- People with HIV appear to have a slightly increased risk of dying from COVID-19. A low CD4 count increases the risk of serious illness.
- People with HIV who have underlying health conditions such as obesity, poorly controlled diabetes, chronic kidney disease 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 a recent diagnosis of a cancer of the blood greatly increase the risk of dying from COVID-19.
Vaccines are now available that greatly reduce the risk of serious illness and death. People with HIV are a priority group for vaccination in many countries, including the United Kingdom.
Are people with HIV at higher risk of infection?
There’s no evidence that people living with HIV are at higher risk of infection with SARS-CoV-2 than HIV-negative people. US researchers compared over 55,000 people with HIV with a comparison group of 3.7 million people who did not have HIV. Testing rates were higher in the group of people with HIV, but among those tested the proportion with SARS-CoV-2 was similar.
Who is at greater risk of COVID-19?
A large study of risk factors for severe COVID-19, OPENSafely, looked at around 40% of GP patients in England (17.2 million people) before vaccines were available.
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.
A study of over 15,000 cases of COVID-19 in people living with HIV carried out by the World Health Organization found that people with HIV had a 30% higher risk of dying after admission to hospital with COVID-19 than people without HIV. Among people living with HIV, diabetes, high blood pressure, being male or over 75 years old were each associated with an increased risk of death.
However, 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.
A global study conducted by the World Health Organization in 268,412 people in 37 countries, including just over 15,000 people living with HIV found that people with HIV were 13% more likely to be admitted to hospital with severe or critical COVID-19 after controlling for age, gender and co-morbidities.
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.
Are people with HIV at higher risk of long COVID?
A large UK study found that three to four months after developing COVID, around 5% of people still had symptoms – and that if people had not recovered after three months, the symptoms tended to persist. A review of 15 studies found that vaccination halved the risk of developing long COVID, where symptoms persist for at least three months after infection.
People with HIV who have not been vaccinated appear more likely to develop long COVID. A small US study found that people with HIV were four times more likely to experience long COVID than a matched control group of HIV-negative people. More evidence is needed on the risk of long COVID and the impact of vaccination 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 meta-analysis of nine studies looking at the impact of underlying health conditions on COVID-19 outcomes in people with HIV concluded that chronic kidney disease raised the risk of death or hospitalisation due to COVID-19 nine times, diabetes seven times and hypertension or chronic respiratory disease four times compared to people with HIV who did not have that condition.
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.
In the United States, the National COVID Cohort Collaborative Consortium reviewed 8270 cases of SARS-CoV-2 infection diagnosed up to May 2021. They found that people with CD4 counts between 350 and 500 were three times more likely to be admitted to hospital with COVID-19 compared to people with CD4 counts above 500. People with CD4 counts below 350 were six times more likely to be admitted to hospital. A detectable viral load raised the risk of being admitted to hospital, even in people with high CD4 counts.
A Spanish study in 13,142 people with HIV receiving care in the province of Catalonia found that 103 were admitted to hospital with severe COVID-19 up to December 2020. People with CD4 counts below 500 and a detectable viral load were more likely to be admitted to hospital or die from COVID-19. In people with suppressed viral load, a CD4 count below 500 did not raise the risk of severe illness.
Research in South Africa’s national hospital surveillance system for COVID-19 identified 13,793 people with HIV admitted to hospital with COVID-19 up to March 2021. People with HIV with CD4 counts below 200 were twice as likely to die after admission as people without HIV, as were people with HIV with detectable viral loads above 1000 copies/ml.
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.
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.
COVID-19 increases the risk of adverse birth outcomes for all pregnant women. A systematic review of 42 studies, published in April 2021 prior to the Delta variant wave, found that SARS-CoV-2 infection during pregnancy raised the risks of pre-eclampsia, stillbirth and pre-term birth in studies largely carried out in Europe, China and North America. COVID-19 doubled the risk of stillbirth in a study of 1.2 million women who gave birth in the United States.
A study in Botswana has shown that women with HIV have a higher risk of adverse birth outcomes if they have COVID-19 during pregnancy. During the study period 11,483 women were tested for COVID-19 around the time of delivery, 4.7% tested positive (539) and of these, 144 were living with HIV. The overall rate of adverse birth outcomes was 31% higher in women who tested positive for COVID-19 and 78% higher in women with HIV who had COVID-19 compared to women with HIV who did not have COVID-19.
Very few of the women who took part in this study had been vaccinated against COVID-19.
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.
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. People with HIV with CD4 counts below 500 may have a weaker response to vaccination; this is improved by a third vaccine dose. Visit our page COVID-19 vaccines for people with HIV for more information on the efficacy and safety of vaccines in people with HIV and vaccination recommendations for people with HIV.
Advice for people living with HIV
People who are extremely clinically vulnerable to COVID-19 are no longer advised to stay at home and shield from the risk of infection in England.
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 – you might want to wait until 14 days after everyone’s second dose of a COVID-19 vaccine before being in close contact with others
- considering continuing to practice social distancing if that feels right for you and your friends
- asking friends and family to take a rapid lateral flow antigen test before visiting you
- asking home visitors to wear face coverings
- avoiding crowded spaces.
HIV clinics are operating normal services wherever possible. The British HIV Association recommends that people with HIV should be seen for routine monitoring tests at least once every 12 months.
BHIVA has 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.