Special Considerations in People With Human Immunodeficiency Virus
Last Updated: October 9, 2020
Prevention and Diagnosis of COVID-19
Management of COVID-19
Management of HIV
Rating of Recommendations: A = Strong; B = Moderate; C = Optional
Rating of Evidence: I = One or more randomized trials with clinical outcomes and/or validated laboratory endpoints; II = One or more well-designed, nonrandomized trials or observational cohort studies; III = Expert opinion
Approximately 1.2 million persons in the United States are living with human immunodeficiency virus (HIV). Most of these individuals are in care, and many are on antiretroviral therapy (ART) and have well-controlled disease.1 Similar to COVID-19, HIV disproportionately affects racial and ethnic minorities and persons of lower socioeconomic status in the United States;2 these demographic groups also appear to have a higher risk for worse outcomes with COVID-19. Information on HIV and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) coinfection is evolving rapidly. The sections below outline the current state of knowledge regarding the prevention and diagnosis of SARS-CoV-2 infection in people with HIV, treatment and clinical outcomes in people with HIV who develop COVID-19, and management of HIV during the COVID-19 pandemic. In addition to these Guidelines, the Department of Health and Human Services (HHS) Panel on Antiretroviral Guidelines for Adults and Adolescents has developed the Interim Guidance for COVID-19 and Persons with HIV.
Prevention of COVID-19 in People With HIV
The COVID-19 Treatment Guidelines Panel (the Panel) recommends using the same approach in advising persons with HIV on the strategies to prevent acquisition of SARS-CoV-2 infection as used for people without HIV (AIII). There is currently no clear evidence that any antiretroviral (ARV) medications can prevent the acquisition of SARS-CoV-2 infection.
Diagnostic and Laboratory Testing for COVID-19 in People With HIV
Diagnosis of COVID-19 in People With HIV
The Panel recommends using the same approach for diagnosis of SARS-CoV-2 infection in people with HIV as in those without HIV (see SARS-CoV-2 Testing) (AIII). There is currently no evidence that the performance characteristics of nucleic acid amplification testing (NAAT) for diagnosis of acute SARS-CoV-2 infection differ in people with and without HIV. The Panel recommends against the use of serologic testing as the sole basis for diagnosis of acute SARS-CoV-2 infection. However, if diagnostic serologic testing is performed, the results should be interpreted with caution, especially in patients with HIV because cross-reactivity between antibodies to SARS-CoV-2 and HIV has been reported.3
Correlation of CD4 Count in People With HIV and COVID-19
The normal range of CD4 T lymphocyte (CD4) cell counts in healthy adults is about 500 to 1,600 cells/mm3. Persons with HIV and CD4 count of ≥500 cells/mm3 have similar cellular immune function to persons without HIV. In people with HIV, a CD4 count <200 cells/mm3 meets the definition for AIDS. For patients on ART, the hallmark of treatment success is plasma HIV RNA below the level of detection by a PCR assay. Lymphopenia is a common laboratory finding in patients with COVID-19; in patients with HIV, clinicians should note that CD4 counts obtained during acute COVID-19 may not accurately reflect the patient’s HIV disease stage.
There have been some reports of persons with advanced HIV who have presented with COVID-19 and another coinfection, including Pneumocystis jirovecii pneumonia.4,5 In patients with advanced HIV with suspected or confirmed SARS-CoV-2 infection, clinicians should consider a broader differential diagnosis for clinical symptoms and consider consultation with an HIV specialist (AIII).
Clinical Presentation of COVID-19 in People With HIV
It is currently not known whether the incidence of SARS-CoV-2 infection or the rate of progression to symptomatic disease is higher in persons with HIV. Approximately 50% of persons with HIV in the United States are aged >50 years and many have comorbidities that are associated with more severe illness with COVID-19, including hypertension, diabetes mellitus, cardiovascular disease, tobacco use disorder, chronic lung disease, chronic liver disease, and cancer.6
There are several case reports and case series that describe the clinical presentation of COVID-19 in persons with HIV.7-17 These studies indicate that the clinical presentation of COVID-19 is similar in persons with and without HIV. Most of the published reports describe populations in which most of the individuals with HIV are on ART and have virologic suppression. Consequently, the current understanding of the impact of COVID-19 in persons with advanced HIV with low CD4 counts or those with persistent HIV viremia is limited.
Management of COVID-19 in People With HIV
Recommendations for the triage and management of COVID-19 in people with HIV are the same as those for the general population (AIII).
