COVID-19 outcomes in HIV positive people in two large US cohorts
Simon Collins, HIV i-Base
Several cohorts reported on COVID-19 data in HIV positive people at AIDS 2020.
The largest of these was from the US Veterans Ageing Cohort Study (VACS). This is an open cohort of HIV positive veterans matched (1:2) to a control group by age, race, sex and clinic site. Laboratory results for COVID-19 were linked to demographics and HIV clinical history records to look for associations with severity of COVID-19. 
Among more than 107,000 VACS participants (30,948 HIV positive, 76,618 HIV negative), 8.4% vs 6.5% tested for COVID-19. Over 16 weeks, similar percentages of tests were positive: 253 (9.7%) vs 504 (10.1%) in the positive vs negative groups [OR]: 1.05, 95% CI: 0.89 to 1.24).
Irrespective of HIV status, higher rates of COVID-19 were seen in black (aOR 1.70, 95% CI: 1.41 to 2.05) and Hispanic (aOR 1.43, 95% CI: 1.06 to 1.92) participants compared to white participants.
Risk of more severe outcomes were also similar in both the positive and negative groups: hospitalisation (34% vs 35%), ICU admission (14% vs 15%), intubation (6.3% vs 7.9%) and death (9.5% vs 11%); HR approximately 1.0, with confidence intervals all crossing 1.0.
The study concluded that future investigation was planned for potential linkages between antiretroviral treatment and CD4 count with COVID-19 severity and progression.
A second study compared COVID-19 outcomes in 4600 participants hospitalised in the Bronx, New York. Although this was a late-breaking oral presentation, only the abstract is still available online. 
This was a retrospective cohort study of 4,662 PCR positive patients hospitalised at a single centre between 10 March and 11 May 2020, of whom 77 (1.7%) were HIV positive. Most recent CD4 was <200, 200-499 and >500 cells/mm3 in 16%, 44% and 40% respectively and 83% had viral load <40 copies/mL
Outcomes were similar: length of stay (median 5 days, IQR: 3 to 9), 13% (10/77) vs 14% (634/4585) were intubated and 38% vs 41% developed chronic kidney disease.
In this study, surprisingly, higher CD4 counts were linked to intubation and all cases of intubation were in people with undetectable viral load.
Another retrospective US study presented outcomes of 93 HIV positive people with COVID-19 who presented to five emergency departments in NYC from 2 March to 15 April 2020. Of these, 72/93 were hospitalised, 53/72 recovered and 19/72 died. 
Median age was 58 (IQR: 52 to 65), 25% were women and 3% were transgender. Approximately 40% were black, 22% white and 36% unknown, with 31% Hispanic/Latinx.
Various levels of HIV history in this cohort included median duration of HIV 20 years (IQR: 15 to 26) (n=57), nadir CD4 320 cells/mm3 (IQR: 139 to 490) (n=81), recent CD4 554 cells/mm3 (IQR: 339 to 752) (n=64), undetectable viral load 83% (n=68) and 70% used ART with either TDF or TAF (n=89).
On presentation, participants showed significant lymphopenia (compared to previous CD4 count) for both absolute lymphocyte counts and CD4 T cell (both p<0.0001) and CD4% (p-0.0012). Inflammation markers (CRP, fibrinogen and d-Dimer) were also elevated (above the upper limit of normal in 100%, 84% and 98% respectively). In a subset of participants with additional samples, IL-6, IL-8 and TNF-a were also significantly elevated at presentation.
Although presenting CD4 counts were not associated with higher mortality (p=0.12), both nadir and final total lymphocyte count were (p=0.0005 and 0.002, respectively). Mortality was associated with higher inflammation markers but not with age, sex, BMI or HIV history (CD4, viral load or ART). This included a conclusion that HIV positive people on effective ART with high CD4 counts are still at risk of serious COVID-19.
Some of these results were previously published in JID. 
- Park LS et al. COVID-19 in the largest US HIV cohort. AIDS 2020, 6 – 10 July. Late-breaking poster LBPE023.
- Patel VV et al. Clinical outcomes by HIV serostatus, CD4 count, and viral suppression among people hospitalized with COVID-19 in the Bronx, New York. AIDS 2020, 6 – 10 July. Oral late breaking abstract OABLB0102.
- Ho JH et al. Immunologic characteristics of acute COVID-19 in people with HIV.AIDS 2020, 6 – 10 July. Oral late breaking abstract OABLB0104.
- Ho JH et al. Clinical Outcomes and Immunologic Characteristics of Coronavirus Disease 2019 in People With Human Immunodeficiency Virus. JOD, jiaa380. DOI: 10.1093/infdis/jiaa380 (30 June 2020).
This article was originally posted on 29 August 2020.