The COVID-19 outbreak has had a series of impacts on HIV health care systems in Jiangsu, China. The number of reported HIV screening tests decreased by 49.0% during the COVID-19 pandemic days compared to the expected estimated data. Almost 60% of people who tested positive during HIV screening tests within that period received confirmatory tests. Moreover, only 80% of confirmed cases were registered in the healthcare system. However, most of the newly diagnosed PLWH enrolled into care did not receive timely health care services. Only an estimated one-third of all newly diagnosed PLWH received CD4 cell count tests, and less than 30% of them initiated ART during the period.

The number of HIV screening laboratories increased rapidly in hospital facilities being part of the response to achieving the global “90–90–90” targets. Therefore, hospital-based screening tests were dominant and accounted for 79.6% of all reported screening tests in 2019 for Jiangsu. However, during the COVID-9 outbreak, the preponderance of hospitals had to shut down clinical services or shifted the majority of their health care resources to complement COVID-19 control efforts [18, 25]. The level one PHER measures halted HIV-related services and decreased the chances for people to check their HIV status during the period. The local CDC offices that also played an essential role in HIV services delivery had to mobilize and relocate all health resources to cope with the COVID-19 outbreak. That also led to the cancellation of some scheduled HIV screening and confirmatory testing during the period under review. Even for institutions that could still provide HIV-related care, the lack of transport due to quarantine and social distancing policies hindered access to the services. In addition, some people shied away from getting routine HIV testing, especially in the hospital during the period as they feared facing COVID-19 related stigma and discrimination [21, 26]. It is also possible that HIV testing rates decreased due to reduced sexual risk behaviors as the majority of people (especially members of high-risk populations) spent most of the time at home during the COVID-19 measures. This explanation is possible as an online survey conducted in China showed that 44% of people reported a decrease in sexual partners around that time [27]. In another study, 45% of MSM reported a decline in their quantity of sexual partners during the COVID-19 measures period in Jiangsu, China [unpublished data]. With the decreased opportunities to have sex, participants may have perceived a less risk of exposure and were less likely to get HIV testing during the period.

PLWH already diagnosed as HIV positive could access free HIV-related health care services (like face-to-face counseling and free ART initiation) in China with the help of service providers (such as healthcare workers, CDC staff, or community-based organization "CBO" staffs) when requested. However, people with reactive results in the screening test phase faced a challenge in accessing confirmatory tests due to lockdowns during the COVID-19 phase [25]. Our findings also showed that about 28.6% of newly diagnosed PLWH became lost to follow-up or failed to get enrolled into care during the COVID-19 pandemic. In addition, the policy on quarantine challenged the timely initiation of ART as only about 20% of newly diagnosed PLWH started their ART during the COVID-19 epidemic. Until 2019, only 40 hospitals could provide ART and needed to meet the needs of more than 20,000 PLWH in Jiangsu province. In addition, PLWH enrolled in care faced potential discontinued of ART due to movement restriction policies implemented during the COVID-19 outbreak. An online survey conducted during the level one PHER found 32.6% of PLWH to be at risk of ART discontinuation soon [4]. In another survey conducted by telephone, 19.1% of PLHW did not get medicine supply in China during the COVID-19 outbreak [1]. Furthermore, some PLWH believed hospital centers to be risky sites for SARS-Cov-2 infection and hence, resisted the urge to receive services at facilities during the outbreak period [26].

Our findings showed how the COVID-19 pandemic affected the whole HIV healthcare system. Being unable to maintain HIV care during the COVID-19 pandemic was a significant hindrance to achieving the “90–90–90” goal. With the temporary discontinuation of public HIV screening systems, CBOs represented one option to bridging the gap in maintaining HIV care services [28,29,30,31]. In addition, HIV self-testing (HIVST) is an innovative approach to providing access to HIV testing safely while maintaining social distancing. Therefore, promoting HIVST will help expand the network of HIV testing especially among key populations in this era [32, 33]. Besides, HIVST affords convenience and privacy which can help expand the coverage of HIV testing to reach persons hindered from accessing facility-based testing [34, 35]. Also, using a “one-stop service” centers approach may reduce the duration between test screening and confirmatory testing [36]. Hence, adopting “one-stop service” centers could also help improve linkage to care success rates. Also, the Chinese NCAIDS guaranteed free antiviral drugs in some selected treatment management agencies to resolve the challenges that resulted from the discontinued ART services. Therefore, PLWH could refill antiviral medications at the nearest selected locations or by post to continue ART.

Our study had some limitations. First, there may have been some delays in entering data entry onto the HIV healthcare system due to the COVID-19 outbreak. That may have affected our data and results. Secondly, as most patients self-reported on their high-risk behaviors, some patients (especially those who had homosexual contacts) may have misreported behaviors due to fear of stigma or misunderstanding, especially amongst patients who have had. In addition, we could not evaluate the clinical outcome on viral load suppression since this cross-sectional study was only evaluating data on PLWH newly diagnosed during the three months of strictly state-enforced COVID-19 preventive measures. Despite these limitations, our study showed that the outbreak of COVID-19 and the policy on quarantine and lockdowns negatively effect the HIV healthcare system.