key: cord-311559-vkb7a4cm
authors: Kanwugu, Osman N.; Adadi, Parise
title: HIV/SARS‐CoV‐2 coinfection: A global perspective
date: 2020-07-28
journal: J Med Virol
DOI: 10.1002/jmv.26321
sha: 
doc_id: 311559
cord_uid: vkb7a4cm

Since its first appearance in Wuhan, China, severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) has rapidly spread throughout the world and has become a global pandemic. Several medical comorbidities have been identified as risk factors for coronavirus disease 2019 (COVID‐19). However, it remains unclear whether people living with human immunodefeciency virus (PLWH) are at an increased risk of COVID‐19 and severe disease manifestation, with controversial suggestion that HIV‐infected individuals could be protected from severe COVID‐19 by means of antiretroviral therapy or HIV‐related immunosuppression. Several cases of coinfection with HIV and SARS‐CoV‐2 have been reported from different parts of the globe. This review seeks to provide a holistic overview of SARS‐CoV‐2 infection in PLWH.

Coronavirus disease 2019 (COVID-19) is a potentially fatal respiratory illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a newly identified coronavirus, which was first recognized in December 2019 in Wuhan, Hubei Province, China and has since rapidly spread to over 200 countries/territories/areas and have been declared a global pandemic by the World Health Organization (WHO). 1 As at the time of writing (3 June 2020), the total confirmed cases were 6 383 805 with 2 732 976 recoveries and a staggering 380 384 deaths have been officially reported globally. 2 The clinical spectrum of COVID-19 is broad, and while most people with COVID-19 develop only mild or uncomplicated illness, especially in the early phase of illness, 14% to 26% of infected persons develop severe disease that requires hospitalization and oxygen support, with some even requiring admission to an intensive care unit. 3, 4 Organ dysfunction, particularly progressive respiratory failure, heart and kidney injuries, is associated with the highest rates of mortality. 5, 6 Clinical evidence has shown that disease severity and mortality are associated with older age and underlying comorbidities, such as diabetes, hypertension, and cardiovascular disease (CVD). 4, 6, 7 In line with this, one of the puzzling questions in the wake of this pandemic is "Does HIV infection increases the risk of getting and disease severity of COVID-19?." This is important, especially in Africa, as the region accounts for more than 70% of the global burden of human immunodefeciency virus (HIV) infection. 8 Generally, people living with HIV (PLWH) are perceived to be at high risk of contracting SARS-CoV-2, even though currently no specific information about the risk of COVID-19 in people with HIV is available. At the end of 2018, it was estimated that 37.9 million people globally were living with HIV with 20.6 million (54%) in the eastern and southern Africa region, 5.9 million in Asia and the Pacific region, 5.0 million in western and central Africa, and 2.2 million in western and central Europe and north America region. 9 In an attempt to halt the spread of COVID-19, governments across the globe are shutting cities down, restricting movements and encouraging residents to stay indoors.

Beyond the unprecedented disruption of lives, the COVID-19 pandemic has severely interrupted HIV care delivery among several other health care services globally as attention, resources and personnel have been diverted to the fight against COVID-19. [10] [11] [12] It is estimated that about 19% of HIV-infected patients were unable to get antiretroviral medications or therapy (ART) refills due to the Osman N. Kanwugu and Parise Adadi contributed equally to this work.

pandemic. In addition, there have been reports that several HIV/ AIDS prevention and control centers globally have been converted to COVID-19 treatment centers, which denies HIV patients of their ART. [13] [14] [15] This has left a greater proportion of the HIV community in a venerable state, considering that they require regular medication to maintain good health. Despite the potentially poor prognosis for most patients within this category when infected with SARS-CoV-2, data on HIV/SARS-CoV-2 co-infection is still scarce. Herein we summarize the global instances of SARS-CoV-2/HIV coinfections.