The treatment of COVID-19 in persons with HIV is the same as that for persons without HIV (AIII). When starting treatment for COVID-19 in patients with HIV, clinicians should pay careful attention to potential drug-drug interactions and overlapping toxicities among COVID-19 treatments, ARV medications, antimicrobial therapies, and other medications (AIII). Remdesivir should be used as recommended in the Remdesivir section of these Guidelines. There are no significant drug-drug interactions expected between remdesivir and ARV drugs. Dexamethasone should also be used as recommended in the Corticosteroids section of these Guidelines. Dexamethasone is an inducer of hepatic enzymes and could potentially lower levels of certain coadministered ARV drugs. However, this interaction is not expected to be clinically significant based on the short duration of dexamethasone therapy (up to 10 days) in the RECOVERY trial. Although some ARV drugs are being studied for the prevention and treatment of COVID-19, no agents have been shown to be effective.
People with HIV should be offered the opportunity to participate in clinical trials of vaccines and potential treatments for COVID-19. A variety of immunomodulatory therapies are prescribed empirically or administered as part of a clinical trial to treat severe COVID-19 disease. Data about whether these medications are safe to use in patients with HIV are lacking. If a medication is proven to reduce the mortality of patients with COVID-19 in the general population, it should also be used to treat COVID-19 in patients with HIV, unless data indicate that the medication is not safe or effective in this population.
Management of HIV in People With SARS-CoV-2/HIV Coinfection
Below are some general considerations regarding the management of HIV in people with SARS-CoV-2/HIV coinfection.
- ART and opportunistic infection prophylaxis should be continued in a patient with HIV who develops COVID-19, including in those who require hospitalization, whenever possible (AIII). ARV treatment interruption may lead to rebound viremia, and in some cases, emergence of drug resistance. If the ARV drugs are not on the hospital’s formulary, administer medications from the patient’s home supplies (if available).
- Clinicians treating COVID-19 in people with HIV should consult with an HIV specialist before adjusting or switching a patient’s ARV medications. An ART regimen should not be switched or adjusted (i.e., by adding ARVs to the regimen) for the purpose of preventing or treating SARS-CoV-2 infection (AIII). Many drugs, including some ARV agents (e.g., lopinavir/ritonavir, boosted darunavir, and tenofovir disoproxil fumarate/emtricitabine), have been or are being evaluated in clinical trials or are prescribed for off-label use for the treatment or prevention of SARS-CoV-2 infection. To date, lopinavir/ritonavir and darunavir/ritonavir have not been found to be effective (see Antiviral Therapy).18,19 Two retrospective studies suggest an effect of tenofovir disoproxil fumarate/emtricitabine in preventing SARS-CoV-2 acquisition or hospitalization or death associated with COVID-19;8,20 however, the significance of these findings is unclear as neither study adequately controlled for confounding variables such as age and comorbidities.
- For patients who are taking an investigational ARV medication as part of their HIV regimen, arrangements should be made with the investigational study team to continue the medication, if possible.
- For critically ill patients who require tube feeding, some ARV medications are available in liquid formulations and some, but not all, ARV pills may be crushed. Clinicians should consult an HIV specialist and/or pharmacist to assess the best way for a patient with a feeding tube to continue an effective ARV regimen. Information may be available in the drug product label or in this document.
- For people who present with COVID-19 and have either a new diagnosis of HIV or a history of HIV but are not taking ART, the optimal time to start or restart ART is currently unknown. For people with HIV who have not initiated ART or who have been off therapy for >2 weeks before presenting with COVID-19, the Panel recommends consultation with an HIV specialist regarding initiation or re-initiation of ART as soon as clinically feasible. If ART is started, maintaining treatment and linking patients to HIV care upon hospital discharge is critical. If an HIV specialist is not available, clinical consultation is available through the National Clinical Consultation Center warmline, Monday through Friday, 9 am to 8 pm EST.
Clinical Outcomes of COVID-19 in People With HIV
No significant differences in clinical outcomes have been noted in several small case series from Europe and the United States.7,9-11,13-17 Data from the Veterans Aging Cohort Study were analyzed to compare outcomes in 253 mostly male participants with HIV and COVID-19 who were matched with 504 participants with only COVID-19.12 In this comparison, there was no difference in COVID-19-related hospitalization, intensive care unit admission, intubation, or death in patients with or without HIV. In contrast, worse outcomes, including increased COVID-19 mortality rates, in people with HIV have been reported in cohort studies from the United States, the United Kingdom, and South Africa.20-23 In a multicenter cohort study of 286 patients with HIV and COVID-19 in the United States, lower CD4 count (i.e., <200 cells/mm3), despite virologic suppression, was associated with a higher risk for poor outcomes.23
Special Considerations in Children and Pregnant Women With HIV Who Develop COVID-19
Currently, there is limited information about pregnancy and maternal outcomes in women with HIV who have COVID-19 and in children with HIV and COVID-19. Readers are referred to sections in these Guidelines on the management of COVID-19 in pregnancy and in children, and to the HHS Interim Guidance for COVID-19 and Persons with HIV.
- Harris NS, Johnson AS, Huang YA, et al. Vital signs: status of human immunodeficiency virus testing, viral suppression, and HIV preexposure prophylaxis—United States, 2013–2018. MMWR Morb Mortal Wkly Rep. 2019;68(48):1117-1123. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31805031.
