HTB

COVID-19 symptoms in HIV positive people similar to general population in Wuhan 

17 April 2020. Related: COVID-19: HIV and COVID-19 coinfection, COVID-19.

Simon Collins, HIV i-Base

The most substantial data to inform risk of HIV and COVID-19 coinfection so far is an analysis from China. However, this is based on self-reported symptoms and the paper is not yet peer reviewed – published only in draft form ahead of press in the Lancet.

Wuhan city in Hubei province has a population of about 9 million people which includes about 6000 people who are HIV positive.

During the coronavirus outbreak, and up to 2 March 2020, at least 49,300 people tested positive for CoV-2 and 2227 residents died from COVID-19.

This paper included a subset of 1178 HIV positive people in two central districts in Wuhan. All participants were prospectively contacted by telephone and those reporting symptoms tested by PCR for CoV-2 and by CT scan for COVID-19. Face-to-face contact was limited due to lock down restrictions. The two districts included approximately 1,800,000 residents and reported 9,000 cases of COVID-19.

Of the 12/1178 people who reported symptoms, 8/12 were confirmed as COVID-19 (6/8 by PCR, 2/8 by CT – and 4/12 were excluded). All eight had undetectable viral load (<20 copies/mL) and were taking NNRTI-based ART, 6/8 with CD4 counts >350 and 2/8 between 100 to 350 cells/mm3.

Of these 8 cases, 6/8 were mild, 1 was severe, and 1 was a critical case who died.

Of the 1162 HIV positive people without symptoms, nine were in close household contact with people who had confirmed COVID-19. Of these, only 1/9 was confirmed positive for CoV-2 by PCR. This person had only recently been diagnosed with a very low CD4 count (27 cells/mm3), had received ART for less than one month and was on chemotherapy for KS.

The cohort also included 41 people with CD4 counts <100 cells/mm3, with only one of these having reported possible symptoms. In the discussion, the paper suggested that a low CD4 count might not reflect lower CoV-2 incidence but masking of symptoms of COVID-19 (but clearly not for the case mentioned above).

Based on self-reported symptoms the rate of COVID-19 in people living with HIV was estimated as 0.68% (95%CI: 0.29% to 1.34%). This was slightly higher than reported for general population in Wuhan (~0.5%) but similar to the overall estimated population rate of 0.83% (75 thousand out of 9 million).

In multivariate analysis, including age, gender, CD4 counts, viral load, and type of ART, only older age was significantly associated with higher risk of COVID-19 (p=0.010). The median age of the eight people with COVID-19 was 57.0 years old (95%CI: 47.5 to 61.5) compared to 36.0 (95%CI: 30.0 to 51.0) of those without COVID-19 (n=1166).

The paper discussed the role of other antiretrovirals in COVID-19. Although no cases were reported among the 178 people taking lopinavir/r, the study was underpowered to comments on individual drugs. Any possible role (would be for antiviral activity in early stage infection rather than in later COVID-19 when organ damage is caused by inflammation.

This reason is given to support the Chinese guidelines (versions 1 to 6) to use corticosteroids to treat COVID-19 to suppress the inflammatory cytokine storm. Other experts, including WHO, disagree with this approach based on several meta-analyses that highlight risk of harm. [2, 3]

comment

This study is welcome for providing some level of direct evidence that HIV positive people in Wuhan were not disproportionately affected by COVID-19. This is helpful in terms of concerns that incidence might be higher and outcomes might be worse.

The limitations from the study (other than lack of peer-review) is the reliance on self-reported symptoms and limiting testing to either those people who were symptomatic or at highest household risk. It doesn’t therefore provide data on incidence and prevalence of CoV-2 which will need antibody testing.

Also, behavioural data on travel and risk was not available, including whether those with lowest CD4 counts were already self-isolating to minimise risk.

While these data are important, we still have much to learn.

It is therefore important that all cases of COVID-19 with either pneumonia or respiratory failure in the UK have their HIV status recorded and the people without a recent negative result are routinely tested for HIV. [4]

These two low-cost initiatives would improve the management of both HIV and COVID-19 care.

Recent studies of lopinavir/r have reported conflicting results but a recent UK study was announced also using dexamethasone. [5, 6, 7, 8]

References

  1. Guo W et al . A survey for COVID-19 among HIV/AIDS patients in two districts of Wuhan China. Lancet. DOI: 10.2139/ssrn.3550029 (13 March 2020)
    https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3550029
  2. WHO. Clinical management of severe acute respiratory infection when novel coronavirus infection is suspected. (13 March 2020)
    www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected
  3. Russell CD et al. Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury. The Lancet 2020. DOI: 10.1016/S0140-6736(20)30317-2. (7 February 2020).
  4. Geretti AM, Collins S, Kelly S, Waters L. COVID-19 and HIV: Calling attention to the importance of ensuring HIV status and testing is included in the management of COVID-19. BMJ web blog. (7 April 2020).
    https://blogs.bmj.com/sti/2020/04/07/covid-19-and-hiv-calling-attention-to-the-importance-of-ensuring-hiv-status-and-testing-is-included-in-the-management-of-covid-19
  5. Cao B et al. A trial of lopinavir–ritonavir in adults hospitalized with severe Covid-19. NEJM. DOI: 10.1056/NEJMoa2001282. (18 March 2020).
    https://www.nejm.org/doi/full/10.1056/NEJMoa2001282 
  6. Deng L et al. Arbidol combined with LPV/r versus LPV/r alone against corona virus disease 2019: a retrospective cohort study. Journal of Infections.  doi: 10.1016/j.jinf.2020.03.002. (11 Mar 2020).
    https://www.ncbi.nlm.nih.gov/pubmed/32171872
  7. Li Y et al. An exploratory randomized, controlled study on the efficacy and safety of lopinavir/ritonavir or arbidol treating adult patients hospitalized with mild/moderate COVID-19 (ELACOI). MedRxIV. 23 March 2020.
    https://www.medrxiv.org/content/10.1101/2020.03.19.20038984v1
  8. Reuters Health News. UK begins trial of HIV medicine, steroid as possible COVID-19 treatments (23 March 2020).
    https://www.reuters.com/article/us-health-coronavirus-britain-tests/uk-begins-trial-of-hiv-medicine-steroid-as-possible-covid-19-treatments-idUSKBN21A2JO

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