Using SA’s HIV experience to counter Covid-19 – Alan Whiteside

There’s never been a better time for researchers in all virology-related fields as the novel coronavirus takes hold where we least expect it and spreads weakly in otherwise highly vulnerable, crowded communities. With no vaccine or effective treatment, the field remains wide open. Theories abound, but proof is lacking and those who go beyond proof of concept to solid evidence and significant findings are guaranteed celebrity status in a world on virtual hold. Prof Alan Whiteside, a leading South African healthcare researcher and policy fundi, whose work in the AIDS field helped put this country in the vanguard of effective treatments and ARV rollouts (winning an OBE), suggests that we build on our AIDS experience to counter the coronavirus. SA’s Human Sciences Research Council carried out National HIV Prevalence, Incidence, Behaviour and Communication Surveys for over 20 years, providing us with a basis, template and methodologies for Covid surveys. Whiteside also suggests getting the National AIDS Councils involved in the response. Historically and currently, we’re ahead of the curve, enabling us to leverage our experience and knowledge. Yet we’re also uniquely challenged by our disease profile and overburdened facilities – with too few medics. Smart suggestions like this, not back-slapping or complacency, are vital. – Chris Bateman

By Alan Whiteside* 

Introduction

Professor Alan Whiteside

‘The times they are a-changin’’ as Bob Dylan sang in 1964.[1] Much is happening and some of it is good. The numbers in Europe’s worst affected countries are stable or declining. Some countries are tentatively starting the process of emerging from lockdown. The feared increases in Africa are still to materialise, the USA with the world’s worst epidemic is experiencing waves with a slight downward trend. That is the good news. On the debit side some leaderships have lost it and economic and social impacts are emerging. They are worse than we dreamed. I have key, usually short, readings at the end.

The Numbers

At 8 am 6th May 2020 the JHU Coronavirus Resource Centre recorded 3,117,756 global infections.[2]

Table 1: Global & National Cumulative Numbers of Confirmed Covid-19 Cases (Alphabetical order)[3]

Date Global casesChinaFranceItalySouth KoreaSouth AfricaSpain United KingdomUnited States
15th Feb69,00068,4001232802943
4th Mar 93,00080,480 2883,1005,600022286149
11th Mar 120,00080,9002,30012,5007,800132,3004591,300
18th Mar 201,50081,1009,10035,7008,40011613,9002,6007,800
25th Mar 423,00081,70025,60074,4009,10070949,5009,60065,800
1st April861,00082,40057,000110,6009,9001,400104,10029,900213,400
8th April 1,431,35782,783110,070135,58610,3841,749141,94255,949399,886
15th April1,982,55283,351131,362162,48810,5912,415174,06094,845609,422
22nd April2,565,25883,864159,300183,95710,6943,465 204,178130,184835,306
29th April3,117,75683,940169,053201,50510,7614,996232,128162,3501,012,583
6th May 3,664,01183,968170,694213,01310,8067,572219,329196,2431,204,475

Remember ‘A confirmed case is “a person with laboratory confirmation of COVID-19 infection” as World Health Organisation (WHO) explains. But specifics can differ and the European CDC, on which we rely, reports confirmed cases according to the applied case definition in the countries.’[4] We are still waiting for an antibody test, although the Independent reported on the 5th May ‘A new antibody test to check whether someone has been infected with coronavirus, and said to be 99 per cent accurate, has been certified for use across Europe’. [5]This development would allow us to test for prevalence of past infections and get an idea of how many people in a country or community have been infected. Mortality data vary in source and accuracy and this will be next week’s special issue.

HIV seroprevalence surveys were, and are routine in many countries and have become increasingly sophisticated. In South Africa, for example, the Human Sciences Research Council has carried out National HIV Prevalence, Incidence, Behaviour and Communication Surveys for over 20 years. Eswatini did their first HIV survey in 1992. These surveys can provide a basis, template and methodologies for Covid surveys.[6] It is logical, where they exist, to get the National AIDS Councils involved in surveys, and all aspects of the Covid response, but not to let competition and bureaucracy stymie these initiatives.

