- Unvaccinated people with HIV have a slightly increased risk of dying from COVID-19, compared to unvaccinated people who do not have HIV. A low CD4 count increases the risk of serious illness.
- Vaccination greatly reduces the risk of serious illness or death from COVID-19.
- People with HIV with a CD4 count above 350 who are vaccinated do not have an increased risk of serious illness or death compared to other vaccinated people.
- People with CD4 cell counts below 200 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 unvaccinated people die after catching this virus. Old age, an organ transplant or a recent diagnosis of a cancer of the blood greatly increase the risk of dying from COVID-19.
SARS-CoV-2 is spread by airborne particles or droplets when people with the virus cough, sneeze or speak.
Vaccines greatly reduce the risk of serious illness and death. A study of the Scottish population showed that vaccination reduced the risk of death from COVID-19 by 90% in the first half of 2021.
People with HIV are a priority group for vaccination in many countries, including the United Kingdom.
People with HIV with CD4 counts below 500 may have a weaker response to vaccination; this is improved by having booster doses. Visit our page COVID-19 vaccines in people with HIV for more information on the efficacy and safety of vaccines in people with HIV as well as vaccination recommendations for people with HIV.
People with HIV are encouraged to have regular booster doses when these are offered.
If you have a low CD4 count (below 200) you may wish to take extra precautions against COVID-19 including:
- considering whether you and those you are meeting have been vaccinated
- asking friends and family to take a rapid lateral flow antigen test before visiting you
- avoiding crowded spaces.
Are people with HIV at higher risk of infection?
There’s no evidence that unvaccinated people living with HIV are at much higher risk of infection with SARS-CoV-2 than HIV-negative people. Among people who are vaccinated, several studies have shown that people with HIV have a slightly higher risk of infection, although breakthrough infections are uncommon.
Who is at greater risk of serious COVID-19 illness?
Old age is by far the strongest risk factor for dying from COVID-19. People over 80 were at least 20 times more likely to die than people aged 50-59 before vaccines were available. Although COVID-19 vaccines greatly reduce the risk of death or serious illness, older people who have been fully vaccinated remain at higher risk of death or serious illness than younger vaccinated people.
Several underlying health conditions raise the risk of severe illness and death in unvaccinated and vaccinated people.
A large UK study found that vaccinated people with the following conditions remained at between two and eight times higher risk of dying from COVID-19: kidney transplant, sickle cell disease, liver cirrhosis, organ transplant or bone marrow transplant, a neurological condition, dementia or Parkinson’s disease.
The following conditions slightly increased the risk of death from COVID-19 in vaccinated people: chronic kidney disease, blood cancer, epilepsy, chronic obstructive pulmonary disease, coronary heart disease, stroke, atrial fibrillation, heart failure, thromboembolism, peripheral vascular disease, and type 2 diabetes.
Other risk factors such as Asian ethnicity, social deprivation and male gender also raised the risk of death.
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.
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.
Several factors related to HIV also raise the risk of severe illness or death in people who are unvaccinated:
- A low CD4 count (especially when it is below 200)
- A current AIDS-defining illness
- Unsuppressed viral load (even in people with high CD4 counts).
Among vaccinated people with HIV, those with CD4 counts below 350 – and especially below 200 – have a higher risk of serious COVID-19 illness.
Some studies have shown that taking the older form of tenofovir (tenofovir disoproxil fumarate, TDF) is associated with a lower risk of severe COVID-19.
Are people with HIV at higher risk of dying from COVID-19?
Several studies have shown that unvaccinated people living with HIV have a raised risk of dying from COVID-19. The estimated increase in risk varies between studies. A large international study of people admitted to hospital with COVID-19 found that people with HIV had a 51% increased risk of dying from COVID-19. Other studies that looked at the whole population estimate that people with HIV have twice the risk of dying from COVID-19 compared to people without HIV.
For people who have been vaccinated, two large studies in the United States and Denmark show that the risk of dying from COVID-19 was no higher in people with HIV compared to the rest of the vaccinated population.
Are people with HIV at higher risk of severe COVID-19 illness?
The majority of studies carried out before the introduction of vaccination showed that people with HIV were at higher risk of being admitted to hospital with COVID-19. But they reached differing conclusions about whether people with HIV were more likely to suffer severe illness requiring intensive care or mechanical ventilation.
Studies in vaccinated people show that people with HIV do not have a higher risk of being admitted to hospital due to COVID-19. A large study in the United States in 2021 showed no increased risk of severe COVID-19 in vaccinated people with HIV except for those with CD4 counts below 350 (see Which people with HIV are at higher risk of COVID-19? above). A large study in Denmark showed that although people with HIV had a higher risk of being admitted to hospital with COVID-19 between 2020 and 2022, this difference in risk fell over time and had disappeared by 2022, largely as a consequence of vaccine coverage and vaccine boosting in people with HIV.
Are people with HIV at higher risk of long COVID?
People with HIV who have not been vaccinated appear more likely to develop long COVID. Among people who are vaccinated, more evidence is needed.
COVID-19 and pregnancy
Pregnancy raises the risk of severe COVID-19 for all women, although the overall risk remains low. It is unclear if women with HIV are at greater risk of severe COVID-19 during pregnancy than other women.
Several large studies have shown that having COVID-19 during pregnancy raises the risk of adverse birth outcomes including pre-eclampsia (dangerous increase in blood pressure during pregnancy), stillbirth and pre-term birth. Regardless of COVID-19, the risk of an adverse birth outcome is higher in women with HIV than women without HIV.
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. In addition, a low CD4 count may lead to a more severe inflammatory response to SARS-CoV-2.
- 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.
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.
The British HIV Association (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.