HIV and COVID 19
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.
·
Vaccines against COVID-19 are highly
effective in preventing serious illness. They are not thought to be less
effective in people with HIV, but more data are needed.
·
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.
Vaccines are now becoming available that
greatly reduce the risk of serious illness. People with HIV are a priority
group for vaccination in several countries, including the United Kingdom.
Who is at
greater risk of COVID-19?
The latest news and research on coronavirus
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 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.
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.
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.
There are no data on ‘long COVID’ (symptoms
which continue for weeks or months after the infection has gone) 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 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.
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.
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.
·
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.
Two studies of the Oxford/AstraZeneca vaccine in people with HIV show that the vaccine produced the same strength of immune response in
people with HIV and people without HIV. There was no difference in the common
vaccine side effects of sore injection site, headache, chills, tiredness or
muscle and joint pains. People in both studies had high CD4 counts (above 500)
and were on antiretroviral treatment.
Basic information on have COVID-19 vaccines been tested in people with HIV?
Experience from vaccinations against
other infections shows that older people and those with low CD4 counts (below
350 now, or below 200 at some point in the past) and people with unsuppressed
HIV show weaker immune responses to some vaccines. This leads to a lower level
of protection or a shorter period of protection. There are no data yet to show
that this is the case for COVID-19 vaccines.
Trials of other COVID-19 vaccines
reported to date had few participants with HIV. It is not possible to say
whether any vaccine is less effective in people with weakened immune systems.
On 15 January 2021, European HIV medical associations including the European AIDS Clinical
Society and the British HIV Association (BHIVA) recommended that people with
CD4 counts below 350 should be prioritised for COVID-19 vaccination. They note that current guidance about prioritisation of people with HIV
for vaccination varies between European countries.
In the United Kingdom, all people with
HIV should have been offered a first dose of a COVID-19 vaccine by March 2021,
based on their place in priority groups 4 or 6 and regardless of age. If you
have not yet been vaccinated and you have not notified your GP that you are
living with HIV, you can be referred to a vaccine hub by your HIV clinic.
In the United States, the Centers for Disease
Control and Prevention lists HIV as a medical condition which may raise the
risk of severe illness from COVID-19. This is relevant for vaccine
prioritisation, although policies are determined by each state.
Advice for
people living with HIV
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 the UK government's ‘shielding’ advice for people who are extremely
vulnerable.
BHIVA 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
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.
This page was last reviewed in April
2021. It is due for review in July 2021.
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