There is a growing body of evidence that people living with HIV may have worse coronavirus disease 2019 (COVID-19) outcomes, highlighting the urgency to prioritize this group of patients for the COVID-19 vaccine, according to an editorial commentary published in Clinical Infectious Diseases.1
The authors listed multiple potential reasons for why people living with HIV may have worse COVID-19 outcomes, including immunodeficiency in those not receiving antiretroviral therapy (ART), low CD4 cell counts, excess inflammation in those receiving ART, high prevalence of comorbidities, and societal inequities.
Several studies have shown that people with HIV and COVID-19 tend to have higher C-reactive protein (CRP) concentrations. Excess inflammation, which has been linked to severe COVID-19, may particularly place people with HIV at a higher risk for COVID-19. However, whether or not excess inflammation leads to increased risk for COVID-19 is uncertain, since a large multicenter study found no difference in CRP concentrations between people with and without HIV coinfected with COVID-19.2
This study also determined no difference in inflammatory markers such as lactate dehydrogenase, erythrocyte sedimentation rate, and ferritin. Additional research is needed to determine the “impact of inflammatory markers on risk stratification,” the authors noted.
In addition, people with HIV, COVID-19, and low CD4 cell counts (<200/mm3) have been shown to have higher risk of hospitalization, intensive care unit (ICU) admission, mechanical ventilation, and death in several studies. This raises a question regarding the relationship between immune dysregulation and its contribution to worse COVID-19 outcomes.
Since increased risk of hospitalization, ICU admission, mechanical ventilation, and death have been linked to a higher prevalence of comorbidities, answering the above question will inevitably require determining whether HIV is a risk factor for severe COVID-19 independent of comorbidities. An important note to remember is that adjusting for relevant comorbidities may result in attenuating the findings.
While more studies are needed, given that people of color often have higher rates of comorbidities and experience more socioeconomic disparities, the authors called for “prioritization of people with HIV for COVID-19 vaccination into the same tier as people with other comorbidities that confer increased risk of severe COVID-19.”
1. Truant VA, Gandhi RT. When epidemics collide: why people with HIV may have worse COVID-19 outcomes and implications for vaccination. Clin Infect Dis. Published online January 4, 2021. doi:10.1093/cid/ciaa1946
2. Hadi YB, Naqvi SFZ, Kupec JT, Sarwari AR. Characteristics and outcomes of COVID-19 in patients with HIV: a multicentre research network study. AIDS. 2020;34(13):3-8. doi:10.1097/QAD.0000000000002666