key: cord-326833-boxgt4kb
authors: Marimuthu, Janakiram; Kumar, Bubby S; Aravind Gandhi, P
title: HIV and SARS CoV‐2 co‐infection: A retrospective, record based, case series from South India
date: 2020-07-07
journal: J Med Virol
DOI: 10.1002/jmv.26271
sha: 
doc_id: 326833
cord_uid: boxgt4kb

HIV prevalence in India is about 0.22%, with the total number of people living with HIV/AIDS (PLHA) is estimated at 21.40 lakhs, constituting third largest epidemic in world. However, no study on HIV‐COVID‐19 co‐infection has been reported from India. We conducted a retrospective, record based case series including three males, 2 females and 1 transgender PLHA co‐infected with SARS CoV‐2 in the Indian state of Tamil Nadu. Fever (5), followed by cough (2) and sore throat (1), were the presenting symptoms. Latest Median CD4 count among our patients was 535 cells/ mm3. One of the patients was not under clinical HIV control, with an opportunistic infection Two among our patients were having hypertension. The mainstay of treatment given for the patients consisted of multi‐vitamins in addition to the ARV drugs, anti‐pyretics and anti‐tussives. One of the patient was on low dose Ritonavir boosted HAART regimen. All patients had stable vitals at room conditions, did not have any complications during their entire stay in health care facility for COVID‐19, treated and discharged. This article is protected by copyright. All rights reserved.

with co-morbidities like Diabetes Mellitus, Hypertension etc also needs to be comprehensively managed. Through literature search in PubMed and World Health organization' (WHO) database on COVID-19, we obtained 5 case reports, and 5 case series on PLHA infected with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS CoV-2). The 5 case series were, one from Germany (32 patients), one from Spain (5 cases), two from United States of America [USA] (9 cases and 4 cases) and one from Turkey (4 cases). [3] [4] [5] [6] [7] India, the second most populous country in the world, reported its first COVID-19 case on January 30, 2020, and presently crossed 548, 318 cases. 1 HIV prevalence in India is about 0.22%, 8 with the total number of PLHA estimated at 21.40 lakhs, constituting third largest epidemic in world. However, no study on HIV-COVID-19 co-infection could be found from India. Hence, we conducted a retrospective, record based case series on the PLHA who were infected with SARS CoV-2, in the Indian state of Tamil Nadu. The data of the HIV-COVID19 patients, treated and discharged, till June 10 th , 2020, was collected using a data extraction sheet from the records of the COVID-19 designated hospitals, across the state.

All data has been anonymized. Ethical permission for the study was obtained (Ref no. 961/AIDS/ART/C2/TANSACS/2018) from the Research Review Committee of Tamil Nadu AIDS Control Society (TANSACS).

Six PLHA co-infected with SARS CoV-2 were identified during the study period: Three males, two females and one transgender patient. The median age of the patients was 38 years (22 -55 years). One of the patients was not under clinical HIV control, with an opportunistic infection. Five (83.3%) of our patients had mild illness with symptoms, while one of the patients was asymptomatic. Fever (5), followed by cough (2) and sore throat (1), were the presenting symptoms in our patients. Five (83.3%) of our patients were symptomatic contacts of known COVID-19 positive cases, and one (16.7%) had a travel history from Mumbai. Five patients were on Highly Active Anti-Retroviral Therapy (HAART), one patient was ART naïve. All patients had stable vitals at room conditions, did not have any complications during their entire stay in health care facility for COVID-19, treated and discharged, according to the Government of India guidelines. Other characteristics of the patients are tabulated in Table 1 .

Latest Median CD4 count among our patients was 535 cells/ mm 3 (129-1047). There was no difference in course of illness and the outcome of the patients with varying CD4 counts in our study, thus indicating CD4 may have no role in COVID-19 prognosis. This is in contrast to the studies which observed that lower CD4 counts could actually protect against severe form of COVID-19. 4, 7 It is based on the hypothesis that immune system activation may actually increase the injury caused by COVID-19. 9 However, Suwanwongse et al observed that low CD4+ count in the HIV infected patients may adversely affect the COVID-19 outcomes . 6 One of our patients presented with orooesophageal candidiasis. It might be an HIV opportunistic infection due to poor ART adherence or treatment failure, which must be probed further. It might also be a secondary infection to SARS CoV-2. Though reports on fungal infection in SARS CoV-2 are inadequate, candida infection has been reported among SARS patients in 2003. 10 Blanco et al reported a concurrent Penumocytis jiroveci infection in one of their cases. 4 Two among our patients had hypertension as co-morbidity. Co-morbidities of hypertension, diabetes mellitus 2, chronic obstructive pulmonary disease, hyperlipidemia were reported among the HIV-COVID 19 co-infected as well as exclusively COVID-19 infected patients, across the globe. [3] [4] [5] [6] [7] The mainstay of treatment given for our patients consisted of multi-vitamins, ART drugs, paracetamol and anti-tussives. Vitamins, especially A and D, have shown to improve the immune system and may have potential benefit against viral infections. 11 Anti-retro Viral(ARV) drugs such as Darunavir, Lopinavir/ritonavir and Remdesivir by virtue of their anti-viral properties may have a prophylactic and protective role in keeping the COVID-19 infection as mild in PLHAs. But clinical evidence against the Lopinavir/ritonavir and other HIV protease inhibitors efficacy in COVID 19 management is emerging. 12 Molecular dynamics (MD) simulation studies have identified Zidovudine as the next potential candidate among the ARVs for clinical trials in COVID 19 treatment. 13 Among our patients, one was on low dose Ritonavir boosted HAART and two were on Zidovudine containing regimen. But the ART naïve patient too had mild infection similar to the ones on HAART, thus giving an inconclusive picture on the effect of HAART on COVID 19 disease course in our study. Recovery rate was 100% among our patients, same as that of Benkovic et al. 3 In contrast, Suwanwongse et al and Harter et al reported a higher case fatality rate (CFR) of 78%, 6 and 9% 5 , respectively. However, Harter et al included only symptomatic COVID-19 PLHA and observed that they might have overestimated the morbidity and mortality than the general population. 5 Our study reports that the clinical features of COVID-19 co-infection among PLHA in South India is mild, and the clinical outcomes are favorable. Co-morbidities were present in our patients, but did not impact the outcome. However, the number of cases included was low and all cases were from a single state. Further studies including greater number of patients should be done, to better understand the epidemiology, clinical outcomes and appropriate treatment modalities in the HIV-COVID 19 co-infection.

This article is protected by copyright. All rights reserved.

Funding: None 10

Zhou P, Liu Z, Chen Y, Xiao Y, Huang X, Fan XG. Bacterial and fungal infections in COVID-19 patients: A matter of concern. Infect. Control Hosp. Epidemiol. 2020;: 1. 

World Health Organization. Coronavirus disease (COVID-19) Situation Report-161

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Clinical features and outcome of HIV/SARS-CoV-2 coinfected patients in The B ronx, New York city

SARS-CoV-2 co-infected patients in Istanbul, Turkey

HIV Facts & Figures | National AIDS Control Organization | MoHFW | GoI

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We would like to thank Mr Deepak Jacob IAS, Project Director, TANSACS for his valuable support in writing the case series and Dr Manimaran Deputy Director (Targeted Interventions) TANSACS for his guidance. We acknowledge the ART Medical Officers and other health care workers who managed the HIV-COVID 19 patients across the state, and aided us in collating the data for the case series.