By Keith Alcom
Black people with HIV are significantly more likely to be admitted to a major London hospital with COVID-19 than other people with HIV, while in Madrid, researchers found that COVID-19 was diagnosed more frequently in people with HIV who had underlying conditions.
The findings, published in Clinical Infectious Diseases and Lancet HIV , are the first of several studies to analyze risk factors for COVID-19 in cohorts of people living with HIV. They provide the first comparisons of people living with HIV who have, or have not, required treatment for COVID-19.
The London study found that people with low CD4 counts were more likely to be hospitalized with COVID-19, but the Spanish study did not find that relationship.
King's College Hospital in south London serves one of the most ethnically diverse districts in Europe, and more than half of its HIV clinic group is Black. Clinicians reported on COVID-19 outcomes in people living with HIV admitted to the hospital with SARS-CoV-2 RNA-confirmed COVID-19 and observed risk factors for severe outcomes, comparing hospitalized patients with the entire King's College HIV cohort (n = 2699).
The King's College HIV cohort is 61% male, 58% black, with a median age of 49 years.
To date, eighteen people living with HIV from the cohort have been hospitalized with COVID-19, all but one black and two-thirds male (12 of 18)
Seven of the 18 patients had serious outcomes (death, mechanical ventilation, or intensive care unit admission), including five who died. There were no significant differences between hospitalized patients with serious and non-serious outcomes.
Of those admitted to the hospital, 56% were obese, 33% had hypertension, and 28% had chronic kidney disease. Chronic kidney disease, obesity, and diabetes were more common in those with severe outcomes, but hypertension was not, compared to non-severe cases. However, statistical significance was not assessed for the differences between severe and non-severe cases.
Five people suffered acute kidney injury during hospitalization, all in the group of patients with severe outcomes.
Among people living with HIV, Black race and a lower CD4 count before COVID-19 hospital admission were the only factors significantly associated with a higher risk of hospitalization. (The study did not compare the prevalence of underlying conditions such as hypertension or diabetes between people with COVID-19 and the full HIV cohort.)
Black people were 12 times more likely to be hospitalized than other ethnic groups (odds ratio 12.22 [95% CI 1.62–92.00], p = 0.015), although the number of patients in this study means that the confidence intervals for this estimate are very wide. Several studies in the UK have reported a higher COVID-19 mortality rate in non-white populations, as was the case with H1N1 influenza in 2009/10. Socioeconomic deprivation, a higher risk of occupational exposure, and a higher prevalence of underlying conditions have been proposed as explanations for the higher mortality rate. Further analysis of larger cohorts is needed to clarify whether Black people with HIV are at greater risk of COVID-19 than other Black people and other people with HIV.
The median CD4 count of hospitalized patients was 395 compared to 573 in the entire outpatient cohort (p = 0.03).
There was also a trend toward more frequent use of a protease inhibitor (specifically, boosted darunavir) in HIV regimens of people diagnosed with COVID-19 (61% vs 39%, p = 0.067), although this trend was not statistically significant.
Madrid: Higher risk of COVID-19 for people with comorbidities
Doctors at the Ramón y Cajal University Hospital in Madrid reported on COVID-19 hospital admissions among people living with HIV. The hospital provides regular care to 2,873 people with HIV, and updated data is available for 1,339 patients.
Fifty-one people with HIV were diagnosed with COVID-19 in the hospital or local health centers and reported to the HIV clinic, up to April 30, 2020. Most were men, with a mean age of 53, who were doing well on HIV treatment.
Thirty-five of the 51 cases were confirmed by virological tests; the rest were diagnosed based on symptoms and chest X-rays. Twenty-eight of the 51 cases were hospitalized, and 13 were defined as severe cases. Six of the 28 hospitalized patients became critically ill and required admission to the intensive care unit; of these, two died. As of April 30, 44 had recovered, five remained hospitalized, and two had died.
Severe cases of COVID-19 had significantly lower total lymphocyte counts, but there were no differences in recent CD4 counts between severe and mild/moderate cases. The only characteristic that differed between severe and mild/moderate cases was smoking history; severe cases were significantly more likely to be current or former smokers (92% vs 58%, p = 0.038).
"The only factors associated with a higher risk of COVID-19 diagnosis were body mass index, comorbidities, and treatment with tenofovir."
Among the severe cases, two had recent CD4 counts below 200, and the study authors note that low CD4 counts in the cohort correlated with laboratory measures of COVID-19 severity (low lymphocyte and platelet counts, higher levels of interleukin-6, although inflammatory markers were measured only in severe cases).
The Madrid cohort found no difference in COVID-19 diagnosis based on ethnicity among people living with HIV receiving care at the hospital's HIV clinic (90% of the cohort were white and 8% were Latin American). The only factors associated with a higher risk of COVID-19 diagnosis were body mass index, comorbidities, and tenofovir treatment.
People with HIV diagnosed with COVID-19 were significantly more likely to be overweight (BMI of 25 or higher) (53% vs 24%, p = 0.024) compared to others in the hospital's HIV cohort.
Las condiciones de salud subyacentes presentes en las personas con VIH diagnosticadas con COVID-19 no diferían de las reportadas en la población en general, excepto por la enfermedad hepática crónica. El 63% de los diagnosticados tenían al menos una comorbilidad en comparación con el 38% de las personas con VIH sin COVID-19 (p = 0,00059). La hipertensión (35% frente a 8%, p <0,0001), diabetes (14% frente a 3%, p = 0,0011) y enfermedad renal crónica (12% frente a 1%, p = 0,00014) tenían muchas más probabilidades de estar presentes en personas diagnosticadas con COVID-19 en comparación con otras personas con VIH. La enfermedad hepática crónica también fue algo más común en personas con COVID-19 (47% frente a 33%, p = 0.034).
People with HIV diagnosed with COVID-19 were significantly more likely to be taking tenofovir before hospital admission than other people with HIV (73% vs. 38%, p = 0.0036). The study authors say the number of people studied is too small to draw any conclusions.
Expert guidance
Recent guidance from European medical groups on HIV, including the British HIV Association, emphasizes that “almost half of people living with HIV in Europe are over 50 years old and chronic medical problems, including chronic lung and cardiovascular diseases, are more common in people living with HIV.”
The guide also notes that HIV did not negatively affect survival in a UK cohort of 16,749 hospitalized COVID-19 patients in which approximately 1% of the cohort were HIV positive.
References
Childs K et al. Hospitalized patients with COVID-19 and HIV: a case series . Clinical Infectious Diseases, online ahead of print, May 27, 2020.
Vizcarra P et al. Description of COVID-19 in HIV-infected individuals: a single-center prospective cohort . Lancet HIV, online ahead of print, May 28, 2020.