**1. Introduction**

In early January 2020, a new coronavirus, named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was linked to a series of atypical pneumonia cases reported the previous month in Wuhan city, Hubei province, China. The virus spread rapidly within China, and then onto Europe, the United States of America (USA) and the rest of the world, causing the disease known as COVID-19. On 11 March 2020, the World Health Organization (WHO) declared COVID-19 to be a global pandemic. By the end of

**Citation:** Thekkur, P.; Takarinda, K.C.; Timire, C.; Sandy, C.; Apollo, T.; Kumar, A.M.V.; Satyanarayana, S.; Shewade, H.D.; Khogali, M.; Zachariah, R.; et al. Operational Research to Assess the Real-Time Impact of COVID-19 on TB and HIV Services: The Experience and Response from Health Facilities in Harare, Zimbabwe. *Trop. Med. Infect. Dis.* **2021**, *6*, 94. https://doi.org/ 10.3390/tropicalmed6020094

7 Academic Editors: Peter A. Leggat, John Frean and Lucille Blumberg

Received: 29 April 2021 Accepted: 27 May 2021 Published: 31 May 2021

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**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

2020, 80 million confirmed cases and 1.8 million deaths had been reported globally to the WHO, making COVID-19 the leading cause of death among infectious diseases [1]. In April 2020, one month after the pandemic had been declared, the epicenters were China, Europe and the USA, and with large volumes of air traffic between these regions and Africa, sub-Saharan Africa was predicted to be the next region to be hard hit by COVID-19 [2,3].

At the start of the COVID-19 crisis, political attention, resources and finances were redirected within the health sector to help it grapple with the escalating numbers of COVID-19 cases. National and local lockdowns restricted movement and forced people to spend more time indoors, limiting access to health facilities. All of this raised concern that countries with high burdens of tuberculosis (TB) and human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) might see interruption of health services and poor quality of care for their patients [4]. Modeling studies suggested that deaths due to HIV/AIDS and TB could increase by up to 10 and 20%, respectively, with the greatest impact on HIV resulting from interruption to antiretroviral therapy (ART) and the greatest impact on TB resulting from delayed diagnosis and treatment of new cases [5].

Similarities were drawn with the Ebola virus disease outbreak in Sierra Leone and Liberia in 2014. Through restrictions in travel, zonal quarantines and understandable community fear of health facilities, the ability of the national TB programs to diagnose TB and continue with HIV testing of their TB patients was adversely affected, and, in the case of Liberia, there was a decline in the rates of TB treatment success [6,7]. HIV testing in the general population and in health facilities decreased in both countries, although access to ART remained unaffected [8,9]. Early on in the COVID-19 pandemic, the Stop TB Partnership and WHO issued guidance about how people with TB could protect themselves and how national TB programs might adjust to COVID-19 outbreaks and national/local lockdowns [10,11]. The United Nations Joint Programme on HIV/AIDS (UNAIDS) provided similar advice and guidance to people living with HIV [12]. This global advice was augmented by urgen<sup>t</sup> calls for practical planning to tackle the growing threat of COVID-19 in sub-Saharan Africa [13].

The first COVID-19 case reported to WHO by Zimbabwe was on 21 March 2020. By 15 April, Zimbabwe had reported 18 COVID-19 cases (with three deaths) [14], and the country had gone into national lockdown. The impact that this would have on public health services for the managemen<sup>t</sup> of TB and HIV/AIDS was unknown. The Zimbabwe National TB Programme (NTP) and National HIV/AIDS Programme (NAP) began preparations for the continued delivery of TB-HIV services in this new environment of restricted movement [15]. The country also drew on the example of Guinea in West Africa, which garnered resources to weather the Ebola virus disease storm and managed to maintain TB services despite numerous obstacles [16].

The Zimbabwe NTP and NAP, working in close collaboration with the International Union Against Tuberculosis and Lung Disease (The Union), the Special Programme for Research and Training in Tropical Disease at WHO (TDR) and Vital Strategies, decided to strengthen the routine and real-time monitoring and evaluation system for TB and HIV case detection. The quarterly (3-monthly) recording and reporting system was supported in selected health facilities in the capital city of Harare by recording and reporting every month. It was hypothesized that if there were declines seen in persons presenting with presumptive TB or in numbers registered and treated for TB, or decreases in persons presenting for HIV testing or in numbers of HIV-positive persons being referred for ART, then programs could act more quickly on monthly information rather than quarterly information to reverse these trends.

The overall aim of the study was to determine the impact of the COVID-19 pandemic on TB case detection, diagnosis and treatment outcomes and on HIV testing and referral to ART through strengthened real-time surveillance. In selected health facilities in Harare, Zimbabwe, specific objectives were on a monthly basis to: (i) document the cumulative monthly increase nationally in COVID-19 cases and deaths and the effects on general health services; (ii) collect, collate and report on specific TB and HIV-related data during the

COVID-19 period (March 2020 to February 2021), (iii) document any specific programmatic responses at the national and local level to TB and HIV diagnosis and treatment during the COVID-19 period and (iv) compare the findings during the COVID-19 period with data collected and collated retrospectively during the pre-COVID-19 period (March 2019 to February 2020).

#### **2. Materials and Methods**

### *2.1. Study Design*

This was a cohort study using programmatically collected aggregate data.
