Emerging evidence on COVID-19 and HIV points to increased risk for those with a low CD4 count
People living with HIV who are virally unsuppressed likely to be more at risk of severe illness and death from COVID-19 than others.
A Lancet review suggests that people living with HIV who are virally unsuppressed are at a moderately increased risk of severe illness and death from COVID-19, possibly linked to the presence of other chronic conditions (known as co-morbidities).
Although evidence on COVID-19 is increasing, data on the relationship between COVID-19 and HIV is still limited and, at times, conflicting.
In an overview of what is known so far, The Lancet HIV reports that people living with HIV who are virally suppressed are experiencing similar outcomes from COVID-19 as people who are HIV negative. But that people living with HIV who are not on effective antiretroviral treatment (ART) have an increased risk of severe illness and death. Evidence of disruption to HIV prevention and treatment services is also emerging, suggesting the consequences of the pandemic for people living with HIV, and those most at risk, could be far reaching.
Global COVID-19 prevalence among people living with HIV is currently between 0·68–1·8%, which is similar to COVID-19 prevalence in the general population (0·6–0·8%). Among people living with HIV who were diagnosed with COVID-19 after having symptoms, 66% had mild symptoms, 22% had severe symptoms, and 12% needed critical care.
Earlier research found no clear evidence of higher COVID-19 infection rates or different disease outcomes among people living with HIV. But these studies were limited by small sample sizes and often involved younger people.
Larger studies have since been published. Some, although not all, have found that people living with who have low CD4 cell counts (less than 200 cells per μL), have a moderately increased risk of severe illness and death from COVID-19 than people who are HIV-negative.
As with other people, research suggests this risk increases with age, and is affected by sex (with men more at risk), and by the presence of certain chronic conditions, such as lung disease. As people living with HIV are susceptible to certain co-morbidities this is likely to increase their risk of severe illness and death from COVID-19. People who inject drugs, who have high rates of co-morbidities, are of particular concern here.
A UK study among people hospitalised due to COVID-19 found that HIV increased the risk of death by a factor of between 1.69 and 2.59. But most people with HIV who died had other co-morbidities. Similar results were found in Western Cape, South Africa.
The review found that COVID-19 lockdowns and stigmatisation have disrupted HIV clinics in many settings, particularly in low-income and middle-income countries. A report from the World Health Organization, conducted between April and June 2020, found that 34 of 127 countries had disrupted ART services. The disruptions to HIV prevention and treatment services may have caused as many as 400,000 excess deaths from AIDS-related illness in 2020, according to one modelling study.
COVID-19 pandemic has had a negative affect on mental health for many people. The Lancet review warns that people living with HIV and those from marginalised groups, such as sex workers and transgender people, are particularly likely to be affected by this because rates of mental health conditions were already high among these groups before the pandemic.
Few people living with HIV have been included in COVID-19 vaccine trials, which means data on this is also limited. What evidence does exist suggests that people living with HIV are likely to have the same response to vaccines as people who do not have HIV. There is an urgent need for more research in this area, particularly on whether two vaccine doses are enough to provide full protection.
Given the findings on the factors associated with COVID-19 ill health, people living with HIV that have low CD4 counts and those with co-morbidities should be considered a priority group for COVID-19 vaccination.