Elevated Inflammatory Markers in HIV May Lead to Worse Outcomes in COVID-19

Medicine pills on the table. COVID-19 (coronavirus) inscription is seen in the background
Despite treatment with antiretroviral therapies, people with HIV may be more likely to experience severe manifestations of COVID-19.

Findings from a retrospective study of COVID-19 in people with HIV suggest that this population may be at increased risk for severe manifestations of coronavirus disease 2019 (COVID-19) despite antiretroviral therapy. According to the results of a study published in the Journal of Infectious Diseases, those with increased markers of inflammation and immune dysregulation are also at risk for worse outcomes.

Investigators systematically identified all individuals with a diagnosis of HIV presenting to 5 New York City emergency departments between March 2 and April 15, 2020, who had a positive nucleic acid amplification test for SARS-CoV-2. Investigators then manually reviewed patients’ electronic medical record; 1 clinician-reviewer recorded demographic data, HIV history, presenting symptoms and signs, general laboratory and HIV parameters during the COVID-19 presentation, and outcomes for all patients while a second clinician-reviewer independently reviewed each data field.

People with HIV and COVID-19 demonstrated both severe lymphopenia and decreased CD4+ T-cell counts (320 cells/uL [interquartile range, 139-490]). Levels of inflammatory markers were also elevated, including C-reactive protein, fibrinogen, D-dimer, interleukin-6, interleukin-8, and TNF-alpha. Overall, 19 of 72 hospitalized patients died (26.4%) and 53 recovered (73.6%). Compared with those who recovered, patients who died had higher levels of inflammatory markers and more severe lymphopenia. Patients who died were also more likely to require ventilator support (57.9%) and care in an intensive care unit (68.4%).

The investigators noted several study limitations, chief among them that this was a retrospective chart review limited to 1 hospital system. Therefore, complete HIV history was not available for all patients, and laboratory markers were obtained at the discretion of treating physicians. The study also lacked a matched HIV-negative comparison group, and comparisons with published data are potentially confounded by disease and epidemiologic factors.

Additionally, high rates of HIV suppression prevented the investigators from drawing conclusions about the risk of severe COVID-19 in viremic people with HIV. Testing in many locations has also been limited due to the strain that the COVID-19 pandemic has placed on the US healthcare system; testing was prioritized for sicker patients during the study period, resulting in a sample biased toward those with more severe disease and who might be predisposed to worse outcomes. Finally, data on race and ethnicity were limited. Disparities based on these factors are likely to be important, especially for people with HIV.

“This analysis reveals that a subset of PWH develop severe COVID-19 associated with a profound inflammatory response,” the investigators concluded. They recommend that future prospective studies proceed with carefully matched control groups to identify determinants of severe COVID-19 in people with HIV. These studies, they noted, will be crucial to understanding the biological mechanisms and clinical impact of SARS-CoV-2 coinfection in this population.


Ho HE, Peluso MJ, Margus C, et al. Clinical outcomes and immunologic characteristics of Covid-19 in people with HIV [published online June 30, 2020]. J Infect Dis. doi:10.1093/infdis/jiaa380