key: cord-0934645-tddwdisb
authors: Hedberg, Pontus; Vesterbacka, Jan; Blennow, Ola; Missailidis, Catharina; Nowak, Piotr; Naucler, Pontus
title: Incidence and severity of COVID‐19 in adults with and without HIV diagnosis
date: 2022-03-21
journal: J Intern Med
DOI: 10.1111/joim.13481
sha: a4c79bb4527f7ffb8a5178c80b0cb067a237b6e7
doc_id: 934645
cord_uid: tddwdisb

nan

Dear Editor, Previous reports have indicated that HIV infection is associated with worse COVID-19 related outcomes [1] [2] [3] and that certain subpopulations among persons living with HIV (PLH) might be at a higher risk of severe COVID-19 [4] . In this registerand population-based cohort study, we analyzed the incidence and severity of COVID-19 from 1 March 2020 to 31 August 2021 in individuals >18 years living with and without HIV in Stockholm, Sweden. Furthermore, we compared demographics, comorbidities, and characteristics of HIV infection in PLH not hospitalized and hospitalized with COVID-19. Cohort definitions, data sources, study variables, and statistical analyses are presented in the supplement.

Out of 1,728,069 individuals ≥18 years in Region Stockholm, 3209 were PLH. Demographics and comorbidities of the general population and PLH are presented in Table S2 . Among individuals living with and without HIV, the median age was 51 (interquartile range [IQR] 43-59) and 47 (IQR 33-63) years, and 51% and 42% had any risk factor for severe COVID-19, respectively. The cumulative incidence of COVID-19 by 31 August 2021 was 12% for both individuals living with and without HIV (Fig. S1 ).

Among 207,646 individuals with COVID-19 during the study period, 364 (0.2%) were PLH. For each PLH, up to 10 individuals without diagnosed HIV were randomly selected, matching on the month of positive SARS-CoV-2 test, sex, age, and the number of comorbidity risk factors for severe COVID-19. Baseline characteristics were balanced between PLH and the 3587 matched controls, except chronic kidney disease (PLH 4%, controls 2%, standardized mean difference [SMD] = 0.13) and substance use disorders (PLH 10%, controls 4%, SMD = 0.26) being more common in PLH and asthma being more common in controls (PLH 5%, controls 7%, SMD = 0.11) ( Table 1) . Among PLH and controls, 9% and 10% were hospi-talized with COVID-19 without intensive care unit (ICU) treatment, and 3% and 2% were hospitalized with COVID-19 with ICU treatment, respectively. The 30-day all-cause mortality was 2% for PLH and 1% for controls. Compared to controls, the adjusted odds ratios (aOR) for COVID-19 hospitalization without ICU treatment, with ICU treatment, and 30-day all-cause mortality in PLH were 0.97 (95% confidence interval (CI) 0.67-1.38), 1.51 (95% CI 0.68-3.14), and 1.26 (95% CI 0.45-3.03), respectively.

Among PLH with COVID-19, a total of 43 persons were hospitalized and 321 not hospitalized, with median ages of 59 years (IQR 55-67) and 48 years (IQR 41-56), respectively (Table S3) . Among hospitalized and not hospitalized individuals, 16% and 2% had >4 risk factors for severe COVID-19, respectively. Older age (50-64 and ≥65 years) was associated with hospitalization for COVID-19, compared to <50 years of age, aOR 4.76 (95% CI 1.93-13.58) and 9.76 (95% CI 3.28-31.87), respectively. Time since HIV diagnosis and initiation of antiretroviral treatment were similar among both groups, whereas hospitalized individuals more often used protease inhibitors (Table S4 ). The median CD4 count was 630 (IQR 480-800) in not hospitalized individuals and 510 (IQR 390-690) in hospitalized individuals (p-value = 0.04), whereas 6% and 8% had a detectable viral load. Twenty-three percent of hospitalized PLH were treated in the ICU, and the 30-day mortality was 5% compared to 1% among individuals not hospitalized with COVID-19.

