Racial/Ethnic and Income Disparities in the Prevalence of Comorbidities That Are Associated With Risk for Severe COVID-19 Among Adults Receiving HIV Care, United States, 2014–2019

John K. Weiser, MD, MPH; Yunfeng Tie, PhD; Linda Beer, PhD; Robyn Neblett Fanfair, MD, MPH; Roy Luke Shouse, MD, MPH


J Acquir Immune Defic Syndr. 2021;86(3):297-304. 

In This Article


Contrary to the early prediction that COVID-19 would be "the great equalizer,"[1] the disease burden in the United States falls disproportionately on non-Hispanic Blacks or African Americans (Blacks), Hispanics or Latinos of any race (Hispanics), people with low income, and those with certain chronic illnesses.

Relative to their proportion of the US population, Blacks and Hispanics have higher COVID-19 attack rates and hospitalization rates, and Blacks have higher death rates than non-Hispanic Whites (Whites).[2–9] Blacks constitute 13% of the US population but accounted for 16% of COVID-19 cases and 20% of COVID-19 deaths, as of November 15, 2020.[9] Hispanics, at 18% of the population, accounted for 26% of cases and 16% of deaths nationwide. Among those with diagnosed COVID-19, Blacks and people with low income are more likely to have severe illness and die.[10–13] Among people with HIV, those who are Black or Hispanic, or have low income, are also disproportionately affected by COVID-19.[14,15]

In addition to these sociodemographic risk factors, several chronic health conditions increase the risk of COVID-19 requiring hospitalization, eg, obesity, chronic kidney disease (CKD), type 2 diabetes, chronic obstructive pulmonary disease (COPD), immunocompromised state from solid organ transplantation, heart disease, and sickle cell disease.[13,16] Hospitalizations are 6 times higher and deaths 12 times higher for people with underlying illnesses.[7]

Although the Centers for Disease Control and Prevention (CDC) lists an immunocompromised state due to HIV as a condition that might increase the risk for severe illness from COVID-19,[16] the available literature in North America and Europe suggests that HIV, in itself, does not increase the risk of SARS-CoV-2 infection or severe illness.[17–22] However, several studies have found that most people with diagnosed HIV and COVID-19 have other comorbidities,[14,15,17,20,23] suggesting these conditions, rather than HIV, may be the driver of severe illness in this population.

With HIV, as with COVID-19, Blacks, Hispanics, and people with low income bear a disproportionate burden of disease in the United States.[24] Compared with Whites, the prevalence of HIV in 2018 was 7.2 times higher among Blacks and 3.0 times higher among Hispanics.[25] Among those with recent HIV infection, 42% were Black and 28% Hispanic. Blacks and Hispanics have poorer outcomes than Whites at all stages of the HIV care continuum, including linkage to HIV care, retention in care, and viral suppression.[26] HIV is also a disease of poverty. Among adults with diagnosed HIV, 43% had a household income below the poverty threshold and one in 5 went without food during the past year because of lack of money.[27]

The burden of poor health outcomes from HIV in heavily affected communities may be compounded by similar patterns in the distribution of COVID-19 and by disparities in the prevalence of comorbidities associated with an increased risk for severe illness from COVID-19 among people with HIV.[28] To examine the prevalence of these comorbidities among people with HIV, we analyzed HIV surveillance data on adults receiving HIV care to determine the percentage with ≥1 diagnosed comorbidity and assessed differences by race/ethnicity, income level, and health insurance type.