- A New York State study assessed data from more than 100,000 HIV-positive people
- Among people with COVID-19, HIV-positive people were more likely to be hospitalized than HIV-negative people
- Once hospitalized, the risk of death was similar regardless of HIV status
Infection with Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) can cause symptoms called coronavirus disease-2019 (COVID-19). In some people, particularly those with underlying conditions—including higher-than-normal blood pressure, abnormal cholesterol levels, diabetes, lung disease and obesity—symptoms of COVID-19 can become severe and require hospitalization.
A team of researchers with the New York State Department of Health has analysed limited health-related data from about 19 million HIV-negative people and 108,062 HIV-positive people. The researchers found that there was no significant difference in the rate of SARS-CoV-2 infection between the two populations in the study. However, HIV-positive people who were diagnosed with COVID-19 were more likely to be hospitalized. Among hospitalized people, there was no significant difference in the risk of death between HIV-positive and HIV-negative people.
HIV-positive people of colour who became infected with SARS-CoV-2 were more likely to develop symptoms and be diagnosed with COVID-19 than HIV-positive white people who became infected with SARS-CoV-2. However, once diagnosed with COVID-19, HIV-positive people of colour were not more likely to be hospitalized, and, once hospitalized, were not more likely to die than HIV-positive white people.
Focus on HIV-positive people
The research team assessed factors that had an impact on hospitalization rates among HIV-positive people after a diagnosis of COVID-19. In general, they found that people under the age of 40 had a lower risk of hospitalization than people aged 40 to 59 years. HIV-positive people aged 60 and older had the greatest risk.
Researchers found other important factors that had an impact on hospitalization for COVID-19 among HIV-positive people, including the following:
- CD4+ cell count – people who had less than 500 CD4+ cells/mm3 were at heightened risk for hospitalization
- viral load – people who had a viral load greater than 200 copies/mL were at heightened risk for hospitalization
- street drugs – people who injected street drugs were at elevated risk for hospitalization after diagnosis of COVID-19
Bear in mind
In the present study, data were previously collected for one purpose (usually in hospital or laboratory administrative databases) and later reanalysed for another purpose. Such retrospective study designs are relatively cheap to implement and produce results relatively quickly. However, retrospective study designs can lead to inadvertently biased conclusions. As a result, findings from such studies must be taken cautiously. For instance, there was no detailed information at the level of individual participants about any diagnoses of underlying conditions and whether such conditions had been modified with treatment (for example, to lower blood pressure or normalize blood sugar or cholesterol levels). This lack of detailed data could have affected the interpretation of trends in the study. Still, in the midst of a public health emergency, retrospective studies can be useful and provide a big picture of what is happening with certain populations. Retrospective studies such as the present one provide a foundation for future research that explores individual medical records that can hopefully provide a more in-depth analysis of risk factors for developing COVID-19 and hospitalization.
Study details
Researchers in New York State accessed administrative databases for this study. These databases have limited information compared to individual patient medical records.
Focus on HIV
The researchers compared health-related information from 108,062 HIV-positive people—2,988 of whom were diagnosed with COVID-19. The average age of these 2,988 people was 54 years; 71% were men and 29% were women. The researchers used the data from a population of 19 million HIV-negative people who lived in New York State for purposes of comparison.
Risk factors for hospitalization among HIV-positive people
Although HIV-positive people had broadly similar rates of infection with SARS-CoV-2 as HIV-negative people, HIV-positive people were at least twice as likely to be hospitalized once they had been diagnosed with COVID-19. This increased risk for hospitalization among HIV-positive people vs. HIV-negative people was the case regardless of gender, age and which part of the state they lived in. Overall, 896 HIV-positive people with COVID-19 were hospitalized.
Age
Among HIV-positive people, those who were under the age of 40 had the lowest risk of hospitalization once diagnosed with COVID-19. The risk increased for people aged 40 to 59 years and was greatest among people aged 60 and older. In general, a relationship between older age and hospitalization risk for COVID-19 has also been seen in studies of HIV-negative people.
