Higher rates of serious outcomes in HIV and COVID-19 coinfection in Germany: cautious review

The first detailed outcomes from a more sizable (but still small) cohort of 33 HIV positive people (30 men, 3 women) diagnosed with COVID-19 has been published in the May issue of the journal Infection. [1]

Until now, evidence of larger cohorts has been published (87/18107 in the ISARIC COVID-19 database and 43/5700 in the New York study reported below), but neither of these include clinical details. [2, 3] Otherwise, more detailed information has only included much smaller numbers, the largest of which was five people reported from Barcelona. [4]

The new study retrospectively analysed anonymous data from 33 people diagnosed with COVID-19 between 11 March and 17 April 2020 in 12 participating German HIV centres. Clinical outcomes were available for 32/33. Mean age was 48 years (range 26 to 82) and all were on ART. Viral load was below 50 copies/mL in all except two who were <1000) copies/mL when critically ill on ICU. Overall, 76% were classified as mild cases, 91% (n=29) recovered and 9% (n=3) died.

A wide range of ART combinations were being used, including all classes and ~ 20 using combinations with F/TAF or F/TDF backbone; 20 with INSTIs, 4 with PIs (all darunavir) and 9 with NNRTIs. 12 people had CD4:CD8 ratio > 1.00.

Likely route of infection included 14 people with close contact with someone documented as CoV-2 positive and 14 with recent history of travel abroad. Most people were diagnosed with COVID-19 as outpatients (n=26) with seven diagnosed in hospital.

The median CD4 count before diagnosed SARS-CoV-2 was 670 cells/mm³ (range 69 to 1715).

Overall, 14/33 (42%) were admitted to hospital and of these, 6/14 (43%) were treated in ICU. The three deaths included the 82 year old man (positive for 28 years and with detectable viral load before COVID-19), a 55 year old man with very low CD4 count of 69 cells/mm³ (and CD4:CD8 ratio of 0.06) and a 59 year old man with hypertension, COPD and Type-2 diabetes.

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Although this retrospective and uncontrolled series included a death rate more than double HIV negative people in Germany (9% vs 3.7%), more severe cases (24% vs ~19%) and more hospitalisations (42% vs 17%), the authors did not conclude their data supported excess morbidity and mortality in people on controlled ART.

They comment that these figures might be overestimated due to caution in admitting HIV positive people to hospital and only including people who were symptomatic. However, mechanical ventilation was needed by both people whose viral load was detectable before COVID-19, perhaps showing the importance of controlled HIV.

These data should be interpreted cautiously but show the urgency for HIV status to be actively included at baseline in management of COVID-19 and for this to also be included in medical records and databases linked to the pandemic.