US interim guidelines on COVID-19 and HIV
27 March 2020. Related: COVID-19: guidelines, COVID-19.
Simon Collins, HIV i-Base
On 20 March 2020, the US Department of Health and Human Services (HHS) published interim guidelines on special considerations about COVID-19 for people living with HIV and their health providers. [1]
The document was drafted by the same writing groups that publish other leading US HIV treatment guidelines for adults and children.
It provides guidance under six main headings, summarised below, but please refer to the full online document for details.
1. Guidance for all people living with HIV
This covers general information about risk for HIV positive people.
This is similar to that provided by BHIVA and WHO in that people on effective ART have similar risk as the general population. [2, 3]
Those not on ART or with a low CD4 count (defined as <200 copies/mL) should cautiously be assumed to have a higher risk. Similar advice to reduce risk by washing hands and limiting social physical interactions are recommended.
The importance of older age (>65 years) and other serious health conditions is emphasised (especially lung, heart, liver and kidney disease). Smoking is also listed as an important risk.
HIV positive people should keep at least one to three months of ART at home, and use home delivery when possible. Unless urgent, changing ART should be delayed until follow-up appointments are easier to arrange.
As with other guidelines, there is no recommendation to use lopinavir/r, especially as a recent study to treat COVID-19 was not successful.
Routine monitoring is less important for people on stable ART. Telephone or virtual appointments are recommended when possible. Any clinic visit should consider the risk and benefits of seeing a doctor compared to the risk of catching coronavirus.
The guidelines also refer to non-technical information produced for HIV positive people by the US CDC:
https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/hiv.html
2. Guidance for specific populations
This section recognises the limited data in most settings and links to specialist information from other organisations. The sections on pregnancy and children do not suggest higher risks than for the general population.
Links:
• People with HIV and in opioid treatment programmes
https://www.samhsa.gov/medication-assisted-treatment
• Pregnant women with HIV
https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/pregnant-women-and-children.html?
https://www.smfm.org/covid19
https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/03/novel-coronavirus-2019
• Children with HIV
https://www.cdc.gov/coronavirus/2019-ncov/hcp/pediatric-hcp.html
3. Guidance for self-isolation or people in quarantine due to exposure to coronavirus
This includes guidelines for both health workers with HIV positive clients (ensuring ART supply and planning for future COVID-19 symptoms).
Information for people living with HIV includes updating your doctor and including information about your current ART supply.
4. Guidance for people who have fever or respiratory symptoms
This section defers to online US CDC recommendations for health workers and people with symptoms.
Health workers:
https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html?
People with HIV:
https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html
- Anyone with a fever and symptoms (e.g. cough, difficulty breathing), should call their doctor or clinic.
- Calling the clinic in advance is important (rather than going to a clinic).
- Anyone who does visit a clinic should use hand washing and shielded coughing etc. If you don’t already have one, ask for a face mask when you arrive. It is essential to tell the clinic about symptoms straight away to reduce further risks of COVID-19 transmission in the clinic.
5. Guidance for managing people with HIV who develop COVID-19
This section covers the different circumstances depending on whether someone can manage symptoms at home or if they need to go to hospital. In both cases, continuing ART is stressed.
Also, unless medically needed, changes to ART should be avoided.
Treatments with long-acting formulations (infusions or injections) might need special arrangements. People using experimental treatment as part of a study should also have this continued if possible.
Continuing ART in people who are critically ill and need GI tube feeding can be informed by this Canadian guide:
https://www.hivclinic.ca/main/drugs_extra_files/Crushing%20and%20Liquid%20ARV%20Formulations.pdf (PDF)
6. Additional guidance for HIV doctors
The final section provides information about the important role HIV doctors have helping get access to care in the US, but that are also important in other countries.
It stresses that HIV positive people might need additional help with food, housing, transportation, and childcare during times of crisis and economic fragility. Doctors can help with getting social assistance and navigating to other essential resources.
Also that the need for physical distancing and isolation might worsen mental health and substance use and that additional telephone and virtual contact with HIV positive patients might be especially important during this crisis.
References
- US Department of Health and Human Services (HHS). Interim Guidance for COVID-19 and Persons with HIV. (20 March 2020).
https://aidsinfo.nih.gov/guidelines/html/8/covid-19-and-persons-with-hiv–interim-guidance-/0?utm - EACS and BHIVA. EACS & BHIVA statement on risk of COVID-19 for people living with HIV (PLWH) (20 March 2020)
https://www.eacsociety.org/home/covid-19-and-hiv.html - WHO. Q&A on COVID-19, HIV and antiretrovirals. (17 March 2020).
https://www.who.int/news-room/q-a-detail/q-a-on-covid-19-hiv-and-antiretrovirals