CD4+ cell count
In general, HIV-positive people with a CD4+ count less than 500 cells/mm3 faced an increased risk of hospitalization. The trend was as follows: the lower the CD4+ cell count, the greater the risk. Among people with less than 500 cells/mm3, the risk was greatest in those with less than 200 cells/mm3.
The researchers stated that there were some people who had relatively high CD4+ cell counts (500 and above) who were hospitalized because of COVID-19. It is not clear why this subset of people with high CD4+ cell counts was at increased risk for hospitalization. It is plausible that some of them had underlying conditions that increase the risk for severe COVID-19. It is also plausible that some of them were recently diagnosed and had not yet initiated antiretroviral therapy (ART) when they developed COVID-19.
Note that HIV infection is associated with chronic inflammation and excessive activation of the immune system. This inflammation is only partially reduced with ART. Chronic inflammation and persistent excess immunological activation may contribute to an increased risk for developing underlying conditions (comorbidities) and may play a role in weakening the functioning of the immune system.
The connection between unfavourable lab test results—lack of viral suppression and/or low CD4+ cell count—and an increased risk for hospitalization in this study is interesting. It is likely that people with these unfavourable lab test results may have been in poorer overall health and therefore more susceptible to developing COVID-19 once infected with SARS-CoV-2. The reasons for the unfavourable HIV lab test results are not clear, as detailed patient medical records were not available.
Injection of street drugs
The study team noted that HIV-positive people who injected street drugs had higher rates of hospitalization than their HIV-positive peers who did not inject street drugs.
Deaths
A total of 207 HIV-positive people died of complications related to COVID-19 while hospitalized during the study. The researchers looked at their databases a year earlier, when COVID-19 was not a pandemic (March to mid-June 2019), and determined that 490 HIV-positive people had died. Thus, the researchers stated, if the same number of non-COVID-19-related deaths that occurred in the three and a half months in 2019 were to happen in 2020, it is likely that COVID-19 would have accounted for “a 42% addition to anticipated deaths during this same interval in 2020.” However, the researchers also stated that “further analyses refining this estimate are needed.”
HIV-positive people who were black or Hispanic were more likely to be diagnosed with COVID-19 than their white counterparts. However, these people of colour were not more likely to be hospitalized once diagnosed with COVID-19 and were not at heightened risk of death once hospitalized for COVID-19.
Beyond administrative databases
As mentioned earlier, this study’s design was retrospective and largely limited to administrative databases. The study could have been more interesting if it had been able to collect detailed, individual patient-level data extracted from medical records. For instance, many HIV-positive people have or are at risk for co-morbidities, including cardiovascular disease, diabetes, higher-than-normal blood pressure and obesity. Information on whether such conditions had been diagnosed, medications prescribed and dispensed, as well as the response of the comorbidities to medications would have been useful. That is, perhaps a relationship between the management of co-morbidities and decreased risk for COVID-19 could have been found. This would be useful for both healthcare providers and HIV-positive people to know.
However, in the chaos of an ongoing public health emergency, it is not easy to find the money for large prospective or longitudinal studies that need to be undertaken, no matter how urgent such studies may be. Researchers sometimes have to do the best with what is available to them, even if resource levels are not ideal.
Still, despite the caveats noted, the present study is useful in that it provides a broad snapshot of what was happening among people with HIV during the first wave of the pandemic in New York State. The findings can be used for efforts to monitor the care and treatment of HIV-positive people who develop COVID-19. Future studies could help uncover why some HIV-positive people are not achieving viral suppression and CD4+ cell count normalization. In such cases, help may be required to assist people to achieve their HIV treatment goals, so that their health can be optimized and their risk for hospitalization from COVID-19 reduced.
—Sean R. Hosein
Resources
HIV and COVID-19 – TreatmentUpdate 238
Managing Your Health During the COVID-19 Pandemic: Information for people living with HIV – CATIE
Coronavirus disease (COVID-19): Outbreak update – Health Canada
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