COVID-19 and coronavirus in people living with HIV

Image: Gerd Altmann/Pixabay

Key points

  • 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.
  • 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.

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 COVID-19?

Several studies have shown that people living with HIV have a raised risk of dying from COVID-19.

Two large studies of the coronavirus pandemic in the United Kingdom found that people living with HIV had between 63 and 130% higher risk of dying of COVID-19 than other people. Both studies showed that co-morbidities such as obesity, poorly controlled diabetes and high blood pressure were important risk factors in people with HIV.

The first study was based on the OpenSAFELY database (described above), looking at people whose HIV status was recorded in GP records and whose death certificates recorded death from COVID-19. While it found that people with HIV were at least twice as likely to die of COVID-19 as others, people with HIV without co-morbidities were not at increased risk of death.

Black people living with HIV were at highest risk of dying from COVID-19; their risk was almost four times higher than Black people without HIV.

But the second study, which looked at deaths in people admitted to hospital with COVID-19 symptoms and who had a positive test for SARS-CoV-2, found no differences in the risk of death according to ethnic group among people living with HIV. The study estimated that the risk of death from COVID-19 was 63% higher in people living with HIV.

This study also found that the risk of death in people with HIV compared to the rest of the population was higher in people under 60. But among people with HIV admitted to hospital, those most likely to die were older. Those who died were also more likely to be obese or to have diabetes with complications, in common with the rest of the population.

The OpenSAFELY study investigators say that the higher risk of death in people living with HIV was most evident during the first 60 days of the pandemic and may reflect less social distancing and/or greater vulnerability to infection during February and March 2020. Beyond the end of April, the difference in risk between people with HIV and others disappeared, they found.

Taken together, these studies suggest that the same risk factors that increase risk for the whole population also increase the risk of death in people living with HIV: older age, Black ethnicity, underlying health conditions such as obesity, poorly controlled diabetes and high blood pressure.

The UK studies reached their conclusions based on a small number of deaths in people with HIV. The study based on GP records may have undercounted people with HIV or been biased towards observing people with HIV who have health underlying conditions. More research is needed that can link HIV clinic records with hospital admissions to get a fuller picture of how COVID-19 affects people living with HIV.

A large study in South Africa has also found that people with HIV were at two to three times higher risk of dying from COVID-19, even after taking into account the impact of known risk factors such as age and diabetes. However, this study might not fully capture information about poverty or obesity, which might be important risk factors, so this finding could be an over-estimate. It is the only large study so far from a country with a high prevalence of HIV.

It’s important to note that these three studies tell us nothing about whether people with HIV are at higher risk than others of catching SARS-CoV-2, of developing symptoms, or of being admitted to hospital if they do.

Several smaller studies have looked at these questions.

A study in New York found that people with HIV were not over-represented among people admitted to hospital with COVID-19 during the first weeks of the pandemic.

A small study of people admitted to hospital with COVID-19 in New York found that people with HIV developed bacterial pneumonia more often than others and everyone who developed bacterial pneumonia died. Another study in New York found that people with HIV were more likely to require mechanical ventilation than others admitted to hospital with COVID-19, although this was a small study.

However, a study in London found that people with HIV did not have a higher risk of severe illness or death after admission to hospital with COVID-19. People with HIV were discharged from hospital more quickly than others of the same age and sex.

Which people with HIV are at higher risk of COVID-19?

Risk factors for COVID-19 are the same in people with HIV compared to the rest of the population, early studies show. Guidance from the British HIV Association and the European AIDS Clinical Society emphasises that older people with HIV with underlying health conditions are more vulnerable.

People with HIV with low CD4 cell counts were more likely to be admitted to hospital with COVID-19 than other people with HIV, a small study in London found, but other studies including a large US study have not found that a low CD4 count increase the risk of severe illness.

A study of people living with HIV receiving care at one London hospital found that Black people with HIV were around seven times more likely to die from COVID-19 than other people with HIV.

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.

Advice for people living with HIV

The British HIV Association (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 ‘shielding’ advice

‘Shielding’ refers to UK government advice for people who are extremely vulnerable. Although the government is no longer advising people to shield from 1 August 2020, you should look out for local alerts and you may choose to be cautious.

Glossary

risk factor

An aspect of personal behaviour or lifestyle, an environmental exposure, or a personal characteristic that is thought to be associated with an infection or a medical condition.

diabetes

A group of diseases characterized by high levels of blood sugar (glucose). Type 1 diabetes occurs when the body fails to produce insulin, which is a hormone that regulates blood sugar. Type 2 diabetes occurs when the body either does not produce enough insulin or does not use insulin normally (insulin resistance). Common symptoms of diabetes include frequent urination, unusual thirst and extreme hunger. Some antiretroviral drugs may increase the risk of type 2 diabetes.

cancer

A collection of related diseases that can start almost anywhere in the body. In all types of cancer, some of the body’s cells divide without stopping (contrary to their normal replication process), become abnormal and spread into surrounding tissues. Many cancers form solid tumours (masses of tissue), whereas blood cancers such as leukaemia do not. Cancerous tumours are malignant, which means they can spread into, or invade, nearby tissues. In some individuals, cancer cells may spread to other parts of the body (a process known as metastasis).

CD4 cell count

A test that measures the number of CD4 cells in the blood, thus reflecting the state of the immune system. The CD4 cell count of a person who does not have HIV can be anything between 500 and 1500. When the CD4 count of an adult falls below 200, there is a high risk of opportunistic infections and serious illnesses.

high blood pressure

When blood pressure (the force of blood pushing against the arteries) is consistently too high. Raises the risk of heart disease, stroke, kidney failure, cognitive impairment, sight problems and erectile dysfunction.

The British HIV Association 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

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.

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