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Intensive Care Society (ICS) and British HIV Association (BHIVA) statement on considerations for critical care for people with HIV during COVID-19

Friday 3 April 2020

Overview

Individual Trusts and STPs have set up their own Clinical Support Units/Ethics committees who may advise on decisions around escalation of care in patients with COVID-19; these will vary according to local capacity.

NICE has produced a COVID-19 rapid guideline for critical care in adults https://www.nice.org.uk/guidance/NG159 recommending the use of the Clinical Frailty Score (CFS), acknowledging its limitations as the sole assessment of frailty, particular limitations in some groups, and the need to consider comorbidities and underlying health conditions in all cases.

In addition, there are some important issues related to antiretroviral therapy (ART) for acutely unwell patients with HIV.

HIV testing is an important part of the diagnostic work-up for people admitted with acute respiratory illness.

The following recommendations aim to support appropriate decision-making around escalation of care for people with HIV and safe maintenance of HIV therapy, including common pitfalls.


Summary

1. People with well-controlled HIV have a normal life expectancy.

2. In the UK 97% of people diagnosed with HIV are on ART and 97% of this group are fully suppressed (ie well controlled.)

3. There is no evidence that outcomes of coronavirus infection (SARS, MERS, COVID-19) for people living with HIV are worse.

4. Patients with an undetectable plasma HIV-RNA on ART & CD4 count of 200 cells/mm3 or greater are not at higher risk of severe COVID-19 [1].

5. Patients with well controlled HIV have similar intensive care outcomes to HIV-negative individuals [2].

6. HIV is not a predictor of mortality in people with acute lung injury admitted to intensive care [3].

7. COVID-19 may be associated with significant T-cell reduction, including CD4 cell count, in all patients [4,5].


Recommendations

1. Well-controlled HIV should not be included as a prognostic indicator when assessing appropriateness for escalation of care.

2. All patients with HIV should be discussed with an HIV team if possible, including a specialist HIV pharmacist.

3. COVID-19 may be associated with significant CD4 decline [4,5] so CD4 should be checked in all patients with HIV hospitalised with COVID-19 and appropriate prophylaxis commenced if necessary in line with national guidance [6].

4. HIV treatment should not be interrupted, even in the event of deterioration; ART can be switched in the setting of acute kidney injury, haemofiltration and dialysis in liaison with the local HIV team [7].

5. Several antiretrovirals inhibit tubular secretion of creatinine which may result in underestimation of GFR using creatinine-based methods; as a consequence, people may be labelled erroneously as having chronic kidney disease. Please consult with the HIV team regarding baseline renal function.

6. Atazanavir is normally associated with unconjugated hyperbilirubinaemia which is of no clinical consequence.

7. Several antiretrovirals, especially ritonavir and cobicistat, are associated with potentially serious drug-drug interactions; the University of Liverpool interaction checker is an invaluable resource [8]:

a. Significant increase in plasma concentration of drugs metabolized by the cytochrome P450 pathway including most steroids (including nebulised), anti-arrhythmics and simvastatin.

b. Significant reductions in antiretroviral concentrations risking virological rebound and drug resistance e.g. proton pump inhibitors.

8. Some antiretrovirals must be dosed with food [9].

9. Some antiretrovirals are available as liquid formulations or can be crushed for administration via NG tube [10].


References

1. BHIVA/EACS statement: https://www.bhiva.org/joint-EACS-BHIVA-statement-on-risk-of-coronavirus-for-PLWH

2. Barbier F et al. Intensive Care Med. 2020; 46(2): 329–342.

3. Mendez Tellez PA et al. Critical Care Medicine: July 2010 - Volume 38 - Issue 7 - p 1530-1535

4. Qin C, Zhou L, Hu Z et al. Dysregulation of immune response in patients with COVID-19 in Wuhan, China. Clinical Infectious Diseases, ciaa248, https://doi.org/10.1093/cid/ciaa248

5. Diao B, Wang C, Tan Y et al. Reduction and Functional Exhaustion of T Cells in Patients with Coronavirus Disease 2019 (COVID-19). doi: https://doi.org/10.1101/2020.02.18.20024364

6. British HIV Association and British Infection Association Guidelines for the Treatment of Opportunistic Infection in HIV-seropositive Individuals 2011 https://www.bhiva.org/file/SwhaEzgXmAGOt/hiv_v12_is2_Iss2Press_Text.pdf

7. https://liverpool-hiv-hep.s3.amazonaws.com/prescribing_resources/pdfs/000/000/095/original/Renal_non- ARVs_2019_Jul.pdf?1562766072

8. https://www.hiv-druginteractions.org/

9. https://liverpool-hiv-hep.s3.amazonaws.com/prescribing_resources/pdfs/000/000/037/original/Food_ARVs_2019_Jul.pdf?1563973044

10. https://liverpool-hiv-hep.s3.amazonaws.com/prescribing_resources/pdfs/000/000/011/original/ARV_Swallowing_2018_Dec.pdf?154391 6096


For further information, email bhiva@bhiva.org or for media enquiries: Jo Josh, Communications Officer, British HIV Association (BHIVA) +44 (0) 7787 530 922 or jo@commsbiz.com. For critical care information or media requests contact: Alex Day, Communications Manager, Intensive Care Society on +44 (0) 20 7280 4350 or alexd@ics.ac.uk.