COVID-19 Testing, Characteristics, and Outcomes Among People Living With HIV in an Integrated Health System

Jennifer J. Chang, MD; Katia Bruxvoort, PhD; Lie H. Chen, DrPH; Bobak Akhavan, MD; Janelle Rodriguez, MD; Rulin C. Hechter, PhD


J Acquir Immune Defic Syndr. 2021;88(1):1-5. 

In This Article


In this population of patients with well-controlled HIV, the incidence of COVID-19, hospitalization, and need for ICU level care as a measure of severity was higher in PLWH than in HIV-uninfected individuals. Comorbidities did not differ significantly between PLWH and HIV-uninfected populations, although PLWH were significantly younger than HIV-uninfected patients with COVID-19.

We found a higher incidence of testing ordered for PLWH (551 per 10,000 patients) than that for HIV-uninfected patients (268 per 10,000 patients). This may be attributed to PLWH being designated as a potential risk group at KPSC during the study period, where prioritization for testing was given to patients in vulnerable populations, including HIV, organ transplantation, pregnancy, malignancy, or elderly populations. Of note, because of national and local limitations in testing capacity, testing policies at KPSC during this period restricted laboratory testing to symptomatic patients at highest risk of hospitalization. Most of the asymptomatic patients were not evaluated for infection during the study period.

Incidence of COVID-19 disease in this study was 57.0 per 10,000 PLWH and 34.6 per 10,000 HIV-uninfected individuals or a 1.6-times higher incidence of COVID-19 in PLWH. It is possible that COVID-19 was underdiagnosed in HIV-uninfected populations because mildly symptomatic patients who were HIV-uninfected without other risk may not have been tested in the early months of the pandemic to conserve testing supplies and prioritize testing for critically ill patients. In addition, a higher incidence of COVID-19 disease in PLWH may also have been attributed to home, community, or occupational risk factors not examined in the HIV-uninfected population.

PLWH in general experience a greater risk of multiple comorbidities associated with aging than HIV-uninfected patients.[20] In our study, prevalence of comorbidities was similar between groups in both hospitalized and nonhospitalized patients perhaps because a greater proportion of HIV-uninfected patients were older than PLWH. In addition, obesity is a significant risk factor of poorer outcomes associated with COVID-19.[4] PLWH in this sample were significantly less obese than HIV-uninfected patients (Table 2), which may have been a protective factor.

Our study had several strengths and limitations. We used population-level data for PLWH and HIV-uninfected individuals in a large integrated health care system to assess the incidence of testing, diagnosis, and hospitalization outcomes for COVID-19. Data were inclusive of patients who exhibited mild illness and did not require hospitalization, which adds to literature describing case series of hospitalized patients with HIV.[7,9,10,13,14,16,17,21]

Analyses were limited by relatively small numbers of PLWH with COVID-19 during the early months of the pandemic. In addition, 4 cases in PLWH with COVID-19 were excluded of an initial 61 identified by ICD-10 diagnostic codes and laboratory results because of incorrect diagnoses. We were unable to manually review all cases of clinically diagnosed COVID-19 in HIV-uninfected patients, potentially overestimating the incidence of diagnosis in HIV-uninfected patients.

In the United States, only 62.7% of all PLWH are virally suppressed, as defined by an HIV viral load of <200 copies/mL.[22] As such, our findings may not be generalizable to all PLWH because both hospitalized and nonhospitalized PLWH in our study exhibited >95% virologic suppression, with very few cases where CD4+ counts were ≤200 cells/mm3.

In this cohort of PLWH with largely well-controlled HIV, we found that both incidence of testing and incidence of diagnosed COVID-19 were higher in PLWH than in HIV-uninfected patients. Hospitalizations were observed to be proportionally higher in PLWH than in HIV-uninfected patients in our study sample.