- People with HIV appear to have a slightly increased risk of dying from COVID-19.
- People with HIV who have underlying health conditions such as obesity, poorly controlled diabetes and high blood pressure appear to be at higher risk.
- In general, the most important risk factors for death from COVID-19 are old age, an organ transplant and a recent diagnosis of a cancer of the blood.
- Vaccines against COVID-19 are highly effective in preventing serious illness. They are not thought to be less effective in people with HIV, but more data are needed.
- People with CD4 cell counts below 50 or an opportunistic illness in the last six months may choose to take extra precautions to protect themselves from infection.
COVID-19 is an illness caused by a new coronavirus (SARS-CoV-2). The main symptoms are fever, cough and breathing difficulties. A small proportion of people develop severe pneumonia and need intensive care.
Around one-in-two-hundred to one-in-one-hundred people die after catching this virus. Old age, an organ transplant or any recent diagnosis of a cancer of the blood greatly increase the risk of dying from COVID-19.
Vaccines are now becoming available that greatly reduce the risk of serious illness. People with HIV are a priority group for vaccination in several countries, including the United Kingdom.
Who is at greater risk of COVID-19?
The largest study of risk factors for severe COVID-19 conducted so far, the OPENSafely study, looked at around 40% of GP patients in England (17.2 million people).
The study found that old age was by far the strongest risk factor. People over 80 were at least 20 times more likely to die from COVID-19 compared to people aged 50-59. People under 40 had a greatly reduced risk compared to the 50-59 age group.
An organ transplant raised the risk of death fourfold. A history of any form of blood cancer including cancer of the bone marrow or lymph nodes (e.g. leukaemia, lymphoma or multiple myeloma) in the past five years raised the risk of death threefold. Any neurological condition, severe obesity or uncontrolled diabetes doubled the risk of death. Men were twice as likely to die as women.
Other risk factors such as Black or Asian ethnicity, social deprivation, liver disease, stroke, dementia and kidney disease raised the risk of death by between 50 and 75%, as did a severe respiratory disease other than asthma.
Chronic heart disease, controlled diabetes, a cancer diagnosis other than blood cancer more than one year ago, asthma, lupus, psoriasis, rheumatoid arthritis, moderate obesity and smoking each raised the risk of death slightly.
People who have many of these risk factors are at far greater risk of dying from COVID-19 than people who have few risk factors, regardless of HIV status.
Are people with HIV at higher risk of dying from COVID-19?
Several studies have shown that people living with HIV have a raised risk of dying from COVID-19. However, studies have come to differing conclusions about how great the risk is, so data from published studies have been combined and analysed together in two meta-analyses, published in the medical journals AIDS and Scientific Reports.
These concluded that HIV increased the risk of death from COVID-19 by between 78 and 95%. The risk in studies which looked at the whole of the population was higher than in studies which only compared outcomes in people admitted to hospital or who tested positive for SARS-CoV-2.
Studies of hospitalised or tested people may underestimate the risk associated with HIV because doctors may test people with HIV and admit them to hospital with less severe symptoms, as a precaution. These people may be less sick than people without HIV and so recover more quickly and have a lower risk of death.
Population studies, on the other hand, capture all the deaths due to COVID-19 in a community. Two large studies, in South Africa and the United Kingdom, have each concluded that people with HIV were at least twice as likely to die from COVID-19 as the rest of the population during the first wave of the pandemic in 2020.
The UK study, OpenSAFELY, found that the risk of death was only raised in people with HIV who had underlying health conditions, such as diabetes or high blood pressure.
Another UK study, presented after the meta-analyses were published, also found that people with HIV had double the risk of dying from COVID-19 during the first wave of the pandemic in England. The study, carried out by Public Health England, found the highest levels of mortality from COVID-19 in Black, Asian and other people from ethnic minorities living with HIV.
Are people with HIV at higher risk of severe COVID-19 illness?
The largest studies looking at the risk of severe illness have reached differing conclusions about the risk for people with HIV of being admitted to hospital or suffering severe illness due to COVID-19.
