Philadelphia’s HIV cases seemed to drop during the pandemic. Why health experts aren’t celebrating.

In another sign of how the COVID-19 pandemic has upended health and medicine across the board, a new report on HIV in Philadelphia has found that last year’s lockdowns seriously impacted testing and care for HIV-positive patients here.

Fewer people were tested, and fewer people were able to access care while most city services were shut down at the beginning of the pandemic in March 2020. The result? HIV counts in Philadelphia from 2020 are likely artificially low, city health officials said in the report, released Tuesday. And people already living with an HIV diagnosis were more likely not to receive care last year, either because HIV services were shut down or because they were afraid of contracting COVID at a doctor’s office or hospital. People with HIV can also be immunocompromised, compounding the fear for contracting the virus.

Health officials are particularly concerned about the COVID-fueled gaps in knowledge around HIV in people who inject drugs, said Kathleen Brady, the acting director of the city health department’s AIDS Activities Coordinating Office. The largest number of HIV cases in Philadelphia are among men who have sex with men, the report found, but new HIV diagnoses among injection drug users have been increasing for years.

From 2020 testing data alone, Brady said, “it looks as though our HIV outbreak in people who inject drugs is going away. But the reality is, if you don’t test people for HIV, you can’t diagnose them. That’s really what we’re seeing here. We don’t have a great understanding of what’s happening in the outbreak right now.”

She added: “My guess is that there’s still been ongoing transmission in this population. They haven’t had access to services to get HIV testing and, for those who are positive, treatment.”

The report shows a dramatic drop in HIV testing that coincided with the first lockdowns in March of 2020. Monthly HIV tests plummeted from around 7,000 in January 2020 to just over 2,000 in April 2020.

Viral load testing -- a measure of the amount of HIV in a patient’s blood -- also decreased dramatically during the lockdowns. These tests can help doctors determine how well a patient’s treatment is going, as the goal is to suppress a patient’s viral load to an undetectable level, halting transmission of the virus. But viral load tests are also a marker of how often HIV-positive patients are accessing care.

Health officials also noted that among people who were diagnosed with HIV in 2020, more were diagnosed with AIDS, the late stage of HIV infection, at the same time. That, the report said, represents “missed opportunities for early HIV diagnosis.”

And fewer people living with HIV had regular treatment appointments during the pandemic, the report found. That could signify less access to care but also could be a sign that some HIV patients visited doctors via telehealth during the pandemic.

Since those virtual visits aren’t counted in the city’s HIV surveillance system, the shift to telehealth has made it harder to track exactly how people with HIV are accessing health care, the report read.

As the city’s lockdowns eased, services for HIV-positive patients reopened, but Brady said Philadelphia’s HIV treatment and testing are still not what they were.

“We are seeing evidence of increased HIV testing in 2021, but we’re not quite back to where I think we were prior to the pandemic,” she said.

And in the same way that COVID has impacted Black and Hispanic communities more severely, communities of color are also more likely to see more new HIV diagnoses and higher rates of AIDS.

“The disparities and diagnoses impacting individuals who are Black and brown has been there historically. Those disparities were already there. It has not changed due to the pandemic,” Brady said.

The city is funding a number of sexual health clinics, some of which are now open, that it hopes can improve testing and surveillance of HIV in Philadelphia, in the process preventing the spread of HIV and other sexually transmitted infections, Brady said. One is focused specifically on Black patients, and others are geared toward those who are LGBTQ, Hispanic, or live in Southwest Philadelphia, where Brady said there’s a dearth of health-care options.

The health department also wants to reconnect with people who inject drugs and lost health care during the pandemic, or were never linked to care.

In the new year, a major concern for the health department is the ongoing transmission of HIV, especially among people who were unable to get tested last year and may not know they’re positive, Brady said.

“The longer someone has HIV and remains undiagnosed, the greater the potential they may actually transmit HIV either through sex or sharing syringes,” Brady said. “We are going to see, potentially in 2021, a further rise in cases in people who inject drugs. The outbreak didn’t disappear. It’s just that we haven’t been able to detect it. And my concern is, it could be much worse.”