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Commentary

Managing the COVID-19 Pandemic: Biopsychosocial Lessons Gleaned From the AIDS Epidemic

Halkitis, Perry N. PhD, MS, MPH

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Journal of Public Health Management and Practice: January/February 2021 - Volume 27 - Issue - p S39-S42
doi: 10.1097/PHH.0000000000001267
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What have we learned from HIV/AIDS that applies to the current COVID-19 pandemic? This is the one question that has been posed to me time and again, likely because I have spent the last 25 years working as a researcher, educator, advocate, and activist to help control the HIV/AIDS epidemic. I recently published a book, The AIDS Generation: Stories of Survival and Resilience,1 which documents the life experiences of gay men who were infected with HIV prior to the biomedical advances that have altered both the management and prevention of the disease. Like me, the 15 men featured in the book witnessed the ravages of AIDS, and we now find ourselves witnessing the current COVD-19 pandemic.

Here is what I have come to know about the 2 viruses. HIV, the virus that causes AIDS, created terror, havoc, and death around the world in the last 2 decades of the 20th century. In the United States, 700 000 people have died of AIDS-related complications since 1981, with another 1.2 million currently infected.2 Within the first 2 decades of AIDS, infection with the virus very often led to death. The advent of effective antiviral therapies and the implementation of highly active antiretroviral therapy (HAART) drastically reduced AIDS-related mortality.3 Despite these biomedical advances in treatment and prevention,4–6 in 2018, some 15 280 individuals died as a result of AIDS-related complications while there were 37 000 incident cases.2

SARS-CoV-2 (the novel coronavirus that causes COVID-19) has taken a brutal toll on the United States. The first case was reported in the United States on January 20, 2020. As of August, there have been some 5 million cases with the number of deaths now reaching 250,000 and possibly 500,000 in a year. This viral pathogen is more widespread than HIV, given the ease with which it is transmitted,7,8 and more fast-acting in terms of mortality than HIV disease, which, if detected early and if untreated would take years, not weeks (like COVID-19), to cause death.9 However, like HIV infection, COVID-19 has overburdened marginalized populations, revealing systemic racism and health inequity.10,11 The incidence of HIV infection is higher in gay and bisexual Black men than in any other group, constituting 26% of all infections in 2018.12 Data recently reported in Georgia are indicative of COVD-19 disparities throughout the country, with 5.2% of those infected identifying as Black non-Hispanic, higher than any other racial/ethnic group.13 In Indiana, a heightened prevalence of 8.3% for SARS-CoV-2 is noted among Hispanics.14 There is much to be gleaned from our response to and management of HIV infection with regard to the current pandemic. There is no doubt that the AIDS epidemic, like COVID-19, propelled public health15 into the spotlight. Many of our modern public health approaches, including the social deterministic models16–18 that direct our understanding of health inequity and disparities promulgated over the last 4 decades, are informed by the changes for which we fought during the early days of AIDS. The lessons of AIDS, informed by a biopsychosocial conceptualization of health,19–21 provide helpful guidance in addressing COVID-19.22

The Biomedical Lessons

As was the case with HIV infection, new biomedical information about COVID-19 is developing rapidly. In the early days of AIDS, the disease was named GRID (Gay-related immune deficiency) and thought to be confined to gay men.23 Inhalant nitrates were implicated as a causal factor in acquiring HIV infection.24–26 Those with multiple anonymous sex partners were thought to be the most vulnerable.27 While not entirely accurate, some of those assumptions held some kernel of truth. Gay men continue to be unduly burdened by HIV infection but not exclusively.28 While inhalant nitrates may have some deleterious effects on decision making and the cardiovascular system, they do not cause AIDS.29 Inhalant nitrates were a “distracting” variable in that they were often evident when gay men had condomless anal sex,30 the main culprit for transmission. While sex is a primary mode of transmission, one can become infected having sex with only one known partner. In fact, recent studies indicate that HIV transmission risk is heightened in the context of a relationship.31,32 Lest we forget the present concern about virus transmission on surfaces, at the onset of the AIDS epidemic, there was widespread panic about transmission from toilet seats, which of course was a fallacy.33

Biomedical information about COVID-19 is evolving rapidly. Initial indications suggested that children and youth were invulnerable to the effects of the viral infection. Masks were deemed unnecessary and surfaces were suggested to be a main source of infection,34 leading Americans to overzealously clean items brought into the home, including groceries. It is now clear that SARS-CoV-2 can infect anyone and leads to multisystem inflammatory syndrome in children (MISC-C). The virus has been shown to be airborne and is easily transmitted from person to person in close proximity; thus, protective masks serve to prevent spread, while the role of surface transmission as a main culprit has been ameliorated.8

Moreover, it has become clear that polymerase chain reaction (PCR) testing viral infection may not be helpful within the first few days of infection with SARS-CoV-2 and thus testing for the virus may yield a high rate of false-negatives.35 As we have come to know from HIV infection, it also takes a few days for the virus to become detectable, reaching its peak some 2 weeks after infection.36,37 Thus, the lessons of viral load should have delayed COVID-19 testing until testing could accurately detect the virus. Finally, and importantly, neutralizing antibodies may hold the key to controlling the SARS-CoV-2 virus. Such antibodies appear to be produced in those who are sick with COVID-19 for an extended length of time, allowing their immune system to develop this reaction. Such findings parallel knowledge developed around initial HIV infection, which suggests that those who have a more pronounced innate immune reaction may ultimately have better outcomes,38 including slower disease progression.39

In all these cases, as was the situation in the early days of AIDS, it is clear that we must remain nimble. In our roles as public health leaders, we must amass new biomedical information in real time and effectively disseminate this knowledge to the public in a manner it can understand and incorporate. At the same time, we must acknowledge that our understanding of the disease is evolving.

