Risk of Adverse Coronavirus Disease 2019 Outcomes for People Living With HIV

Maya M. Mellor; Anne C. Bast; Nicholas R. Jones; Nia W. Roberts; José M. Ordóñez-Mena; Alastair J.M. Reith; Christopher C. Butler; Philippa C. Matthews; Jienchi Dorward


AIDS. 2021;35(4):F1-F10. 

In This Article

Abstract and Introduction


Objective: To assess whether people living with HIV (PLWH) are at increased risk of coronavirus disease 2019 (COVID-19) mortality or adverse outcomes, and whether antiretroviral therapy (ART) influences this risk.

Design: Rapid review with meta-analysis and narrative synthesis.

Methods: We searched databases including Embase, Medline, medRxiv and Google Scholar up to 26 August 2020 for studies describing COVID-19 outcomes in PLWH and conducted a meta-analysis of higher quality studies.

Results: We identified 1908 studies and included 19 in the review. In a meta-analysis of five studies, PLWH had a higher risk of COVID-19 mortality [hazard ratio 1.95, 95% confidence interval (CI): 1.62–2.34] compared with people without HIV. Risk of death remained elevated for PLWH in a subgroup analysis of hospitalized cohorts (hazard ratio 1.60, 95% CI: 1.12–2.27) and studies of PLWH across all settings (hazard ratio 2.08, 95% CI: 1.69–2.56). Eight other studies assessed the association between HIV and COVID-19 outcomes, but provided inconclusive, lower quality evidence due to potential confounding and selection bias. There were insufficient data on the effect of CD4+ T-cell count and HIV viral load on COVID-19 outcomes. Eleven studies reported COVID-19 outcomes by ART-regimen. In the two largest studies, tenofovir disoproxil fumarate-based regimens were associated with a lower risk of adverse COVID-19 outcomes, although these analyses are susceptible to confounding by co-morbidities.

Conclusion: Emerging evidence suggests a moderately increased risk of COVID-19 mortality among PLWH. Further investigation into the relationship between COVID-19 outcomes and CD4+ T-cell count, HIV viral load, ART and the use of tenofovir disoproxil fumarate is warranted.


By September 2020, over 30 million people worldwide had been diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).[1] Although SARS-CoV-2 infection may be asymptomatic or cause only mild symptoms, a proportion of people develop severe coronavirus disease 2019 (COVID-19), leading to hospitalization, acute respiratory distress syndrome or death. Established risk factors for severe COVID-19 among the general population include older age,[2] chronic kidney disease and obesity.[3]

People living with HIV (PLWH), who constitute approximately 0.5% of the global population,[4] may have an increased risk of adverse outcomes from COVID-19 as a result of HIV-associated immune dysfunction.[5] There may also be a higher prevalence of co-morbidities among PLWH that predispose to unfavourable COVID-19 outcomes.[6] Conversely, PLWH may have more favourable outcomes due to increased health awareness or close medical follow-up. Some antiretroviral agents are under consideration as potential treatments for COVID-19,[7] but the influence of antiretroviral therapy (ART) on COVID-19 outcomes is not known. In this rapid review, we aim to evaluate the evidence regarding the risk of adverse COVID-19 outcomes in PLWH, and the extent to which this risk is modified by other factors including ART.