COVID-19 and HIV infection: what are the risks?
So far there is no evidence for a higher COVID-19 infection rate or different disease course in people living with HIV (PLWH) than in HIV-negative people. Current evidence indicates that the risk of severe illness increases with age, male sex, obesity and with certain chronic medical problems such as cardiovascular disease, chronic lung disease and diabetes. Although people living with HIV who are on treatment with a normal CD4 T-cell count and suppressed viral load may not be at an increased risk of serious illness, many people living with HIV may have other conditions that increase their risk. Indeed, almost half of people living with HIV in Canada are older than 50 years and chronic medical problems, such as cardiovascular and chronic lung disease, are more common in people living with HIV.
Although there is no evidence, one might speculate that immune suppression, indicated by a low CD4 T-cell count (<200 cells/µL), or not receiving antiretroviral treatment, will also be associated with an increased risk for more severe COVID-19 disease presentation. For patients with low CD4-counts (<200 cells/uL), or who experience a CD4-decline during a COVID-19 infection, remember to initiate opportunistic infection (OI) prophylaxis against PJP in attempt to avoid superinfection. Smoking is a risk factor for respiratory infections; smoking cessation should therefore be encouraged for all patients. Influenza and pneumococcal vaccinations should be kept up to date.
COVID-19 treatment: antiretrovirals & further options
There are a number of clinical trials ongoing around the world in attempts to find therapies to help manage COVID infection. Many TGH HIV clinic doctors and research staff have lent their expertise and are involved in the design and conduct of these studies taking place in Toronto. HIV infection is not an exclusion criteria for participation in these clinical trials.
There is ongoing discussion and research around some HIV antiretrovirals which may have some activity against COVID-19. The first randomized clinical trial with lopinavir/ritonavir demonstrated no benefit over standard care in 199 hospitalized adults with severe COVID-19. However, the patients studied had advanced disease and their therapy was initiated late. It is unclear whether there could be benefits earlier in disease or as prophylaxis. There is no evidence to support the use of other antiretrovirals, including protease inhibitors; indeed, structural analysis demonstrates no darunavir binding to COVID-19 protease.
Hydroxychloroquine, an agent used to treat lupus and other rheumatological diseases, has shown activity in a test tube against SARS-CoV-2, the virus which causes COVID-19 illness. A recent case series on hydrochloroquine with or without the antibiotic azithromycin was not able to demonstrate a clear clinical benefit due to methodological issues. The study investigators suggest that this combination may provide an infection control benefit of more rapid viral clearance, although there was a lack of control arm for direct comparison.
A further potential drug candidate for treatment of COVID19 is remdesivir which was originally developed for Ebola therapy. Remdesivir has broad in vitro antiviral activity against SARS-CoV-2. First cases where COVID19 patients were treated with remdesivir suggest potential clinical benefit. The results from ongoing clinical trials are eagerly awaited.
Our clinic doctors are watching these and other studies closely. At the present time, there is no evidence for any effective therapy, and encourage anyone who is diagnosed with COVID-19 to consider enrollment in a clinical trial. Dr. Alice Tseng has updated her HIV/HCV drug therapy app to include any potential drug interactions with these experimental therapies and HIV medications.
Currently there is no evidence is available to justify switching a patient from their usual antiretroviral therapy. Switching could be associated with adverse outcomes such as new side effects or loss of viral control. Additionally there is no evidence to support HIV-negative people taking antiretrovirals outside the context of pre-exposure prophylaxis (PrEP) to prevent HIV acquisition – PrEP should be taken as directed and there is no current evidence that PrEP is effective against COVID-19.
It is important to be in contact with your treatment team if you have any questions and to ensure that you have an adequate supply of your medication as we are unsure how long the epidemic and the restrictions will last. Follow the recommendations of the public health authorities on maintaining social distancing and keep well.
Where to go for additional information:
- What to Know about HIV and COVID-19 (Centers for Disease Control and Prevention)
- Interim Guidance for COVID-19 and Persons with HIV (U.S. Dept of Health and Human Services)
- The 2019 Novel Coronavirus (COVID-19) (Ontario Ministry of Health)
- Intensive Care Society (ICS) and British HIV Association (BHIVA) statement on considerations for critical care for people with HIV during COVID-19.
- Q&A on COVID-19, HIV and antiretrovirals, World Health Organization.
- COVID-19: Implications for Managing Antiretroviral Therapy in Patients with HIV.
1 Cao B, Wang Y, Wen D, et al. A trial of lopinavir-ritonavir in adults hospitalized with severe Covid-19. N Engl J Med. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32187464.
2 https://www.jnj.com/lack-of-evidence-to-support-darunavir-based-hiv-treatments-for-coronavirus accessed 1 April 2020.
3 Gautret P, Lagier JC, Parola P et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. Int J Antimicrob Agents. 2020; In Press. (DOI 10.1016/jantimicag.2020.105949) https://www.ncbi.nlm.nih.gov/pubmed/32205204
4 Gautret P, Lagier JC, parola P et al. Clinical and microbiological effect of a combination of hydroxychloroquine and azithromycin in 80 COVID-19 patients with at least a six day follow-up: an observational study. https://www.mediterranee-infection.com/wp-content/uploads/2020/03/COVID-IHU-2-1.pdf accessed 1 April 2020.
5 LescureF-X, Bouadma L, Nguyen D, et al. Clinical and virological data of the first cases of COVID-19 in Europe: a case series. Lancet Infect Dis 2020; published online. https://doi.org/10.1016/S1473-3099(20)30200-0