The Psychosocial Lessons

As critical as our biomedical advances are in our war on COVID-19, in and of themselves, biomedical approaches are insufficient. In the United States, the current pandemic (like HIV/AIDS) illustrates the myriad disparities in our society and provides a clear direction to public health leaders to continue to advance approaches that attenuate inequity.

While HIV/AIDS is caused by a virus, the health disparities evidenced in HIV infection indicate that this disease is directed by social and structural factors. This assertion is noted in the burden of HIV infection in marginalized populations, namely, among the poor, gay, transgender, and/or Black and Latinx populations.40–42 These data align with patterns emerging in the COVID-19 pandemic where higher mortality rates are being noted in Black and Brown populations than in their White counterparts.10,43 Populations of color are confronted with the realities of having lower economic means, being overwhelmingly represented in nonprivileged essential workers such as supermarket clerks and delivery people (as compared with highly respected and well-compensated physicians). Members of Black and Brown populations are also subjected to the ongoing onslaught of discrimination and hate perpetuated by social conditions and state-sanctioned laws and policies that undermine well-being,44,45 including but not limited to health care access.46 Social and structural factors drive disease prevalence whether it is HIV/AIDS, COVID-19, or chronic diseases such as obesity and hypertension.16,47,48 In effect, the lesson from AIDS is that we must tackle social conditions if we are to contain the disease. Consider, for example, that in the current pandemic, we ask families in mutigenerational homes of limited space or those with housing instability to isolate. With regard to place, those environments in which discrimination runs rampant, where health care access is limited, and where politics undermine science, SARS-CoV-2, like HIV, is unbridled in its transmission patterns,49,50 creating disease hotspots. The spread of both HIV and SARS-CoV-2 throughout the southern United States demonstrates the notion that social context matters.

Much like our efforts at the height of AIDS, we also must fight COVID-19 on the political front. The need for activism is as apparent today as it was in the 1980s. Like gay men and other HIV-infected individuals whose health was ignored and ostracized by Ronald Reagan51 at the height of the AIDS epidemic, Black and Brown people confront the racism and wrath of Donald Trump, his administration, and the GOP more generally.52 These conditions suggest a need for ongoing vigilance and activism to counter the damage being caused by a president, who has chosen to politicize COVID-19 at the expense of lives, much as Reagan did when he ignored AIDS to appease his support among Evangelicals.53 Trump's xenophobic response to COVID-19 (calling it “kung flu”54 and blaming Mexico for the spread of the virus) is akin to the immigration restrictions imposed by Reagan on people living with HIV infection, although the restrictions were later removed by President Obama.55 Finally, the lack of a coherent and clear federal response to COVID-19 is reminiscent of Reagan's policy on AIDS; in fact, a domestic AIDS strategy56 was not developed until Obama's presidency.

AIDS also taught us that altruism is a powerful tool. The activist Larry Kramer warned gay men about caring for each other and not spreading HIV in the early days of AIDS, as exemplified in his 2005 speech at Cooper Union.57 The use of condoms was one of the few tools in our arsenal to maintain the virus prior to the development of biomedical prevention efforts.6 Coupled with HIV testing, altruism is a critical element in preventing the spread of HIV.58,59 Face masks are the condoms of the current pandemic. Like condoms, which were inconsistently used across all populations,60,61 face masks, one of the few tools we have to prevent the spread of SARS-CoV-2, are being rejected by segments of the US populace and thus increasing the vulnerabilities of those most at risk of COVID-19 mortality. In fact, intentional nonuse of condoms, colloquially labeled barebacking, was not uncommon.62–64 In effect, the majority of people were motivated by altruism to protect their partners and communities from the ravages of AIDS. During the current pandemic, we must motivate individuals to actively protect their social circles, as well as essential workers and the general public with whom they interact, from COVID-19 by consistently utilizing face masks to prevent the spread of the virus. In this regard, we must apply altruism as a tenet to effectively enhance our contact tracing efforts.65 The idea of altruism, which has proved so powerful in HIV infection, will also play a significant role in containing COVID-19 as we recognize that we are all in this together.66

Conclusion

The knowledge and tools we have developed in our 4-decade war on HIV provide guidance on how we can control and untimely defeat SARS-CoV-2 to bring an end to the COVD-19 pandemic. Significantly, the lessons of AIDS point to the imperative that we tackle this virus using a multipronged approach informed by a biopsychosocial perspective of health. As such, we must create not only tools to control the virus biologically but also tools to work with human beings whose cognitions must be shaped and whose fears must be managed to curtail the further spread of this virus.67

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