Key Questions: HIV and COVID-19

Just as the COVID-19 pandemic hit the United States (U.S.), the nation was ramping up efforts to address a different epidemic, HIV. Successful HIV outcomes require consistent access to care and medication, as does harnessing the preventive benefits of HIV treatment adherence. Similarly, key tools in HIV prevention are HIV testing and PrEP which necessitate access to health services. Yet, with options for medical care reduced, social distancing guidelines in place, and fears about COVID-19 exposure, COVID-19 threatened access to HIV care and prevention services and national efforts to address HIV. In addition, understanding the interplay of COVID-19 disease, vaccination, and HIV is important to the health of people with and at risk for HIV and curbing both epidemics. This analysis explores key questions around COVID-19 and HIV – what we know and what we are still learning.

Are people with HIV at higher risk for COVID-19?

NIH guidance states “whether people with HIV are at greater risk of acquiring SARS-CoV-2 infection is currently unknown.” While some researchers have proposed that people with HIV who are not virally suppressed or on treatment may be at increased risk of contracting SARS-CoV-2, the virus that causes COVID-19, because of a compromised immune system, others have found no such correlation. Most research and guidance to date has focused on whether people with HIV are more likely to experience severe outcomes from COVID-19 (e.g. severe illness, hospitalization, and death). Findings in this area were mixed for many months but a recent WHO report examining data from 24 countries and more than 15,500 people with HIV hospitalized for COVID-19 finds HIV is an independent risk factor for severe or critical COVID. Most previous research concludes that risk appears greatest for those who are immunocompromised or face other comorbid conditions. This study is particularly notable as it isolates HIV as a risk factor after controlling for disease severity and comorbidities along with a range of other factors. A significant limitation to the study, however, is that it lacked data on engagement with HIV treatment or viral suppression. Additional data on HIV and COVID risk includes:

• Referring to severity of COVID-19 outcomes, the CDC states that while information is still somewhat limited, “we believe people with HIV who are on effective HIV treatment have the same risk for COVID-19 [disease] as people who do not have HIV.” Elsewhere CDC states that people “who have serious underlying medical conditions might be at increased risk for severe illness” and this may include “people who have weakened immune systems,” including people with HIV with a low CD4 cell count or not engaged in HIV treatment. As such CDC includes HIV in its list of conditions that “can” make someone more likely to get severely ill from COVID-19.
• NIH guidance and a recent article by Dr. Anthony Fauci and others also finds the evidence as to whether people with HIV are at higher risk for COVID-19 or severe disease outcomes mixed. However, it concludes, “it is clear that the COVID-19 pandemic has had a great negative impact on persons with HIV” and that “the severity of COVID-19 disease in persons with HIV is related strongly to the presence of comorbidities that increase the risk of severe disease in COVID-19 patients in the absence of HIV.” Indeed, some of these comorbidities are more common in people with HIV than in those who are HIV negative.
• Another review article finds that “the interaction between SARS-CoV-2 and HIV infection is still unclear and data are, at times, conflicting” but highlights larger more recent studies that find “that people living with HIV (particularly with low CD4 cell counts or untreated HIV infection) might have a more severe clinical course than those who are HIV-negative.”

Notably, many people with HIV in the U.S. could be considered at increased risk for severe COVID-19 illness based on the CDC definition due to uncontrolled HIV. An estimated 7% of people with HIV had a geometric mean CD4 count of less than 200 cells/µL (a marker of severely impaired immune system), another 11% had a CD4 count of less than 350 cells/µL. Further, just 60% of people with HIV report 100% antiretroviral therapy dose adherence in the preceding 30 days and over one-third (38%) do not have sustained viral suppression.

Beyond risk associated with HIV infection, immunosuppression, or comorbidities, there are broader structural and contextual factors – the social determinants of health – that may have an impact on COVID-19 susceptibility among those with HIV.

How do the social determinants of health, and their relationship to HIV, affect COVID-19 risk?

Apart from HIV, or comorbidities that heighten the risk for increased COVID-19 severity, people with HIV are overly represented in many of the demographic groups that that have been hardest hit by the COVID pandemic. Indeed, many are the very factors that place communities at risk for HIV. As such, people with HIV may be at higher risk for severe COVID-19 outcomes by virtue of their representation in these groups.

