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Chief, Division of Infectious Diseases
Brigham and Women's Hospital
Harriet Ryan Albee Professor of Medicine
Harvard Medical School
Daniel R. Kuritzkes, MD, has disclosed that he has received funds for research support from Atea, Gilead Sciences, Merck, Novartis, and ViiV Healthcare and consulting fees from Abpro, Atea, Decoy, Gilead Sciences, GlaxoSmithKline, Janssen, Merck, Rigel, and ViiV Healthcare.
Interplay of HIV and COVID-19
The syndemics of HIV and COVID-19 have taken a considerable toll worldwide among persons with HIV (PWH). Even among those who remain healthy and free of SARS-CoV-2, the disruptions caused by the COVID-19 pandemic have curtailed in-person clinic visits, new starts of pre-exposure prophylaxis, and laboratory monitoring of antiretroviral therapy (ART) for those with HIV who are receiving ART. Diversion of laboratory capacity toward testing for SARS-CoV-2 has delayed the turnaround time for viral load testing and, in some settings, has resulted in shortages of antiretroviral medication because of delays in timely delivery of critical drug supply.
How preexisting HIV affects risk of acquiring COVID-19 and clinical outcomes among PWH have been uppermost in the minds of healthcare professionals caring for such patients since the onset of the SARS-CoV-2 pandemic. Contradictory reports have emerged from studies during the past 18 months, some suggesting that HIV does not increase the risk of severe disease or death from COVID-19 and other studies concluding the opposite.
Data From 3 Studies in PWH and COVID-19 Presented at IAS 2021
A study presented at IAS 2021 by Silvia Bertagnolio of the World Health Organization (WHO) shed new light on this important question. The Global Clinical Platform for COVID-19 collected anonymized patient-level data; the analysis described here included data from January 1, 2020, through April 29, 2021. Data collected from 168,649 patients from 24 countries hospitalized with COVID-19 and with known HIV status were included in the current analysis. In total, 15,552 patients (9.2%) were PWH; information on ART use was available for only 40% of the PWH. Outcomes that were analyzed included the association of demographic and clinical characteristics with HIV status, COVID-19 severity, and in-hospital mortality. Of those with HIV, the mean age was 45.5 years and 37.1% were male. Of note, 94.6% of PWH included in this analysis were from South Africa, which may have resulted in substantial skewing of results based on characteristics of PWH from that country. Recall that information regarding use of ART was available on only 40% of the PWH—unfortunately, data on virus loads and CD4+ cell counts were unavailable.
Overall, the study found that HIV was independently associated with a significantly increased risk of severe or critical COVID-19 at the time of hospital admission and a significantly increased risk of in-hospital mortality. Sensitivity analyses that excluded data from South Africa confirmed these findings, although because such analyses included only 5% of the original number of PWH, they must be considered with caution. Analyses showed that as in the general population, aged 65 years or older, male sex, and preexisting diabetes and/or hypertension were each individually associated with an increased risk of severe COVID-19 and in-hospital mortality.
Results of the WHO study stand in contrast to those of the American Heart Association (AHA) COVID-19 Cardiovascular Disease Registry. That study tracked outcomes among 21,528 persons hospitalized with COVID-19 in 2020 at 107 US hospitals. This study found no difference in in-hospital mortality between persons with and without HIV. However, the AHA study was considerably smaller than the WHO study and included only 220 persons with HIV. Data from a study in Spain of 13,142 PWH, 749 of whom developed COVID-19, found that detectable HIV-1 RNA, older age, chronic comorbidities, and migrant status were each associated with a higher risk of severe outcomes of COVID-19.Taken together, these studies suggest that the impact of preexisting HIV on COVID-19 outcomes is dependent on the clinical setting. Patients with poorly controlled HIV are more likely to suffer severe outcomes of COVID-19. These findings support the WHO recommendation that PWH be prioritized for vaccination against COVID-19, and the recent recommendation by the CDC that people with poorly controlled or advanced HIV disease (CD4+ cell count <200 cells/mm3) receive a third vaccination to be considered fully immunized. These findings underscore the importance of universal access to ART for all PWH and ensuring equitable access to COVID-19 vaccination worldwide.