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

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 However, this is based on self-reported symptoms and the paper is not yet peer reviewed – published only in draft form ahead of press in the Lancet.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]


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]


  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)
  2. WHO. Clinical management of severe acute respiratory infection when novel coronavirus infection is suspected. (13 March 2020)
  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).
  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). 
  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).
  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.
  8. Reuters Health News. UK begins trial of HIV medicine, steroid as possible COVID-19 treatments (23 March 2020).

Links to other websites are current at date of posting but not maintained.