Disruption of HIV Service Provision and Response in Hong Kong During COVID-19: Issues of Privacy and Space.

The impact of the COVID-19 pandemic on sexual and reproductive health and rights is a significant public health issue. HIV/AIDS related services have been severely disrupted during the pandemic in different aspects. This paper highlights how privacy concerns affected HIV service provision during COVID-19 in Hong Kong, by sharing the experience of AIDS Concern Hong Kong. Based on our experience of working with our local MSM clients, temporary closure of center-based testing, venue-based testing in gay saunas, and mobile testing, meant that MSM could not easily go to a safe space to get anonymous and gay-friendly testing. To mitigate this, AIDS Concern Hong Kong put effort into promoting and making self-testing available during periods of testing center closure. We also made sure that people can choose to have test kits delivered to an anonymous pick-up station.

The impact of the COVID-19 pandemic on sexual and reproductive health and rights is a significant public health issue. The provision of many sexual and reproductive health services, such as pre- and post-natal checks, safe abortion, contraception, HIV/AIDS, and sexually transmitted infections related services, has been severely disrupted by the COVID-19 pandemic and its associated implementation of quarantine, social distancing, and community containment measures.

HIV/AIDS related services have been severely disrupted during the pandemic in different aspects, for instance, there have been reduced access to routine HIV testing, delayed linkage to HIV care, and hindrance to ART continuation. HIV service providers in USA have discussed how they had to cut face-to-face and walk-in services and increasingly rely on telephone or videoconferencing for service delivery. In sub-Saharan Africa, home-based testing services have been scaled up because facility-based HIV testing has been affected. Meanwhile, HIV-focused community-based organizations in the Philippines have faced disruptions to services because of travel restrictions and physical distancing advisories.

This paper adds to this debate on the disruption of HIV service provision and response during COVID-19 by highlighting the dimension of privacy and space. Due to HIV stigma, some users have privacy concerns about accessing HIV services, where such concerns are especially notable within ethnic minority groups.[6,7] This article discusses the experience of AIDS Concern Hong Kong from January 2020 to September 2021 and highlights how the continuation of HIV service provision in Hong Kong during COVID-19 has been made difficult by issues of privacy and space.

AIDS Concern Hong Kong was established in 1990 as the first non-government charity organization committed to the service of AIDS care in Hong Kong. It provides community education to people at risk of HIV, HIV testing, and support services for people living with HIV. The Hong Kong HIV epidemic has recently been dominated by infections among MSM (men who have sex with men). The latest figures at the time of writing show that of the 131 newly reported HIV cases, involving 109 males and 22 females, 75 acquired the infection via homosexual or bisexual contact, 33 via heterosexual contact, and two via drug injection, with an increasing number of infections found among MSM aged 20 to 29. Thus, MSM is one of the major client groups of AIDS Concern Hong Kong.

Many MSM whom AIDS Concern Hong Kong serves are not open about their sexuality with their family or friends. MSM in Hong Kong often struggle with family relationships because of “family biopolitics” and the family expectation of producing offspring and carrying on the family name. Fewer Chinese non-heterosexual people have come out of the closet as compared to their North American counterparts. This is coupled with the fact that the living environment in Hong Kong is very crowded as property prices are among the highest in the world, as is the Gini coefficient of inequality, meaning that MSM may struggle to find a living space of their own, like many other residents in the city.

Before COVID-19, AIDS Concern Hong Kong has been operating a number of HIV testing models including center-based testing, venue-based testing in gay saunas, mobile testing using a vehicle, and HIV self-testing. Such center-based, venue-based, and mobile services provided anonymity for our MSM clients to get tested at discrete locations. Our testing center in Jordan, one of the prime downtown locations in Hong Kong, is discretely signposted in a multistory building. Our venue-based and mobile services are also provided in many districts in Hong Kong, many of which are away from where our MSM clients live. In addition, AIDS Concern Hong Kong rolled out HIV self-testing in April 2019, following piloting. HIV self-testing is still a new concept for many Hong Kong people, most do not know it is available; while those who have heard about it are often concerned about whether the kits are of good quality. Furthermore, some people are worried about others seeing them buying or using the kit. AIDS Concern Hong Kong has produced written and online guides about HIV self-testing to provide more information to users of self-testing kits.