In this study, the cumulative incidence of COVID-19 was similar in PLH and the general population. This observation is in line with previous studies from high-income settings, but substantial differences between populations with different demographic and socioeconomic distributions might occur [5] . HIV infection was not associated with COVID-19 hospitalization, and a relevant association between HIV infection and ICU admission or 30-day all-cause mortality could not Length of COVID-19 hospitalization 7 (3-14) 6 (3-11) 7 (3-13) -30-day all-cause mortality 4162 (2) 6 (2) 44 (1) -Note: PLH was, for this analysis, defined as individuals having a B20-B24 ICD-10 diagnosis registered any time up to the day of first positive SARS-CoV-2 test. Individuals having their first HIV diagnosis registered after the COVID-19 were excluded from this analysis (n = 3). Standardized mean differences (SMD) were used to assess cohort balance between PLH and matched controls. Continuous variables are presented as median (interquartile range) and categorical variables are presented as numbers (percentage). Abbreviations: COVID-19, coronavirus disease 2019; ICU, intensive care unit; IQR, interquartile range; PLH, people living with HIV; SMD, standardized mean differences. a The risk factors for severe COVID-19 were based on the Centers for Disease Control and Prevention description of medical conditions associated with higher risk for severe COVID-19; see Table S1 for a description of each condition.

be demonstrated nor excluded. Previous reports on the risk of severe outcomes in COVID-19 in PLH are conflicting, with different study designs and comparison groups precluding direct comparisons [6] .

Earlier studies have reported that older and frailer PLH with lower CD4+ counts and higher levels of HIV-viremia have a higher risk of severe COVID-19 [1, 7] . Herein, among PLH with COVID-19, hospitalized patients were older, had more comorbidities, lower CD4+ counts, and more often were on protease inhibitors. The overrepresentation of protease inhibitor treatment in our hospitalized individuals may be a reflection of the use of these drugs being more common in older PLH.

Limitations of the study include limited sample size, and lack of body mass index and COVID-19 vaccination data. A major strength of our study is the access to population-based data on comorbidities, drug prescriptions, and SARS-CoV-2 positive tests, facilitating the matching of PLH with controls.

In summary, our study indicates that in a cohort of well-treated PLH, HIV infection is not a risk factor for severe outcomes in COVID-19.

The work was supported by EuCARE and Region Stockholm. P. H. was supported by Karolinska Institutet (combined clinical studies and PhD training program). The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

The need for consent was waived by the Swedish Ethical Review Authority (Dnr 2018/1030-31, COVID-19 research amendment Dnr 2020-01385) since analyses are based on retrospectively collected data from the administrative health registry.

COVID-19 outcomes among persons living with or without diagnosed HIV infection in New York State

Associations between HIV infection and clinical spectrum of COVID-19: a population level analysis based on US National COVID Cohort Collaborative (N3C) data

HIV infection and COVID-19 death: a population-based cohort analysis of UK primary care data and linked national death registrations within the OpenSAFELY platform

Sociodemographic, clinical, and immunological factors associated with SARS-CoV-2 diagnosis and severe COVID-19 outcomes in people living with HIV: a retrospective cohort study

SARS-CoV-2 infection and coronavirus disease 2019 severity in persons with HIV on antiretroviral treatment

Epidemiology and outcomes of COVID-19 in HIV-infected individuals: a systematic review and meta-analysis

SARS-CoV-2 testing & positivity among persons with & without HIV in 6 US cohorts

Correspondence: Pontus Hedberg, Division of Infectious Diseases

None of the authors reports competing interests.

Pontus Naucler had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. All authors have read and approved the manuscript. Study concept and design: All authors Acquisition, analysis, or interpretation of data: PH, JV, PNo, Pna Drafting of the manuscript: PH, JV, CM, PNo, Pna Critical revision of the manuscript for important intellectual content: All authors Statistical analysis: PH

No data are available. Data from deidentified the administrative health registry are not freely available due to the protection of the personal integrity of the participants.

Additional Supporting Information may be found in the online version of this article:Supplementary Material. Cohort definitions, data sources, study variables, and statistical analyses.