Impact of COVID-19 on the Accessibility of HIV Services among Persons with Disabilities in Nigeria

Abstract

As the COVID-19 pandemic continues its rampage all over the world, health care services are distorted across struggling health systems. World leaders are directing vast resources in response to this global pandemic in their respective nations. While this is quite commendable, the pandemic has overshadowed other aspects of health services, particularly HIV services, which constitute HIV prevention, testing and treatment services, accessed by the majority of vulnerable populations all over the globe. Persons with disabilities are not exempt from these vulnerable populations affected by the already existing HIV epidemic in Nigeria, as they have been struggling to access HIV services even before the advent of COVID-19. With COVID-19, the predominant barriers of stigma and discrimination are more pronounced and need to be addressed promptly. This article highlights the use of an Intersectionality-based approach to confronting these barriers to accessibility and inclusion for a much effective integrated service delivery for HIV services amidst the COVID-19 pandemic. Furthermore, Stakeholders need to actively collaborate towards the inclusion of persons with disabilities in the HIV and COVID-19 response.

Keywords

COVID-19, HIV, Persons with disabilities, Nigeria

Introduction

According to the WHO Global Disability Action Plan 2014-2021 report (2015) [1], over one billion persons are living with disabilities in the world. That amounts to about 15% of the world's population or about one in seven people. Unfortunately, the number of persons with disabilities continues to increase as a result of factors such as population increase, ageing, increase in chronic health conditions globally, and medical advances that preserve and prolong life. This has increased the demand for health services [2]. So far, there is no unified definition of disability, however, a person living with a disability could be best described as an umbrella term that incorporates individuals with various forms of impairments, (i.e. having a problem with body structure or function), participation limitations, or activity limitations (having difficulty in executing an action or task). Aside from an individual having a disability from birth, disability may arise in an individual as a result of environmental factors such as road traffic crashes, violence, falls, humanitarian crisis including conflict and natural disasters, substance abuse, and unhealthy diet [3].

There is a growing relationship between HIV/AIDS and disability, as persons with disabilities are at risk of exposure to HIV and this is a cause of concern hence the need for good access to health care services. Note that notwithstanding the developing connection between HIV/AIDS and disability, individuals with disabilities have not gotten adequate consideration inside the national responses to the HIV and AIDS programmes in developing nations [4]. Ordinarily, persons living with disabilities experience huge boundaries in accessing medical services. The emergence of the COVID-19 pandemic has significantly increased the difficulty in accessing HIV services by people living with disabilities.

From the beginning of the COVID-19 pandemic, one of the characterizing messages has been that older individuals were more affected by the pandemic [5]. However, both health and non-health impacts on people of all categories (including persons with disabilities) are proving to be significant. This worldwide emergency is aggravating existing vulnerabilities and inequalities. Coronavirus is not just straightforwardly causing high morbidity and mortality; it is also additionally upsetting fundamental systems for health and sabotaging projects to address HIV and other global health needs. The response to the COVID-19 pandemic has put health systems around the globe under tremendous stress. It has in several ways, disrupted the delivery of everyday health services and information to persons with disabilities, distinctly limiting access to sexual and reproductive health services, interrupting immunization timetables, and cutting off persons with disabilities access to HIV/AIDS and other health services delivered through medical outreaches and sensitization campaigns as a result of physical distancing and lockdown measures [6].

With the spread of the pandemic to developing nations with a relatively higher number of persons living with disabilities and weaker health care systems, direct and indirect impacts on persons living with disabilities in accessing HIV/AIDS services have skyrocketed. For instance, young persons with disabilities who require some assistance with probably anti-retroviral drug administration, nutritional food supplements, and psychological support may be disproportionately affected as a result of interrupted homes, social services, and support, and including personal assistance. In addition, the deprioritization of rendering HIV treatment and prevention services by health workers to persons living with disabilities may have significant health impacts on this segment of the population. In addition, COVID-19 restrictions have brought about limitations in producing quality HIV/AIDS preventive information in accessible formats (for example, simple to understand materials, recordings with closed captioning and sign language, materials in Braille) and this increases the risk for especially young people with disabilities [7]. Also, the repurposing of HIV clinics and healthcare workers, travel restrictions, messaging that keeps people away from services, emerging human rights abuses, and worsening social and economic contexts are also disrupting the continuity of services. These service disruptions associated with COVID-19 are impacting global efforts to end the epidemics of HIV, tuberculosis, and malaria [8].

From the economical point of view, the lockdown measure as a means to curtail the spread of the virus crippled many economies. Many people lost their jobs. Those with HIV/AIDS living with disabilities face many problems which include but are not limited to lack of funds to transport to and from medical centers as well as to purchase high nutritional diets to supplement and boost their already suppressed immune systems as a result of HIV infection. Individuals living with various forms of disabilities, especially those infected and/or affected with HIV need to be given special consideration when it comes to issues regarding health.

While governments all over the world attempt to slow the spread of COVID-19, they should likewise intensify efforts to guarantee a continuous supply of essential commodities and services to react to HIV/AIDS treatment and prevention and other worldwide health needs. This research work details how the emergence of the COVID-19 pandemic has impacted the accessibility of HIV/AIDS services by persons living with a disability.

