COVID-19 and People living with HIV – Revisited

Impact of HIV infection on COVID-19 clinical outcome

 

In June 2020, STI shared a podcast describing the first available data about the outcomes of COVID-19 related hospitalisation for people living with HIV (PLWH). We shared some  take-home points: 

1) Encourage disclosure of known HIV status on COVID-19 related hospital admittance 

2) Encourage HIV testing in all people admitted into hospital for COVID-19 

3) When PLWH are admitted into hospital for COVID-19, have early discussions with the HIV specialist team about optimal management of HIV therapy and any concomitant condition and medications. Discourage antiretroviral therapy (ART) interruption even in severely ill patients without specialist consultation. 

These recommendations still hold. At the same time, there remain many uncertainties about how HIV infection impacts COVID-19 related outcomes and the exact mechanisms of this interaction.

The latest episode of the 2021 STI podcast series continues the discussion with Dr Fabiola Martin, Professor Anna Maria Geretti and Dr Paddy Ssentongo. They present two new peer-reviewed publications, outline their strengths and limitations, and discuss how they align with the recently published World Health Organization (WHO) report on COVID-19 and people living with HIV.

These studies and the WHO report are freely accessible below:

Outcomes of Coronavirus Disease 2019 (COVID-19) Related Hospitalization Among People With Human Immunodeficiency Virus (HIV) in the ISARIC World Health Organization (WHO) Clinical Characterization Protocol (UK): A Prospective Observational Study

Epidemiology and outcomes of COVID-19 in HIV-infected individuals: a systematic review and meta-analysis

Clinical features and prognostic factors of COVID-19 in people living with HIV hospitalized with suspected or confirmed SARS-CoV-2 infection.

Facts

  • The studies and the WHO report indicate that a subset of PLWH who are hospitalised with COVID-19 are at increased risk of adverse outcomes, including severe disease at admission and an ~2-fold increased risk of day-28 mortality, even after considering other risk factors such as older age and comorbidities. It is notable that, at least in the first stages of the pandemic, PLWH who were hospitalised with COVID-19 were much younger when compared to HIV negative populations.
  • The clinical data available to researchers on PLWH is collected using methods not tailored to collecting HIV-related measures. This limits the ability to examine the possible mechanisms underlying the effects seen, including current and nadir CD4 counts, CD4/CD8 ratios and ART history. Due to small sample sizes and the many potential confounding factors, in addition to multiple adjustments, studies have attempted to strengthen the validity of their findings by conducting extensive sensitivity analyses. These are a way for researchers to exploit statistical methods to try to prove the initial conclusions.

Where do we go from here?

  • We need to consider HIV infection with or without immune reconstitution as an independent risk factor for severe COVID-19 infection.
  • Further studies are needed to understand whether the impact of COVID-19 is mitigated in PLWH by the improvements in the management of the disease that has taken place since the first phase of the pandemic, now that standardised COVID-19 treatment protocols are better established. 
  • HIV-specific studies are necessary to unveil the predictors of COVID-19 related risk for PLWH to ensure appropriate counselling and protective measures and to determine if the effect of HIV on COVID-19 outcomes remains.
  • We need to continue to encourage HIV testing: Early diagnosis and early ART initiation prevent severe immunosuppression, which may contribute to adverse COVID-19 outcomes in PLWH.
  • Prevention of SARS-CoV-19 infection is of the utmost importance: Freely accessible vaccines are critical.
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