Deaths from COVID-19 have fallen much less sharply in people with HIV compared with the rest of the population since the arrival of the Omicron variant of SARS-CoV-2, the World Health Organization (WHO) reported last week at the 12th International AIDS Society Conference on HIV Science (IAS 2023) in Brisbane.
The study found that one in five people with HIV admitted to hospital with COVID-19 died during the Omicron wave compared to one in ten people without HIV.
The Omicron variant of SARS-CoV-2 emerged in late 2021 and swiftly replaced other variants as the cause of almost all hospital admissions for COVID-19. Although more transmissible than any previous variant of SARS-CoV-2, it became apparent within weeks of its emergence that Omicron was less likely to cause severe illness than the preceding Delta variant.
But there have been hints that Omicron continues to cause higher levels of serious illness in people with HIV. A WHO analysis presented at AIDS 2022, looking at the period up to May 2022, found a higher risk of death in the Omicron wave in South Africa among people with HIV compared with the rest of the population.
To explore this question further, WHO researchers analysed data on 821,331 people admitted to hospital with COVID-19 in 38 countries, submitted to the WHO Global Clinical Platform. The analysis compared outcomes after hospitalisation by HIV status between three waves of the pandemic: the pre-Delta wave in 2020, the Delta wave in 2020-21, and the Omicron wave in late 2021-early 2022. Around 90% of the data on people with HIV was contributed from South Africa; the researchers did not report whether results are consistent across global regions.
Two-thirds of cases were reported in the pre-Delta period, 18% in the Delta period and 15% in the Omicron period. Just over 5% of cases (43,699) were reported in people with HIV.
Overall, 19% of people without HIV and 23% of people with HIV died after hospital admission. Among people without HIV, the death rate steadily declined during each phase of the pandemic, from 22% in the pre-Delta wave to 20.9% in the Delta wave and 9.8% in the Omicron wave.
But in people with HIV, the reduction was modest. The death rate in people with HIV was 24.2% in the pre-Delta wave, 23.4% in the Delta wave and 19.6% in the Omicron wave. Living with HIV was associated with a steadily greater risk of dying after hospital admission with COVID-19. Whereas people with HIV had approximately 50% higher risks of dying in the pre-Delta and Delta waves, they were almost two-and-a-half times more likely to die after hospital admission in the Omicron wave.
“These findings emphasise the need to implement WHO recommendations for giving booster vaccine doses for all people living with HIV."
People with unknown HIV status were also at higher risk of dying than people without HIV, by 30% in the pre-Delta wave, 14% in the Delta wave and 47% in the Omicron wave.
Vaccination was associated with a 39% lower risk of dying after hospital admission in the Delta wave and a 38% lower risk in the Omicron wave.
In the pre-Delta wave, the risk of death after hospital admission in people with HIV was higher among people with severe or critical COVID-19 at admission, people over 65, people with CD4 counts below 200 and those with either chronic kidney disease, latent or active TB, or diabetes.
In the Delta wave, age over 75 years, severe or critical COVID-19 at admission, CD4 count below 200, chronic kidney disease or diabetes raised the risk of death. In the Omicron wave, age between 65 and 75 years, CD4 count below 200 and severe or critical COVID-19 at admission raised the risk.
Across all three waves, older age was the strongest risk factor, raising the risk of death four to six-fold. But the precise age band at higher risk varied between time periods.
Severe or critical COVID-19 at admission approximately doubled the risk of death across the three pandemic waves. A CD4 count below 200 raised the risk of death by 52% to 79%. The WHO study team say that the consistent finding that low CD4 counts increase the risk of death from COVID-19 highlights the need for intensified HIV testing and treatment initiation to reduce the risk of severe outcomes.
“These findings emphasise the need to implement WHO recommendations for giving booster vaccine doses for all people living with HIV even during the less severe and low incidence SARS-CoV-2 variant waves,” the researchers concluded.
Bertagnolio S et al. High in-hospital mortality in SARS-CoV-2 infected patients living with HIV during pre-Delta, Delta and Omicron variant waves: finding from the WHO Global Clinical Platform for COVID-19. 12th IAS Conference on HIV Science, Brisbane, abstract OALBC0604, 2023.