HIV Infection Prevalence Significantly Intersects With COVID-19 Infection at the Area Level

A US County-Level Analysis

Hui Luan, PhD; Insang Song, MA; David A. Fiellin, MD; Yusuf Ransome, DrPH


J Acquir Immune Defic Syndr. 2021;88(2):125-131. 

In This Article

Abstract and Introduction


Background: Limited empirical evidence exists about the extent to which the current HIV epidemic intersects with COVID-19 infections at the area/geographic level. Moreover, little is known about how demographic, social, economic, behavioral, and clinical determinants are jointly associated with these infectious diseases.

Setting: Contiguous US counties (N = 3108).

Methods: We conducted a cross-sectional analysis and investigated the joint association between new HIV infection prevalence in 2018 and COVID-19 infections (January 22, 2020 and October 7, 2020) and explore the contribution of factors such as income inequality, binge drinking, and socioeconomic deprivation. We used Bayesian multivariate spatial models to estimate the cross-disease correlations between these diseases and identified hotspots, which we defined as a county with a posterior probability greater than 80% of being in the top decile of that disease.

Results: New HIV infection prevalence and COVID-19 infection moderately and significantly intersect [spatial correlation = 0.37, 95% credible interval (CrI) = 0.36–0.37]. Seventy-five counties, mostly in the south, were at elevated burden for HIV and COVID-19 infections. Higher income inequality was positively associated with both COVID-19 (relative risk 1.05, 95% CrI = 1.03–1.07) and HIV infection (relative risk = 1.12, 95% CrI = 1.09–1.15).

Conclusions: We found that there is a considerable intersection between the current distribution of HIV burden with COVID-19 infections at the area level. We identified areas that federal funding and vaccination campaigns should prioritize for prevention and care efforts.


Addressing the intersecting epidemics of COVID-19 and HIV infection has emerged as a global priority. The preponderance of studies thus far has focused on the biological or psychological effects and implications of COVID-19 infections for individual-level biomedical prevention among people with HIV (PWH).[1] Some studies have reported excess risk for COVID-19 infection and mortality in the presence of an HIV infection among adults.[2] However, these results have been mixed. Some findings indicate that PWH who had interruptions in taking antiretroviral therapy as prescribed are more vulnerable to COVID-19 infection because their immunity will have been compromised because of an uncontrolled HIV viral load.[3] However, some studies show no difference in COVID-19 severity between the HIV-positive and HIV-negative population[4,5] or PWH who have their HIV suppressed to undetectable levels have similar risk of COVID-19 infection and severity as those who are not HIV-positive.[3]

Beyond biological plausibility, the susceptibility to COVID-19 infection among PWH is related to distributions of social determinants, including higher rates of housing insecurity and congregate living and employment interruptions, which affected people's availability to access treatment and afford their medications. COVID-19 also affected population health through shifting demand on the health systems where hospital beds, diagnostic screening capacities, and other policies diverted funding away from diseases such as cancer and HIV to COVID-19.[6]

At the individual level, COVID-19 infection and HIV infection are influenced by similar risk behaviors such as substance use,[7] which compromises one's immunological state.[8]

To date, however, there is less published empirical evidence about how the HIV epidemic intersects with the COVID-19 pandemic at the area level. Moreover, it is unknown how demographic, social, economic, behavioral, and clinical determinants underlie the joint distribution of these diseases. When one considers geography, we know that the burden of COVID-19 infection and mortality is concentrated among communities with a high proportion of people of color.[9,10] Social epidemiology studies have shown that higher risk of infection and poorer prognosis of disease burden (whether COVID-19 or HIV infection) cannot be adequately explained by compositional attributes such as biological differences or risk behaviors of individuals residing in those areas.[11–14] Rather, higher burden of disease and disparities across COVID-19 and HIV infection are shaped by the inequitable distribution of socioeconomic resources[15–18] and other vulnerability-related determinants[19,20] such as environmental health hazards, violence, poorer access to care, and other trauma-causing exposures.[6,21,22]

In this analysis, we quantified the extent of coclustering between these 2 diseases at the area level. We then quantify the extent that demographic, social, economic, and environmental factors are related to both. The vast disparities and persistence of the COVID-19 pandemic and HIV epidemic necessitates ecological analysis like these that potentially inform COVID-19 vaccination distribution and identify regions of greatest need for Ending the HIV Epidemic interventions.[23]