**1. Introduction**

In early January 2020, a new coronavirus named "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2) was identified in China as the cause of a cluster of atypical pneumonia cases in Wuhan city, Hubei Province. The disease that it causes, coronavirus

**Citation:** Thekkur, P.; Tweya, H.; Phiri, S.; Mpunga, J.; Kalua, T.; Kumar, A.M.V.; Satyanarayana, S.; Shewade, H.D.; Khogali, M.; Zachariah, R.; et al. Assessing the Impact of COVID-19 on TB and HIV Programme Services in Selected Health Facilities in Lilongwe, Malawi:Operational Research in Real Time. *Trop. Med. Infect. Dis.* **2021**, *6*, 81. https://doi.org/10.3390/tropicalmed 6020081

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

Received: 4 May 2021 Accepted: 17 May 2021 Published: 19 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/).

disease 2019 (COVID-19), then spread with frightening rapidity across the world. On 11 March 2020, the World Health Organization (WHO) declared COVID-19 to be a global pandemic. One year later, over 113 million confirmed cases of COVID-19 and 2.5 million deaths had been reported globally to WHO [1]. At the start of the pandemic, the epicentres were in China, certain European countries, and the United States. The large volumes of air traffic between these countries and Africa led to concerns that sub-Saharan Africa might be hard hit by COVID-19 [2,3].

With enormous resources and finances being redirected to enable countries to cope with the COVID-19 crisis and population lockdowns being imposed to prevent transmission of infection, there was anxiety at the beginning of the epidemic that countries with high burdens of tuberculosis (TB) and human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) might not be able to provide uninterrupted and quality health care services and people-centred care to their patients [4]. It was thought that fear of COVID-19 and the inability of affected patients to move around would adversely affect health-seeking behaviour and reduce access to the diagnosis and care of TB and HIV/AIDS [5]. Modelling studies suggested that the burden of undetected TB would increase dramatically [6]. These studies further 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 delayed treatment of new cases [7].

Similarities were made with the Ebola virus disease outbreak in the West African countries of Sierra Leone and Liberia in 2014. The widespread travel restrictions and community fear of health facilities led to large decreases in the diagnosis of TB and, in the case of Liberia, TB treatment success rates also declined [8,9]. In both countries, HIV testing capabilities for the general population and for those in health facilities decreased, although access to ART was maintained [10,11]. Early on in the COVID-19 pandemic, The Stop TB Partnership and WHO issued guidelines about how people with TB could protect themselves and how national TB programmes might maintain services when faced with the COVID-19 crisis and population lockdowns [12,13]. The Joint United Nations Programme on HIV/AIDS (UNAIDS) provided similar guidance to people living with HIV [14]. This global advice was supported by urgen<sup>t</sup> calls for practical planning to tackle the growing threat of COVID-19 in sub-Saharan Africa [5,15].

We, therefore, set up a project to measure the impact of COVID-19 on TB and HIV services in three sub-Saharan African countries, Kenya, Malawi, and Zimbabwe. This is the report from Malawi.

The first three COVID-19 cases reported to WHO by Malawi were on 2 April 2020, although the cases had been identified in-country during March. By 15 April, Malawi had reported 16 COVID-19 cases with two deaths [16]. At that time, the severity of the COVID-19 pandemic, its duration and the impact that it might have on public health services for the control of TB and HIV/AIDS was unknown.

The National TB Programme and the National HIV/AIDS Programme in Malawi, 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, therefore aimed at the early stage of the COVID-19 outbreak to strengthen routine and real-time monitoring and evaluation systems for TB and HIV case detection and disease control. In selected health facilities in Lilongwe, the capital city, the quarterly (3 monthly) recording and reporting system was augmented by monthly recording and reporting. The hypothesis was that if there were decreases in numbers of persons presenting with presumptive TB or being diagnosed, registered and treated with TB or if there were decreases in numbers presenting for HIV testing or numbers of HIV-positive persons being referred for ART, then programmes might be able to act more quickly on monthly information to reverse these trends.

The overall aim of the study was to determine the impact of the COVID-19 pandemic on TB and HIV programme services in eight selected health facilities in Lilongwe, Malawi, through strengthened real-time surveillance. Specific objectives were on a monthly basis to: (i) document the 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 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 aggregate data collected as part of programme activity.