Barriers to Accessibility of HIV Services among People with Disabilities amid the COVID-19 Pandemic

COVID-19 threatens to disrupt progress towards the Sustainable Development Goals (SDGs), including those related to health, HIV and socioeconomic advancement. However, it can also offer an opportunity to respond to inequality and to build stronger, equity-oriented systems for health, strengthen social protection systems and improve public services with a focus on sustainability, solidarity and many-sided collaboration to support social cohesion, reduce inequality and support community resilience [9]. People with disabilities often experience increased risk factors associated with acquiring HIV including poverty, increased vulnerability to sexual violence and abuse, limited access to education and healthcare, and lack the information and resources needed to facilitate safer sex. People with disabilities are often overlooked in HIV sexual and reproductive health and rights programming and face increased barriers to accessing services.

More than one billion people, 15% of the world's population, live with a disability. Four out of five people with disabilities live in low- and middle-income countries. This includes between 150-200 million children and adolescents (aged 0 to 18 years) [10].

Persons with disabilities are not a homogenous group as they have different needs, limitations and barriers. People are disabled by physical, intellectual or sensory impairments, medical conditions or mental illness. Such impairments, conditions or illnesses may be permanent or transitory in nature [11].

Issues relating to disability have moved up the global development agenda in the last decade. In 2006, the UN Convention on the Rights of Persons with Disabilities, which as of October 2017 has been ratified by 172 countries, stated that people with disabilities should be included in all global development and health initiatives. The Sustainable Development Goals also include people with disabilities within several targets International Disability and Development Consortium (2015) [12].

HIV and disability are linked in several ways. Although HIV-related data on people with disabilities is extremely limited, growing evidence suggests disabled people are more likely to experience factors that put them at higher risk of HIV infection than people who are not disabled. In addition, there is a misconception that people with disabilities are sexually inactive or unlikely to use drugs or alcohol, which means they have been left out of HIV programming [13].

Health Disparities

As with HIV, the COVID-19 pandemic reveals the systemic inadequacies that produce health disparities. What these illnesses demonstrate is a disproportionate burden on already vulnerable populations experiencing poverty and other systemic stressors. The United Nations report has indicated that increases in food costs and market stockpiling have had the most harmful impact on vulnerable communities, particularly those in underdeveloped and developing countries [6]. Although vulnerable populations vary across nations, those with stigmatized or marginalized intersecting identities often experience the highest-burden, including MSM, transgender women, people who inject drugs, commercial sex workers, young women, and youths (15-24), who account for a third of all new HIV infections [14]. Furthermore, immigrants are at increased risk of infectious diseases, including both HIV and COVID-19, as are other people who are displaced [15].

Not surprisingly, the COVID-19 pandemic also appears to more commonly affect those with marginalized intersecting identities, exacerbating racial/ethnic, socioeconomic, disability status, and age-related disparities [14]. This is demonstrated in the disease risk and case fatality rates [16].

Why are People with Disabilities at Risk of HIV?

Exclusion from programming: People with disabilities are often overlooked in HIV prevention, testing and treatment programming and sexual and reproductive health and rights (SRHR) services and face increased barriers to accessing services [11]. Often family, caregivers, employers and healthcare providers fail to fully understand or appreciate the sexual and reproductive health needs of people with disabilities. In addition, many people with disabilities are unaware of their sexual and reproductive health and rights [6].

Similarly, the results of a study of 30 disabled adults from Mpumalanga Province, a rural area of South Africa, suggest that the barriers to HIV services that participants experienced extended far beyond physical obstacles. Many reported how experiences of discrimination, social exclusion and isolation stopped them from accessing services, underpinned by numerous context-specific experiences, including exposure to violence [17].

Women with Disabilities and HIV

The vulnerabilities that put people with disabilities at higher risk of HIV are amplified by gender inequality. Women and girls with disabilities face particularly severe discrimination. Evidence suggests women with disabilities fare worse than both women without disabilities and men with disabilities when it comes to poverty, education and vocational success [6].

A study from sub-Saharan Africa revealed a gradient in the risk of HIV infection according to gender and disability status, with risk increasing for men with disabilities and even more so for women with disabilities when compared to non-disabled men [18].

Tackling Access and Inclusivity through an Intersectionality-based Approach (Recommendations)

The COVID-19 pandemic continues to bring to light the inequalities faced by people with disabilities across all facets such as education, healthcare, and employment/socioeconomic status [19]. In a recent research article by Shakespeare, et al., accessing health care and implications from being affected during COVID, due to disability is termed as a 'triple jeopardy' [20]. As the COVID-19 pandemic continues to distort systems and countries, the attention of health services is naturally shifted towards response to halting the pandemic spread, reducing delivery of sexual and reproductive health and services particularly HIV services (testing, prevention, and treatment) [21]. In addressing stigma/discrimination issues that restrict access to HIV care services for persons with disabilities, there is a pressing need to confront these issues through an Intersectionality-based approach [22].