However, during COVID-19, venue-based services had to stop, which had a particularly severe impact on some MSM who find the anonymity afforded by testing at a discreet center an important consideration for testing for HIV. In response to COVID-19, the Hong Kong government issued guidelines strongly recommending or requiring that people to reduce social contact and encouraging the population to stay at home. In line with these guidelines, AIDS Concern Hong Kong had to frequently review operating arrangements for services. In February 2020, during the first wave of infections amid the serious outbreak in mainland China, AIDS Concern Hong Kong closed its HIV testing center, stopped all physical outreach, venue-based testing, education programs and testing at saunas, and encouraged people to self-test. Limited venue-based service was available in March but had to be stopped again after two weeks with COVID-19 cases rising. On July 14, the third wave of COVID-19 began, requiring closure of venue-based testing service until August 24, after which the service was able to resume. Such frequent disruption to venue-based service means that MSM cannot easily go to a safe space where it is anonymous as well as gay-friendly for testing. It is difficult to ascertain the exact extent to which such disruption to center-based testing has affected HIV testing at AIDS Concern Hong Kong (see Tables 1 and 2). The number of HIV tests conducted at AIDS Concern Hong Kong fell by 55.4% from 3935 between February and September 2019 to 1735 compared to the same period in 2020.

Table 1.

Monthly Data on HIV Tests Conducted at AIDS Concern Hong Kong.

Month (2020 notes in brackets)	Number of HIV tests 2021	Number of HIV tests 2020	Number of HIV tests 2019	Change year over year (2020/2019)
January	77	374	540	−31%
February (closed)	133	0	452	−100%
March (some closure)	459	242	578	−58%
April (some closure)	380	119	378	−69%
May	432	435	540	−19%
June	427	405	471	−14%
July (some closure)	442	201	549	−63%
August (closed)	484	67	491	−86%
September	443	284	476	−40%

Table 2.

Monthly Data on MSM HIV Tests Conducted at AIDS Concern Hong Kong.

Month (2020 notes in brackets)	Number of MSM HIV tests 2021	Number of MSM HIV tests 2020	Number of MSM HIV tests 2019	Change year over year(2020/2019)
January	61	303	375	−19%
February (closed)	92	0	316	−100%
March (some closure)	357	176	403	−56%
April (some closure)	302	86	272	−68%
May	348	304	390	−22%
June	343	312	354	−12%
July (some closure)	318	152	410	−62%
August (closed)	335	56	359	−84%
September	329	216	366	−41%

Following the relative containment of COVID-19 in Hong Kong, HIV testing numbers at AIDS Concern Hong Kong have begun to return close to pre-COVID levels, although some of the cases were likely to be people who chose to delay testing while the control measures were in place.

The number of diagnosed HIV cases in Hong Kong for the first three months of 2020 was 12% lower than that of 2019, but this may be a result of lower testing rates. The data for the second quarter shows a smaller year-over-year drop of 3% in new HIV infections, but such data may have included cases which would have otherwise been found in the first quarter if there were no disruption to testing services. The 2021 first quarter HIV diagnosis data shows a 21.7% drop in new HIV positive cases diagnosed compared to 12 months before (which was just before the COVID restrictions became serious). Some of these were attributable to a steep drop in testing numbers at AIDS Concern Hong Kong and other providers in the first quarter of 2021. However, it is noticeable, from the 2021 s first data when testing numbers have rebounded to a similar pre-COVID level, that the overall HIV positive cases identified continued to drop. The 2021 s first diagnosis cases were 7% lower than the same quarter in 2020. This may suggest a general fall in HIV infection rates during the COVID-19 period. However, more long-term data will be required to understand what has happened.

