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


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

In This Article


We found a population of 415 patients with HIV within the RECOVER Network. Nearly half of those with HIV were SARS-CoV-2 positive. With some exceptions, the groups had similar characteristics and similar (median) duration of symptoms before presenting to US EDs for care. Expectedly, patients with SARS-CoV-2 (both HIV-positive and HIV-negative) died at higher rates, were more often intubated, and had longer hospital length of stays, compared with those without SARS-CoV-2. However, patients with HIV and SARS-CoV-2 did not seem to have markedly worse outcomes (death, intubation, and hospital length of stay) compared with patients without HIV but with SARS-CoV-2.

Our study is not the first to demonstrate that outcomes associated with SARS-CoV-2 are not worse among patients with an HIV infection (compared with those without an HIV infection).[20–24] A US multicenter study that included 404 patients with HIV found no differences in outcomes through propensity-matched analysis.[20] Of note, most (70%) patients in this study had a history of antiretroviral therapy (ART).[20] These findings are congruent with a Zambian study of 443 hospitalized patients with HIV;[21] HIV was not found to be independently associated with poor outcomes (caveat being that those with severe HIV disease were more likely to develop severe SARS-CoV-2 or die of SARS-CoV-2).[21] A third study that did not identify worse outcomes also represented a population of patients with controlled HIV infections (eg, 94% had viral load <20 copies/mL).[22]

However, reports have differed.[4,25] One recent US study (2988 persons living with HIV concurrently infected with SARS-CoV-2) demonstrated that hospitalization rates were higher among those without viral suppression and among those with lower CD4 counts.[4] This is in the context of recent work from the World Health Organization that reported HIV infection (among individuals with concurrent SARS-CoV-2 infections) was independently associated with a higher risk of death.[25] Of note, much like our current work, this World Health Organization study was limited given that ART information was absent for a majority (60%) of patients.

Although the overall impressions of these works seem conflicting, 1 potential underlying explanation is that SARS-CoV-2–associated clinical outcomes may be more related to the severity of an HIV infection (eg, high viral low, low CD4 count, and absence of ART) and not necessarily just the presence (or absence) of an HIV infection. Given this, it is possible that our similar outcomes among patients with SARS-CoV-2 and an HIV infection (compared with those without an HIV infection) may stem from a population of patients with controlled or less severe HIV infections. Unfortunately, given the high degree of missingness on HIV treatment status and CD4 count in our secondary analysis, we are unable to confirm this or offer a more thorough explanation. Future work remains necessary.

We further found that the population with both HIV and SARS-CoV-2 disproportionately identified as Black or African American. HIV disproportionately affects those who identify as Black or African American;[12] these findings likely stem from the disproportionate burden of SARS-CoV-2 (both population prevalence and overall mortality) seen within Black and African American communities across the United States.[26,27] These are the same Black communities that suffer from clearly demonstrated, longstanding, inequities in both health risks and outcomes that existed well before the start of the current pandemic.[26,27]

Interestingly, and counter to our a priori beliefs, patients with SARS-CoV-2 infections were less often smokers. Recent work suggests that smoking is an independent risk factor for both hospital admission and death from SARS-CoV-2.[28,29] However, there is limited evidence to support this phenomenon, and contradictory thoughts on the association of tobacco use and SARS-CoV-2 infection do exist.[28–30] We are uncertain as to the implications of this current finding in our HIV-positive population (a finding that was also noted among the larger, primary, analysis). Unfortunately, an explanation is beyond the limited scope of this current work. Further study is required and is currently being completed in the larger RECOVER Network.


There are several limitations to this work, the first and most notable of which is missing information on both HIV treatment status and CD4 count and our inability to account for these in our study. This is a limitation shared by other work on the topic.[25] Our work was a planned secondary analysis of a larger, national, registry. The primary study was focused on characterizing patients who presented to US EDs with suspected SARS-CoV-2 infections. Despite each site and investigator attempting to obtain this information, in many situations the information was not present in the electronic health record. Given the possibility that SARS-CoV-2–related outcomes may be dependent on severity of HIV infection, it would have been of interest to explore whether patients not on ART or with deranged CD4 cell count and HIV viral load had similar outcomes.[4,21]

However, independent of either treatment status or CD4 count, there is still a clear need for our work (and works like our current study) that explores outcomes (including mortality) associated with SARS-CoV-2 infections in patients with HIV and how these findings compare with individuals without HIV. Our findings add to the literature base and will be useful given the ongoing global pandemic and conversation around risk stratification and vaccine prioritization for patients with HIV.[4,11]

A second limitation of this work stems from the site-to-site variability and potential concerns for generalizability inherent to any national, multicenter registry (eg, hospital-specific intensive care unit admission practices or policies on invasive oxygen techniques); a limitation likely more compounded given that SARS-CoV-2 prevalence and hospital resources were likely not equal across sites (eg, hospitals in regions with higher SARS-CoV-2 prevalence may have had limited ability to offer invasive respiratory support).[15,16] We are unable to account for the possible contributions of site-specific differences given the sample size presented here, the period of study for this population, and the changing epicenters of SARS-CoV-2 infections across the United States.

Despite these limitations, to the best of our knowledge, our work is the first such report that focuses on patients with HIV who presented to US EDs with suspected SARS-CoV-2 infections and also includes information on both hospitalization characteristics and patient mortality. Our work is also one of the few studies not limited to a single center or region[5–7,9] but instead reflects a national, multicenter registry.[4,8,10]