The COVID-19 pandemic, as well as measures taken by governments across the world, to minimize its spread has triggered unintended consequences in terms of HIV testing and care. 16 quarantine and treatment facility. 18 In the Hubei province of China, about 64.15% of HIV patients could not have access to their ART due to the measures imitated to curb the spread of the virus. 19 As Gokengin et al reported, antiretrovirals are purchased and distributed via designated clinics 20 thus, patients living outside the perimeter could not have access to their ART. The situation is further aggravated by shortage of medication as medical consignments are stuck in procurement systems in other countries with no further supplies able to come in. 21 The pandemic has as well compromised the psychological and emotional wellbeing of PLWH. Shiau et al 22 reported that many HIV patient being managed via telephone have indicated that they are extremely stressed, anxious, and unable to sleep. A recent survey in China, 19 revealed that 28.93% of the respondents hoped they had some social and psychological support. Therefore, these psychosocial issues have to be addressed to avoid exacerbating adverse medical consequence among PLWH. 22 2 | METHODS SCOPUS, Web of Science, PubMed and Google Scholar were searched for relevant peer-reviewed publications from December 2019 to 3 June 2020, using the following combination of terms: ("HIV" AND "COVID-19"), ("Immunodeficiency" AND "COVID-19") and ("HIV" AND "Coronavirus"). The search was limited to only publications in English. Publications with information on HIV/SARS-CoV-2 co-infection were manually sorted out and included in this study.

Websites of relevant organizations including WHO, CDC, and USAIDS were also reviewed for additional information. Data on coinfection cases were extracted and entered into Microsoft Excel.

Statistical analyses were carried out using IBM SPSS Statistics version 25.

The first case of HIV/SARS-CoV-2 coinfection was reported in Wuhan, China, the terminus a quo of the pandemic. Subsequent cases of coinfection have been reported in UK, USA, Spain, Italy, Germany and other countries (Table 1) . Interestingly, only two cases of coinfection have been reported in the whole of the Africa continent, notwithstanding the fact that South Africa which is at present the epicenter of the COVID-19 pandemic in Africa 1 and home to over close to 8 million PLWH, the largest HIV epidemic in the world. 23 The situation of Africa is probably not because less PLWH have actually contracted COVID-19, but more likely due to unpublished data, taking into account the uncoordinated and poor data collection and management in hospitals and health centers, lack of enthusiasm and ability of most health professionals to conduct research and prepare manuscripts for publication as well as poor collaboration between researchers and health professionals. The region currently accounts for just a little of 1% of global health publications 24 with a significant part being championed by researchers from high income countries. 25 Nonetheless, 378 HIV/SARS-CoV-2 coinfection cases have so far been reported globally with a majority originating from UK (101 cases) and USA (122 cases). The high number of coinfection cases from these countries however does not particularly suggest any increased risk of COVID-19 among PLWH in them. It is worth noting that studies characterizing a larger population of patients with COVID-19 originated from these countries, and hence the high re- considering reports from China, 32-34 Japan, 35 Spain, 36 cases. 26, 27 The low proportion of PLWH among patients with COVID-19 should, however, be interpreted with caution as it could be as a result unyielding commitment to safety precautions (including wearing of nose masks, hand hygiene, social distancing, etc.) by individuals with HIV to limit their exposure to the SARS-CoV-2, bearing in mind their compromised immune system and the fact that even before COVID-19 they were at risk of a broad range of infections, including respiratory tract infections, 23 rather than protection afforded by HIV or ART. It could also be that less of the HIV population is being screened for COVID-19, looking at the fact some are not even enthused to visit treatment centers and clinics for their ART refills. 18 In general, 214 of a total 334 coinfection cases were uncomplicated (ie, mild and moderate) cases while the remaining 35.9% were classified as either severe or critical (complicated), requiring oxygen therapy and/or admission to intensive care unit ( Figure 2 ). Among subjects with known outcomes (closed cases; n = 300) 82.3% had recovered while the remaining (53 patients) died, thus giving an overall case-fatality rate of 14% among PLWH, which is more than 2 times higher than the current rate among the global population. 1 However, just like the country-specific case-fatality ratio of COVID-19 in the general population, the case-fatality rate among PLWH differ from one country to another, ranging from as high as 27.7% in UK to 0% in China (Figure 3 ). Similar to UK, the results of the analysis indicated USA also has a high case-fatality ratio (13.9%) among its HIV population which is 2.4 time higher than that of the general population (5.8%). 39 Among the top five countries in terms of number of coinfection cases reported, the case-fatality ratio among PLWH in Spain (3.6%) and Italy (4.3%) are lower than that recorded for the general population, 11.3% and 14.4% respectively. 39 characteristics of the healthcare system, among others. 39 Nonetheless, it should be noted that majority of the cases included in this study (particularly from UK and USA) were hospitalized patients and as such the high case-fatality rates recorded might not be particularly peculiar to HIV/SARS-CoV-2 coinfection since as much as 26% (in UK) 26 and 21% (in USA) 27 

We acknowledge the selfless efforts of healthcare professionals and all other essential service providers in the fight against COVID-19.

The authors declare that there are no conflict of interests. 

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