Friday 7 August 2020

Since our original guidance on COVID-19 risk, The British HIV Association (BHIVA) and Terrence Higgins Trust (THT) have continued to monitor the emerging evidence and are now able to provide an update based on the latest available data.

So far, there have been only a few large cohort studies examining the impact of COVID-19 for people living with HIV, and the majority of these studies include only a small number of patients. Whilst some studies report a higher risk of COVID-19 related death for people living with HIV, others do not. Any increased risk is relatively small and no analysis has fully adjusted for potential confounders, such as kidney disease, diabetes or obesity, which might affect the results.

We advise that people living with HIV (PLWH) should continue to follow Government advice regarding hand washing, distancing and face coverings. There is insufficient evidence from the UK, or similar settings, to advise any additional precautions at present but, as per our previous recommendations, anyone with a detectable viral load or CD4 less than 200, but particularly people with advanced HIV (CD4 count < 50 or a recent HIV related disease) should be cautious and ensure they minimise the risk of exposure.

Recent updates:

1. Data from a UK database including 115 people with HIV and 47,979 HIV-negative controls shows a 1.63-fold increase in mortality for people with HIV compared to HIV-negative individuals. There was insufficient data to investigate the impact of ART use, specific ART agents, viral load and CD4 or to undertake detailed adjustment for socio-economic status. This signal warrants further analysis and confirmation in larger studies, but does not change our overall advice at present [1].

2. Data from South Africa that analysed 22,308 individuals with COVID-19 demonstrated a 2.4-fold increased risk of death associated with HIV (and 3.35-fold in people with CD4 <200 or viral load >1000) amongst the 2,978 hospitalised patients (of whom 550 were people with HIV) has attracted a lot of coverage [2]. Importantly the researchers were unable to adjust for obesity or socio-economic status. Other important potential confounders also include malnutrition as well as access to healthcare and differences in health seeking behaviour. Healthcare in South Africa differs markedly to the UK so these findings may not be generalisable to a UK setting.

3. There are several small case series and cohorts from Europe, China & the United States. Limitations include small sample size, lack of direct comparison with people without HIV, or inability to adjust for comorbidities. Some have shown no association between HIV and hospitalisation risk or clinical outcomes, two studies (one from Spain and one from New York) suggested increased mortality amongst PLWH. Again, the quality of evidence, and conflicting results, warrant further studies but provide no strong support to change our recommendations. One case control study from New York did not demonstrate an association between HIV and mortality [3] but the baseline characteristics of individuals studied differed from the UK analysis so cannot be compared directly.

4. Data from a London case series showed compared to their whole cohort, hospitalised people with HIV and COVID-19 were more likely to be of black ethnicity [4] which is consistent with data in the general population, that black people (and other minority ethnic groups) are more likely to be hospitalised with COVID-19 compared to white people.

We will continue to monitor evidence examining the association between HIV and COVID-19 outcomes. Large cohort studies are required to answer these questions and BHIVA is working to create a large dataset of patients to inform policy and practice with key partners including Public Health England. It remains important to support smoking cessation, weight reduction and to follow BHIVA vaccine guidelines regarding influenza and pneumococcal vaccination.

For further information, please contact Jo Josh on +44 (0)7787 530922 or [email protected].

References

1. Geretti AM. BHIVA Virtual Conference, 3rd July 2020.

2. Davies MA et al. HIV and risk of COVID-19 death: a population cohort study from the Western Cape Province, South Africa. medRxiv 2020.07.02.20145185, 3 July 2020 (open access). https://doi.org/10.1101/2020.07.02.20145185

3. Sigel K, Swartz T, Golden E et al. Covid-19 and people with HIV infection: outcomes for hospitalized patients in New York City. Clinical Infectious Diseases, ciaa880, https://doi.org/10.1093/cid/ciaa880

4. Childs K, Post FA, Norcross C et al. Hospitalized Patients With COVID-19 and Human Immunodeficiency Virus: A Case Series. Clinical Infectious Diseases, ciaa657, https://doi.org/10.1093/cid/ciaa657