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Frequently Asked Questions on COVID-19 in Special Populations and Patients With Comorbidities

Vikramjit Mukherjee, MD
Paul E. Sax, MD
Lynora Saxinger, MD, FRCPC, CTropMed
Dr Wong Chen Seong
Released: July 8, 2020

Questions & Answers

Is it okay to change antiretroviral therapy for patients with HIV during the pandemic?

Short Answer: If necessary.

Wong Chen Seong, MBBS, MRCP(UK), FAMS (9/29/20):
Recommendations from multiple guideline organizations, including the British HIV Association,[BHIVA] have generally recommended that HIV treatment regimens not be modified during the pandemic, especially if there are concerns about safely accessing healthcare or visiting healthcare institutions or HIV clinics. This recommendation is to reduce the need for people living with HIV to go to a clinic where the risk of being exposed to someone with COVID-19 may be high. Also, when antiretroviral therapy is changed, there is generally a need for laboratory investigations to monitor for potential adverse events and to check for efficacy of the new treatment.

Therefore, we need to be more circumspect about the decision to change HIV therapy. Obviously, if someone is experiencing virologic failure with his or her current regimen or is experiencing unacceptable adverse events/drug-related toxicities, then treatment needs to be changed as clinically indicated, and clinicians should proceed with those changes. However, if a regimen change is being considered purely for regimen simplification or other nonurgent reasons, then I think most experts would advise to defer changes to the regimen until a time when it becomes a little bit safer for patients to come back to the clinic on a regular schedule.

Of course, this recommendation can be modified somewhat based on local circumstances. In Singapore, for example, where I practice, we can sometimes leverage technological support because we have ramped up the use of telemedicine in seeing our patients with HIV. For us, any regimen changes can be done by supplying new medications via home delivery. It works if the healthcare system is set up for it. Generally, however, it is best to try to avoid regimen changes at this time unless absolutely clinically indicated. 

There have been several cases showing that patients with well-controlled HIV do not appear to have an increased risk for severe COVID-19. Could this be due to antiviral effects of antiretroviral therapy or potential mild immunosuppression protecting them from the cytokine storm?

Short Answer: It’s complicated.

Lynora Saxinger, MD, FRCPC, CTropMed (9/15/20):
This is an interesting question, but we do not have a clear answer yet. I know my patients with HIV were very concerned at the outset of the pandemic but have been reassured by most studies reported thus far. There does seem to be a strong suggestion that in people with well-controlled HIV, immune dysfunction is not severe enough to really cause excess risk of severe COVID-19. There are also some in vitro anti–SARS-CoV-2 effects of some of the antiretroviral drugs used in HIV therapy, particularly protease inhibitors. However, it is a relatively weak antiviral effect. In studies evaluating HIV antiretroviral drugs for COVID-19 treatment in patients who do not have HIV infection, they do not appear to have efficacy against the virus. This suggests that it is unlikely antiretroviral drugs are protective for people receiving HIV treatment.

The second idea mentioned in the question is an interesting one, that not all immune suppression is the same. Aside from active, uncontrolled autoinflammatory or autoimmune diseases, receipt of steroids, or treatment with active cancer therapies, which are associated with higher risk of severe COVID-19, other forms of immune-modulating therapy do not appear to be associated with increased risk of severe disease and may be associated with reduced risk.[Simon 2020; Zrzavy 2020] Of course, data on this issue will be influenced by the fact that people who are more worried about their risk because they are receiving immune-based therapies are also likely to be more careful about contracting SARS-CoV-2 infection. But even when evaluating the patients receiving certain immunomodulatory therapies who acquire SARS-CoV-2 and then require hospitalization, COVID-19 does not appear to be as severe, and there is a slight implication that some immunomodulators might protect against severe disease, possibly by that mechanism of reducing the inflammatory consequence of infection.[Zrzavy 2020] This potential association will be something to watch as more information becomes available. But my usual thought on immune suppression is that we should be careful not to lump it altogether because some of it is, obviously, more important for severe COVID-19, and some of it might even be protective against severe COVID-19. It is quite a complex area of research.

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