Are people with HIV at greater risk of COVID-19 mortality?

People with HIV (PWH) who are hospitalized due to COVID-19 may have an increased mortality risk, according to a study from the UK.

The researchers used data from the ISARIC WHO CCP* to identify 47,592 adults who were hospitalized for laboratory-confirmed or highly likely SARS-CoV-2 infection between 17 January and 4 June 2020 at 207 centres in the UK. Of these, 0.26 percent (n=122) were HIV-positive, of whom 91.8 percent (n=112) were on antiretroviral therapy (ART).

At hospital admission, PWH were younger than those without HIV (median age 56 vs 74 years; p<0.001). They had fewer comorbidities overall but were more likely to have moderate or severe liver disease and higher lymphocyte counts and C-reactive protein levels than those without HIV. Respiratory rate and presence of chest infiltrates did not differ between patients with and without HIV.

At day 28, the cumulative incidence of mortality did not differ between patients with and without HIV (26.7 percent vs 32.1 percent; p=0.16). [HIV Glasgow 2020, abstract O422; Clin Infect Dis 2020;doi:10.1093/cid/ciaa1605]

However, among patients aged <60 years, mortality risk was elevated in patients with vs without HIV (21.3 percent vs 9.6 percent; p<0.001). Adjustment for age showed a trend toward a higher mortality risk among patients with vs without HIV (adjusted hazard ratio [adjHR], 1.47, 95 percent confidence interval [CI], 1.01–2.14; p=0.05). The risk was particularly elevated in patients aged <60 years (adjHR, 2.87, 95 percent CI, 1.70–4.86; p<0.001).

The risk of admission to critical care did not differ between patients with and without HIV (adjusted odds ratio, 1.22; p=0.35).

In the cohort of PWH, there was a higher prevalence of obesity and diabetes with complications in the group of patients who died compared with those who survived. Patients who died were also slightly older than those who survived by day 28 and were less likely to have recorded ART use.

“There is conflicting evidence about the influence of HIV on the outcomes of COVID-19,” said the researchers.

“This study found evidence suggesting an age-adjusted 47 percent increased risk of day-28 mortality among PWH hospitalized with COVID-19 compared to HIV-negative individuals,” they said. In patients aged <60 years, the mortality risk was twofold in HIV-positive vs HIV-negative patients, they added.

“Despite effective ART and normalized CD4 cell counts, a subset of PWH continue to experience immune activation, inflammation, and a pro-coagulatory state which may modulate the risk of COVID-19-related morbidity and mortality,” they suggested.

Prior to updated guidelines, older PWH may have had “uncontrolled HIV replication” for years before treatment initiation and may also have been subject to prior “suboptimal” treatment regimens which could have affected immune function, they theorized.

“As the pandemic continues to spread, including in areas of increased HIV prevalence, it is important to record the HIV status of people hospitalized with COVID-19 and gather further data to corroborate our findings and confirm the population-specific determinants of outcomes,” they said.