multi-faceted, with a lot of rippling effects.”

Notably, new HIV diagnoses in New York City declined by 21% in 2020, compared with a more modest 8% decline the prior year. However, COVID-19 disruptions also slowed early viral suppression for newly diagnosed New Yorkers.

While reported new HIV diagnoses have steadily decreased each year since the peak in 2001, the 21% drop in 2020 was greater than expected, Braunstein said.

COVID-19 reduced HIV testing and disrupted people’s social and sexual networks, which likely contributed to that, she explained.

Social distancing also curtailed the NYC Health Department’s surveillance work to investigate and confirm the number of new diagnoses, she said, which “takes a lot of boots on the ground.”

What’s more, COVID-19 lockdowns and social distancing in 2020 may have contributed to a reduction in the number of new HIV infections, Braunstein said. “It’s hard to tease out how much to attribute to each of those factors,” she cautioned.

In 2020, 1,396 New Yorkers were diagnosed with HIV, down from 1,772 the prior year. That 21% decrease was even higher than the 17% decline nationally, according to May 24 data from the Centers for Disease Control and Prevention.

Stable Linkage to Care

Despite COVID-19’s disruptions to health care, including HIV treatment, fully 88% of New Yorkers newly diagnosed with HIV in 2020 were linked to care within three months–the same rate as the prior year. “It suggests that even if fewer people were diagnosed with HIV, a pretty stable proportion of the people who were diagnosed were linked to care in a timely fashion,” Braunstein said.

Even so, the viral suppression rate at three months after a new HIV diagnosis dropped noticeably–from 53% in 2019 to only 40% in 2020. For people newly diagnosed with HIV, Braunstein said, COVID-19 may have created obstacles to connecting with an HIV care provider and initiating treatment.

Viral suppression is critical to ending the HIV epidemic, since reducing the viral load for people living with HIV to below 200 copies/mL means it is both undetectable and untransmittable, or U=U.

In more encouraging news, longer-term viral suppression for people already living with HIV remained stable in 2020, Braunstein said. Fully 78% of New Yorkers estimated to be living with HIV were virally suppressed–and for those receiving HIV medical care, that figure jumps to 86%.

For perspective, New Yorkers newly diagnosed with HIV in 2020 represented just 1.6% of the 84,700 New Yorkers estimated to be living with HIV.

“The vast majority of people living with an HIV diagnosis in New York City have been diagnosed for a while,” Braunstein explained. Because they are more likely to have an established care provider and a prescription for antiretroviral medication, she said, it may have been easier for them to pivot to telehealth to maintain their HIV care.

Service Disruptions

Early on in the COVID-19 pandemic, public health departments and other HIV service providers like GMHC quickly adapted to the shutdowns by offering HIV self-tests and telehealth care services.

That innovation mitigated disruptions to HIV care and treatment to some extent, but it made new HIV diagnoses harder to quantify, Braunstein said. “If someone redeems a coupon for an HIV self-test kit and tests positive, we wouldn’t get the data,” she said, unless a lab test confirming the diagnosis was reported to the NYC Health Department.

The NYC Health Department’s HIV surveillance system uses lab reports of positive HIV tests and its own surveillance activities to track new cases, she explained.

After declines through early 2021, Braunstein added, the volume of HIV-positive lab tests rose substantially from March through June 2021, the latest confirmed data available.

That suggests that by early 2021, HIV testing and treatment likely had started to rebound, because COVID-19 mitigation measures were in place and lockdowns were less stringent, she said, cautioning that these data are preliminary. The NYC Health Department will release 2021 figures on new HIV diagnoses and other key metrics in December.

The Outlook

Going forward, Braunstein said, it’s critical for providers to stay connected with clients–and to reconnect with those who have fallen out of care. “We have programs and funding working to do that,” she added.

Telehealth medicine is essential for broadening access to HIV care, she said, adding that it’s also critical for providers to educate the communities and populations most affected by HIV about the importance of seeking out sexual health services. For New York City, 79% of cisgender and transgender men newly diagnosed with HIV were Black or Latinx, as were 92% of newly diagnosed cisgender and transgender women.

According to New York City’s 2020 Ending the HIV Epidemic Plan, the NYC Health Department’s priority populations include Black and Latinx cisgender and transgender men who have sex with men, Black and Latinx cisgender and transgender women, all people of trans experience, young people ages 13 to 29, and people ages 50 and older living with HIV.

In 2020, the viral suppression rates for many of these populations within three months of an HIV diagnosis were lower: at just 39% for Black people, compared with 44% for white people and 42% for Latinx people; and just 33% for transgender people, compared with 41% for men and 40% for women.

What’s on Braunstein’s mind now, she said, is how HIV prevention and treatment work in New York City will be affected by the ongoing COVID-19 pandemic, as well as the emergent monkeypox outbreak and “future as-yet-unknown public health issues.”

“There are so many lessons learned, along with experience and expertise to draw on from the HIV epidemic over the last 40 years,” she said. “How do we harness the energy and capacity of our HIV workforce to respond to COVID-19, monkeypox and the future?”

Meanwhile, Braunstein said, it’s important to stay focused on HIV. “We still have work to do. We’ve made so much progress toward ending the HIV epidemic in the last few years–but there are still a lot of inequities.”