COVID-19 and HIV co-infection

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Main article: COVID-19

For COVID-19 frequently asked inpatient questions, click here

For COVID-19 frequently asked outpatient questions, click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Harmeet Kharoud M.D.[2]

Synonyms and keywords:

Overview

• An observational prospective study found out that the incidence of HIV-infected individuals to be affected by SARS-CoV-2 was similar to the general population.
• Specific antiretroviral therapy did not affect COVID-19 severity.
• Immunosuppression(low CD4 cell counts) was associated with COVID-19 severity.
• Patients with HIV infection often have other comorbidities(lung disease, cardiovascular disease) therefore, increasing the risk for severe-COVID-19 disease.
• Patients with HIV infection with CD4 cell count<200/mm3 are at increased risk for complications from other respiratory infections. However, we do not know if this is the scenario with COVID-19

Historical Perspective

• COVID-19 caused by SARS-CoV-2 was first identified in late December 2019 in Wuhan, Hubei China.
• Due to its rapid spread worldwide from person to person it was declared as a pandemic by WHO on March 11, 2020. another most dangerous virus causing acquired immunodeficiency syndrome (AIDS). According to WHO, there are ~37.9 million people living with HIV
• A first single center clinical case series published in Lancet first described 5 cases of HIV individuals who were infected with COVID-19
• In March 2020 CDC mentioned that people with HIV would be at increased risk for severe COVID-19 infection.

Classification

There is no established system for the classification of HIV and COVID-19 coinfection.

Pathophysiology

• The pathophysiology of SARS-CoV-2 virus in HIV infected individuals is similar to general population.
• COVID-19 is caused by SARS-CoV-2 virus which enters into the cells by attacking its primary receptor, Angiotensin-converting enzyme 2. ACE-2 receptors are expressed in pulmonary tissues and extra pulmonary system tissues(heart, kidney, endothelium, and intestine).
• Patients with HIV with co-existing underlying comorbidities like diabetes mellitus, hypertension, etc may have increased expression of ACE-2 receptors in the tissues causing increased binding of SARS-CoV-2 virus and replication leading to high viral load. This might be exaggerated in people with low CD4 cell count.
• High viral load of SARS-CoV-2 virus could lead to manifestations of pneumonia, cardiac dysfunction, multi-organ dysfunction

Causes

COVID-19 infection in HIV infected individuals is caused by SARS-CoV-2 virus

Differentiating from other disease

COVID-19 infection in HIV individuals should be differentiated from other opportunistic infection and infection by other microbes.

Epidemiology and Demographics

• Different studies have not shown any difference in incidence rate of COVID-19 in HIV individuals as compared to general population.
• A prospective observational study of 2873 HIV individuals showed an incidence of rate of COVID-19 in HIV individuals of 17.7 cases per 1000 population.

Age

• The median age found out in a study was 53.3 years.

Comorbitdities

There is increased prevalence of comorbidities in HIV–SARS-CoV-2 co-infected individuals. They are associated with following comorbidities.

• Hypertension
• Cardiovascular disease
• Diabetes
• Chronic kidney disease
• Chronic liver disease
• Chronic respiratory disease.
• High BMI

Risk Factors

At present people with HIV who are at greatest risk of Severe COVID-19 infection are people -

• who have low CD4 cell count.
• not on antiretroviral therapy.

Specific Populations with HIV at risk for COVID-19

Pregnancy

• Pregnant individuals with HIV are at greater risk for severe illness, morbidity, or mortality as compared with the general population due to coronavirus infections(SARS-CoV and MERS-CoV) and other viral respiratory infections like influenza. Data related to COVID-19 is limited but pregnant individuals with HIV are suspected to be at greater risk due to SARS-COV-2 similarity with other coronaviruses (SARS-CoV and MERS).
• They are suspected to be at increased risk of preterm delivery, adverse neonatal outcomes. In a small series of pregnant women with COVID-19 adverse outcomes such as fetal distress and preterm delivery have been noted. They have also been reported with SARS-CoV and MERS.
• Vertical Transmission of COVID-19 has not been found.

Older Adults

• Older adults(>50 years age) with HIV have a greater risk of having co-existing comorbidity including diabetes, hypertension, cardiovascular disease, and chronic lung disease as compared with general population. Therefore, older adults with HIV are suspected to be at an increased risk of COVID-19 infection.
• It is recommended that they follow the recommendations outlined for patients with HIV.

Diagnosis

Diagnostic Criteria

• The diagnosis of COVID-19 in HIV patients remains the same as compared to the general population.
• The challenge of diagnosing COVID-19 in HIV patients is to clinically distinguish it from common mimickers such as Influenza, Parainfluenza, and other common respiratory illnesses. Currently, history of exposure and epidemiological risk factors are the two biggest historical cues, aside from respiratory symptoms, that can guide clinician into considering COVID-19 in the differential diagnosis.