Data and its implications

The South African news agency GroundUp wrote succinctly:

“Infections are underestimated because many … never show symptoms or only become mildly ill. Deaths are underestimated because many people die at home, or never get tested for Covid-19. This is confirmed by analyses of historical deaths versus what’s happened the past few weeks in several parts of Europe and the United States… These are countries with good death registration data (which South Africa does have). It’s even harder to estimate deaths in many developing countries.”[7]

Reviewing the data leaves many mystified. The New York Times wrote:

“The question of why the virus has overwhelmed some places and left others relatively untouched is a puzzle that has spawned numerous theories and speculations but no definitive answers. That knowledge could have profound implications for how countries respond to the virus, for determining who is at risk and for knowing when it’s safe to go out again. There are already hundreds of studies underway around the world looking into how demographics, pre-existing conditions and genetics might affect the wide variation in impact.”[8]

Perhaps, they suggest, the shape of the curve is determined by a combination of the interventions put in place, timing and luck. There are so-called super spreaders – the infected woman “patient 31” in South Korea, a member of the fringe church Shincheonji, infected many fellow worshippers in January.[9] There have been similar events in other settings.

There is new information emerging constantly. On 5th May the BBC reported the disease may have reached Europe in December, a month before it was reported from Wuhan. “A patient treated in a hospital near Paris on 27 December for suspected pneumonia actually had the coronavirus… Dr Yves Cohen said a swab taken at the time was recently tested, and came back positive for Covid-19… (the patient had) no idea where he caught the virus as he had not travelled abroad.”[10] Another BBC report tells of Iranian airline Mahan Air, a company linked to the Islamic Revolutionary Guard Corps (IRGC), flying infected passengers to Lebanon, Iraq and China, despite having claimed it had ceased operations.[11]

Asia

China’s data indicate very few new Covid-19 cases. There is an escalating war of words with Trump, who appears to believe the virus escaped from a laboratory in Wuhan, and China could have done better in controlling the epidemic. A critical independent analysis of the Chinese data is necessary, indeed there is a good argument for a global Commission of Inquiry as to what exactly happened – but not until this epidemic has passed. The current blame game is unhelpful. South Korea and Taiwan have the epidemic under control. India’s case load has risen to 46,476 up from 31,332 on 29th April. The epidemic in Singapore illustrates how fragile success can be. The government believed it was managing the outbreak, but numbers have risen dramatically in migrant populations. New Zealand believes their epidemic over, but this is subject to monitoring.[12]

Europe

The situation in Europe remains dire, but most countries are seeing fewer new cases (Table 1) although cumulative numbers rise. There are outliers here, Greece has just 100 new cases (week-on-week). The UK is worst affected due to shockingly poor, slow leadership and slow, and initially wrong decision making. On 6th April it had 196,243 cases and 29,501 deaths. Care home deaths are included in the death toll. New daily cases are falling and the population has been mostly compliant,[13] but endurance is wearing thin. Further analysis should ask why some EU countries such as Greece, Austria, Portugal have seen smaller epidemics.

Africa

The low numbers and slow growth continue. South Africa leads with 7,220 cases followed by Egypt with 6,813. There are growing numbers in coastal west Africa. Most other countries report slow growth. In next week’s communique we will include a more in depth analysis of the epidemic and response in South Africa.

The Americas

Numbers are growing rapidly in South and Central America. Brazil leads with 108,620 (73,235 cases on 29th April). followed by Peru and Ecuador. All other countries are below this but seeing a steady increase. Canada had 61,956 cases on 5th May, an increase from 51,150 cases on 29th April. Provincial level analysis may be more appropriate. Care homes are severely hit.

The US numbers remain astonishing, it is first in global rankings. There is merit in looking at the data by state, race and place of residence. A commentary by the Kaiser Family Foundation suggests that the US’s rural areas may be hard hit because of the combination of older populations, with co-morbidities, and a lack of health care facilities.[14] It is clear that African Americans are disproportionately adversely affected and the question is why? Again, a topic to be picked up in future weeks. The health care system in the US is not designed for this pandemic and to be poor or unemployed, as increasing numbers are, is to be in a desperate situation.