One important aspect of AIDS Concern Hong Kong's response during COVID-19 was to provide HIV self-testing to people who needed to test but cannot reach a clinic. Free self-test kits were distributed to people who could not go to the testing center during periods of service closure. The tests were also sold through online platforms and pharmacies. There has been a sharp rise in the number of people accessing self-testing and a proportion has unquestionably been due to COVID-19. The number of self-test kits purchased is partly a function of the number of people taking risks and the level of promotion at any time. However, there was a noticeable spike in the number of self-test kits being sold in March when the biggest service closure was in place (see Table 3). Overall, from February to September 2020, self-testing made up 42% of AIDS Concern Hong Kong's testing over the period.

Table 3.

Number of Self-Test kit Sales at AIDS Concern Hong Kong.

Month 2020	Self-test kit sales
January	120
February	120
March	248 (AC service closed)
April	171
May	169
June	178
July	175
August	166 (AC service closed)

However, providing self-test kits to our MSM clients during COVID-19 was a challenge. During COVID-19, many MSM in Hong Kong, similar to those in other parts of the world, followed social distancing measures and had to stay at home more than before; however, many of them did not have family members who are accepting of their sexuality. A recently published study found that during COVID-19, 92.3% of the lesbian, gay, and bisexual (LGB) respondents in Hong Kong lived with their family members/ partners/ friends. They may be worried about having to explain to their family the delivery of a testing kit to their home. Thus, AIDS Concern Hong Kong has made sure that users can choose to have self-testing kits delivered to an anonymous pick-up station. This affords MSM with the anonymity that is of paramount importance to them when they have not come out to their family. Counselling support for people taking the self-test has been offered, however, very few have taken it up. This is likely because it is easy to follow the testing instructions without help, or perhaps it was not easy for our MSM clients to find a quiet, discreet space at home to talk to a counsellor without the risk of being overheard.

To increase access to self-test kits further and in anticipation of future waves of COVID-19, AIDS Concern Hong Kong has designed vending machines which are placed in community venues and gay bars so that people will be able to buy them conveniently. Such an initiative has gone live, and AIDS Concern Hong Kong is also planning on an upgrade of their website and internet technology to allow provision of more services online.

The issue of space may be associated with changes in sexual behavior during COVID-19 in Hong Kong. Data from Australia on sexual behavior of MSM and reports from London clinics suggest that, overall, MSM in those locales have been reducing sexual contact and this may be helping to reduce HIV transmission. In Hong Kong, there is no clear data, but the picture seems to be more nuanced. The COVID-19 lockdown measures in the city have not been as stringent as in other countries and the COVID-19 infection numbers have remained relatively low—this may have reduced community anxiety about the need for caution. The operation of gay bars and saunas have been severely impacted with many closed for long periods of time. However, it is notable that hotel prices have fallen significantly, following the huge drop in the number of tourist visitors. Therefore, it is now more common for Hong Kong people to take a “staycation” which means to vacation locally in Hong Kong. This option provides a venue for sex in Hong Kong, which would have been unaffordable for many people before the COVID-19 pandemic. Thus, there is a need to further understand how issues of space may have affected our clients’ sexual behavior during COVID-19.

The paper has highlighted how privacy concerns affected HIV service provision during COVID-19 in Hong Kong, by sharing the experience of AIDS Concern Hong Kong. Based on our experience of working with our local MSM clients, temporary closure of center-based testing, venue-based testing in gay saunas, and mobile testing meant that MSM could not easily go to a safe space to get anonymous and gay-friendly testing. To mitigate this, AIDS Concern Hong Kong put effort into promoting and making self-testing available during periods of testing center closure. We also made sure that people can choose to have test kits delivered to an anonymous pick-up station. This affords MSM with the anonymity that is of paramount importance to them when they have not come out to their family. Meanwhile, few people taking the self-test took up counselling support. It is likely that HIV service providers need to adapt to the “new normal” in which the impact of COVID-19 will be felt for at least the near future. On one hand, it would be important to re-imagine how the future of venue-based testing would look like—for social distancing, would pre-booking become required? Would walk-in service become discouraged? This of course would come with its downside in terms of flexibility for clients. On the other hand, despite the great promise of telemedicine and videoconferencing for service delivery, and the inevitable rise of self-testing in an age when people are encouraged to stay at home, what impact may it have on the relationship between HIV service providers and their clients, and the associated social and mental health support for the clients? These are important questions for all to consider.