In the United States, the National COVID Cohort Collaborative analysed COVID-19 cases up to February 2021 and found that people with HIV were at 32% higher risk of being admitted to hospital with COVID-19 and 86% higher risk of requiring mechanical ventilation.
Similarly, a US study which matched people with HIV admitted to hospital with COVID-19 to people without HIV by sex, race, body mass and underlying conditions found that people with HIV were 70% more likely to require in-patient care.
However, a study of COVID-19 admissions in major UK hospitals up to 31 May 2020 found that HIV status did not affect a person’s chances of improvement after admission, when the analysis controlled for severity of illness at admission, frailty, pre-existing conditions, age and ethnicity. Nor were people with HIV at greater risk of requiring mechanical ventilation.
Each of these studies of severe outcomes found that underlying health conditions contributed substantially to the increased risk observed in people with HIV. A high prevalence of underlying health conditions such as diabetes, kidney disease and hypertension in people with HIV leads to higher COVID-19 risk but may not entirely explain it.
Other smaller studies have reached contradictory conclusions and more research is needed to show if people with HIV are more likely to experience severe COVID-19.
There are no data on ‘long COVID’ (symptoms which continue for weeks or months after the infection has gone) in people with HIV.
Which people with HIV are at higher risk of COVID-19?
Most studies show that people with HIV who have underlying health conditions such as obesity, diabetes or high blood pressure have a higher risk of severe illness or death than other people with HIV.
A registry of COVID-19 cases in people living with HIV in the United Kingdom found that people who were obese had four times the risk of severe illness compared to people in the normal weight range. Each underlying condition raised the risk of severe illness by 24%.
The UK registry also found that people with a current AIDS-defining illness were three times more likely to suffer severe illness than other people with HIV.
Several studies have shown that a low CD4 cell count increases the risk of severe outcomes, even without underlying health conditions. The UK registry found that people with CD4 counts below 200 had a higher risk of death or prolonged hospitalisation than people with CD4 counts above 200.
An analysis of 175 cases of SARS-CoV-2 infection diagnosed in people with HIV receiving care at hospitals in Madrid, Milan and 16 German cities up to June 2020 showed that people with CD4 counts below 350 were almost three times more likely to experience severe illness. Underlying health conditions did not raise the risk of severe illness in this study and 24% of those who developed severe illness had no underlying health conditions.
An analysis of 286 cases of SARS-CoV-2 infection diagnosed at 36 hospitals in the United States found that people with CD4 counts below 200 were almost three times more likely to die of COVID-19 than people with CD4 counts above 500. In this study, co-morbidities were strongly associated with hospital admission. People with three or more co-morbidities were three-and-a-half times more likely to be admitted to hospital compared to people with HIV without co-morbidities (odds ratio 3.57, 95% CI 1.29-9.9, p = 0.01) and five times more likely to have a severe outcome.
Another multicentre study in the United States, which matched 404 people with HIV diagnosed with SARS-CoV-2 to HIV-negative controls found that the increased risk of death in people with HIV from COVID-19 was explained by a higher burden of underlying health conditions.
A study in England which looked at 17.2 million NHS patients, including 27,480 people with HIV, found that people with HIV who had no underlying health conditions were not at increased risk of death. It is possible that this study undercounted people with HIV with underlying health conditions, but a correct count of people with underlying health conditions would only strengthen the relationship between underlying health conditions and risk of death due to COVID-19 in people with HIV.
This study also found that Black people were at almost four times higher risk of dying from COVID-19 than Black people without HIV. A study of all deaths from COVID-19 in England in the first wave of the pandemic, carried out by Public Health England, reached the same conclusion. The study also found a raised risk of death among Asian people living with HIV as well as other non-White ethnic groups.. More research is needed on the relationship between ethnicity and COVID-19 risk, especially to understand the extent to which underlying health conditions, social deprivation or occupational risk explain these findings.
There is no strong evidence that any antiretroviral drug protects against COVID-19.
People with viral hepatitis (B or C) do not appear to be at higher risk of severe illness unless they also have advanced liver cirrhosis.
