This article was reviewed by Dr. Carolina Camargo, one of our subject matter experts.

The paper we’ll be demystifying can be found here, if you’d like to follow along!

TL;DR

Adults living with HIV are similarly affected by COVID-19 in comparison to the public. Therefore, HIV-infected adults should receive similar COVID-19 treatment options as the general population.

Introduction

According to the World Health Organization, 38 million people live with HIV. Thus, HIV continues to be a major global health issue. There is limited information on whether HIV-infected adults are more at-risk for COVID-19. There is also limited information on COVID-19 outcomes experienced by HIV-infected adults. The correlation between HIV and COVID-19 is interesting and complex as HIV-patients may have less reactive immune systems. In addition, HIV patients receiving treatment are prescribed anti-viral medications, such as Tenofovir.  Although HIV and COVID-19 are different viruses, there may a potential overflown effect from the anti-viral medications, which triggers the immune system. Therefore, the present study described the COVID-19 infection rate and the outcomes among HIV-infected adults that were diagnosed with COVID-19.

Methods

The present study is categorized as an observational prospective study. Under these conditions, the researchers observe the effect of the disease on participants without attempting to control the outcome of the study.¹ Moreover, participants are enrolled into the study prior to being diagnosed with the disease that is being investigated.²

Study participants were all adults living with HIV from Madrid. 2873 participants were included in the study.  Researchers compared symptoms and outcomes of HIV-infected adults with COVID-19 patients also diagnosed with HIV. Data was pulled from electronic health records. The SARS-CoV-2 infection was confirmed in the HIV patients by qRT-PCR. It is worth noting that qRT-PCR has several limitations.

Discussion

Out of 2873 participants, 51 participants were diagnosed with COVID-19. The average age of the infected participants was 53, which was slightly lower than the general population. Eight participants (16%) were women, and 32 participants (63%) were diagnosed with additional diseases, other than HIV. Among these 51 participants, 38 participants (75%) experienced mild or moderate COVID-19 symptoms, whereas 13 participants (25%) experienced severe COVID-19. Six participants (12%) were also critically ill, and two participants (4%) passed away.

CD4 cells are white blood cells. CD4 cell counts can indicate how the immune system is functioning. A higher CD4 cell count indicates a strong immune system. The CD4 cell count of an individual without HIV is between 500 to 1500. HIV patients with cell counts over 500 have pretty good immune systems, whereas HIV patients with cell counts below 200 have a high risk of developing other serious illnesses. Two out of the six critically ill patients had CD4 counts that were below 200.  

After analyzing the data, the researchers in the present study concluded that there was no association between CD4 cell counts and COVID-19. Nevertheless, the researchers identified that lower CD4 cell counts were correlated with disease severity. The researchers also found that HIV patients with severe COVID-19 had lower CD4 cell counts in comparison to HIV patients with non-severe COVID-19. These results indicate that there may be a higher risk of COVID-19 complications in HIV-patients with low CD4 counts. Further research must be conducted with a larger sample size to provide stronger evidence for this low CD4 count hypothesis.

The most common COVID-19 symptoms experienced were cough, fatigue, fever, and difficulty breathing. In comparison to the general public, the COVID-19 infection rate among HIV-infected adults were similar or slightly higher than the general public. However, when suspected and unconfirmed cases of COVID-19 were included in the analysis, researchers found that the infection rate of COVID-19 among HIV-infected adults was slightly lower.

COVID-19 symptoms experienced by HIV-infected adults were similar to COVID-19 symptoms experienced by the public. In addition, two (4%) of the COVID-19 participants passed away. This mortality rate is lower than the public. Nonetheless, 13 participants (25%) experienced severe COVID-19, and 12% of the participants were admitted to the ICU. Compared to the general population, the severity rate of COVID-19 among HIV-infected adults was higher. Future studies must be conducted to confirm whether this is common among HIV-infected adults.

Comorbidity is when a person is diagnosed with more than one disease. Researchers found that participants living with comorbidities and that were diagnosed with COVID-19 had higher rates of diabetes, chronic kidney disease, chronic liver disease, hypertension and high BMI in comparison to those only diagnosed with HIV or COVID-19. It was concluded that comorbidities may be a risk factor for COVID-19 among HIV-infected adults. Furthermore, researchers identified a positive correlation with the use of Tenofovir (an anti-viral medication), comorbidities, higher BMI and COVID-19.

Overall, COVID-19 outcomes among adults living with HIV were somewhat similar to COVID-19 outcomes among the public.

Limitations

The major limitation of the study was the study population size. The small number of participants may have impacted the accuracy of the conclusion. Future studies must be conducted with larger population sizes. 

Among this, researchers in the study were unable to accurately compare the COVID-19 infection rate. This is a limitation as the infection rate in the present study varied depending on whether suspected and unconfirmed COVID-19 cases were included. Moreover, the infection rate estimated may actually be lower as COVID-19 testing was limited and there were high misdiagnosis rates at the beginning of the pandemic.

Inflammatory markers are used to identify the presence or activity of an inflammatory disease in patients. In the present study, inflammatory markers were only used to assess severe cases. This is an important limitation as this severely biased the interpretation of the results. The time of undetectable HIV-RNA level or treatment adherence were also not sufficiently analyzed. This is another limitation as being HIV-positive does not necessarily mean that the anti-viral treatment regime is being followed. Specifically, this can also severely bias the interpretation of the results.

Conclusion

It was concluded that HIV-infected adults are similarly affected by COVID-19 in comparison to the public. It was also concluded that comorbidities may be a risk factor for COVID-19 among HIV-infected adults. In addition, HIV-infected adults also have similar infection rates compared to the public as HIV independently may not be a significant risk factor to COVID-19. Thus, HIV-infected adults must receive similar COVID-19 treatment options in comparison to the general population.