HIV Not Linked to Increased Risk for Severe COVID-19

Patients who are HIV-positive with a probable or proven severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may not be at a greater risk for severe disease or death compared with patients who are HIV-negative,

Patients who are HIV-positive with a probable or proven severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may not be at a greater risk for severe disease or death compared with patients who are HIV-negative, according to results of a study published in Clinical Infectious Diseases.1

The SARS-CoV-2 infection pandemic has affected more than 5.5 million people globally, and has led to more than 350,000 deaths. 2 Evidence has shown that risk factors associated with a negative prognosis of SARS-CoV-2 include older age, diabetes mellitus, hypertension, male sex, and cardiovascular, lung, and/or kidney disease. However, the effect of HIV infection on the clinical outcomes of patients infected with SARS-CoV-2 is unclear, due to the fact that the current literature consisting of only case reports or small case series. Although individuals with HIV who have a normal CD4 T-cell count and suppressed viral load may not be at increased risk for serious illness, there are other conditions that increase their risk for severe illness with coronavirus disease 2019 (COVID-19); roughly half of patients with HIV are aged >50 years, are male, and are affected by chronic cardiovascular and lung diseases. Therefore, this retrospective, observational study described the clinical characteristics and outcomes of regularly followed patients with HIVs with a probable/proven diagnosis of SARS-CoV-2 infection.

Data was obtained from the Department of Infectious Diseases database; it included approximately 6000 patients who are HIV-positive, with 90% patients having a viral load of < 20 copies/mL and 76% patients with a CD4 cell count of > 500 mm3. Of these patients, 47 patients were identified to have a proven or probable SARS-CoV-2 infection during the observation period. A total of 76% of these patients were men, and the mean age of the cohort was 51 years. A probable SARS-CoV-2 infection diagnosis was based on the presence of respiratory symptoms (cough and dyspnea) and fever, epidemiologic risk factors, including being a healthcare worker or having relatives or close colleagues with a proven COVID-19 diagnosis, and/or a chest radiograph or computed tomography diagnosis of interstitial pneumonia. A proven SARS-CoV-2 infection diagnosis required a throat swab that was positive for viral nucleic acid.

Results suggested that compared with patients who are HIV-negative, those with HIV with SARS-CoV-2 infection may not be at a greater risk for severe disease or death. Of the 47 patients with HIV with proven or probable SARS-CoV-2 infection, 28 (>50%) patients tested positive and the others were diagnosed with COVID-19 based on their clinical symptoms and presence of risk factors; the mean age of patients with HIV who were diagnosed with COVID-19 was 51 years. Most the patients showed suppressed HIV viremia and acceptable immune reconstitution, and 64% of the patients with HIV had at least 1 comorbid disease.

Of the 28 confirmed-positive patients, 13 were hospitalized; 6 patients had severe lung disease, 2 of these patients required mechanical ventilation: 1 patient recovered and 1 patient died. In addition, 1 patient who had cardiovascular disease and a recent diagnosis of lung cancer died during hospitalization. Forty-five patients recovered within roughly 14 days (±8 days) after symptom onset and there were no significant differences between men and women (P =.338). For comparative purposes, the investigators noted that the crude mortality rate of patients with COVID-19 without HIV at their hospital was 17%.

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Treatments with potential anti-SARS-CoV-2 medications were administered to < 50% of patients: 17% received hydroxychloroquine, 15% received azithromycin, 11% received lopinavir/ritonavir, 1 patient received tocilizumab and remedesivir, and 1 patient receive toxicizumab alone.

The study authors reported that the more favorable outcomes observed in patients with HIV may be explained by the presence of a suboptimal immune system among this population (even in the case of successful antiretroviral therapy), with some showing some persistent immune activation; this may have contributed to preventing COVID-19 from progressing to a severe cytokine storm. Furthermore, the study authors noted that antiretroviral therapy may not play a key role in this favorable outcome: most patients (80%) with HIV with favorable outcomes were receiving integrase inhibitors, and 11% of patients were receiving protease inhibitors. Overall, the study authors concluded that, “[O]ur findings suggest that HIV-positive patients with SARS-CoV-2 infection are not at greater risk of severe disease or death than HIV-negative patients. However, the observed more favorable outcomes need to be confirmed in larger cohort studies.”


  1. Gervasoni C, Meraviglia P, Riva A, et al. Clinical features and outcomes of HIV patients with coronavirus disease 2019 [published online May 14, 2020]. Clin Infect Dis. doi:10.1093/cid/ciaa579/5837155
  2. Johns Hopkins University School of Medicine. Coronavirus COVID-19 global cases. Updated May 27, 2020. Accessed May, 27, 2020.