key: cord-1007552-igdgufav
authors: Collins, Lauren F
title: Persons with HIV and the COVID-19 Pandemic: A Viral Synergy of Biology and Sociology
date: 2020-11-08
journal: Clin Infect Dis
DOI: 10.1093/cid/ciaa1715
sha: cfa6b47fab6648e1e92b6c44d4bcd9ced64d29ab
doc_id: 1007552
cord_uid: igdgufav

nan

A c c e p t e d M a n u s c r i p t were nearly two decades younger, had fewer comorbidities, and included a significantly higher proportion of men and individuals of Black race. Age-adjusted 28-day mortality was higher among PWH compared with people without HIV (HR 1.47, 95% CI 1.01-2.14); and this effect persisted after adjusting for sex, race/ethnicity, the presence of 10 major comorbidities and A c c e p t e d M a n u s c r i p t other key variables. This large and timely study is an important contribution to the growing, somewhat conflicted, evidence base on COVID-19 outcomes among PWH.

In multiple early series from the United States (US) and Europe, the clinical outcomes of PWH with COVID-19 did not appear worse than those of the general population 4-10 . Among patients hospitalized for COVID-19 in New York City, including 88 PWH and >400 HIV-negative matched comparators (by age, sex, race/ethnicity and calendar week of infection), no differences were observed by HIV status in COVID-19 severity on admission, need for mechanical ventilation, or cumulative incidence of death 11 . Likewise, in a similarly matched analysis using data from the Veterans Aging Cohort Study, COVID-19 outcomes were comparable among patients with and without HIV 12 . On the contrary, among ~3.5 million patients in South Africa, HIV was associated with COVID-19 mortality (aHR 2.14, 95% CI 1.70-2.70) in models adjusted for age, sex, comorbidities and clinic location 13 . Data analyzed from the OPENSafely platform in the UK suggested that PWH had nearly 3-fold the risk of COVID-19 death than persons without HIV when age-and sex-adjusted; this finding was attenuated though remained significant after accounting for race/ethnicity and socioeconomic status 14 .

It is possible that traditional risk factors (age, comorbidities, social determinants of health) may influence COVID-19 disease severity and outcomes among PWH more so than HIV infection itself or HIV-related variables (degree of immunocompetency, viral suppression, ART regimen). In the general population, persons of older age and those with medical comorbidities are at greatest risk of severe illness from SARS-CoV-2 infection 15 . Other demographic factors, including male sex and non-white race, have been associated with a disproportionately high number of infections and deaths from COVID-19 in the US and the UK 15, 16 . Specifically, Black, Hispanic, and South Asian individuals appear to be most affected, likely related to underlying disparities in social determinants of health 16, 17 . Importantly, many of these demographics are common among PWH. In the US, it is estimated that more than half of PWH are aged ≥50 years A c c e p t e d M a n u s c r i p t old 18 . Further, aging PWH suffer from a high burden of non-AIDS comorbidities 19 including hypertension, diabetes, cardiovascular and lung disease, cancer and other chronic conditions associated with worse COVID-19 outcomes 5,6 . HIV disproportionately affects persons of racial and ethnic minorities and therefore the contribution of racial disparities in mediating COVID-19 incidence and outcomes may be exacerbated among PWH. The COVID-19 pandemic is catalyzing our long overdue need to better understand and eliminate drivers of health inequity, such as structural racism, unstable housing and food insecurity, not only for PWH but for all while Geretti et al primarily used time-to-event methods, a sensitivity analysis employing competing risk methods did not alter the main findings. Of importance, the investigators were not able to adjust for markers of health disparity (e.g. socioeconomic status) in multivariable analyses, nor was the potential for regional variability across the 207 centers explored. Both of these unmeasured factors, and others, may be associated with COVID-19 outcomes and findings should be interpreted in this context. HIV-specific indices including CD4 count and HIV viral load were not routinely collected as part of the ISARIC CCP and therefore not included in the description of COVID-19 presentation for this study.

In conclusion, this important population cohort study by Geretti et al suggests that COVID-19 mortality risk is higher among PWH than HIV-negative persons, in a region where the vast majority of PWH are virologically suppressed on ART. Additional study is needed to evaluate COVID-19 risk factors, clinical course and outcomes among diverse groups of PWH including those of varying clinical stability and residing in different geographic settings. Future investigations will be crucial in disentangling the effects of age, comorbidities, immune function, HIV virologic control, ART and social determinants of health on COVID-19 disease as well as vaccine and treatment uptake and responses. Finally, the impact of COVID-19 on our fight against the HIV/AIDS epidemic should be rigorously monitored, evaluated and intervened on so that we can conquer the challenges born of synergized pandemics and deliver accessible care, ART, health and wellbeing for all PWH.

UNAIDS. Global HIV & AIDS statistics -2020 fact sheet

What one pandemic can teach us in facing another

Outcomes of COVID-19 related hospitalization among people with HIV in the ISARIC WHO Clinical Characterization Protocol (UK): a prospective observational study

COVID-19 in patients with HIV: clinical case series

Clinical characteristics, comorbidities and outcomes among persons with HIV hospitalized with coronavirus disease

Disproportionate burden of coronavirus disease 2019 among racial minorities and those in congregate settings among a large cohort of people with HIV

Clinical features and outcomes of HIV patients with coronavirus disease 2019

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

SARS-CoV-2 and HIV coinfection: clinical experience from Rhode Island, United States

Incidence and Severity of COVID-19 in HIV-Positive Persons Receiving Antiretroviral Therapy : A Cohort Study

Covid-19 and People with HIV Infection: Outcomes for Hospitalized Patients

COVID-19 in the largest US HIV cohort

Risk factors for COVID-19 death in a population cohort study from the Western Cape Province, South Africa

HIV infection and COVID-19 death: population-based cohort

Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area

Factors associated with COVID-19-related death using OpenSAFELY

Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019 -COVID-NET, 14 States

Diagnoses of HIV infection in the United States and dependent areas

The Prevalence and Burden of Non-AIDS Comorbidities among Women living with or at-risk for HIV Infection in the United States

Comorbidities in Persons With HIV: The Lingering Challenge

Extrapulmonary manifestations of COVID-19

Clinical and immunological features of severe and moderate coronavirus disease 2019

M a n u s c r i p t Funding: L. F. C. is supported by the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH) (award numbers UL1TR002378 and KL2-TL1TR002381). This work was also supported by the Emory Center for AIDS Research (award number P30-AI-050409).A c c e p t e d M a n u s c r i p t