HIV Does Not Appear to Worsen COVID-19 Outcomes

Heather Boerner

July 02, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

People living with HIV who are admitted to the hospital with COVID-19 are no more likely to die than those without HIV, an analysis conducted in New York City shows. This is despite the fact that comorbidities associated with worse COVID-19 outcomes were more common in the HIV group.

"We don't see any signs that people with HIV should take extra precautions" to protect themselves from COVID-19, said Keith Sigel, MD, associate professor of medicine and infectious diseases at the Icahn School of Medicine at Mount Sinai in New York City, and the lead researcher on the study, published online June 28 in Clinical Infectious Diseases.

"We still don't have a great explanation for why we're seeing what we're seeing," he added. "But we're glad we're seeing it."

The findings have changed how Sigel talks to his patients with HIV about protecting themselves from COVID-19. Some patients have so curtailed their behavior for fear of acquiring COVID-19 that they aren't buying groceries or attending needed medical appointments. With these data, Sigel said he's comfortable telling his patients, "COVID-19 is bad all by itself, but you don't need to go crazy. Wear a mask, practice appropriate social distancing and hygiene, but your risk doesn't appear to be greater."

The findings conform with those on the lack of association between HIV and COVID-19 severity seen in a cohort study from Spain, a case study from China, and case series from New Jersey, New York City, and Spain.

One of the only regions reporting something different so far is South Africa. There, HIV is the third most common comorbidity associated with death from COVID-19, according to a cohort analysis conducted in the province of Western Cape.

The intersection of HIV and COVID-19 will be a major theme of the virtual International AIDS Society (IAS) Virtual Conference 2020. Along with data from HIV prevention and treatment trials, the conference will feature updates on where the world stands in the control of HIV during the COVID-19 pandemic. And for an even more focused look, the International AIDS Conference 2020 will immediately follow that meeting.

The New York City Cohort

For their study, Sigel and his colleagues examined the 4402 COVID-19 cases at the Mount Sinai Health System's five hospitals between March 12 and April 23.

They found 88 people with COVID-19 whose charts showed codes indicating they were living with HIV. All 88 were receiving treatment, and 81% of them had undetectable viral loads documented at COVID admission or in the 12 months prior to admission.

The median age was 61 years, and 40% of the cohort was black and 30% was Hispanic.

Patients in the comparison group — 405 people without HIV from the Veterans Aging Cohort Study who had been admitted to the hospital for COVID-19 — were matched in terms of age, race, and stage of COVID-19.

The study had an 80% power to detect a 15% increase in the absolute risk for death in people with COVID-19, with or without HIV.

Patients with HIV were almost three times as likely to have smoked and were more likely to have chronic obstructive pulmonary disease, cirrhosis, and a history of cancer.

"This was a group of patients that one might suspect would do worse," Sigel said. And yet, "we didn't see any difference in deaths. We didn't see any difference in respiratory failure."

In fact, people with HIV required mechanical ventilation less often than those without HIV (18% vs 23%). And when it came to mortality, one in five people died from COVID-19 during follow-up whether they had HIV or not (21% vs 20%).

The only factor associated with significantly worse outcomes was a history of organ transplantation, "suggesting that non-HIV causes of immunodeficiency may be more prominent risks for severe outcomes," Sigel and his colleagues explain.

A Surprise Association

What's more, the researchers found a slight association between the use of nucleoside reverse-transcriptase inhibitors (NRTI) by people with HIV and better outcomes in COVID-19. That echoes findings published last week in the Annals of Internal Medicine, which showed that people with HIV taking the combination of tenofovir disoproxil fumarate plus emtricitabine (Truvada, Gilead Sciences) were less likely to be diagnosed with COVID-19, less likely to be hospitalized, and less likely to die.

This has led some to wonder whether NRTIs have some effect on SARS-CoV-2, the virus that causes COVID-19. Sigel said he wonders that too, but right now, it's just musings.

"These studies are not even remotely designed" to show that NRTIs are protective against COVID-19, he explained. "Ours was extremely underpowered to detect that and there was a high potential for confounding."

"I'd be wary of any study in a subpopulation — which is what we're dealing with here — that is looking for signals of protection with certain medications," he added.

A "Modest" Increase

Using the South African data, released on June 22, public health officials estimate that people with HIV are 2.75 times more likely to die from COVID-19 than those without HIV, making it the third most common comorbidity in people who died from COVID-19, behind diabetes and hypertension. This held true regardless of whether the people with HIV were on treatment.

But when they looked at COVID-19 deaths in the sickest of the sick — those hospitalized with COVID-19 symptoms — HIV was associated with just a 28% increase in the risk for death. The South African researchers called this risk "modest."

"While these findings may overestimate the effect of HIV on COVID-19 death due to the presence of residual confounding, people living with HIV should be considered a high-risk group for COVID-19 management, with modestly elevated risk of poor outcomes, irrespective of viral suppression," they wrote.

HIV does not pop out. It's still social determinants of health. It's still underlying conditions. It's still age as a primary factor.

Epidemiologist Gregorio Millett has been tracking the effect of HIV on COVID-19 outcomes since the start of the pandemic in his role as vice president and head of policy at the American Foundation for AIDS Research (amFAR).

Back in April, he and his colleagues looked at rates of COVID-19 deaths and hospitalizations in counties with disproportionate levels of black residents. These areas often overlapped with the communities selected for the Ending the HIV Epidemic plan to control HIV by 2030. What they found was that there was more HIV and COVID-19 in those communities.

What they didn't find was that people with HIV in those communities had worse outcomes with COVID-19. This remained true even when they reran the analysis after the number of cases of COVID-19 in the United States surpassed 100,000. Those data have yet to be published, Millett reported.

"HIV does not pop out," he said. "It's still social determinants of health. It's still underlying conditions. It's still age as a primary factor."

"People living with HIV are mainly dying of underlying conditions — so all the things associated with COVID-19 — rather than the association being with HIV itself," he added.

Although he's not ruling out the possibility that an association like the one in South Africa could emerge, Millett, who will present a plenary on the context of the HIV epidemic at the AIDS 2020 conference, said he suspects we won't see one.

"If we didn't see an association with the counties that are disproportionately African American, in the black belt where we see high rates of HIV, particularly where we see the social determinants of health that definitely make a difference — if we're not seeing that association there, where we have a high proportion of African Americans who are at risk both for HIV and COVID-19 — I just don't think it's going to emerge," he said.

International AIDS Conference 2020.

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