HIV and coronavirus (COVID-19): are HIV positive people at higher risk?
Hi, with all the news about coronavirus, am I at higher risk because I am living with HIV? I am on treatment with an undetectable viral load and a good CD4 count.
Thanks for your question. This Q&A answer was updated on 25, 23, 21, 20, 19, 18, 17, 14 and 10 March from a question first posted on 27 February. Recently updated text is in bold. It will be continue to be updated. Please bookmark and check again later).
The news about COVID-19 (coronavirus disease 2019 – the disease linked to this strain of coronavirus) is changing each day. But (so far) there is very little data about how it affects people living with HIV. Although there is no data to suggest that HIV positive people are at any higher risk, HIV is sometimes included in the list of health conditions you need to be extra careful about. This will depend on your CD4 count and other factors. Serious cases have also now been reported in younger people.
- Information from Public Health England on 16 March 2020 included HIV as an increased risk. Please see below for discussion about CD4 count.
- However, WHO advice, published on 17 March 2020 state that the risks for people on effective HIV treatment (ART) who have a good CD4 count are similar to risks for the general population.
- The BHIVA statement on 19 March 2020 stated that being on effective ART makes risks similar to general population, but that having a low CD4 count (less than 200 cells/mm3) might increase risk.
- A joint EACS/BHIVA statement on 20 March 2020 emphasised that neither ART nor PrEP can prevent or treat COVID-19.
- US HHS guidelines published on 20 March 2020 are similar to the BHIVA and WHO interpretation, with a caution for having a CD4 count <200 cells/mm3.
- BHIVA on 23 March 2020 explained that having a CD4 count <50 will mean following UK government advice for “social shielding” for people who are extremely vulnerable. This means minimal face-to-face contact for 12 weeks. Not being on ART, having a CD4 count between 50 and 200, or having a detectable viral load makes it more urgent to closely follow social physical distancing.
- On 25 March, BHIVA added statements on government advice for people who are extremely vulnerable and about managing HIV positive women who are pregnant.
There is also limited data about COVID-19 and other populations with lower immunity. So the general advice is to follow the news for any announcements by your national health authority. This information is rapidly changing.
COVID-19 is currently major news and this is likely to continue for some time. As seasonal influenza routinely affects many more people, including having serious and fatal outcomes, getting the pneumococcal and seasonal flu vaccines (see below) was originally important. However, with the latest information about restricted social interactions and priority access to GP and other services, this might now be more difficult. For the UK and other countries moving into spring an summer, the flu vaccine is not so important as the flu season is ending.
Older people (because immune function reduces after age 60) are at higher risk from COVID-19. This is especially if older than 70 and even more so if older than 80. This is based on observations in the general population in China, Italy and other high incidence settings. Serious cases in Italy, France and the USA have been reported in younger people.
Other chronic health conditions also increase the risks with COVID-19. For example, having heart disease, kidney disease, diabetes, lung/breathing problems and cancer. Smoking is also a risk. HIV is included in this list by the UK government. BHIVA (UK), European, WHO and US guidelines see HIV positive people on ART as being at similar risk to general population.
Some other people who have lowered immunity, such as pregnant women and young children, have not so far been at higher risk from COVID-19. This might just be because they came into less contact with risk. At least one case has reported transmission of COVID-19 either during pregnancy or at birth. Other cases did not see this. US guidelines link to detailed information about pregnancy and also about children.
If COVID-19 is likely to be a higher risk for HIV positive people, this might be related to having a low CD4 count. This opinion is not supported by evidence from the general population. Anyone on treatment with a CD4 count above 500 is considered similar to being HIV negative. Even having a CD4 count between 350 to 500 is still very good, especially if viral load is undetectable on treatment. However, there is no data so far to support the view that a lower CD4 count has any effect on COVID-19.
Having a CD4 count under 200, not being on ART or not having undetectable viral load might increase any risk. This makes it more important to follow general advice more strictly. This includes good practice like washing your hands and minimising touching your face. It also makes “social physical distancing” more important. This is not the same as self-isolation or social distancing. It is important for your well-being to keep in contact with friends and family by phone, video calls and social media.
This advice on CD4 and risk is based on expert opinion rather than direct evidence, but being cautious now is important.
During flu season HIV positive people are recommended to get vaccinated each year. It is also recommended to have the pneumococcal vaccination (PCV-13) (at any time of the year if you haven’t had this) which provides cover for 5-10 years (see below for details).
From the outset, older HIV positive people and those with other health conditions, need to be especially careful. This should not be interpreted though that being young will protect you. As the epidemic spreads, this includes serious cases in much younger people have been reported.
- Transmission is largely from microdroplets in air breathed out from someone during the infectious period (generally <1 day before symptoms to average 5 days, but up to 14 days).
- As well as the direct risk from breathing in these droplets if someone has just sneezed or coughed without shielding themselves, these can remain infectious on hard surfaces for an unknown time. This is likely to be at least several hours which is why hand-washing and not touching your face is important.