"Intersectionality" is a way of understanding the interconnectedness of multiple and overlapping systems of discrimination. It aims to illuminate various interacting factors that affect human lives and tries to identify how these different systemic conditions varying in place, time, and circumstance cooperate to reproduce conditions of inequality [23]. Intersectionality brings to light the place of 'invisible power' also termed as, power differentials, which always have prejudicial effects on persons with disabilities. Poverty is also a strong deterrent for persons with disabilities to access HIV services in Nigeria, from mobility issues to the cost of HIV care, which is not completely free [24].

Recommendations that will tackle these issues include

Cross-disability (multiple disabilities) approach: In developing intervention programs to assist people living with HIV and disability, considerations must be made to the fact that people with disabilities are not a homogeneous group i.e., people with disabilities have different experiences as there are different types of disabilities. Therefore, utilizing effective Implementation research, HIV programming would be more reflective of the different needs and experiences of people with disabilities particularly during the period of COVID-19. For instance, a person with an intellectual disability might forget the dates for their HIV appointment and will require frequent reminders; this is quite different from another person with a locomotive disability who will require mobility support to access HIV services at a health facility. As disturbing as these sounds, this is the reality for people with disabilities in low resource communities in Nigeria. Understanding these intersections will go a long way in designing programs and interventions utilizing an approach that takes the diverse needs of people with disabilities into account.

Integration: Intersectionality continues to uncover the realities people with disabilities face in regards to accessing healthcare. Alongside, exposing the numerous systemic and institutional barriers restricting people with disabilities. This renders these persons more vulnerable during the COVID-19, even as they struggle to obtain HIV services. Statistics show that people with disabilities are less likely to have formal employment talk more about health insurance which comes as a workplace benefit [10]. This should be addressed by integrating all sectors relevant to eradicating these structural barriers i.e., looking at service delivery in healthcare from a holistic approach that serves to address all other barriers that hinder accessibility and smooth delivery of that service. For example, for a visually impaired woman living with HIV, who needs to access HIV care support services, integrated service delivery would actively involve engaging the client in a needs assessment that will address barriers she faces with sustainable solutions to achieve better care and impact, towards effectively eradicating systemic/structural barriers that would have hindered her and many others with the same disability.

Community participation: People with disabilities live all around us, in rural communities and urban areas alike, confronting discrimination and social exclusion daily; it is safe to say that disability is not only a health issue but a social one as well. At the community level, especially in Nigeria, discrimination could take the form of negative attitudes, beliefs, name-calling, stemming from cultural or religious beliefs/norms, surrounding the causes of disabilities. Creating consistent community awareness through health education has been a proven method to help community members see people with disabilities, not as something cursed or in negative hindsight, but as persons who need special care and support to reach their full potential. Here, effective Community engagement or participation will utilize the Social model [25], to understand disability as something that is created by the barriers and attitudes in society, not a trait or characteristic that is inherent in the person. This constitutes modifying the already existing environment to eliminate barriers affecting people disabilities by, providing information in accessible formats and ensuring that everyone supports full participation and non-discrimination.

Health financing, policy implementation and government: Evidence from UNAIDS reveals that persons with disabilities "represent one of the largest and most underserved populations" regarding health and HIV services worldwide [13]. Despite these daunting figures, health financing is drastically low in developing countries especially Nigeria, where the population is on a rise. Policies have been formulated towards the inclusion of people with disabilities, such as the Discrimination against Persons with Disabilities (Prohibition) Act of 2018, but there has been little implementation of these policies in the country. This implies there are few provisions for inclusivity for persons with disabilities to access HIV services or receive support during COVID-19.

Therefore, it is imperative that policymakers and the implementation arm of government sit with members or representatives of people from amongst persons with disabilities, to be more aware of, and employ the application of national and international instruments that seek to ensure the rights of persons with disabilities are respected and put into consideration, implementation is adequately financed and Inclusivity in all aspects is achieved.

Conclusion

In the face of uncertainty of the COVID-19 pandemic, there is still hope for people with disabilities if the above recommendations are considered. The lack of research data, on the impact of the pandemic on the accessibility of HIV services among persons with disabilities in Nigeria, implies there is still much work to be done on uncovering this silent, yet daunting situation. Building a better, healthy and inclusive world, starts from eliminating barriers affecting people with disabilities. Collaboration between Ministries, Government, NGOs, Communities of People with Disabilities, International organizations, Stakeholders across all Sectors is a necessity to mitigate the impact of COVID-19 on the accessibility of HIV services among persons with disabilities in Nigeria.

Declarations

Funding

Funding

Conflicts of interest

The authors declare no conflict of interest.

Ethics approval

Not applicable.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Availability of data and material

Not applicable.

Authors' contributions

Archibong Edem Bassey conceptualized the topic/idea, wrote, revised and approved the manuscript. Emmanuel Nathaniel James wrote and approved the manuscript, Kehinde Precious Fadele wrote and approved the manuscript, Goshen David Miteu wrote and approved the manuscript.

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