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British HIV Association update on COVID treatments for people with HIV

COVID guidance evolves rapidly. Please see NHS, NICE, JCVI & GOV.UK websites and the prescribing advice for individual treatments for the latest advice

Friday 17 December 2021

New COVID treatments

COVID-specific treatments currently approved for use in the UK are summarised in the table at the end of this statement. Guidance for treatment of non-hospitalised people, a letter template for people who may be at risk and the COVID Medicine Delivery Unit (CMDU) directory for England are available here: https://www.gov.uk/get-coronavirus-test.

PANORAMIC Trial: https://www.panoramictrial.org/

This UK-wide University of Oxford trial of community COVID-19 treatments is open to anyone with symptoms, a positive PCR test and who meets one of the following criteria:

  • Aged 50 or older

  • A condition associated with worse COVID outcomes which includes ALL people with HIV

The first phase compares molnupiravir plus standard of care vs standard of care alone. Participants who are also contacted for routine NHS treatment should speak to the trial team.

Routine NHS outpatient treatment

People meeting the following criteria will be eligible for community treatment with a neutralising monoclonal antibody (nMAB) or molnupiravir if an nMAB is contra-indicated, not recommended, not available or not possible to administer:

  • Positive SARS-CoV-2 PCR test within last 5 days AND

  • Onset of COVID-19 symptoms within last 5 days AND

  • Member of a high-risk group which includes the following people with HIV
    - Uncontrolled/untreated HIV or acute AIDS defining diagnosis
    - On stable treatment for HIV with CD4 <350
    - On ART with CD4 >350 + additional risk factors (e.g. age, diabetes, obesity, cardiovascular, liver or renal disease, homelessness or alcohol dependence) *see below for BHIVA advice regarding these criteria

Depending on service pressure and/or drug supplies, eligibility criteria will be revised. If necessary, we recommend the people considered eligible for a 3rd COVID vaccine are prioritised for COVID treatment over other HIV-related eligibility criteria, which means anyone:

  • With A CD4 count <200

  • With a recent (within 12 months’) AIDS-defining condition

  • Persistent/recurrent viraemia or not on ART (excluding elite controllers)

Eligible people will be contacted by the NHS and should ensure they have a PCR test kit at home which can be accessed here: https://www.gov.uk/get-coronavirus-test. In England, regional hubs will cross-check positive PCR results against a list of potentially eligible people to contact to discuss treatment; speciality services will also be asked to identify people who are eligible and they, or GPs, can refer directly to COVID hubs if those people have a positive COVID PCR test. HIV services have been asked to send a COVID treatment eligibility letter to people who have not shared their HIV status with their GP or who are newly diagnosed. Arrangements differ in devolved nations e.g. in Scotland & Wales local services will identify eligible people. People who have been advised they are eligible but do not hear from the NHS within 24 hours of a positive test, or who think they are eligible for treatment but have not been contacted, are advised to contact:

  • Their GP if it is during the day OR

  • NHS 111 if it is on an evening or a weekend.

Of note it is likely that some people with HIV who do not meet the specific criteria above will still receive letters but, if they are contacted after a positive test, they may be advised that they are not eligible for treatment as they are not considered to be at higher risk.

People who have not shared their HIV status with their GP will need to do so to ensure they are listed as eligible.

*BHIVA suggests the following be considered additional risk factors: age 55 years or older, diabetes requiring treatment (i.e not just diet-controlled), BMI >30, chronic kidney disease (eGFR <60), liver cirrhosis, congestive heart failure (New York Heart Association class II, III, or IV), moderate-to-severe asthma

Summary of current COVID treatments & HIV-specific advice

DRUG

LICENSE

ART DDI

PREGNANCY

UK GUIDANCE

Anti-IL-6 monoclonal antibodies

Tocilizumab IV

Off-license

Nil expected

Risk of harm in animal studies; do not use unless clearly necessary

People hospitalised with hypoxaemia + raised CRP or requiring ventilatory support (high flow nasal oxygen, CPAP, NIV or IV regardless of CRP)

Sarilumab IV

Off-license

Nil expected

No/limited data, use only if benefits >risks

People hospitalised with hypoxaemia + raised CRP or requiring ventilatory support (high flow nasal oxygen, CPAP, NIV or IV regardless of CRP) when tocilizumab unavailable

Anti-SARS-CoV-2 monoclonal antibodies (neutralising monoclonal antibodies or nMAB)

Casirivimab + imdevimab IV (Ronapreve)

Prophylaxis and treatment of acute COVID-19

Nil expected

No/limited data, use only if benefits >risks

Offer to all aged ≥12 years hospitalised due to COVID-19, SARSCoV-2 seronegative AND local hospital Omicron variant prevalence <50% OR non-Omicron variant on genotyping. Consider for hospital-onset COVID-19 if non-Omicron variant AND ‘highest risk’ group OR other eligibility as per policy

Sotrovimab IV (Xevudy)

Symptomatic acute COVID-19 in people aged ≥12 years, not requiring oxygen at increased risk of severe infection

Nil expected

No data, use where expected benefit > risk

Hospitalised: as above where local hospital Omicron variant prevalence is 50% or more, or Omicron variant on genotyping. Non-hospitalised: as outlined above for people at higher risk.

Antivirals

Remdesevir IV

COVID-19 in people aged ≥12 years requiring oxygen

Nil expected

No/limited data, do not use unless clinically required

Consider up to 5 days for hospitalised people requiring oxygen; Timing/dose/oxygenation status may vary if severely immunocompromised (BHIVA advises CD4 <200, recent ADI, not on ART or detectable VL)

Molnupiravir PO (Lagevrio)

Mild/moderate COVID-19 in adults with at least one risk factor for severe illness

Low (not a substrate, inhibitor, or inducer of enzymes or transporters)

Reproductive toxicity in animal studies, should not be used in pregnancy

PANORAMIC community-based trial OR Available through routine NHS care from 16th December 2021 for non-hospitalised people at higher risk with a positive SARS-CoV2 PCR test and not suitable for nMAB

References:
NICE COVID-19 rapid guideline: Managing COVID-19; v18.1 published 14/12/2021; NHS Interim clinical commissioning policy: Remdesivir for patients hospitalised with COVID-19 (adults and children 12 years and older) version 3, published 15 June 2021; NHS Interim Clinical Commissioning Policy: Neutralising monoclonal antibodies or antivirals for non-hospitalised patients with COVID-19, published 16 December 2021, effective from 20 December 2021; NHS Interim Clinical Commissioning Policy: Neutralising monoclonal antibodies in the treatment of COVID-19 in non-hospitalised patients, published 16 December 2021, effective from 20 December 2021

Click here to view this table as a PDF


For further information, please contact bhiva@bhiva.org or for media enquiries, please contact Jo Josh at jo@commsbiz.com or +44 (0)7306 391875.



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