Retention in care for HIV-infected patients in the eye of the Ebola storm

According to the World Health Organization 1 December report, Liberia is the country most affected by the current Ebola outbreak in West Africa, with an estimated number of 7635 cases, and 3145 deaths [1,2]. In addition, more than 50% of Ebola-related deaths in healthcare workers were reported from Liberia [3], although Guinea and Sierra Leone have been affected for longer. The reasons why Liberia paid the heaviest toll to this scourge are many [4], but the long and devastating civil war that lasted from the 1980s to the beginning of the 2000s probably played a significant part: although the healthcare system was carefully rebuilt after 2003, this 10-year-old system proved to be fragile in terms of infection prevention and control (IPC), trust among users (patients and healthcare workers), and above all its capacity to address an emerging public health threat of this size [5]. Soon after the Ebola outbreak established a foothold in Liberia, in June 2014, the three largest hospitals in the capital city (Redemption Hospital, John Fitzgerald Kennedy Hospital, and Saint-Joseph Catholic Hospital) had to interrupt most activities due to their inability to protect their healthcare workers from occupational risk of Ebola, which translated into numerous deaths, including at the highest level of responsibility (hospital director, head of emergency department, internal medicine, laboratory) [3]; strikes, and refusal of healthcare workers to return to work until personal protective equipment could be provided. The 5-month closing of most inpatients and emergency departments in the three main hospitals of the city had consequences that will never be accurately estimated [6]. These probably include significant increases in the lethality of most severe diseases (malaria, invasive bacterial infections, diabetes, cardiovascular events), road traffic accidents, or any obstetrical complication [6,7]. During a recent field visit to our colleagues in the context of hospitals partnership (http://www.esther.fr) [8], we have witnessed the continuity of care for HIV-infected patients followed in the HIV care and treatment clinics within these hospitals (Fig. 1), despite this dreadful scenario, through an active collaboration between the main local players in the field: clinical staff of these clinics (doctors, nurses, assistants, pharmacists), patients associations such as ‘Positive Living with AIDS in Liberia’, and the National AIDS Control Program. Solutions implemented to ensure that patients on antiretroviral treatment (ART) would remain in care, and on treatment, were the following: regular opening hours of HIV clinics were maintained throughout the Ebola crisis, in two of the three clinics, even with limited staff, to ensure that patients who would come for drugs refill would be attended; for the one HIV clinic that closed (by administrative decision), the National AIDS Control Program reorganized one of its offices to become a temporary HIV outpatient clinic, with ART dispensation; ART were dispensed for an extended duration (generally, 3 months), to limit the contacts of HIV-infected patients with the hospitals, and to decrease the workload, taking into account limited human resources; communication in the community, through peers (Positive Living with AIDS in Liberia), that HIV clinics were not closed, and that ART should not be interrupted. In addition, following the national policy set-up to decrease the occupational risk of Ebola, invasive tests were limited, including blood sampling for ART monitoring, and voluntary counseling and testing activities.Fig. 1: Number of patients attended each month at the HIV clinic, Redemption Hospital, Monrovia, Liberia (January–October 2014).Which lessons emerged from these observations? First, IPC is of utmost importance to guarantee that the healthcare system is robust, and will be able to survive in a storm such as the 2014 Ebola outbreak. This lesson must be kept in all minds when the healthcare system will be progressively rebuilt in the post-Ebola era [9]: hospitals must reopen with robust IPC programmes. To our surprise, 8 months after the start of the epidemic in Liberia, most inpatients department were still closed despite the large amount of funding and international aid announced, and personal protective equipment was unavailable in the two main hospitals we visited. If this is neglected, the system may collapse in a few weeks again with the next outbreak of Ebola or any other pathogenic and transmissible disease. Second, the commitment and the pragmatic decisions taken by the healthcare workers and patients associations involved in HIV care are to be commended: with limited support, they spontaneously set up a system that allowed the majority of HIV-infected patients followed before the Ebola outbreak to remain in care, and on ART, whereas patient follow-up was tailored to the situation of crisis they were facing. Given the dreadful situation in Monrovia during the summer 2014, this sounds like a miracle, mostly due to the high level of commitment encountered in most humans involved in HIV care in this city. Acknowledgements All authors are involved in HIV care in Liberia, participated in the writing of the study, and approved the final version. Conflicts of interest There are no conflicts of interest.