Race/Ethnicity

People of color have been disproportionately impacted by both COVID-19 and HIV, with overlapping risk factors. Compared to White people, people of color have been harder hit by COVID-19 in terms of cases, hospitalization, and deaths. This is true among Black, Hispanic, and especially American Indian or Alaskan Native people. American Indian or Alaskan Native people faced 1.6 times the case rate, 2.4 times the death rate, and 3.5 times the hospitalization rates compared to White people. Hispanic people also faced higher comparative rates at 2.0, 3.0, and 2.3 times that of White people, respectively (see figure 1). While case rates among Black people were similar to those among White people, rates of hospitalization and death were higher at 3.0 and 2.3 times the rate, respectively.

Notably, Black and Hispanic people, groups hard hit by COVID-19, are also hardest hit by HIV. While Black people represent just 12% of the U.S. population, they account for 41% of HIV cases; Hispanic people make up 19% of the US population but 23% of HIV cases (see figure 2). In addition, compared to White people with HIV, people of color with HIV have lower rates of viral suppression and engaging in HIV care, which could also make them more vulnerable to severe COVID-19 illness.

Age

Severe COVID-19 disease and deaths have been concentrated among older adults and on average, people with HIV are older compared to the general population. Nearly all (95%) COVID related deaths occurred among those 50 years and older; 81% have been among those 65 years and older. Those aged 64-74 have forty-times the risk of COVID-19 hospitalization compared to children aged 5-17 and the risk is ninety-five times greater among those 85 and older.

While people 55 years or older make-up just over one-third of the US population (35%), they comprise 58% of people with HIV. COVID deaths are heavily concentrated among older adults. In addition, HIV has been associated with premature aging, even among those with viral suppression, which can lead to comorbidities typically seen in those 10-13 years older without HIV. As some of these comorbidities, such as cancer and heart disease, are also associated with severe COVID morbidity and mortality, people with HIV may be at greater risk for severe COVID-19 compared to those without HIV.

Sexual Orientation

While national data on COVID-19 cases and outcomes by sexual orientation is not available, LGBT people have been hard hit by the pandemic in other ways, including with respect to job loss and negative mental health effects. Our recent survey found that a larger share of LGBT adults compared to non-LGBT adults report that they or someone in their household has experienced COVID-era job loss (56% v. 44%). In addition, three-fourths of LGBT people (74%) say that worry and stress from the pandemic has had a negative impact on their mental health, compared to 49% of those who are not LGBT, and LGBT people are more likely to say that the negative impact has been major (49% v 23%).

People with HIV are more likely to be LGBT than those in the general population and thus could be especially vulnerable to these negative effects of the pandemic. Over half (53%) of people with HIV identify as lesbian, gay, bisexual, or have a sexual identity other than heterosexual. Separately, two percent identify as transgender. This compared to 4.5% of people in the general population who identify as LGBT.

Income

People who live on lower incomes are thought to be at higher risk of exposure to SARS-CoV-2 and for serious illness if they become infected, compared to those who live on moderate to high incomes. Given that on average people with HIV live on substantially lower incomes than the general population, this too could put them in a higher risk group for COVID-19. Forty-three percent (43%) of adults with HIV live below the poverty level compared to 11% of U.S. adults overall.

Factors that contribute to these increased risks include socioeconomic and demographic circumstances and higher rates of certain comorbidities. People who live on lower incomes may be more likely to live in dense settings, work in essential jobs that did not allow for work remotely during the pandemic, or work in high-risk environments, such as in the service and healthcare industries. People on lower incomes may also be at higher risk due to increased rates of certain health conditions. For example, one KFF study found that non-elderly adults earning below $15,000 a year had double the risk of serious illness if they contracted COVID-19 compared to those earning $75,000 per year based on the presence of certain high-risk health conditions.

How likely is it that people with HIV live in COVID-19 hot spots?

People with HIV commonly live in counties hard hit by the COVID-19 pandemic. Three-quarters (75%) of the top 20 US counties by HIV prevalence are also among the top 20 counties by COVID case and/or death burden. These 15 counties are home to 32% of people with HIV (see figure 3). While some of the overlap might be accounted for by urbanicity, 20% (4 in 20) of the counties hardest hit by COVID and HIV were not among the nation’s 20 most populous counties. In addition, counties hard hit by the COVID-19 pandemic also face high levels of racial and ethnic, income, and other structural inequalities driven by deeply rooted discrimination.

