As health care services worldwide undergo major reconfiguration to respond to the coronavirus crisis, there are simple and affordable ways to improve outcomes that relate to both HIV and COVID-19 care.
The first step is to make sure that the HIV status is recorded on all hospital admissions relating to COVID-19. This in turn will ensure that antiretroviral treatment (ART) is maintained during hospital stay, including during intensive care. Interrupting ART typically results in the rapid rebound of HIV replication, with a detrimental effect on immune and inflammatory responses that can complicate the management of COVID-19. Because HIV care is centred around a few specialised centres, HIV-positive people suffering from COVID-19 are likely to access care at hospitals that might have less experience in managing HIV. Establishing HIV status and access to expert opinion will be beneficial to the management of HIV-positive patients with COVID-19 and supportive of overburdened care teams. Examples include guidance on drug formulations suitable for critically ill patients and advice on drug-drug interactions. In addition to aiding clinical management, recording HIV status serves an important public health function: it can enrich research-based data collection platforms, and enable researchers to generate a much-needed dataset to inform guidelines and policies for both people with HIV and those affected by COVID-19. Currently, advice from specialist societies including the European AIDS Clinical Society (EACS) and the British HIV Association (BHIVA) is based on extremely limited data and expert opinion.
The second step is for a policy to routinely include HIV testing for all people hospitalised with suspected or diagnosed COVID-19 whose HIV status is unknown. Whilst estimates vary geographically, despite successful efforts to promote testing, in 2018 there were an estimated 7,500 people living with an undiagnosed HIV infection in the United Kingdom. It is paramount that in a COVID-19 focussed environment clinicians do not forget the importance of HIV testing in the work up for acute pneumonia and respiratory failure and, as such, do not delay diagnosis of HIV-related conditions such as pneumocystis carinii pneumonia, which can present in a similar way. By definition, people with undiagnosed HIV will not be on ART and will commonly have reduced immune function and increased inflammation, both of which are likely to increase the risk of SARS-CoV-2 complications. As to decisions about starting ART after a new HIV diagnosis, expert opinion will be paramount. Paradoxical worsening of pre-existing infectious processes following the initiation of ART – known as the immune reconstitution inflammatory syndrome – is a recognised phenomenon in people with advanced HIV infection. There are currently no data to inform the risk/benefit of initiating HIV treatment in people with COVID-19. It is hoped that dedicated studies will be designed to address this important question. Meanwhile, an HIV diagnosis will ensure appropriate linkage with specialist HIV care during admission and upon discharge from hospital. This strategy will improve health outcomes for those individuals who do not currently know they are HIV positive and will counteract their risk of transmission to partners.
Healthcare workers – doctors, nurses, laboratory personnel and all members of hospital staff – are responding amazingly well to the urgency of large numbers of people needing acute care for COVID-19. We make a call for increased awareness of the importance of recording HIV status, continuing HIV treatment for those known to be HIV-positive and establishing a diagnosis for those who have an unknown HIV status, as essential for all hospitals dealing with COVID-19.
Prof Anna Maria Geretti1, Mr Simon Collins2, Dr Sophie Kelly1, Dr Muge Cevik3, Dr Laura Waters4
- University of Liverpool; 2. HIV i-Base, London; 3. University of St. Andrews; 4. Mortimer Market Centre, London