Multicenter Study of Outcomes Among Persons With HIV Who Presented to US Emergency Departments With Suspected SARS-CoV-2

Christopher L. Bennett, MD, MA; Emmanuel Ogele, MD; Nicholas R. Pettit, DO, PhD; Jason J. Bischof, MD; Tong Meng, MPP; Prasanthi Govindarajan, MBBS, MAS; Carlos A. Camargo, Jr, MD, DrPH; Kristen Nordenholz, MD, MSC; Jeffrey A. Kline, MD

Disclosures

J Acquir Immune Defic Syndr. 2021;88(4):406-413. 

In This Article

Results

Patient Characteristics

We identified 415 patients from the RECOVER registry with HIV (1.6% of our data cut of the registry); 201 patients (48%) with HIV were found to have a polymerase chain reaction–confirmed SARS-CoV-2 infection. Characteristics of these patients stratified by SARS-CoV-2 and HIV infection status are presented in Table 1. Patients with both SARS-CoV-2 and HIV (compared with those with SARS-CoV-2 but without HIV) were more often male (76.1% versus 52.4%), more often identified as Black or African American (59.7% versus 34.8%), more often insured through either Medicaid or Medicare (70.1% versus 57.0%), and more often undomiciled (4.0% versus 1.1%). With some exceptions, such as cancer (13.4% versus 6.8%) and some types of substance use [eg, tobacco (20.9% versus 7.1%), marijuana (5.5% versus 1.6%), or methamphetamine (3.0% versus 0.3%)], the medical and substance use histories of the 2 populations were similar.

Patients who were SARS-CoV-2 negative but HIV-positive (compared with patients with neither SARS-CoV-2 nor HIV infections) were more often male (74.3% versus 45.5%), more often identified as Black or African American (44.9% versus 22.3%), more often insured through either Medicaid or Medicare (59.3% versus 48.7%), and more often undomiciled (15.0% versus 4.2%). Again, with some exceptions, such as some types of substance use [eg, tobacco (43.0% versus 23.3%), cocaine use (7.5% versus 2.3%), and marijuana (18.2% versus 7.2%)], the medical and substance use histories of the 2 populations were similar (Table 1).

Risk Factors and Presenting Symptoms

Patient's self-reported risk factors for infection, presenting symptoms, and days since symptom onset (stratified by SARS-CoV-2 and HIV infection status) are presented in Table 2. With a few exceptions [eg, patients with both SARS-CoV-2 and HIV infections, compared with patients with SARS-CoV-2 but without HIV infection, less often had exposure to SARS-CoV-2 from nursing homes (1.5% versus 8%) but were more likely to report abdominal pain (44.8% versus 35.1%) or chest pain (53.2% versus 42.4%)], self-reported risk factors and presenting symptoms were similar across the strata. Furthermore, days since symptom onset were similar across the strata (a median of 4 days of symptoms for both HIV-positive and HIV-negative patients with SARS-CoV-2 infections and a median of 3 days of symptoms for both HIV-positive and HIV-negative patients without SARS-CoV-2 infections, Table 2.

Clinical Outcomes

Clinical characteristics of patients on arrival to the ED along with hospitalization characteristics (if admitted) are presented in Table 3 stratified by SARS-CoV-2 and HIV status. Patients with both SARS-CoV-2 and HIV (compared with patients with SARS-CoV-2 but without HIV) had similar ED triage vitals (eg, median oxygen saturations on arrival of 96% and 93%, P = 0.48) and admission rates (62.7% versus 58.6%, P = 0.24); those who were admitted also had similar hospitalization characteristics [eg, 5.0% versus 6.3% (P = 0.45) were admitted to the intensive care unit from the ED and 10% versus 13.3% (P = 0.17) required respiratory support with intubation] and rates of death (13.9% versus 15.1%, P = 0.65). Furthermore, among the subgroups of patients with SARS-CoV-2 who died, those who died did so at similar times [death occurred a median number of 11.5 days (HIV-positive) versus 8 days (HIV-negative) from the initial ED visit, P = 0.57]. Patients without SARS-CoV-2 but with HIV (compared with patients without either SARS-CoV-2 or HIV) had similar ED triage vitals and, for the subpopulation admitted, similar hospitalization characteristics and outcomes (Table 3).

Comparison of Patients With HIV Stratified by SARS-CoV-2 Infection Status

Information specific to the subpopulation of patients with HIV (both with and without SARS-CoV-2 infections) is presented in the Supplemental Table, Supplemental Digital Content, http://links.lww.com/QAI/B720. Patients with both HIV and SARS-CoV-2 infections (compared with patients with HIV but without SAR-CoV-2) were older (median ages of 57 versus 50 years, P < 0.001), more often identified as Black or African American (59.7% versus 44.9%, P < 0.01) but were less often undomiciled (4% versus 15%, P < 0.001). Furthermore, these patients were more often admitted to the hospital (62.7% versus 49.1%, P < 0.01), required respiratory support with intubation (10% versus 3.3%, P < 0.01), had longer hospital length of stays (median of 7 days versus 4 days, P < 0.01), and more frequently died (13.9% versus 5.1%, P < 0.01), and among the subpopulation that died, they died more quickly (death occurred in a median number of 11.5 days versus 34 days from the initial ED visit, P < 0.01).

Factors Associated With Death, Intubation, and Hospital Length of Stay Among Patients With HIV

In unadjusted analyses of factors associated with the outcomes of death, intubation, and hospital length of stay, among the subpopulation of patients with HIV and SARS-CoV2, we found that identifying as White was associated with an increased odds of death [OR 3.06 (95% CI: 1.19 to 7.86)] and intubation [OR 4.10 (1.47–11.44)] and identifying as Black was associated with a decreased odds of respiratory support through intubation [OR 0.25 (0.09–0.69)]. In multivariable analyses of the subpopulation of patients with HIV and SARS-CoV-2, we found that identifying as Black was associated with decreased odds of death [OR 0.24 (95% CI: 0.08 to 0.70)] and respiratory support through intubation [OR 0.17 (95% CI: 0.05 to 0.60)].

Survival Analysis

Kaplan–Meier Survival estimates for the population of patients with SARS-CoV-2 (stratified by HIV-positive and HIV-negative status) are shown in Figure 1; patients with HIV and SARS-CoV-2 infections had a similar probability of death at any given point compared with patients without HIV but with SARS-CoV-2 infection (log-rank P = 0.72). Survival estimates for the population of patients with HIV (stratified by SARS-CoV-2–positive and SARS-CoV-2–negative status) are shown in Figure 2; patients with both HIV and SARS-CoV-2 infections had a higher probability of death compared with patients with HIV but without SARS-CoV-2 at any point (log-rank P < 0.0001).

Figure 1.

Kaplan–Meier survival estimates for patients with SARS-CoV-2 infections stratified by HIV-positive (red) and HIV-negative (blue) status.

Figure 2.

Kaplan–Meier survival estimates for patients with HIV stratified by SARS-CoV-2–positive (red) and SARS-CoV-2–negative (blue) status.

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