Clinical Outcomes of Patients With and Without HIV Hospitalized With COVID-19 in England During the Early Stages of the Pandemic

A Matched Retrospective Multi-Centre Analysis (RECEDE-C19 Study)

Ming Jie Lee; Luke Blagdon Snell; Sam T. Douthwaite; Sarah Fidler; Naomi Fitzgerald; Lynsey Goodwin; Lisa Hamzah; Ranjababu Kulasegaram; Sarah Lawrence; Julianne Lwanga; Rebecca Marchant; Chloe Orkin; Adrian Palfreeman; Padmini Parthasarathi; Manish Pareek; Kyle Ring; Hamed Sharaf; Eleanor Shekarchi-Khanghahi; Rebecca Simons; Jhia Jiat The; John Thornhill; Clare van Halsema; Marie Williamson; Martin Wiselka; Achyuta Nori; Julie Fox; Colette Smith

Disclosures

HIV Medicine. 2022;23(2):121-133. 

In This Article

Abstract and Introduction

Abstract

Background: The contribution of HIV to COVID-19 outcomes in hospitalized inpatients remains unclear. We conducted a multi-centre, retrospective matched cohort study of SARS-CoV-2 PCR-positive hospital inpatients analysed by HIV status.

Methods: HIV-negative patients were matched to people living with HIV (PLWH) admitted from 1 February 2020 to 31 May 2020 up to a 3:1 ratio by the following: hospital site, SARS-CoV-2 test date ± 7 days, age ± 5 years, gender, and index of multiple deprivation decile ± 1. The primary objective was clinical improvement (two-point improvement or better on a seven-point ordinal scale) or hospital discharge by day 28, whichever was earlier.

Results: A total of 68 PLWH and 181 HIV-negative comparators were included. In unadjusted analyses, PLWH had a reduced hazard of achieving clinical improvement or discharge [adjusted hazard ratio (aHR) = 0.57, 95% confidence interval (CI): 0.39–0.85, p = 0.005], but this association was ameliorated (aHR = 0.70, 95% CI: 0.43–1.17, p = 0.18) after additional adjustment for ethnicity, frailty, baseline hypoxaemia, duration of symptoms prior to baseline, body mass index (BMI) categories and comorbidities. Baseline frailty (aHR = 0.79, 95% CI: 0.65–0.95, p = 0.011), malignancy (aHR = 0.37, 95% CI 0.17, 0.82, p = 0.014) remained associated with poorer outcomes. The PLWH were more likely to be of black, Asian and minority ethnic background (75.0% vs 48.6%, p = 0.0002), higher median clinical frailty score [3 × interquartile range (IQR): 2–5 vs, 2 × IQR: 1–4, p = 0.0069), and to have a non-significantly higher proportion of active malignancy (14.4% vs 9.9%, p = 0.29).

Conclusions: Adjusting for confounding comorbidities and demographics in a matched cohort ameliorated differences in outcomes of PLWH hospitalized with COVID-19, highlighting the importance of an appropriate comparison group when assessing outcomes of PLWH hospitalized with COVID-19.

Introduction

SARS-CoV-2 infection is estimated to cause mild to moderate disease (coronavirus disease 2019 or COVID-19) in about 80% of people but can cause severe lower respiratory tract infection in approximately 15–20%, particularly among those in high-risk groups, defined by advanced age (≥ 65 years), ethnicity (African and Asian), other social determinants of health, or presence of comorbidities or obesity.[1–4]

There is increasing evidence from large population-based studies that suggest people living with HIV (PLWH) have a higher risk of severe COVID-19 and worse outcomes. Reports from large population-based cohorts from the USA,[5] the UK,[6,7] South Africa[8] and the World Health Organization[9] suggest there is increased mortality from COVID-19 amongst PLWH. However, these cohorts were often limited by incomplete data and lack of data on CD4 T-cell count, viral load or HIV treatment. Mortality end-points may miss non-mortality outcomes such as time to recovery and long-term disability. Apart from the OPENSAFELY cohort in the UK,[6] these studies were not able to adjust for socio-economic deprivation. Conversely, cohorts matched for various confounders[10–13] and an unmatched cohort from South Africa[14] have not shown an increased risk of severe disease in PLWH.

It remains unclear if differences in COVID-19 outcomes are driven by differences in HIV-specific factors, underlying health conditions or adverse social determinants of health, the latter two factors disproportionately affecting PLWH.[15] In the OPENSAFELY cohort, people without comorbidities were not at increased risk of death. The study was not able to look at the impact of viral suppression on COVID-19 mortality due to a lack of HIV-specific data. A Spanish study found that although CD4 T cell count did not affect the risk of severe COVID-19 in people with suppressed viraemia, a CD4 T cell count <500 was associated with increased risk of severe COVID-19 outcomes in people with detectable viraemia.[16]

We conducted a multi-centre, retrospective analysis of people living with and without HIV hospitalized with COVID-19 across England during the early pandemic, matched for age, gender and socioeconomic deprivation to estimate the association of HIV status and other confounding variables with hospitalization outcomes among PLWH hospitalized with COVID-19.

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