HIV and COVID-19 – an international registry

In an attempt to assess the impact of COVID-19 on HIV-positive people, a team of researchers in the U.S., Spain and Singapore pooled health-related information. A total of 286 people with both HIV and COVID-19 were found in the researchers’ databases. About 94% were on antiretroviral therapy (ART) at the time COVID-19 was diagnosed. Out of 286 people, nearly 60% were hospitalized within 30 days of being diagnosed with COVID-19; about 9% subsequently died. These figures seem large, but they should be treated with caution. That is, readers should not assume that such a large proportion of HIV-positive people who have a diagnosis of COVID-19 will be hospitalized and die in other settings. Indeed, other studies from the U.S. and other countries do not reveal such a high rate of hospitalization and death among HIV-positive people who have COVID-19.

Study details

Participants were recruited between April 1 and July 1, 2020, from three high-income countries. The average profile of participants at the time they entered the study was as follows:

• age – 51 years
• 75% men, 25% women
• major ethno-racial groups: black – 48%; Hispanic – 28%; white – 17%, Asian/other – 8% (figures do not total 100 due to rounding)
• most people had been HIV positive for more than five years
• CD4+ count – 531 cells/mm³
• proportion with a suppressed viral load – 89%
• most people on ART (61%) were taking a regimen anchored by an integrase inhibitor together with two nucleoside analogues; other people were taking regimens anchored by a non-nuke (NNRTI) or protease inhibitor
• a majority of people (90%) were from the U.S.

Many people had underlying health conditions, or comorbidities:

• obesity – 32%
• diabetes – 21%
• chronic lung disease (including asthma and chronic obstructive pulmonary disease) – 17%
• chronic kidney disease – 17%
• cardiovascular disease – 11%
• chronic liver disease – 10%
• active cancer – 5%

About 38% of participants smoked tobacco.

Only 14% of participants had no comorbidity.

COVID-19 symptoms

Common symptoms associated within 72 hours of testing positive for COVID-19 were as follows:

• cough
• fever
• fatigue

People who were not hospitalized tended to have the following symptoms:

• sore throat
• stuffy nose
• headache

About 60% of people were hospitalized and researchers stated that those people were more likely to have the following symptoms:

• fever
• fatigue
• difficulty breathing
• gastrointestinal symptoms
• “altered mental status”

Most hospitalized people had abnormalities on their chest X-ray or CT scan.

Focus on hospitalization

Overall, 164 people were hospitalized, 29% of whom required admission to an intensive care unit (ICU). Once in the ICU, 23% of people needed mechanical ventilation. A total of 27 hospitalized people (17%) died within eight to 24 days after testing positive for SARS-CoV-2.

Taking many factors into account, people with one or more of the following were more likely to be hospitalized:

• older age
• lower CD4+ count
• chronic kidney disease
• chronic lung disease

Severe outcomes

The doctors defined “severe outcomes” as any of the following—admission to an ICU, the need for invasive mechanical ventilation, or death.

In total, 18% of all participants had such an outcome. Also, severe outcomes were more common among hospitalized people (31%).

Researchers found that having one or more of the following factors was significantly associated with a severe outcome:

• older age
• lower CD4+ count
• chronic lung disease
• higher-than-normal blood pressure
• having more than one comorbidity

Survival

Based on data from 47 people admitted to ICU and 27 people who died in this study, researchers suggested that the CD4+ count may have had an impact on major outcomes—admission to an ICU and survival. Intuitively this makes sense, as, in general, HIV-positive people with higher CD4+ cell counts are usually in better overall health than people with lower cell counts. Analysis found that people with less than 200 CD4+ cells were more likely to require admission to an ICU or subsequently die compared to people with more than 500 CD4+ cells.

Bear in mind

The study found that COVID-19 symptoms in HIV-positive people are similar to what has been reported in HIV-negative people.

The researchers stated that people of colour, particularly black and Hispanic people, were at heightened risk for severe symptoms of COVID-19. However, race/ethnicity was not a factor associated with worse outcomes in this study.

HIV-positive people with COVID-19 seem to have a relatively high rate of underlying conditions. These underlying conditions are a risk factor for hospitalization in both HIV-positive and HIV-negative people.

“Based on our analyses, rates of ICU admission, mechanical ventilation use, and death among [HIV-positive people with COVID-19] were consistent with general U.S. data,” according to the researchers.

Untreated HIV infection was not a risk factor for severe symptoms of COVID-19. The researchers stated that this was likely because the proportion of untreated people was relatively small and not statistically meaningful.

The present study found that having a low CD4+ count (less than 200 cells) was a risk factor for poor outcomes. Although there were some deaths in people with more than 200 CD4+ cells/mm³, most deaths occurred in people with less than 200 CD4+ cells.

Like nearly every study done in the midst of the coronavirus pandemic, there are missing data. For instance, it might have been useful to assess the lowest-ever (“nadir”) CD4+ cell count. This could be used to estimate past immunological injury. It also might have been useful to have patients’ CD4 to CD8 ratios. A normal ratio is at least 1.0. A smaller ratio, which is relatively common even among some ART users, is suggestive of immunological weakness. These missing data could have allowed researchers to better understand the immunological underpinnings of COVID-19 in people with HIV.

Other missing pieces of information concerned the following:

• the exact cause of death
• socio-economic information
• any formal comparison to HIV-negative people with COVID-19

Despite these caveats, the present study provides a picture of what has happened to some people with HIV who have been hospitalized with COVID-19, mostly in the U.S. It will be interesting to see the results of larger data sets as the pandemic continues.

—Sean R. Hosein

REFERENCE:

Dandachi D, Geiger G, Montgomery MW, et al; HIV-COVID-19 consortium. Characteristics, comorbidities, and outcomes in a multicenter registry of patients with HIV and coronavirus disease-19. Clinical Infectious Diseases. 2020; in press.