- Meyerowitz EA, Kim AY, Ard KL, et al. Disproportionate burden of coronavirus disease 2019 among racial minorities and those in congregate settings among a large cohort of people with HIV. AIDS. 2020;34(12):1781-1787. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32604138.
- Food and Drug Administration. New York SARS-CoV-2 real-time reverse transcriptase (RT)-PCR diagnostic panel. 2020. Available at: https://www.fda.gov/media/135847/download. Accessed September 8, 2020.
- Coleman H, Snell LB, Simons R, Douthwaite ST, Lee MJ. Coronavirus disease 2019 and Pneumocystis jirovecii pneumonia: a diagnostic dilemma in HIV. AIDS. 2020;34(8):1258-1260. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32501852.
- Blanco JL, Ambrosioni J, Garcia F, et al. COVID-19 in patients with HIV: clinical case series. Lancet HIV. 2020;7(5):e314-e316. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32304642.
- Centers for Disease Control and Prevention. HIV surveillance report: estimated HIV incidence and prevalence in the United States 2014-2018. 2020. Available at: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-supplemental-report-vol-25-1.pdf. Accessed: September 8, 2020.
- Byrd KM, Beckwith CG, Garland JM, et al. SARS-CoV-2 and HIV coinfection: clinical experience from Rhode Island, United States. J Int AIDS Soc. 2020;23(7):e25573. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32657527.
- Del Amo J, Polo R, Moreno S, et al. Incidence and Severity of COVID-19 in HIV-Positive Persons Receiving Antiretroviral Therapy: a cohort study. Ann Intern Med. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32589451.
- Gervasoni C, Meraviglia P, Riva A, et al. Clinical features and outcomes of HIV patients with coronavirus disease 2019. Clin Infect Dis. 2020; Published online ahead of print. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32407467.
- Harter G, Spinner CD, Roider J, et al. COVID-19 in people living with human immunodeficiency virus: a case series of 33 patients. Infection. 2020; Published online ahead of print. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32394344.
- Karmen-Tuohy S, Carlucci PM, Zervou FN, et al. Outcomes Among HIV-Positive Patients Hospitalized With COVID-19. J Acquir Immune Defic Syndr. 2020;85(1):6-10. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32568770.
- Park LS, Rentsch CT, Sigel K, et al. COVID-19 in the largest U.S. cohort. Presented at: 23rd International AIDS Conference. 2020. Virtual.
- Patel VV, Felsen UR, Fisher M, et al. Clinical outcomes by HIV serostatus, CD4 count, and viral suppression among people hospitalized with COVID-19 in the Bronx, New York. Presented at: 23rd International AIDS Conference. 2020. Virtual.
- Shalev N, Scherer M, LaSota ED, et al. Clinical characteristics and outcomes in people living with HIV hospitalized for COVID-19. Clin Infect Dis. 2020; Published online ahead of print. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32472138.
- Sigel K, Swartz T, Golden E, et al. COVID-19 and people with HIV infection: outcomes for hospitalized patients in New York City. Clin Infect Dis. 2020; Publsihed online ahead of print. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32594164.
- Stoeckle K, Johnston CD, Jannat-Khah DP, et al. COVID-19 in hospitalized adults with HIV. Open Forum Infect Dis. 2020;7(8). Available at: https://www.ncbi.nlm.nih.gov/pubmed/32864388.
- Vizcarra P, Perez-Elias MJ, Quereda C, et al. Description of COVID-19 in HIV-infected individuals: a single-centre, prospective cohort. Lancet HIV. 2020;7(8):e554-e564. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32473657.
- 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;382(19):1787-1799. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32187464.
- Chen J, Xia L, Liu L, et al. Antiviral activity and safety of darunavir/cobicistat for the treatment of COVID-19. Open Forum Infect Dis. 2020;7(7):ofaa241. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32671131.
- Davies MA. HIV and risk of COVID-19 death: a population cohort study from the Western Cape Province, South Africa. medRxiv. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32637972.
- Bhaskaran K, Rentsch CT, MacKenna B, et al. HIV infection and COVID-19 death: population-based cohort analysis of UK primary care data and linked national death registrations within the OpenSAFELY platform. medRxiv. 2020. Available at: https://www.medrxiv.org/content/10.1101/2020.08.07.20169490v1.
- Geretti A, Stockdale A, Kelly S, et al. Outcomes of COVID-19 related hospitalisation among people with HIV in the ISARIC WHO Clinical Characterisation Protocol UK Protocol: prospective observational study. medRxiv. 2020. Available at: https://www.medrxiv.org/content/10.1101/2020.08.07.20170449v1.
- Dandachi D, Geiger G, Montgomery MW, et al. Characteristics, comorbidities, and outcomes in a multicenter registry of patients with HIV and coronavirus disease-19. Clin Infect Dis. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32905581.