Why people living with HIV may have worse COVID-19 outcomes
While several studies have observed worse outcomes in people with HIV, understanding of the reasons for these is incomplete. Possible explanations include:
- HIV-specific factors. It is possible that chronic inflammation (ongoing activation of the immune system) in response to HIV infection may raise the risk of severe COVID-19 outcomes. Excess inflammation is most pronounced in individuals who have had a very low CD4 count in the past or with incomplete reconstitution of their immune system.
- Underlying health conditions. If people with HIV have higher rates of underlying health conditions that are risk factors for severe COVID-19, this will affect outcomes. Researchers try to take these into account in their analyses, but studies may not collect enough information on all relevant conditions.
- Social determinants of health. In many places, significant numbers of people with HIV are economically disadvantaged, live in overcrowded housing, work in frontline jobs or belong to ethnic minorities. However, studies do not usually collect data on many of these factors.
COVID-19 vaccines for people living with HIV
Vaccines against COVID-19 are highly effective in preventing serious illness. COVID-19 vaccination is recommended for people living with HIV and there are no safety concerns that are specific to people with HIV.
Two studies of the Oxford/AstraZeneca vaccine in people with HIV show that the vaccine produced the same strength of immune response in people with HIV and people without HIV. There was no difference in the common vaccine side effects of sore injection site, headache, chills, tiredness or muscle and joint pains. People in both studies had high CD4 counts (above 500) and were on antiretroviral treatment.
Experience from vaccinations against other infections shows that older people and those with low CD4 counts (below 350 now, or below 200 at some point in the past) and people with unsuppressed HIV show weaker immune responses to some vaccines. This leads to a lower level of protection or a shorter period of protection. There are no data yet to show that this is the case for COVID-19 vaccines.
Trials of other COVID-19 vaccines reported to date had few participants with HIV. It is not possible to say whether any vaccine is less effective in people with weakened immune systems.
On 15 January 2021, European HIV medical associations including the European AIDS Clinical Society and the British HIV Association (BHIVA) recommended that people with CD4 counts below 350 should be prioritised for COVID-19 vaccination. They note that current guidance about prioritisation of people with HIV for vaccination varies between European countries.
In the United Kingdom, all people with HIV should have been offered a first dose of a COVID-19 vaccine by March 2021, based on their place in priority groups 4 or 6 and regardless of age. If you have not yet been vaccinated and you have not notified your GP that you are living with HIV, you can be referred to a vaccine hub by your HIV clinic.
In the United States, the Centers for Disease Control and Prevention lists HIV as a medical condition which may raise the risk of severe illness from COVID-19. This is relevant for vaccine prioritisation, although policies are determined by each state.
Advice for people living with HIV
BHIVA and Terrence Higgins Trust recommends that:
- People with a CD4 count over 200, who are taking HIV treatment and have an undetectable viral load are considered at no greater risk than the general population. They should follow general advice to stay at home and maintain social distancing.
- People with a CD4 count below 200, or who are not taking HIV treatment, or who have a detectable viral load may be at higher risk of severe illness. Nonetheless, they should still follow the same general advice.
- People with a very low CD4 count below 50 or who have had an opportunistic illness in the last six months should follow the UK government's ‘shielding’ advice for people who are extremely vulnerable.
BHIVA issued guidance in May 2020 recommending that people with suppressed viral load who do not need to change their current HIV treatment can skip their next six-monthly clinic appointment. Anyone who needs to start HIV treatment should receive Biktarvy (bictegravir/tenofovir alafenamide/emtricitabine), a first-line combination requiring minimal testing and patient follow-up.
BHIVA has also issued guidance designed to minimise the number of medical visits for pregnant women with HIV and mothers of newborns.
If you are admitted to hospital with COVID-19 and HIV
The clinical management of COVID-19 in people with HIV is the same as for people who do not have HIV.
BHIVA advises that it is a good idea to tell the healthcare team looking after you in hospital that you are living with HIV so that they can do tests to rule out other lung infections that may occur in people with HIV. Keep a list of the HIV medications you are taking so that they can be prescribed as soon as possible if you are admitted.
CD4 cell counts can fall during COVID-19, so doctors should remember to give opportunistic infection prophylaxis if the CD4 cell count falls below 200.
Further guidance on what to do if you are admitted to hospital with COVID-19 is published on the BHIVA website.