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


More than one-third of adults receiving HIV care in the United States (37.9%) had ≥1 diagnosed comorbidity associated with an increased risk for severe illness from COVID-19. Those with low income or public insurance alone and Blacks (adjusting for age) with income either above or below the poverty threshold were more likely to have ≥1 diagnosed comorbidity.

To the best of our knowledge, these are the first population-based data exploring these issues among people with HIV. In the general adult population, based on data from the Behavioral Risk Factor Surveillance System, a slightly higher percent (40.7%) of adults reported having ≥1 of these comorbidities.[34] However, methodologic differences between the 2 surveys (self-reported data for the Behavioral Risk Factor Surveillance System and medical record review for the MMP) prevent direct comparison of the prevalence of comorbidities in the general population and people receiving HIV care.

Our finding that Blacks (but not Hispanics) receiving HIV care were more likely than Whites to have ≥1 diagnosed comorbidity is consistent with an analysis of surveillance data exploring racial/ethnic disparities in progression of COVID-19 from mild illness to hospitalization and death.[35] Holtgrave constructed a continuum of COVID-19 outcomes, modeled on the HIV care continuum,[36] and found that although infection rates were higher for Blacks and Hispanics than Whites, hospitalization rates (given infection) were higher for Blacks but not Hispanics. Together, our findings suggest that different interventions may be needed to build COVID-19 health equity in Black and Hispanic communities. Reducing the burden of severe illness from COVID-19 in both communities may require addressing factors related to exposure, eg, housing density, food and housing insecurity, dependence on public transportation, and reliance on front-line jobs that makes physical distancing difficult. To reduce burden in Black communities, structural changes to mitigate the higher prevalence of underlying health conditions may also be needed, including increased access to medical care and supportive services, healthy food options, and recreational spaces.[37,38] Findings from a study of 6916 patients with COVID-19 at the Kaiser Permanente of Southern California support this assumption.[39] In contrast to most population-based studies, the risk of death from COVID-19, once diagnosed, was comparable among Black and White adults, suggesting that equalized access to health care within an integrated health care system may mitigate the high COVID-19 case fatality rate among Blacks.

Although many of the structural barriers that underlie the higher prevalence of comorbidities among Blacks receiving HIV care are linked to poverty, we found a higher prevalence of comorbidities among Blacks with incomes above and below the poverty threshold, suggesting that factors in addition to poverty (eg, segregation and discrimination) may limit access to health services, health messaging, and healthy lifestyle options in Black communities.

The intersection of poverty with HIV and COVID-19 is complex. People with low income are at increased risk for acquiring and having poor outcomes from both illnesses, for many of the reasons discussed above. In turn, COVID-19 has caused unemployment and loss of employer-based health insurance for millions of Americans,[40] potentially weakened the health safety net,[41] and challenged recent efforts to end the HIV epidemic.[42] Interrupting the mutually reinforcing cycle of HIV, COVID-19, and poverty may require sustained economic support to prevent worsening of income and health disparities.

About half of US adults with HIV have Medicaid and/or Medicare as their only health insurance,[43] and this proportion may increase as people who lose employer-based insurance during the pandemic become newly eligible for Medicaid.[44] We found that adults receiving HIV care who had public insurance alone were more likely than those with private insurance to have ≥1 diagnosed comorbidity (43.4% vs. 33.1%), suggesting Medicare and Medicaid programs may bear increased responsibility as payers of care for adults with HIV at increased risk of severe illness from COVID-19. Conversely, we found that those whose only health coverage was RWHAP assistance were less likely than those with private insurance to have comorbidities, at least in part because they are, on average, younger than others.

Because a large proportion of patients receiving HIV care at Ryan White–funded facilities have social determinants associated with poor health outcomes,[45] we expected a higher percentage of patients at those facilities to have comorbidities. However, there was no difference, again at least in part, because RWHAP-funded facilities serve younger patients. However, any conclusion about the burden of severe illness from COVID-19 among patients receiving HIV care at RWHAP-funded facilities should be tempered by knowledge that Blacks and Hispanics, who comprise three-quarters of HIV patients at these facilities,[45] die from COVID-19 at younger ages than Whites.[8]