What do we know about COVID-19 vaccines and HIV?

NIH clinical guidelines on COVID-19 and people with HIV state that “people with HIV should receive SARS-CoV-2 vaccines, regardless of CD4 or viral load, because the potential benefits outweigh potential risks” and also notes that people with HIV “who are well controlled on antiretroviral therapy (ART) typically respond well to licensed vaccines.” In addition, CDC states “people with moderately to severely compromised immune systems are especially vulnerable to COVID-19, and may not build the same level of immunity to 2-dose vaccine series compared to people who are not immunocompromised.” As such the agency “recommends that people with moderately to severely compromised immune systems receive an additional dose of mRNA COVID-19.” CDC includes people with “advanced or untreated HIV infection” in this group.

People with HIV were at first excluded from COVID-19 vaccine trials but were permitted to join midway through phase 3 clinical trials. Ultimately, all companies with vaccines authorized for use in the U.S. included people with HIV in their phase 3 trials. The largest group was in the Jansen (J&J) trial which enrolled 1,218 participants with HIV, representing 2.8% of the trial population, split evenly in the vaccine and placebo groups. In analysis the company provided to the FDA in February 2021, vaccine efficacy could not be observed specially among people with HIV based on limited data availability. However, data were not suggestive of any harm. Smaller numbers of people with HIV were enrolled in Moderna and Pfizer vaccine trials. In addition, AstraZenenca, Novavax, Sanofi/GlaxoSmithKline, which do not have authorization in the US, also recruited HIV positive participants. Overall, because participation to date has been relatively low, drawing conclusions about immune response among people with HIV is not yet possible.

Finally, CDC includes HIV among a list of conditions that can make someone more likely to get severely ill from COVID-19. In the past, the CDC list was divided into conditions known to have an increased risk for severe COVID-19 and conditions that might pose an increased risk. HIV was not included in the original list on its own, but “immunocompromised state,” defined to include immunocompromised due to HIV, was included in the second list. When making recommendations regarding prioritizing high-risk populations for COVID-19 vaccination, CDC referred to the main list which was also used by most states. States varied in how they incorporated the second list, including immunocompromised state, in their vaccine prioritization. Separately, some states elected to include HIV as a standalone priority condition. As a result, states varied on how early they prioritized people with HIV in their vaccine efforts.

The HIV Medical Association (HIVMA) and the Infectious Diseases Society of America (IDSA) provide a regularly updated frequently asked questions documents on HIV and COVID-19 vaccinations aimed at clinicians.

What role is the federal government playing in addressing COVID-19 among people with HIV?

Several federal agencies or programs have specifically responded to the impact of COVID-19 on people with and at risk for HIV, including, the Centers for Disease Control and Prevention (CDC), the Health Resources Service Administration’s (HRSA) Ryan White HIV/AIDS Program, the National Institute of Health (NIH), and Housing and Urban Development’s (HUD’s) Housing Opportunities for People with AIDS (HOPWA) program:

