key: cord-0924513-zs0onz4s
authors: Swaminathan, Neeraja; Moussa, Peter; Mody, Nidhi; Lo, Kevin B.; Patarroyo‐Aponte, Gabriel
title: COVID‐19 in HIV‐infected patients: A case series and literature review
date: 2020-12-01
journal: J Med Virol
DOI: 10.1002/jmv.26671
sha: 0e46b735fdd896beb0c7e338bcba6acaec2b93a4
doc_id: 924513
cord_uid: zs0onz4s

During the current COVID pandemic, there is growing interest to identify subsets of the population that may be at a higher than average risk of infection. One such group includes people living with HIV.

During the current COVID pandemic, there is a growing interest to identify subsets of the population that may be at a higher than average risk of infection. One such group includes people living with HIV (PLWH). While immune deficiency could increase the risk of acquiring viral infections, reports suggest that defective cellular immunity could paradoxically bode better outcomes in COVIDassociated cytokine dysregulation. Furthermore, antiretroviral drugs (protease inhibitors [PIs] ), are being tested as a therapeutic option owing to their potential to inhibit the 3-chymotrypsin-like protease of COVID. [1] [2] [3] This case series reviews the clinical and laboratory characteristics of COVID in PLWH admitted to a community hospital.

COVID in PLWH raises certain unique concerns because older PLWH have a higher risk of comorbidities compared with uninfected individuals of the same age, while younger PLWH are more likely to be noncompliant with antiretroviral therapy (ART), thereby leading to reduced HIV viral suppression. 4 It may also multiply pre-existent issues in PLWH, such as access and adherence to ART, mental health burden, substance use, food insecurity, and so forth. 4 While social isolation slows the spread of COVID, its implications on the abovementioned issues remains to be seen. Socioeconomic and ethnic disparities can affect clinical outcomes and there is a need for more data to make any definitive conclusions. 4 In one patient, ART was discontinued as per the discretion of the supervising physician; others were continued on their home ART regimen. The mean CD4 count was 765, with only one patient having a detectable viral load. The distribution of COVID severity was one mild, three moderate, one severe, and one critical. Two patients expired due to post-cardiac arrest syndrome and worsening hypoxic respiratory failure, respectively. Of the remaining four, two required supplemental oxygen during admission and the other two did not.

One patient was discharged on home-oxygen. The average duration of hospitalization was 7.5 days. Other clinical/diagnostic findings are in Tables 1-3. Our case series was set in a community hospital in Philadelphia from March to April 2020 and this period was picked because it had a rapid increase in COVID cases. To date, Philadelphia has had approximately 25,000 cases and 1500 deaths, with a peak of 603 new cases in a single day on April 15, 2020. 5 With regard to impact in immunosuppression/immunodeficiency, a systematic review demonstrated that both had increased severity of COVID illness, 3.29-and 1.55-fold, respectively, but this difference was not statistically significant. 6 With regard to HIV, Table 4 summarizes the available evidence. [1] [2] [3] [7] [8] [9] [10] [11] Available data does not point to HIV being an independent risk factor for poor prognosis in COVID but PLWH are at a higher risk for the noncommunicable comorbidities that are associated with worse clinical outcomes. 4 In our case series, we noted that the two patients who died had more medical comorbidities. These two patients also had elevated procalcitonin. Although both received broad-spectrum antibiotics, there was no growth in their blood/ sputum cultures. Hence, it is difficult to assess if they truly had a superadded bacterial infection making them sicker or if it was a nonspecific finding.

Richardson et al. 15 looked at an exclusive inpatient COVID population in New York and found that mortality was 21% overall but as high as 88% in critically ill patients with underlying comorbidities.

COVID mortality in PLWH has been noted to be highly variable, ranging anywhere from 3% to 77%. [1] [2] [3] [7] [8] [9] [10] [11] This variability is due to the heterogeneity of the patients studied, differing in key elements, such as inpatients/outpatients, age group, and baseline characteristics. In our case series, limited to inpatients, the mortality rate was 33%, which seems higher than the average of 20%-21% but this should be interpreted with caution as both the patients that died required significant ventilatory support and had more comorbidities.

The mean age in our case series (64 years) was notably higher than that described in the aforementioned studies, 1-3,7-11 which ranged from 38 to 60 years. When adjusted for higher mean age, severity of illness, and ventilator needs, the mortality rate in our case series is comparable with other studies.

Contrary to the concern for worse outcomes in HIV, some data suggest favorable outcomes for COVID in PLWH, perhaps due to the protective effect of ART. 1 However, PIs (lopinavirritonavir, darunavir) tested in clinical trials did not show increased efficacy compared with standard supportive care. Current guidelines do not recommend any change in ART to boosted PI-containing regimen. 7 In vitro studies show that remdesivir was the most effective against COVID when compared against medications like tenofovir, lamivudine, emtricitabine, and so forth.

Tenofovir though has anti-RNA-dependent RNA polymerase activity akin to remdesivir and hence its protective effect cannot entirely be ruled out. 1, 8 Despite the largely reassuring data regarding COVID in PLWH in terms of disease severity and mortality, there are many aspects

that are yet to be studied. Some data demonstrates that there is a more pronounced decline of CD4 count in the PLWH population with severe COVID and that the lymphopenia can take several weeks to return to baseline. It is unclear if this translates into an increased risk of opportunistic infections and need to be studied. 3 Studying these long-term effects is challenging, given the 

Clinical features and outcomes of HIV patients with coronavirus disease 2019

COVID in patients with HIV: clinical case series

COVID in people living with human immunodeficiency virus: a case series of 33 patient

People living with HIV: a syndemic perspective

Testing and data: Department of Public Health

Impacts of immunosuppression and immunodeficiency on COVID: a systematic review and metaanalysis

A trial of lopinavir-ritonavir in adults hospitalized with severe COVID

Comparative antiviral activity of remdesivir and anti-HIV nucleoside analogs against human coronavirus 229E (HCoV-229E)

Interim guidance for COVID and persons with HIV

HIV/ SARS-CoV-2 coinfected patients in Istanbul, Turkey

Clinical features and outcome of HIV/ SARS-CoV-2 coinfected patients in The Bronx

Outcomes among HIV-positive patients hospitalized with COVID-19

Clinical characteristics and outcomes in people living with HIV hospitalized for COVID-19

Description of COVID-19 in HIV-infected individuals: a single-centre, prospective cohort

Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID in the New York City area

This case series shows that despite a higher mean age and all our patients having at least one other medical illness, the morbidity and mortality were comparable to other previously conducted studies.The limitation of this study is that it is a single-center retrospective analysis and bigger prospective studies with longer follow-up are needed to assess the effect of HIV and ART in COVID and also look at its other long-term sequelae.

http://orcid.org/0000-0002-9043-0420Peter Moussa http://orcid.org/0000-0001-6885-7551