The consequences

Employment

The disease means tens of millions citizens in OECD countries are losing their jobs. There is massive government support of various types being put in place. In the UK the furlough scheme, where the government pays 80% of the wages, will be extended. Similar schemes are in place in other countries. In the US unemployment benefits are the main option and claims have increased dramatically. There have been over 30 million new claims and it is estimated that the unemployment rate is over 16 percent, and it will continue to rise.

Production has plummeted. Data from just one industry, the motor sector, shows in the UK only 4,000 new cars were registered in April 2020, mainly by companies. By contrast in 2019 161,064 new cars were registered.[15] In South Africa the National Association of Automobile Manufacturers of South Africa data for April show only 105 cars, a drop of 99.6%.[16] The impact is upstream, on manufacturers, and downstream on car sales outlets down to garages and mechanics. Of course, the transport and tourism sectors are a disaster. Many airlines are simply not flying at all, with their aircraft parked on runways at airports around the world. In Norwich there are six or seven different liveries on the tails of the planes, from Lufthansa to British Airways.

In the global South, although it may be hard to believe, the picture is much more bleak. The economies and unemployment are being as badly, if not worse affected, and there is not the social support system of the OECD countries. Interestingly one of the poorest countries in the world, Malawi, has said they will launch an emergency cash transfer program targeted at the 1 million people and the small businesses affected by the pandemic. The amount is small , just $40, but households will receive this monthly through mobile cash transfers. Cash transfers rather than food aid is the way to go since, this stimulates the local economies from the growers to markets. Hopefully countries and donors will recognise this.

Writing in the Daily Maverick, South African academic Gavin George addresses the issue of coercion and compliance.[17] South Africa has a four S strategy: stay at home; maintain social distancing; sanitise; and screen. This is all good common sense, and for three weeks the nation largely complied. Unfortunately, the lockdown was extended and various ministers and the police resorted to coercion and made threats. Additionally messages have been mixed. Tobacco and alcohol sales were banned in level 5 lockdown, in level four it is not clear if tobacco is allowed. The promise to ‘skop and donner’ [18] were heavy-handed and have eroded the goodwill of the citizens.

Of course, the way we do our work is also changing. For many workers there will be less need to go into offices, and have face to face contact. This in turn will have massive psychological and social consequences which have yet to be fully explored.

We know that the majority of deaths in some locations occur in care homes among the elderly residents. Carers are among the worst paid people in the economy. Will we see their status, wages and salaries increase? What about those settings where much care is provided by the private sector, what will happen to the demand? These are all issues needing further examination.

Leadership

The last week has given us examples of good and bad leadership. I remain unimpressed by the quality of the British political leadership. It has vacillated and ignored many vulnerable groups. On the other hand, the rapid expansion of the health service and pouring of money into this was admirable. The Nightingale Hospitals, setup to deal with the expected influx of cases, have operated far below capacity and are now, happily, being scaled back, and in some cases closed.

The US shenanigans continue to horrify. The award for this week’s worst leader, though, goes to the President of Tanzania, John Magufuli. He went on record to say that he had instructed the security forces to check the quality of the Covid tests. They were given samples from a pawpaw (papaya), goat and sheep. Two tests were positive calling into question the accuracy of all according to him. Magufuli announced he is going to try a herbal treatment being promoted by the President of Madagascar. [19] These are shades of the beetroot, lemon juice, and garlic debacle of the AIDS epidemic in South Africa in 2000. Presidents should stick to what they understand, which is not epidemiology, virology or immunology.

Conclusion

One of my main concerns was an overlap between HIV and Covid. The evidence is still sketchy but it seems that people who are HIV-infected and on treatment are not at greater risk than others.[20] Of course we do not know yet what the situation will be for those who are infected, on treatment, but have low CD4 counts. We do not know what will happen to HIV infected people who are not on treatment. Inference suggests they will be at high risk.

