People With HIV Have a Higher Risk of COVID-19 Diagnosis But Similar Outcomes to the General Population

Michael E. Tang; Thaidra Gaufin; Ryan Anson; Wenhong Zhu; William C. Mathews; Edward R. Cachay


HIV Medicine. 2022;23(10):1069-1077. 

In This Article

Abstract and Introduction


Background: We investigated the effect of HIV on COVID-19 outcomes with attention to selection bias due to differential testing and comorbidity burden.

Methods: This was a retrospective cohort analysis using four hierarchical outcomes: positive SARS-CoV-2 test, COVID-19 hospitalization, intensive care unit (ICU) admission and hospital mortality. The effect of HIV status was assessed using traditional covariate-adjusted, inverse probability-weighted (IPW) analysis based on covariate distributions for testing bias (testing IPWs), HIV infection status (HIV-IPWs) and combined models. Among people living with HIV (PWH), we evaluated whether CD4 count and HIV plasma viral load (pVL) discriminated between those who did and those who did not develop study outcomes using receiver operating characteristic analysis.

Results: Between March and November 2020, 63 319 people were receiving primary care services at the University of California San Diego (UCSD), of whom 4017 were PWH. The PWH had 2.1 times the odds of a positive SARS-CoV-2 test compared with those without HIV after weighting for potential testing bias, comorbidity burden and HIV-IPW [95% confidence interval (CI): 1.6–2.8]. Relative to people without HIV, PWH did not have an increased rate of COVID-19 hospitalization after controlling for comorbidities and testing bias [adjusted incidence rate ratio (aIRR) = 0.5, 95% CI: 0.1–1.4]. PWH did not have a different rate of ICU admission (aIRR = 1.08, 95% CI: 0.31–3.80) or of in-hospital death (aIRR = 0.92, 95% CI: 0.08–10.94) in any examined model. Neither CD4 count nor pVL predicted any of the hierarchical outcomes among PWH.

Conclusions: People living with HIV have a higher risk of COVID-19 diagnosis than those without HIV but the outcomes are similar in both groups.


Since the beginning of the COVID-19 pandemic, many have been concerned that people living with HIV (PWH) will have a more severe course of COVID-19 after infection than the general population. Reasons for concern include impaired inflammatory cell responses in PWH, making it more challenging to control respiratory viral infections, leading to more complications and death.[1] PWH are known to have a high prevalence of comorbidities associated with increased COVID-19 disease severity and a high prevalence of barriers to care such as mental illness, drug and alcohol use, and homelessness[1] that impact both risks of acquisition and access to care during an evolving COVID-19 pandemic.

Independent effects of HIV on COVID-19 positivity, hospitalization and mortality have been inconsistently observed.[2–9] It is unclear whether differences among the studied populations with respect to HIV-induced immunosuppression, prevalence of medical comorbidities, socioeconomic disparities or methodological issues account for the disparate results. Among methodological considerations are differences in study samples,[4,10] variant preponderance,[3,11–13] adequacy of control for selection bias[14] and confounding.[15] All observational studies presented have lacked appropriate control for potential collider bias, which can induce a spurious association between the exposure and outcome. We performed a nested cohort study in San Diego, California, to evaluate the effect of HIV infection status on hierarchical outcomes of COVID-19 disease. We focused on controlling for comorbidity burden, HIV immunosuppression status and selection bias due to differential SARS-CoV-2 testing.