Evidence of health-system resilience in the uptake of antiretroviral therapy in Sierra Leone during the COVID-19 pandemic: a nationwide retrospective study

BackgroundSustained access to and uptake of antiretroviral therapy (ART) among people living with HIV is a critical component of the HIV response. Limited data exist evaluating the extent to which the COVID-19 pandemic may have disrupted HIV treatment services in Sierra Leone. This study aims to describe differential patterns in the uptake of ART before, during, and after the COVID-19 emergency period in the country. MethodsWe conducted a retrospective cross-sectional study using aggregated secondary program data extracted from the national health information system to reflect the uptake of ART in three time periods: March 2019-February 2020 (pre-COVID-19); March 2020-February 2021 (during COVID-19) and March 2021- February 2022 (post COVID-19). Outcomes were compared across the three time periods and stratified by sex and by region. ResultsThere was a steady increase in the overall ART uptake from 365,326 pre-COVID-19 to 416,069 during COVID-19 and 518, 426 post-COVID-19, which masks the more significant relative decline affecting new ART initiations due to COVID-19: pre-COVID-19 (8, 958), during COVID-19 (8,777), and post-COVID-19 (13, 996). A sharp decline in new ART initiation was consistent with the surge in COVID-19, reflected geographical variability, but showed no sex difference. ConclusionVariations on the impact of COVID-19 across regions underscores the need for targeted interventions to mitigate the impact of future structural shocks on HIV services. The steady increase in overall uptake of ART suggests resiliency to a significant disruption and reflects pre-emptive health systems adaptations. The notable increase in new initiations in the post-COVID-19 period could suggest catch-up of delayed new initiations or more also reflect increasing HIV incidence and the critical importance of sustained investments for resiliency.