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CATIE News

17 March 2020 

Coronavirus disease (COVID-19), HIV and hepatitis C: What you need to know

  • An HIV-positive person on effective treatment is not expected to be at higher risk of becoming seriously ill with COVID-19
  • A person with untreated HIV or a low CD4+ cell count may be at higher risk of becoming seriously ill with COVID-19
  • People with HIV or hepatitis C are more likely to have other conditions that carry a greater risk of becoming seriously ill with COVID-19

The World Health Organization has declared that there is a pandemic caused by the spread of a new coronavirus. This virus is called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and causes a disease called coronavirus disease 2019 (COVID-19).

Human coronaviruses cause infections of the nose, throat and lungs. They are most commonly spread from an infected person through:

  • respiratory droplets generated when you cough or sneeze, which briefly remain in the air within about 2 metres (6 feet) of an infected person
  • close personal contact
  • touching something with the virus on it, then touching your mouth, nose or eyes before washing your hands

Current evidence suggests person-to-person spread is efficient when there is close contact.

SARS-CoV-2 can cause a flu-like syndrome in infected people. In most cases (80%) a person will feel like they have a mild cold or flu. However, other people with COVID-19, can develop more serious symptoms and complications. The symptoms of COVID-19 have included:

  • fever
  • cough
  • difficulty breathing
  • pneumonia in both lungs

In severe cases infection can lead to death.

It is very important that people at increased risk for serious illness with COVID-19 as well as those who provide support and care for them take precautions to reduce the risk of transmission. Information about who is at increased risk appears later in this bulletin.

How can you reduce the risk of transmission?

Because the virus can spread so quickly and can cause serious complications in some people, public health officials are asking all people to take precautions to avoid transmission.

To reduce your risk of becoming infected with the coronavirus the Government of Canada recommends the following steps:

  • wash your hands often with soap and water for at least 20 seconds
    • use alcohol-based hand sanitizer if soap and water are not available
  • when coughing or sneezing:
    • cough or sneeze into a tissue or the bend of your arm, not your hand
    • dispose of any tissues you have used as soon as possible in a lined waste basket and wash your hands afterwards
  • avoid touching your eyes, nose, or mouth with unwashed hands
  • clean and disinfect the following high-touch surfaces frequently:
    • counters and tabletops
    • doorknobs and door handles
    • bathroom fixtures
    • toilets
    • bedside tables
    • toys
    • phones
    • keyboards, tablets, electronic mice and remote control devices

Note: hand sanitizer should contain at least 60% alcohol

Additional measures to limit the spread of coronavirus include the following:

  • avoid international travel
  • avoid crowds or large gatherings
  • when possible, keep a distance of 2 metres from other people
  • avoid visiting individuals in hospitals and long-term care centres, especially older adults and those with chronic conditions or compromised immune systems
  • avoid having visitors to your home

Who is at increased risk for serious illness with COVID-19?

The vast majority of people (about 80%) who become infected with the coronavirus will not have severe symptoms. They will feel as if they have a mild cold or flu. However, a small proportion of people who become infected will feel as if they have a severe flu or cold. An even smaller proportion will develop difficulty breathing and, in some cases, pneumonia. People aged 65 and older seem to be at heightened risk, especially if they have other health conditions.

Research suggests that, in general, people at high risk for serious illness related to coronavirus infection tend to have the following underlying conditions:

  • cardiovascular disease – including a history of heart attack, stroke, or high blood pressure
  • chronic respiratory conditions – these can affect one’s ability to breathe and include conditions such as COPD (chronic obstructive pulmonary disease), asthma and so on
  • diabetes
  • kidney disease

These underlying conditions may also be associated with other conditions or diseases as described below.

