SARS-CoV-2 Infection Among People Living With HIV Compared With People Without HIV

Survey Results From the MACS-WIHS Combined Cohort Study

Gypsyamber D'Souza, PhD; Weiqun Tong, MS; Deborah Gustafson, PhD; Maria L. Alcaide, MD; Cecile D. Lahiri, MD; Anjali Sharma, MD; Audrey L. French, MD; Frank J. Palella, MD; Mirjam-Colette Kempf, MD; Matthew J. Mimiaga, ScD; Catalina Ramirez, MPH; Seble Kassaye, MD; Charles R. Rinaldo, PhD; Todd T. Brown, MD; Phyllis C. Tien, MD; Adaora A. Adimora, MD


J Acquir Immune Defic Syndr. 2022;89(1):1-8. 

In This Article

Abstract and Introduction


Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (COVID-19) symptoms among people living with HIV (PLWH) are not well described.

Setting: Longitudinal survey within the MACS/WIHS Combined Cohort Study (MWCCS) of PLWH compared with similar HIV-seronegative (SN) individuals.

Methods: Telephone-administered survey of MWCCS participants at 13 clinical research sites across the United States addressing COVID-19 symptoms, SARS-CoV-2 testing, and pandemic impact on social distancing and antiretroviral therapy (ART) use. Primary data collection occurred during May (wave 1), June–July (wave 2), and August–September, 2020 (wave 3).

Results: One-third of MWCCS participants were tested for SARS-CoV-2 infection; 10% was tested ≥2 times. Similar proportions of PLWH and SN participants were tested, but SARS-CoV-2 positivity was higher among PLWH than among SN individuals (9.4% vs 4.8%, P = 0.003). Odds of SARS-CoV-2 positivity remained higher among PLWH after adjusting for age, sex, race/ethnicity, and study site (adjusted odds ratio = 2.0, 95% confidence interval = 1.2 to 3.2). SARS-CoV-2 positivity was not associated with CD4 cell counts among PLWH. Among SARS-CoV-2 positive participants, 9% had no symptoms, 7% had 1–2 mild symptoms, and 84% had ≥3 symptoms. Most of the (98%) participants reported physical distancing during all survey waves; self-reported ART adherence among PLWH was not adversely affected during the pandemic compared with the previous year (similar adherence in 89% of participants, improved in 9% of participants, and decreased in 2% of participants).

Conclusions: Despite similar SARS-CoV-2 testing and physical distancing profiles by HIV serostatus among MWCCS participants, PLWH who reported SARS-CoV-2 testing were more likely to have a positive test result. Additional studies are needed to determine whether and why PLWH are at increased risk of SARS-CoV-2 infection.


Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for coronavirus disease 2019 (COVID-19), manifests itself with a variety of clinical symptoms during infection. Although most people who become infected are either asymptomatic or experience mild symptoms, the illness can be severe and/or life-threatening.[1] Between March and September 2020, with infection levels surging across the United States,[2] more than 7 million people tested positive for SARS-CoV-2 and 200,000 people died.[3,4] In an effort to mitigate the impact of the pandemic, many states mandated policies of social distancing and closures of businesses and other venues.[5]

COVID-19 severity increases among adults with each decade of advancing age[6] and among those with certain underlying health conditions and comorbidities. It is unclear whether SARS-CoV-2 infection is higher among people living with HIV (PLWH); however, some recent studies suggest that PLWH may have increased disease severity and risk of hospitalization.[7] A recent review of SARS-CoV-2 cases among PLWH indicated that although documented combined HIV and SARS-CoV-2 coinfection was uncommon globally, greater HIV-related immunosuppression predisposed PLWH to more severe COVID-19 disease.[8,9] Analysis of 192 PLWH suggested that a CD4 count <200 cells/μL (vs ≥200 cells/μL) was associated with a 4.9-fold higher odds of progression to severe COVID-19.[8] Currently, recommendations for prevention of SARS-CoV-2 infection and COVID-19 management among PLWH are no different than those for the general population. The US Centers for Disease Control and Prevention (CDC) recommend that "until more is known, additional caution for all PLWH, especially those with advanced or poorly controlled HIV, is warranted" and that PLWH should follow CDC prevention recommendations.[10] However, PLWH are more likely than the general population to have risk factors associated with greater SARS-CoV-2 exposure and/or worse COVID-19 outcomes, including higher prevalence of adverse social determinants of health (eg, unstable housing and public transportation use) and comorbidities (eg, cardiovascular disease, obesity, and smoking).[11] PLWH in the United States are also disproportionately represented among racial minorities and groups hit hardest by the SARS-CoV-2 pandemic.

We previously reported similar prevalences and types of COVID-19 symptoms among PLWH and similar HIV-seronegative (SN) adults in the MACS/WIHS Combined Cohort Study (MWCCS) during Spring 2020.12(p1) In this analysis, we characterize the evolving pandemic among MWCCS participants by extending our initial report to include additional waves of data collection through September 2020, after the surge of COVID-19 that occurred in the United States in the Spring and Summer of 2020.