Update on Western Cape data: people with HIV have small increased risks from COVID-19
26 June 2020. Related: COVID-19: HIV and COVID-19 coinfection, COVID-19.
Polly Clayden, HIV i-Base
Routine public sector data from Western Cape South Africa, showing a modestly increased risk of mortality from COVID-19 among people living with HIV (and the largest assessment of SARS-CoV-2 and HIV coinfected people to date), were presented on a webinar and widely-reported earlier in June. [1, 2]
These data have been slightly updated and published on 22 June 2020 by the National Institute for Communicable Diseases. 
Between 1 March and 4 June 2020, there were 12,522 people, aged 20 and above, diagnosed with COVID-19 and alive at the time of analysis and 435 COVID-19 deaths.
The proportion of men was lower among COVID-19 cases vs non-cases (30% vs 42%) – the authors suggest that this was likely due to early cases occurring in essential workers in sectors largely employing women.
Slightly higher proportions of COVID-19 cases had diabetes mellitus (13% vs 8%), hypertension (20% vs 16%) and HIV (18% vs 16%).
COVID-19 patients who died were considerably older than those who survived: median 63 years (IQR 54 to 71) vs 37 (IQR 30 to 48).
Of the people with HIV and COVID-19 who died and survived, 69% and 66% were considered “well on ART” (by the definition of the analysis).
The authors also looked at whether the association between HIV and COVID-19 mortality could be associated with unmeasured confounding eg by socio-economic status or raised BMI – which was not captured in the analysis.
They calculated the E-value for an unmeasured confounder for both above analyses. This value is an estimate of how strong the association between a confounder and the outcome would need to be to account for all of the association between, in this case, HIV and COVID-19 death.
They found the E-value for analysis among all public sector patients to be 4.94 (3.60 for the lower bound of the CI). This suggests that there would need to be a strong association between both HIV and low socio-economic status (or raised BMI), and COVID-19 death to account for all the association between HIV and COVID-19 death.
Among all public and private sector diagnosed COVID-19 cases, there were 97 deaths among an estimated population of approximately 520,000 people with HIV in the Western Cape province (187 deaths/million) vs 573 deaths among 6.36 million people without HIV (90 deaths/million).
The SMR for COVID-19 mortality in people with HIV, relative to HIV negative people, was 2.33 (95% CI 1.83 to 2.91) and 8.2% (95% CI: 5.3 to 11.2) of deaths were considered to be associated with HIV.
Although the published findings do not differ from those presented earlier by webinar, it is worth reading the more comprehensive data set.
And it is important that the authors have now looked at potential unmeasured confounding for the association between HIV and COVID-19 in this setting.
This article was first published online on 25 June 2020.
- Davies MA et al. Western Cape: COVID-19 and HIV/Tuberculosis. Webinar: when epidemics collide. Bhekisisa Centre for Health Journalism. 9 June 2020.
https://storage.googleapis.com/stateless-bhekisisa-website/wordpress-uploads/2020/06/94d3ea42-covid_update_bhekisisa_wc_3.pdf (Mary-Ann Davies’ presentation pdf)
- Clayden P. HIV positive people in South Africa at increased risk of dying from COVID-19: first data from country with high prevalence of HIV and TB. HTB.17 June 2020.
- Davies MA et al. Risk of COVID-19 death among people with HIV: a population cohort analysis from the Western Cape province, South Africa. Covid-19 special public health surveillance bulletin. 22 June 2020.
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