- Best ways to minimise risk of infection include washing your hands more carefully – for at least 20 seconds – and frequently – and not touching your face.
- Soap and water is better than hand sanitisers (and more readily available).
Trials of remdesivir – the best current treatment – are already underway and a candidate vaccine is expected to be fast-tracked. Of interest, some HIV medicines (including lopinavir/r) are being looked at to treat COVID-19, though evidence supporting any benefit is also very limited.
An overview of the current knowledge about COVID-19 was included in the recent CROI 2020 conference. (View webcast from CROI 2020).
The UK government also provided more information about what is involved in “self-distancing” for people at higher risk. This is different to “self-isolation”. Please read here for information about self-distancing.
Does PrEP or HIV meds (ART) protect against or treat coronavirus?
No. Neither HIV meds nor PrEP reduce the risk of catching coronavirus. They also will not help to treat coronavirus.
British HIV Association (BHIVA)
BHIVA have posted eight online statements about COVID-19. They are collected on this page where future updates will be added.
management of a pregnant woman living with HIV and infant testing during Coronavirus (COVID-19) (25 MArch 2020).
This cover management of HIV positive pregnant women during the coronavirus crisis and testing advice for the infant depending on level of risk.
This statement updates government advice for the general population to stay home.
- People should only go outside for food, health reasons or work (where this absolutely cannot be done from home).
- To stay 2 metres (6 feet) away from other people;
- Wash your hands as soon as you get home.
This information looks at how to protect against COVID-19 depending on your CD4 count. Having a CD4 count less than 50 cells/mm3 makes someone “extremely vulnerable”. This means following advice for “shielding” – basically isolating at home for three months with support to get supplies and food.
- People with a CD4 count <50 or opportunistic illness in last 6 months: follow shielding advice for extremely vulnerable. This includes avoiding face-to-face contact for 12 weeks – and will need support to do this.
- People with CD4 <200, detectable viral load or not on ART: follow social distancing advice very closely.
- People with CD4 >200 and undetectable on ART: follow general population advice (ie social physical distancing).
This joint statement is to emphasise consistent expert opinion across Europe that HIV is not an additional risk for COVID-19 if someone is on effective ART. Having a CD4 count below 200 cells/mm3 or not being on ART is likely to increase the risk though.
There is no evidence to support any benefit from HIV meds against coronavirus. Neither ART nor PrEP will protect against or treat coronavirus.
Liverpool University have published a new website (www.covid19-druginteractions.org) for the experimental drugs being studied to treat COVID-19.
This update answers eight common questions about COVID-19 for HIV positive people. It includes that HIV drugs are not effective against coronavirus, to continue taking ART as usual, and that there are no problems with supplies of HIV meds. Self-distancing is important (not self-isolation), as is following advice for general population to reduce risk.
This update mainly refers people to the UK Government website to explain how to respond to the advice to limit social interactions.
Following CROI 2020, there continues to be no evidence that people with HIV are at higher risk of COVID-19, or severe disease if affected, and no evidence regarding the impact of viral load or CD4 on either of these.
You may have read that the HIV drug lopinavir/ritonavir (Kaletra) is being studied as a possible treatment for COVID-19 but this is based on very limited evidence for similar viruses. So far there is no good evidence that lopinavir/ritonavir is beneficial, and no evidence that other HIV drugs will help. For anyone taking HIV drugs for treatment or prevention, we recommend continuing to take treatment as recommended, and not increasing the dose or switching to other medications unless otherwise indicated.
There has been one case report published of a man with HIV and diabetes who was hospitalised with COVID-19, treated with lopinavir/ritonavir and who subsequently recovered. However, this provides no further information on the impact of either HIV per se, or lopinavir/ritonavir, on COVID-19: https://onlinelibrary.wiley.com/doi/10.1002/jmv.25732
We continue to recommend following national advice as provided here https://www.gov.uk/guidance/coronavirus-covid-19-information-for-the-public and encouraging people with HIV to ensure they have had their flu and appropriate pneumococcal vaccines (as per BHIVA vaccine guidelines.) We also advise that patients have at least 30-days medication available and sufficient supply to allow for possible travel restrictions or quarantine, if they are planning to leave the UK.
Individual organisations will be making their own contingency plans, and most non-urgent services are being asked to minimise face-to-face appointments. As the set-up and capacity of services will vary significantly, we cannot give specific recommendations, but if people have examples of good practice they wish to share, BHIVA can facilitate this. Sensible steps include updating your website if you have one, using out-of-office replies to direct patients to appropriate advice and ensuring all patient-facing staff are aware of the latest national information and guidance.
We advise against prescribing longer than usual medication supplies as stocks can be fragile at any time. Please also note, for those of you based in England, NHSE have instructed us to avoid signing new people up to Homecare as they need to focus on maintaining current capacity.
- Following the regularly updated advice from Public Health England, Health Protection Scotland, Public Health Wales, the Department of Health Northern Ireland and the Health Service Executive Ireland.
- Ensuring people with HIV have received influenza and pneumococcal vaccination in line with BHIVA vaccine guidelines.