COVID-19 Susceptibility and Outcomes Among People Living With HIV in San Francisco

Darpun Sachdev, MD; Elise Mara, MPH; Ling Hsu, MPH; Susan Scheer, PhD, MPH; George Rutherford, MD; Wayne Enanoria, PhD, MPH; Monica Gandhi, MD, MPH


J Acquir Immune Defic Syndr. 2021;86(1):19-21. 

In This Article

Abstract and Introduction


Introduction: Studies to examine whether HIV predisposes to a higher incidence of COVID-19 or more severe disease are accumulating. Initial studies from New York City suggested more severe disease among people living with HIV (PLWH), but this was during a time when hospitals were over-capacity and health systems stretched. This report presents the incidence and outcomes among PLWH with COVID-19 in San Francisco over the first 6 months of the pandemic.

Methods: Community transmission of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was first reported in San Francisco on March 5, 2020. This report examines the match of the San Francisco Department of Public Health COVID-19 testing database and the San Francisco Department of Public Health HIV Surveillance case registry from March 24, 2020, to September 3, 2020.

Results: Among 4252 COVID-19 tests performed among PLWH, 4.5% (N = 193) were positive for COVID-19, compared with a 3.5% (N = 9626) positivity rate among the 272,555 people without HIV tested for COVID-19 (P < 0.001). The mean age of those infected with HIV/COVID-19 was 48 years (20–76), 38.9% White, 38.3% Latinx, 11.9% Black, and 91.2% were men. Only 54.6% of coinfected PLWH were housed, with the remainder marginally housed. The rate of severe illness with COVID-19 was not increased among PLWH.

Discussion: In San Francisco, susceptibility to COVID-19 was increased among PLWH over the first 6 months of the pandemic, although clinical outcomes were similar to those without HIV. Homelessness and higher rates of congregate living situations among PLWH likely accounted for this disparity. Special efforts to house patients with marginal housing during the COVID-19 pandemic are needed.


Data are accumulating regarding the impact of HIV infection on either susceptibility to COVID-19 infection or disease severity. There are reasons to think that people living with HIV (PLWH) may be more susceptible to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in urban centers in congregate living situations where social distancing is more difficult to achieve. In San Francisco, PLWH have higher rates of unstable housing at 8.0% compared with 1.0% among the general San Francisco population,[1] with subsequently higher rates of living in single residency occupancy hotels, shelters, or tent encampments. There are also reasons to consider why PLWH could have more severe manifestations of COVID-19 than those without HIV. There is a higher rate of comorbidities among PLWH than those without HIV that predispose to severe COVID-19, including pulmonary disease,[2] cardiovascular disease,[3] and smoking.[4] Moreover, nearly half of the PLWH in the United States (and 67% of PLWH in the city of San Francisco)[1] are over 50 years old.

On the other hand, there is speculation that tenofovir-based antiretroviral therapy (ART) could protect PLWH from COVID-19 infection or severe disease. Because the phosphorylated forms of both tenofovir disoproxil fumarate (TDF) and tenofovir alafenamide (TAF) have in vitro activity against the SARS-CoV-2 RNA-dependent RNA polymerase,[5] analogous to remdesivir, tenofovir could modulate SARS-CoV-2 susceptibility or disease. A recent cohort study of PLWH diagnosed with COVID-19 in Spain demonstrated less severe disease among patients on TDF-based regimens,[6] although channeling bias could not be ruled out (with healthier patients put on TDF), especially because the same association was not seen with TAF-based ART. A randomized controlled trial to ascertain whether TDF/emtricitabine protects health care workers from contracting SARS-CoV-2 in Spain is ongoing.[7]

Initial case series describing HIV/COVID-19 coinfections to date were small, with reports from New York City[8] and Italy[9] showing more severe outcomes of COVID-19 among PLWH. The largest studies to date on HIV/COVID-19 coinfection are from the Veterans Aging Cohort Study (VACS),[10] the above-mentioned cohort study from Spain,[6] and a larger cohort from Western Cape Town, South Africa.[11] In the VACS, outcomes were compared between PLWH and COVID-19 (n = 253), PLWH and no COVID-19 (n = 2346), HIV-uninfected persons with COVID-19 (n = 504), and HIV-uninfected persons without COVID-19 (n = 4473).[10] HIV did not increase susceptibility to SARS-CoV-2 infection, nor incidence of severe COVID-19 disease, although PLWH were more likely to be tested for COVID-19 than those without HIV.[7] In South Africa, PLWH who contracted SARS-CoV-2 (n = 3978) died at 2.39 times the rate of patients without HIV without COVID-19, although HIV was a minor risk factor for severe COVID-19 compared with typical comorbidities associated with severe COVID-19 (age, diabetes, and cardiopulmonary disease), even in this setting of high HIV prevalence.[11] And, finally, in a recent cohort study from Spain, COVID-19 occurred at a higher incidence among PLWH (n = 236) but was not associated with more severe disease.[6] This study examines the incidence of COVID-19 infection and outcomes among PLWH across San Francisco over the 6 months after community transmission was reported in the city.