Factors associated with severity of COVID-19 disease in a multicenter cohort of people with HIV in the United States, March-December 2020

Abstract

Background: Understanding the spectrum of SARS-CoV-2 infection and COVID-19 disease in people with HIV (PWH) is critical to provide clinical guidance and implement risk-reduction strategies. Objective: To characterize COVID-19 in PWH in the United States and identify predictors of disease severity. Design: Observational cohort study. Setting: Geographically diverse clinical sites in the CFAR Network of Integrated Clinical Systems (CNICS) Participants: Adults receiving HIV care through December 31, 2020. Measurements: COVID-19 cases and severity (hospitalization, intensive care, death). Results: Of 16,056 PWH in care, 649 were diagnosed with COVID-19 between March-December 2020. Case fatality was 2%; 106 (16.3%) were hospitalized and 12 died. PWH with current CD4 count <350 cells/mm3 (aRR 2.68; 95%CI 1.93-3.71; P<.001) or lowest recorded CD4 count <200 (aRR 1.67; 95%CI 1.18-2.36; P<.005) had greater risk of hospitalization. HIV viral load suppression and antiretroviral therapy (ART) status were not associated with hospitalization, although the majority of PWH were suppressed (86%). Black PWH were 51% more likely to be hospitalized with COVID-19 compared to other racial/ethnic groups (aRR 1.51; 95%CI 1.04-2.19, P=.03). Chronic kidney disease (CKD), chronic obstructive pulmonary disease, diabetes, hypertension, obesity, and increased cardiovascular and hepatic fibrosis risk scores were associated with higher risk of hospitalization. PWH who were older, not on ART, with current CD4 <350, diabetes, and CKD were overrepresented amongst PWH who required intubation or died. Limitations: Unable to compare directly to persons without HIV; underestimate of total COVID-19 cases. Conclusions: PWH with CD4 <350 cells/mm3, low CD4/CD8 ratio, and history of CD4 <200, have a clear excess risk of severe COVID-19, after accounting for comorbidities also associated with severe outcomes. PWH with these risk factors should be prioritized for COVID-19 vaccination, early treatment, and monitored closely for worsening illness.

HIV, Aging, and Comorbidities Research in Clinical Cohorts: 3 Lessons Learned Using Examples From the CNICS Cohort

“…For example, CNICS developed an extensive case ascertainment protocol for COVID-19 based on rapidly evolving diagnoses, expanding laboratory criteria, and complemented this with verification both to confirm the cases as well as to validate and better understand different ascertainment criteria and how they varied by site and over time. A recent CROI presentation 27 described the first 198 COVID-19 cases identified among 13,862 PWH and found increased risk among women, PWH who were Black or Hispanic, and those with a body mass index > 30. Among PWH with COVID-19, the relative risk of being hospitalized was 2-fold higher among PWH aged 60 years and older.…”

Mitigation strategies to safely conduct HIV treatment research in the context of COVID‐19

“…A WHO report, based on surveillance data from 37 countries between 01 January 2020 and 29 April 2021, demonstrated that PLWH hospitalized with COVID-19 had an increased risk of severe disease and in-hospital mortality than people without HIV [23]. For PLWH with severe immunosuppression or uncontrolled HIV viraemia, fatality rates for COVID-19 remain uncertain [19,20,24,25], although recent evidence suggests that these individuals have a higher risk of severe COVID-19 disease [26,27]. Similarly, a higher risk of complications from COVID-19 has been reported among PLWH with a low CD4 + T cell count nadir prior to ART initiation compared to those with higher nadirs [28].…”