key: cord-338572-5ifc2lx6
authors: Nagarakanti, Sandhya R.; Okoh, Alexis K; Grinberg, Sagy; Bishburg, Eliahu
title: Clinical outcomes of patients with COVID‐19 and HIV coinfection
date: 2020-09-19
journal: J Med Virol
DOI: 10.1002/jmv.26533
sha: 
doc_id: 338572
cord_uid: 5ifc2lx6

BACKGROUND: Patients with Human Immune Deficiency Virus (HIV) infection may be at an increased risk for morbidity and mortality from the Coronavirus disease‐2019 (COVID‐19). We present the clinical outcomes of HIV patients hospitalized for COVID‐19 in a matched comparison with historical controls. METHODS: We conducted retrospective cohort study of HIV patients who were admitted for COVID‐19 between March 2020 and April 2020 to Newark Beth Israel Medical Center. Data on baseline clinical characteristics and hospital course was documented and compared with that of a matched control group of COVID‐19 patients who had no history of HIV. Kaplan Meier Survival curves and the log‐rank tests were used to estimate and compare in‐hospital survival between both unmatched and matched groups. RESULTS: Twenty‐three patients with HIV were hospitalized with COVID‐19. Median age was 59 years. The rates of in‐hospital death, the need for mechanical ventilation and intensive care unit admission were 13% (n=3), 9% (n=2) and 9% (n=2) respectively. The HIV infection was well controlled in all patients except for 3 patients who had presented with acquired immune deficiency syndrome (AIDS). All AIDS patients were discharged home uneventfully. A one‐to‐one propensity matching identified 23 COVID‐19 patients who served as a control group. In both pre‐ and post‐match cohorts, survival between HIV and control groups were comparable. CONCLUSIONS: In our cohort of HIV infected patients hospitalized for COVID‐19, there was no difference in mortality, ICU admission and the need for mechanical ventilation when compared to a matched control of COVID ‐19 patients with HIV. This article is protected by copyright. All rights reserved.

Since the declaration of the coronavirus disease 19 (COVID-19) as a pandemic by the world health organization (WHO), the Centers for Disease Control and Prevention (CDC) have cautioned that, compared to the general population, This article is protected by copyright. All rights reserved.

people living with Human Immunodeficiency virus syndrome (HIV) may be at a higher risk for complications and death associated with COVID-19. 1 Disease severity in COVID-19 caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has been described to vary in different demographic populations based on their age, body mass index, traditional cardiovascular risk factors and underlying co-existing conditions. The elderly and people with chronic conditions are more likely to experience worse outcomes from COVID-19. 2 Patients living with HIV may be at an increased risk for COVID-19 related complications due to (i) a higher rate of co-existing conditions than the general population (ii) side effects of anti-retroviral therapy (ART), and (iii) traditional cardiovascular risk factors such as obesity, alcohol, and tobacco use disorder. 3 An early report suggested that, HIV-related lymphopenia may have a protective role from severe disease in HIV patients who are susceptible to Moreover, the role of ART in the outcomes of HIV patients who present with COVID-19, has been controversial, with some in-vitro data showing activity of ART against SARS coronavirus and SARS-CoV-2. [5] [6] To the best of our knowledge, data on COVID 19 patients with underlying immunodeficiency such as HIV has been limited to few cases and clinical outcomes of hospitalized patients has not been well characterized. In this report, we sought to describe our experience with HIV patients who were hospitalized for COVID 19. We evaluated their clinical outcomes and compared them to that of a well-matched control group of patients with no HIV.

This study is a retrospective review of a prospectively maintained institutional review board (IRB) approved COVID-19 database in Newark Beth Israel Medical Center, in Newark, New Jersey. The database includes all patients with laboratory-confirmed COVID-19 infection, which was defined as a positive result Accepted Article on a reverse-transcriptase-polymerase reaction (RT-PCR) assay (Abbott m2000 real time system, Chicago, IL) of a specimen collected on a nasopharyngeal swab. We queried the database for, (a) adults 18-years of age or older (b) with a history of HIV (Confirmed with Architect HIV1/2 antigen/antibody combination fourth generation testing) and hospitalized between March 10, 2020 and May 10, 2020 for COVID-19 infection with follow up through May 30, 2020.

There were no clear strict guidelines used for admission. Hospitalization decision was mainly based on the individual admitting physician's discretion. Some of the criterial used for admission were (a) signs of sepsis or septic shock defined by the 2016 Third International Consensus Definition for sepsis and septic shock 7 (b) dyspnea requiring a step up in oxygenation therapy to maintain oxygen saturation between 88% -94%. We collected data on demographic, laboratory, and clinical outcomes from electronic medical records using a standardized data collection protocol. These data points included HIV-associated characteristics such as most recent CD4+ T cells, CD4/CD8 ratio, ( obtained by flow cytometry Clinical outcomes of hospitalized patients were compared to that of a propensity matched cohort of COVID-19 patients who had no history of HIV infection. Inhospital survival was compared between both unmatched and matched groups.

All data were summarized by using descriptive statistics, presenting continuous variables as median, interquartile range and categorical variables as proportions or percentages. We used the Mann-Whitney U test, Chi-square, or Fisher's exact tests to compare differences when appropriate.

To estimate the effect of HIV on clinical outcomes, we accounted for covariates that predicted the probability of presenting with COVID. Propensity scores from a This article is protected by copyright. All rights reserved. We used Kaplan Maier Survival curves and the log-rank and stratified log rank tests to estimate the survival and compare their differences between study groups. Statistical significance was considered when a two-sided alpha of less than 0.05 was reached. All analyses were performed using the JMP version 14.0.2 statistical software (SAS Institute Inc., Cary, NC, USA).

During the study period, 23 HIV patients were admitted for COVID-19. The most common presenting symptoms were cough (n=20), fever (n=18) and dyspnea (n=17) over a median duration of 3 days ( Figure 1 ). Shown in Table 1 

undetectable viral load except for three patients who had advanced AIDS. One patient had a CD4 count of 10 cells/µL and HIV RNA viral load 26,900copies/ml, the other one had CD4 count of 116 cells /µL and an HIV RNA viral load of > 2 million copies mL and the other one had CD 4 of 179µL. The viral load in the last patient with AIDS was unavailable. All patients were discharged home alive after medical management which included anti-microbial therapy, administration of steroids, and respiratory support.

Given in Table 2 are the demographic, clinical and outcomes comparison between HIV and non-HIV infected patients before and after 1:1 propensity score matching. A cohort of 254 non-HIV patients who were hospitalized was compared to 23 HIV patients who were also hospitalized during the same period. may not be generalizable to other centers and may also be limited by its small sample size. A larger study from multiple centers will be needed to verify findings from this study. We attempted to account for the differences in clinical characteristics by using a propensity score method to identify the control group and to reduce selection bias. Also, we did not have full data on the immunological profile of all study subjects. A direct association between immunological profile and outcomes can therefore not be inferred from the presented dataset. Nevertheless, the hundred percent survival rates of the 3 patients who presented with AIDS may suggest a paradoxical association between a worse immunological profile and improved outcomes in COVID-19.

This article is protected by copyright. All rights reserved.

In this cohort of HIV patients hospitalized for COVID-19, we found a similarity in morbidity and mortality to that of historical controls. In-hospital survival was 87% and 9% required ICU admission. All patients had well controlled HIV infection except for 3 who had presented with AIDS. As the science regarding the management of COVID-19 evolves, larger scale studies are needed to better understand the prognosis of HIV patients who present with COVID. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. This article is protected by copyright. All rights reserved.

Vital Signs at Presentation (14) 44 ( 

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