Joint BHIVA/EACS update on HIV and COVID-19 (April 2020)

Simon Collins, HIV i-Base

On 30 April 2020, BHIVA and EACS published a summary of recent research into COVID-19. [1]

Main points are quoted below but please see full report for details including references.

Latest studies reporting no evidence so far on increased risk from COVID-19 in people on effective ART compared to HIV negative people. [2, 3, 4]
The risk of severe illness increases with age, male sex and with certain chronic medical problems such as cardiovascular disease, chronic lung disease and diabetes. Although people living with HIV who are on treatment with a normal CD4 T-cell count and suppressed viral load may not be at an increased risk of serious illness, many people living with HIV have other conditions that increase their risk. Indeed, almost half of people living with HIV in Europe are older than 50 years – and chronic medical problems, such as cardiovascular and chronic lung disease, are more common in people living with HIV. Smoking is a risk factor for respiratory infections; smoking cessation should therefore be encouraged for all patients. Influenza and pneumococcal vaccinations should be kept up to date.
It assumes that immune suppression, indicated by a low CD4 T-cell count (<200 cells/mm³), or not receiving ART, will also be associated with an increased risk for a more severe disease presentation. OI prophylaxis should be used in these cases.
Evidence supports potential for COVID-19 vertical transmission [5, 6, 7], although so far clinical outcome for the newborn have been very good.
Existing national guidelines should be followed in terms of reducing risk for acquiring a COVID-19 infection and managing symptoms.
No benefit has been seen with use of lopinavir/r (Kaletra) for treating COVID-19 and that there is no evidence to support the use of other antiretrovirals, including protease inhibitors; indeed, structural analysis demonstrates no darunavir binding to COVID-19 protease.
Despite a lack of in-vitro data to support antiviral activity of TDF/FTC against CoV-2, and only limited evidence of molecular docking and binding data, a large randomised phase 3 placebo-controlled study in Spain using the HIV PrEP combination TDF/FTC and low-dose hydroxychloroquine (HCQ) as prophylaxis for COVID-19 in health workers is planned. Documented COVID-19 infections in people who are HIV on TDF/TAF containing ART suggests that complete protection is unlikely.
In discussing ongoing HCQ as a treatment for COVID-19, with or without azithromycin, the document notes that no acute viral infection has ever been successfully treated with either product.
Comments on remdesivir are slightly more positive. While noting a lack of effect in some studies the statement refers to a press release from a US NIAID study in which 1063 hospitalised patients with advanced COVID-19 and lung involvement randomised to remdesivir recovered faster than similar patients who received placebo. Specifically, the median time to recovery was 11 days for patients treated with remdesivir compared with 15 days for those who received placebo. Results also suggested a survival benefit, with a mortality rate of 8.0% for the group receiving remdesivir versus 11.6% for the placebo group (p=0.059) [8]. Gilead also reported top-line results from their late-stage SIMPLE study, showing that a five-day dosing duration of remdesivir led to “similar improvement in clinical status” as the 10-day treatment course being evaluated in the NIAID study and other ongoing trials. [9] The initial phase of the SIMPLE trial, which is not placebo-controlled, randomised 397 hospitalised patients with severe manifestations of COVID-19 disease to receive intravenous remdesivir until either day five or 10, on top of standard care. An expansion phase of the study has recently been added and will enroll an additional 5600 patients, including patients on mechanical ventilation. The full results from these trials, as well as other ongoing clinical trials especially in early COVID-19 disease, are eagerly awaited
A new website is recommended from Liverpool University on drug interactions with COVID-19 treatments.
www.covid19-druginteractions.org
Two new resources are recommended for data collection on COVID-19.
I) www.NEAT-ID.org
https://mailchi.mp/neat-id/covid-19-hiv-co-infection-data-dashboard-4783628
ii) The Lean European Open Survey on SARS-CoV-2 Infected Patients (LEOSS) launched by the German Society for Infectious Diseases (DGI) and ESCMID’s Emerging Infections Task Force (EITaF).
https://leoss.net/statistics

Selected references

EACS & BHIVA Statement on risk of COVID-19 for people living with HIV (PLWH). (30 April 2020).
https://www.bhiva.org/EACS-BHIVA-statement-on-risk-of-COVID-19-for-people-living-with-HIV-PLWH
Blanco JL et al. COVID-19 in patients with HIV: clinical case series. Lancet HIV. 2020 Apr 15. pii: S2352-3018(20)30111-9.
Härter G et al. Infection (2020). DOI: 10.1007/s15010-020-01438-z. (11 May 2020).
https://link.springer.com/article/10.1007/s15010-020-01438-z
Guo W et al. A survey for COVID-19 among HIV/AIDS patients in two districts of Wuhan, China. Preprint research paper, The Lancet, 2020.
Zeng L, et al. Neonatal early-onset infection with SARS-CoV-2 in 33 neonates born to mothers with COVID-19 in Wuhan, China. JAMA Pediatr 2020; DOI: 10.1001/jamapediatrics.2020.0878.
Alzamora MC et al. Severe COVID-19 during pregnancy and possible vertical transmission. Am J Perinatol. 2020 Apr 18. doi: 10.1055/s-0040-1710050. [Epub ahead of print]
Zamaniyan M et al. Preterm delivery in pregnant woman with critical COVID-19 pneumonia and vertical transmission. Prenat Diagn. 2020 Apr 17. doi: 10.1002/pd.5713. [Epub ahead of print]
NIAID press release. NIH clinical trial shows remdesivir accelerates recovery from advanced COVID-19. (29 April 2020).
https://www.niaid.nih.gov/news-events/nih-clinical-trial-shows-remdesivir-accelerates-recovery-advanced-covid-19
Gilead press release. Gilead announces results from phase 3 trial of investigational antiviral remdesivir in patients with severe COVID-19. (29 April 2020).
https://www.gilead.com/news-and-press/press-room/press-releases/2020/4/gilead-announces-results-from-phase-3-trial-of-investigational-antiviral-remdesivir-in-patients-with-severe-covid-19