History and Symptoms

• There hasn't been any observable difference in clinical presentation among people with HIV infection as compared to the general population.
• Common symptoms for COVID-19 are
  • Fever or chills
  • Cough
  • Shortness of Breath or difficulty breathing
  • Fatigue
  • Muscle or Body aches
  • Headache
  • New loss of taste or smell
  • Sore Throat
  • Congestion or runny nose
  • Nausea or vomiting
  • Diarrhea

Laboratory Findings

HIV individuals with coinfection with COVID-19 are associated with following laboratory findings

• High ESR
• Lymphopenia
• Neutrophilia
• Anemia
• Thrombocytopenia
• Abnormal fibrinogen
• Hypoalbuminaemia
• Elevated creatiine kinase (CK)
• Elevated LDH
• Elevated triglycerides

Inflammatory markers

Elevation of inflammatory markers like ESR, C reactive protein, procalcitonin, IL-6, IL-12, d-dimer, ferritin is seen in HIV patients co-infected with HIV

Diagnostic Study of Choice

• RT-PCR is the standard diagnostic of choice to confirm cases and for active COVID-19 cases. It may take up to 8 weeks for RT-PCR to become negative, and so a repeat RT-PCR is no longer required to document recovery.
• Antibody tests are helpful in detecting previous COVID-19 infection and are likely to be most useful if used within 15 days or more after the onset of symptoms

X-ray

Xray of patients with HIV co-infected with COVID-19 may show

• Consolidation
• Interstitial pulmonary infiltrates
• Bilateral pulmonary infiltrates

Treatment

Medical Therapy

• Treatment of COVID-19 patients with HIV is similar to current guidelines of treatment of general population with COVID-19 along with current maintenance of their antiretroviral therapy. No specific antretroviral therapy has been found effective against SARS-CoV-2 virus. Following treatment have been used in HIV individuals with COVID-19 infection.

• Supportive care-Patients with HIV who develop mild COVID-19 illness could be treated with supportive care with symptomatic relief at home. They should continue their antiretroviral therapy.
• In case of moderate to severe COVID-19 infection they might need to be hospitalized. ART therapy should be continued when hospitalized.
• Llopinavir–ritonavir- It inhibits the activity of the HIV-1 protease. Clinical trial found that treatment with lopinavir–ritonavir was not associated with clinical improvement in COVID-19 patients.
• Tocilizumab -which is a monoclonal antibody which binds to interleukin-6,. It has been used in patients with HIV who develop COVID-19. A retrospective study found it effective in reducing nortalility in severe COVID-19 patients
• Darunavir- It has been used in HIV SARS-CoV-2 coinfected individuals as part of their continued anti retroviral therapy. Trial has found no benefit in COVID-19 patients.
• Antibiotics such as azithromycin have been used inHIV SARS-CoV-2 coinfected individuals.
• Patients who are taking investigational ARV medication as part of their regimen, should be continued on the same medication if possible.

• Patients who have underlying medical conditions should be managed accordingly to prevent complications of COVID-19 infection.

Use of Medications in HIV positive patients.

COVID-19 treatment
interferon beta -1b
hydroxychloroquine(77%)
antibiotics(49%)
corticosteroids(38%)
tocilizumab(10%)
Ritonavir based lopinavir(36%)
Darunavir(21%)

Recommendations for Patients with HIV

• Maintain the supply for antiretroviral therapy for a minimum of 30 days and ideal supply for 90 days.
• People with suppressed HIV viral load and in stable health, should postpone their routine medical care and laboratory visits to the extent possible.Virtual visit and telemedicine should be considered for non-urgent care and non-adherence counseling
• Whenever possible their order for medications should be delivered at home to avoid the exposure.
• If they develop symptoms of COVID-19 like fever, cough, shortness of breath, etc they should seek medical advice.
• They should make sure their vaccination status is updated. Influenza and pneumococcal vaccinations should be kept up to date.
• Switching of the antiretroviral therapy should be delayed until close follow up monitoring is possible. No antiretroviral therapy has been found effective for treatment or prevention of COVID-19. Therefore, their Antiretroviral therapy should not be switched for the purpose of prevention of COVID-19 infection.
• If the HIV patient has been quarantined or self isolated due to exposure to SARS-CoV-2, it should be ensured that they have adequate antiretroviral therapy and additional drug refills should be expedited as needed.
• HIV individuals should follow the standard precautions of hand sanitizing, social distancing, covering face with face masks whenever they have to go out in public places or clinics.