HIV infection and related factors

There is not much research on the impact of COVID-19 on HIV-positive people. According to Anthony Fauci MD, the Director of the U.S. National Institutes of Allergy and Infectious Diseases (NIAID), an otherwise healthy HIV-positive person who is taking HIV treatment and who has an undetectable viral load and a normal or near-normal CD4+ cell count, is expected to be at low risk for serious illness with COVID-19. Each laboratory has a different range for what is considered a normal CD4+ count. However, the lower end of the normal range for CD4+ cell counts is usually around 500 cells/mm3.

HIV-positive people who are not on treatment, particularly those with very low CD4+ cell counts may be at increased risk for serious illness with COVID 19. Additionally, many HIV-positive people are older, some elderly, and studies suggest that HIV-positive people are more likely to have an underlying condition than the average HIV-negative person of the same age. In general, these underlying conditions tend to be as follows:

  • abnormal levels of cholesterol
  • higher-than-normal blood pressure
  • diabetes
  • kidney disease

Regular monitoring and doctor recommended treatment can help manage and minimize these underlying conditions. Some of these conditions may be associated with more serious illness with COVID-19.

The California Department of Public Health, Office of AIDS, has advice for what additional precautions you should take if you are at higher risk of illness from COVID-19:

  • Make sure that you have adequate supplies and refills for your antiretrovirals and other medications
  • Keep away from others who are sick, limit close contact and wash your hands often
  • If there is a COVID-19 outbreak in your community, stay home as much as possible but maintain a social network remotely to help you stay socially connected and mentally healthy
  • Establish a plan for clinical care, including use of telemedicine, if you have to stay home

Autoimmunity and transplantation

There are some conditions whereby the immune system attacks the body; these are called autoimmune diseases and can include the following:

  • some forms of arthritis
  • Crohn’s disease and related conditions
  • Lupus
  • psoriasis

Some people with these conditions, as well as those who have transplanted organs or tissues, are prescribed treatments that suppress the immune system. As a result, they may be at higher risk for becoming infected with and developing serious illness with COVID-19.

Pregnancy

There is no information at this time about the effect of coronavirus on the health of the mother or the fetus.

Hepatitis viruses and other liver disease

Viruses such as hepatitis B virus (HBV) and hepatitis C virus (HCV) infect the liver and over time, degrade this vital organ. As the liver degrades, a person’s overall health worsens and specific conditions can develop. People who have extensive liver injury arising from HCV and who have not yet been cured can have underlying conditions such as kidney injury, cardiovascular disease, and diabetes. Note that HCV can be cured in as little as eight weeks with treatment that is taken once daily. HCV treatment is widely available in Canada.

People with HBV can also have underlying conditions such as those mentioned above. HBV can be managed with medications

As a result, people with hepatitis viruses may be at higher risk of serious illness with COVID-19.

Fatty liver disease

There are other liver diseases such as nonalcoholic fatty liver disease (NAFLD). This can be broken down into two subtypes – simple fatty liver disease and nonalcoholic steatohepatitis (NASH). These can occur in people with and without HBV, HCV or HIV. People who have some form of fatty liver disease may also have an underlying condition such as the following:

  • pre-diabetes or diabetes
  • obesity
  • higher-than-normal blood pressure
  • abnormal levels of cholesterol in their blood

Thus people with fatty liver may be at increased risk of developing serious illness with COVID-19.

Vulnerable populations

Some populations, including people who use substances and homeless people, may also have underlying conditions that place them at increased risk for serious illness with COVID-19. Additionally, those with inadequate or overcrowded housing, are more dependant upon others for basic needs and less able to maintain social distance, therefore are also more at risk of COVID-19.

What to do if you think that you have COVID-19?

Getting help:  If you think you have been exposed to the coronavirus and develop a fever and symptoms, such as cough or difficulty breathing, call a health care professional or the public health authorities in the province or territory where you are located.

There is a test for SARS CoV-2 in Canada. Public health authorities in your region can tell you more about this test and how to get access to it.

