The Association Between Comorbidities and Coronavirus Disease 2019 Hospitalization Among People With HIV Differs by age

Caitlin A. Moran; Nora T. Oliver; Brittany Szabo; Lauren F. Collins; Minh Ly T. Nguyen; N. Sarita Shah; Abeer Moanna; Jonathan A. Colasanti; Valeria D. Cantos; Wendy S. Armstrong; Anandi N. Sheth; Ighovwerha Ofotokun; Colleen F. Kelley; Vincent C. Marconi; Cecile D. Lahiri


AIDS. 2023;37(1):71-81. 

In This Article

Abstract and Introduction


Objectives: To determine whether factors associated with coronavirus disease 2019 (COVID-19) hospitalization among people with HIV (PWH) differ by age stratum.

Design: Retrospective cohort study.

Methods: All adult PWH with a positive SARS-CoV-2 PCR in a public safety-net health system between 1 March 2020 and 28 February 2021 and a Veterans Affairs Medical Center between 1 1 March 2020 and 15 November 2020 in Atlanta, Georgia were included. We performed multivariable logistic regression to determine demographic and clinical factors associated with COVID-19 hospitalization overall and stratified by age less than 50 and at least 50 years.

Results: Three hundred and sixty-five PWH (mean age 49 years, 74% cisgender male, 82% black) were included. Ninety-six percent were on antiretroviral therapy (ART), 87% had CD4+ T-cell count at least 200 cells/μl, and 89% had HIV-1 RNA less than 200 copies/ml. Overall, age [adjusted odds ratio (aOR) 95% confidence interval (CI) 1.07 (1.04–1.10)], later date of SARS-CoV-2 infection [aOR 0.997 (0.995–1.00)], heart disease [aOR 2.27 (1.06–4.85)], and history of hepatitis C virus (HCV) [aOR 2.59 (1.13–5.89)] were associated with COVID-19 hospitalization. Age-adjusted comorbidity burden was associated with 30% increased risk of hospitalization [aOR 1.30 (1.11–1.54)]. Among 168 PWH less than 50 years old, older age [aOR 1.09 (1.01–1.18)] and no ART use [aOR 40.26 (4.12–393.62)] were associated with hospitalization; age-adjusted comorbidity burden was not (P = 0.25). Among 197 PWH at least 50, older age [aOR 1.10 (1.04–1.16)], heart disease [aOR 2.45 (1.04–5.77)], history of HCV [aOR 3.52 (1.29–9.60)], and age-adjusted comorbidity burden [aOR 1.36 (1.12–1.66)] were associated with hospitalization.

Conclusion: Comorbidity burden is more strongly associated with COVID-19 hospitalization among older, rather than younger, PWH. These findings may have important implications for risk-stratifying COVID-19 therapies and booster recommendations in PWH.


Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic in late December 2019, it has been well established that advanced age, comorbidity burden, and immunosuppression are risk factors for severe COVID-19.[1,2] However, for people with HIV (PWH), risk factors for severe COVID-19 remain unclear. PWH have been shown to be at increased risk of severe COVID-19 including hospitalization[3,4] and death[5–8] after controlling for age and sex, but reasons for this elevated risk are likely multifactorial. There is mounting evidence, mostly from cohorts of PWH with well controlled HIV in North America and western Europe that an increased comorbidity burden plays a large role in severe COVID-19 risk among PWH.[9,10] Other larger studies from similar settings also implicate HIV-specific parameters including CD4+ T-cell count, CD4+/CD8+ ratio, HIV-1 RNA viremia, and specific antiretroviral therapy (ART) use.[7,11–13] These data suggest that, while age and comorbidity burden are important contributors to COVID-19 severity among PWH, HIV-related factors, particularly CD4+ T-cell count, may also play a role.

Most of the available data do not address specific risk factors for COVID-19 hospitalization among PWH by age group. If differences by age group exist, they may have important implications for COVID-19 treatment and prevention guidelines. One cohort study conducted in the United Kingdom through June 2020 found that COVID-19 mortality was greater among PWH age less than 60 years compared with people without HIV in the same age group.[8] Current COVID-19 treatment guidelines consider age at least 65 years to be a risk factor for severe disease,[14] but this age cutoff may need to be reconsidered in PWH. Stratification at age 50 was chosen a priori based on evidence of increased risk for multimorbidity in PWH at that age.[15] Previous work has shown that PWH experience accelerated aging and age-related comorbidities at earlier ages compared with the general population,[16,17] and risk of these comorbidities appears to increase after age 50, often sooner than in the general population.[15,16] Therefore, we sought to determine risk factors for hospitalization for COVID-19 among PWH overall and stratified by age less than 50 years and at least 50 years.