Factors associated with severity of COVID-19 disease in a multicenter cohort of people with HIV in the United States, March-December 2020

  1. Adrienne E. Shapiro
  2. Rachel A. Bender Ignacio
  3. Bridget M. Whitney
  4. Joseph A. Delaney
  5. Robin M. Nance
  6. Laura Bamford
  7. Darcy Wooten
  8. Jeanne C. Keruly
  9. Greer Burkholder
  10. Sonia Napravnik
  11. Kenneth H. Mayer
  12. Allison R. Webel
  13. H. Nina Kim
  14. Stephen E. Van Rompaey
  15. Katerina Christopoulos
  16. Jeffrey Jacobson
  17. Maile Karris
  18. Davey Smith
  19. Mallory O. Johnson
  20. Amanda Willig
  21. Joseph J. Eron
  22. Peter Hunt
  23. Richard D. Moore
  24. Michael S. Saag
  25. W. Christopher Mathews
  26. Heidi M. Crane
  27. Edward R. Cachay
  28. Mari M. Kitahata
  29. for the CFAR Network of Integrated Clinical Systems
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Abstract

Background

Understanding the spectrum of SARS-CoV-2 infection and COVID-19 disease in people with HIV (PWH) is critical to provide clinical guidance and implement risk-reduction strategies.

Objective

To characterize COVID-19 in PWH in the United States and identify predictors of disease severity.

Design

Observational cohort study.

Setting

Geographically diverse clinical sites in the CFAR Network of Integrated Clinical Systems (CNICS)

Participants

Adults receiving HIV care through December 31, 2020.

Measurements

COVID-19 cases and severity (hospitalization, intensive care, death).

Results

Of 16,056 PWH in care, 649 were diagnosed with COVID-19 between March-December 2020. Case fatality was 2%; 106 (16.3%) were hospitalized and 12 died. PWH with current CD4 count <350 cells/mm3(aRR 2.68; 95%CI 1.93-3.71; P<.001) or lowest recorded CD4 count <200 (aRR 1.67; 95%CI 1.18-2.36; P<.005) had greater risk of hospitalization. HIV viral load suppression and antiretroviral therapy (ART) status were not associated with hospitalization, although the majority of PWH were suppressed (86%). Black PWH were 51% more likely to be hospitalized with COVID-19 compared to other racial/ethnic groups (aRR 1.51; 95%CI 1.04-2.19, P=.03). Chronic kidney disease (CKD), chronic obstructive pulmonary disease, diabetes, hypertension, obesity, and increased cardiovascular and hepatic fibrosis risk scores were associated with higher risk of hospitalization. PWH who were older, not on ART, with current CD4 <350, diabetes, and CKD were overrepresented amongst PWH who required intubation or died.

Limitations

Unable to compare directly to persons without HIV; underestimate of total COVID-19 cases.

Conclusions

PWH with CD4 <350 cells/mm3, low CD4/CD8 ratio, and history of CD4 <200, have a clear excess risk of severe COVID-19, after accounting for comorbidities also associated with severe outcomes. PWH with these risk factors should be prioritized for COVID-19 vaccination, early treatment, and monitored closely for worsening illness.

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