According to the U.S. Centers for Disease Control and Prevention (CDC) here is some advice if you think that you have COVID-19:

Stay home except to get medical care

  • Stay home: People who are mildly ill with COVID-19 are able to isolate at home during their illness. You should restrict activities outside your home, except for getting medical care.
  • Avoid public areas: Do not go to work, school, or public areas.
  • Avoid public transportation: Avoid using public transportation, ride-sharing, or taxis.

Separate yourself from other people and animals in your home

  • Stay away from others: As much as possible, you should stay in a specific room and away from other people in your home. Also, you should use a separate bathroom, if available.
  • Limit contact with pets & animals: You should restrict contact with pets and other animals while you are sick with COVID-19, just like you would around other people. Although there have not been reports of pets or other animals becoming sick with COVID-19, it is still recommended that people sick with COVID-19 limit contact with animals until more information is known about the virus.
  • When possible, have another member of your household care for your animals while you are sick.
  • If you are sick with COVID-19, avoid contact with your pet, including petting, snuggling, being kissed or licked, and sharing food. If you must care for your pet or be around animals while you are sick, wash your hands before and after you interact with pets and wear a facemask.

Call ahead before visiting your doctor

  • Call ahead: If you have a medical appointment, call the healthcare provider and tell them that you have or may have COVID-19. This will help the healthcare provider’s office take steps to keep other people from getting infected or exposed.

Wear a facemask if you are sick

  • If you are sick: You should wear a facemask when you are around other people (e.g., sharing a room or vehicle) or pets and before you enter a healthcare provider’s office.
  • If you are caring for others: If the person who is sick is not able to wear a facemask (for example, because it causes trouble breathing), then people who live with the person who is sick should not stay in the same room with them, or they should wear a facemask if they enter a room with the person who is sick.

Avoid sharing personal household items

  • Do not share: You should not share dishes, drinking glasses, cups, eating utensils, towels, or bedding with other people or pets in your home.
  • Wash thoroughly after use: After using these items, they should be washed thoroughly with soap and water.

Clean all “high-touch” surfaces everyday

  • Clean and disinfect: Practice routine cleaning of high touch surfaces.
  • Disinfect areas with bodily fluids: Also, clean any surfaces that may have blood, stool, or body fluids on them.
  • Household cleaners: Use a household cleaning spray or wipe, according to the label instructions. Labels contain instructions for safe and effective use of the cleaning product including precautions you should take when applying the product, such as wearing gloves and making sure you have good ventilation during use of the product.

Monitor your symptoms

  • Seek medical attention: Seek prompt medical attention if your illness is worsening (e.g., difficulty breathing).
  • Call your doctor: Before going to a healthcare facility, call your healthcare provider and tell them that you have, or are being evaluated for, COVID-19.
  • Wear a facemask when sick: Put on a facemask before you enter the facility. These steps will help the healthcare provider’s office to keep other people in the office or waiting room from getting infected or exposed.

Treatment and vaccines

There are no approved treatments or vaccines for SARS CoV-2. However, research is underway with different potential treatments for coronavirus infection.

There are suggestions from laboratory research with cells and viruses that an older HIV treatment can inhibit the SARS CoV-2. This treatment is lopinavir-ritonavir and sold as Kaletra in Canada and other high-income countries, and as Aluvia (and in generic formulations) in other regions. Clinical trials are underway to find out if Kaletra is effective in people with COVID-19. Note that Kaletra is associated with side effects such as diarrhea, loose stools and nausea. It also has the potential to interact with many other medicines and substances, raising or lowering their levels in the body and vice versa.

There is no evidence that other anti-HIV drugs have activity against SARS CoV-2

Further information

Federal, provincial/territorial, and local public health authorities are providing ongoing guidance regarding additional precautions that should be taken to limit the spread of the virus in your region.

Information about COVID-19 is changing rapidly. Please consult the resources below for the most current information:

Acknowledgements

CATIE thanks Professor William Cameron MD, University of Ottawa and Isaac Bogoch MD, University of Toronto, for their input and helpful comments in developing this article.

—Sean R. Hosein and Timothy Rogers