JOIN USCovid is especially risky for people with HIV, as per a large study
People living with HIV are more likely to become severely ill with Covid-19 and more likely to die if hospitalised than others infected with the coronavirus, according to a large new study. Nearly half of HIV-infected men older than 65 who are hospitalised for Covid-19 may die, the study found.
The results, released before an AIDS conference in Berlin, suggest that people with HIV should be first in line for vaccines, along with older adults and others with weak immune systems, scientists said.
The data is especially pressing because many countries with high numbers of people with HIV are battling surges of the coronavirus, fuelled by the contagious delta variant and a dearth of vaccines. About 95% of the people with HIV included in the analysis were from sub-Saharan Africa, which is home to two-thirds of HIV cases worldwide.
“The strength of this analysis is that we report data from the continent where the HIV burden actually is occurring,” said Dr. Silvia Bertagnolio, an HIV researcher at the World Health Organization who led the study.
Bertagnolio and her colleagues analysed anonymized clinical data for 268,412 people hospitalised with Covid-19 that was reported to the WHO from health facilities and national health registries in 37 countries from January 2020 to April 2021.
Of that group, the researchers had data for 15,522 people from 24 countries who were also infected with HIV. They had an average age of 45.5 years, and 37% were male. Nearly 92% were being treated with antiretroviral drugs. And many of the HIV-infected patients, like others hospitalised for Covid-19, had other conditions such as high blood pressure, diabetes and obesity.
More than one-third of patients with HIV were severely ill at the time of admission, and nearly 1 in 4 of those who were hospitalised for Covid-19 died. The risk of death in those older than 65 was higher still, and highest for older men.
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After adjusting for age, sex, disease severity and the presence of other conditions, the researchers estimated that HIV infection increases the odds of dying from Covid-19 by 30%.
The result contradicts findings from several smaller studies earlier in the pandemic that suggested that HIV infection has no bearing on a person’s risk of severe illness or death from the coronavirus. But the new study is more biologically plausible than that earlier research, given HIV’s ability to disrupt immune defences, experts said.
“HIV knocks out all the brakes on the immune system, and as a consequence you get this inflammatory response that’s robust and sustained — and now you got Covid on top of that,” said Dr. Steven Deeks, an HIV expert at the University of California, San Francisco. “I would be surprised if HIV was not associated with progression” of Covid-19.
Deeks disagreed with the study researchers’ decision to adjust the calculations for the presence of other conditions such as obesity because HIV infection itself can cause many of those illnesses. “For 25 years, we’ve been arguing that a history of HIV infection is an independent risk factor of progressing to heart disease, cancer, ageing,” he said. Without that statistical adjustment, he said, the increased risk of death for these patients would have most likely been higher than the 30% reported by the study.
Many earlier studies had a bias that might have masked some of the risk: Doctors are more likely to admit Covid-19 patients with HIV to the hospital, out of an abundance of caution, leading to patients who are less sick, and more likely to survive, compared with those who do not have HIV. That larger pool of patients would make HIV infection appear to be less of a problem than it is, said Dr. Matthew Spinelli, an infectious disease physician at San Francisco General Hospital.
“Early studies may have led people down the wrong track on this question,” he said. The new study’s findings are more in line with large, population-based studies from South Africa and England showing that HIV infection doubles the risk of dying from Covid-19, and from a similar study in New York state, he added.
The new findings should prompt doctors to provide people with HIV swift access to monoclonal antibodies or antiviral drugs to treat Covid-19, Deeks said. The data also underscores the need to understand how HIV infection affects a person’s response to a Covid vaccine and whether some people with HIV need boosters as many immunocompromised people do.
AIDS activists successfully fought for inclusion of people with HIV in clinical trials of coronavirus vaccines, but the data is limited. A clinical trial in South Africa showed higher efficacy for the coronavirus vaccine made by Novavax when the analysis excluded people with HIV, suggesting that HIV infection undermines the immune response to vaccines.
Out of 100 countries that have released information, 40 have listed people living with HIV as a priority group for Covid-19 vaccination, said Dr. Meg Doherty, who directs HIV programmes at the WHO.
“We’re hoping in the future that we can make sure that HIV is considered one of those potential risk factors for prioritisation” in all countries, she said.