This pandemic continues to surprise. Depressingly it is going to be a long haul. We are, to use a cricketing metaphor, approaching the morning tea break on the first day of a five day test match. There have been some encouraging signs, the Malawian cash transfer, the easing up of greenhouse gas emissions, and for some the opportunity to spend time with their families. The losers are, yet again, the poor and marginalised. One has to hope events like the killing of a security guard at a Michigan Family Dollar store by a family told to wear state-mandated face masks are outliers.[21]

And a complete non-sequitur that pleases the inner Alan nerd. Flight Radar is a website on which one can see all the planes in the air at a given moment. Most are identified, showing where they are from and going and type and registration. Currently there are few in European airspace and it is fascinating to see the number of executive jets with absolutely no identification. The super-rich or intelligence services?

Readings:

Geoff Schreiner, Trying to think through Covid-19 impacts and our economy, Daily Maverick 3rd May www.dailymaverick.co.za/opinionista/2020-05-03-trying-to-think-through-covid-19-impacts-and-our-economy/

The New York Times, The Covid-19 Riddle: Why Does the Virus Wallop Some Places and Spare Others, www.nytimes.com/2020/05/03/world/asia/coronavirus-spread-where-why.html 5th May

Groundup, Covid-19 report2, questions don’t yet have answers, 4th May 2020, www.groundup.org.za/article/covid-19-report-2-questions-dont-yet-have-answers/

Tim Marshall, Prisoners of Geography: Ten Maps that Tell You Everything you need to know about Global Politics, Elliot and Thompson, 2015 (longer, book length, read but enjoyable)

Thank you to everyone reading, reposting and providing comments.  For those who are interested in the economics of Covid-19, join the group “Economics of Covid-19” LinkedIn group. What I write is public domain, share, forward and disseminate. My contact: [email protected] 

[1] https://www.youtube.com/watch?v=e7qQ6_RV4VQ

[2] https://coronavirus.jhu.edu/map.html

[3] These data are from the JHUM website. The countries are chosen because of their epidemics.

[4] https://ourworldindata.org/coronavirus#cases-of-covid-19

[5] https://www.independent.co.uk/life-style/health-and-families/coronavirus-antibody-test-what-is-it-virus-blood-nhs-matt-hancock-covid-19-a9423571.html

[6] http://www.hsrc.ac.za/en/departments/saph/HAST_National_HIV_Survey

[7] https://www.groundup.org.za/article/covid-19-report-2-questions-dont-yet-have-answers

[8] https://www.nytimes.com/2020/05/03/world/asia/coronavirus-spread-where-why.html

[9] https://www.aljazeera.com/news/2020/03/31-south-korea-sudden-spike-coronavirus-cases-200303065953841.html

[10] https://www.bbc.co.uk/news/world-europe-52526554

[11] https://www.dailymail.co.uk/news/article-8287615/Iranian-airline-fuelled-Middle-Easts-coronavirus-crisis-continuing-flights-China.html

[12] www.bbc.co.uk/news/world-asia-52436658

[13] www.theguardian.com/world/2020/apr/01/what-are-your-rights-in-lockdown-britain-coronavirus

[14] COVID-19 in Rural America – Is there cause for concern?

https://www.kff.org/other/issue-brief/covid-19-in-rural-america-is-there-cause-for-concern

[15] https://www.bbc.co.uk/news/business-52508010

[16] https://www.biznews.com/global-investing/2020/05/05/sa-consumer-car-sales-comair-phumelela-caxton

[17] Gavin George, ‘Covid-19 and the tussle between coercion and compliance’, www.dailymaverick.co.za/opinionista/2020-05-04-covid-19-and-the-tussle-between-coercion-and-compliance

[18] literally ‘kick and hit’

[19] https://www.voanews.com/covid-19-pandemic/president-queries-tanzania-coronavirus-kits-after-goat-test   and Africa: Where Does Africa Stand 2 Months After Covid-19 Outbreak? https://allafrica.com/stories/202005010333.html

[20] https://www.dailymaverick.co.za/article/2020-05-01-first-data-on-hiv-and-covid-19-offers-tentative-hope/

[21] https://edition.cnn.com/2020/05/04/us/michigan-security-guard-mask-killing-trnd/index.html

  • Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal www.alan-whiteside.com.
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