Outcomes Among HIV-Positive Patients Hospitalized With COVID-19

Savannah Karmen-Tuohy, BS; Philip M. Carlucci, BS; Fainareti N. Zervou, MD; Ioannis M. Zacharioudakis, MD; Gabriel Rebick, MD; Elizabeth Klein, BS; Jenna Reich, BS; Simon Jones, PhD; Joseph Rahimian, MD

Disclosures

J Acquir Immune Defic Syndr. 2020;85(1):6-10. 

In This Article

Discussion

The impact of HIV coinfection on the clinical course of patients with COVID-19 has yet to be fully characterized. Overall, our findings suggest that HIV status did not significantly impact clinical outcomes in patients with SARS-CoV-2 infection. However, we did detect trends suggesting that outcomes may be worse in HIV-positive patients, as a greater percentage of HIV-positive patients required ICU level care, required mechanical ventilation, or died or were discharged to hospice, compared with the non-HIV cohort. A previous study investigating outcomes in all patients admitted to NYU Langone Health hospitals found that 28.1% of patients required mechanical ventilation, and 18.5% were discharged to hospice or died.[7] In our study, both cohorts had a lower rate of mechanical ventilation (23.8% of HIV-positive patients and 11.9% of non-HIV patients) and a higher rate of mortality (28.6% of HIV-positive patients and 23.8% of non-HIV patients), as compared to data from the larger study of all patients hospitalized at NYU Langone Health. In addition, a recent study reporting outcomes among patients in New York City found a 21% mortality rate for hospitalized patients, whereas a study from China reported a 28% mortality rate among hospitalized patients,[1,8] contributing to a wide range of published mortality data. The mortality rate of both cohorts in this study falls within this established range, and further investigation is merited into the impact of HIV coinfection on COVID-19 outcomes.

As reported in Table 1, Supplemental Digital Content,http://links.lww.com/QAI/B494, there was a trend toward a greater percentage of African American patients in the HIV-positive cohort, compared with the non-HIV cohort. In further analysis, none of the African American patients in either group died. These data suggest that the nonsignificant difference in the percentage of African American patients between cohorts did not have a significant effect on the mortality data presented.

T-cell subset labs were drawn for HIV-positive patients before admission or on admission, and patients did not have these tests repeated during their hospital course. No patient in the non-HIV cohort had T-cell subset labs performed. Data from Wuhan, China, suggest that patients with COVID infection demonstrate a drop in lymphocytes, specifically CD4 T cells, a finding that is more prevalent in patients with severe disease.[9] At the time of our data collection, it was not routine practice to perform T-cell subset labs on non-HIV patients in our hospitals, and, as such, none of the patients in the non-HIV had these labs performed. Further investigation into the impact of COVID infection on T-lymphocyte levels, specifically CD4 cells, is needed in both HIV and non-HIV patients.

We found an increased frequency of chest x-ray abnormalities on admission imaging in HIV-positive patients, and this trend persisted throughout the course of hospitalization. A previous study reported up to 84% of patients with COVID-19 present with abnormal chest x-rays on admission, an incidence similar to the HIV-positive cohort in our study.[10] Admission x-ray was not a reliable indicator of illness severity in HIV-positive patients, a similar finding to what has been reported in the general population.[10]

In this cohort, 4 patients were clinically treated for superimposed bacterial infection based on positive sputum culture results, 3 of whom were HIV-positive. All 3 HIV-positive patients with bacterial superinfection died in the hospital. Existing data highlight the higher incidence of bacterial pneumonias in HIV-positive patients compared with the general population, in addition to the significant mortality burden of non-AIDS bacterial infections in this population.[11–15] Risk factors associated with contracting severe non-AIDS bacterial infections include immunosuppression and a history of cancer and diabetes, comorbidities that have also been associated with worse prognosis in SARS-CoV-2 infection.[2,8,16] This study was not powered to conclude that superimposed bacterial infections were a predictor of mortality in HIV-positive patients with SARS-CoV-2 infection. However, all HIV-positive patients with a bacterial pneumonia died, and this finding should be considered when making clinical decisions about these patients. Future studies should investigate whether SARS-CoV-2 infection increases the risk of secondary bacterial infection in similar patients and whether bacterial pneumonia might serve as a predictor of mortality in the HIV-positive population.

All HIV-positive patients in the study were on highly active antiretroviral therapy before hospital admission, and only 1 patient in the HIV-positive cohort had both a CD4 count less than 200/μL and a viral load greater than 50 copies/mL. Therefore, these findings may not apply to a population with poorly controlled HIV or AIDS. Only one patient was taking a protease inhibitor, a class of drugs under investigation for potential therapeutic benefit in COVID-19 treatment.[17] Given the lack of data in our cohort, we are unable to comment on the clinical impact of protease inhibitor use in HIV-positive patients with SARS-CoV-2 infection. This was a retrospective study that is susceptible to confounding variables, and our limited sample size prevented us from detecting small differences among groups. Larger prospective studies should examine the impact of poorly controlled HIV on the SARS-CoV-2 clinical course. Taken together, our findings are reassuring that HIV-positive patients may not experience significantly worse outcomes in SARS-CoV-2 infection, as compared to matched non-HIV patients.

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