• CDC: CDC provides general guidance on people with HIV and COVID-19, including an evolving statement on risk and, as noted above, includes HIV in a list of conditions that can make someone more likely to get severely ill from COVID-19. HIV was not included in an earlier version of this list.
  .
  In addition to providing public health guidance on people with HIV and COVID-19, CDC has also modified some of its prevention activities in light of the pandemic. CDC released guidance related to home or self-HIV testing, recognizing that “HIV testing that requires face-to-face contact has been scaled back or suspended because of the COVID-19 pandemic response.” Similarly, the agency also released guidance around PrEP and COVID-19 for “when facility-based services and in-person patient-clinician contact is limited,” describing options for home STI specimen collection and self-testing for HIV.CDC HIV program staff are also contributing significantly to the nation’s COVID response which has, per the agency, caused disruptions to care and treatment activities as the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. As of April 2021, nearly 700 CDC staff (with 1,125 cumulative deployments) from the National Center had been deployed to work on the COVID response since the epidemic began, in part, leveraging infectious disease expertise.¹
• NIH: NIH’s national HIV guidelines now include a section on “Interim Guidance for COVID-19 and Persons with HIV.” In addition, the NIH’s COVID-19 treatment guidelines include a “special population” section on “Special Considerations in People With Human Immunodeficiency Virus.” These sections review recommendations for ongoing HIV treatment during the pandemic (and in the case of COVID-19 infection) as well as COVID-19 prevention, treatment, and vaccination among people with HIV and are considered “living documents,” updated on a regular basis as more data become available.
• The Ryan White Program (HRSA): Ryan White, the nation’s safety-net for HIV care and treatment, faced significant challenges in the wake of the Coronavirus pandemic. In our survey of Ryan White care providers conducted in late 2020, we found that operating challenges were common. Among those surveyed, 28% shut down all or most of their HIV prevention services in response to the pandemic at some point and others faced difficulty connecting with service partners or increased operating costs. Dealing with client and staff trauma and isolation was a significant challenge. However, in many cases, programs reported transforming to meet shifting client needs and to improve safety for staff and clients, including through offering telehealth, providing COVID-19 testing, and engaging in multi-month prescribing, among other activities.
  .
  Recognizing the potential for increased need among people with HIV during the pandemic and, in order to “to prevent, prepare for, and respond to coronavirus,” Congress provided the Ryan White Program with $90 million in emergency funding in the CARES Act, the 3^rd major COVID-relief package signed into law in March 2020. The Ryan White Program distributed the funding to 581 program grantees across the country, including to health departments, health clinics, community-based organizations and national training centers. In June 2021, The Program released a report examining grantees use of CARES Act funds for activities such as telehealth, COVID-19 testing, and other traditional program activities. It finds that, in December 2020, over 85,000 Ryan White clients received a service funded through the CARES Act grants. Grantees have used CARES Act funding to conduct and build out telehealth services including for ambulatory and mental health services, medical case management, and support services as well as to conduct COVID-19 testing, purchase protective equipment for staff and clients, fund client nutrition assistance programs, and support staff positions needed as part of pandemic response, and for other purposes. Between January 20, 2020 and December 31, 2020 CARES Act funded providers served nearly 19,000 clients with newly diagnosed COVID-19.In addition, the program has encouraged grantees to utilize existing flexibilities and waived certain requirements when possible, recognizing that business as usual has been challenged by the pandemic. In particular, the program has asked grantees to “reassess their organization’s eligibility and recertification policies and procedures and remove any procedures that may impede social distancing or other public health strategies necessary to minimize COVID-19 transmission, or that impose” unnecessary requirements. Historically, while some grantees have already simplified these processes, others have policies in place that can create barriers not required by the program. Certain penalties and requirements were waived for all grantees either automatically or by request, though some were only able to be extended to CARES Act funded activities. Waivers generally relate to penalties and how funds can be used.The program maintains an updated list of frequently ask questions about Ryan White and COVID-19. In addition, In January 2021, The Program issued a letter outlining how grant recipients can engage in vaccination efforts, noting that Ryan White grantees and subgrantees may “play an important role in COVID-19 vaccine administration” and that all play “a critical role in addressing COVID-19 vaccine hesitancy and distributing information about local access to vaccines.”

• Housing Opportunities for People AIDS Program (HOPWA) (HUD): The CARES Act also provided $65 million for the HOPWA program to maintain operations, for rental assistance, supportive services, and other necessary actions, in order to prevent, prepare for, and respond to coronavirus. Grants were distributed to 140 formula grantees, 82 current HOPWA competitive renewal grantees, and existing technical assistance providers. The HOPWA program also provided grantees with clarity around waivers and flexibilities to improve services during the pandemic.

What do we know about HIV care, treatment, and prevention service use during the pandemic?

It appears that for some, HIV care and especially prevention access, in the U.S., has been impacted by the COVID-19 pandemic. While in some cases services and prescription fills have improved, it does not yet appear they have returned to the pre-pandemic baseline:

• Care and Testing: As noted above, despite pivots to providing care in new ways that mitigated some of the impact, Ryan White providers reported that their ability to provide certain services declined during the pandemic, though there are some reports that it has picked up to a certain extent. While some patients were harder to reach through telemedicine, others thrived with the technology and some who had been out-of-care, were brought back in.
  .
  CDC researchers found that HIV testing and viral load monitoring declined in the wake of the pandemic. While HIV testing and viral load monitoring has begun to pick back up, as of September 2020, it had not recovered to 2019 levels. In a separate analysis, CDC also found that ambulatory care visits and viral load testing declined while telemedicine visits increased in 2020. However, despite the increase in telemedicine, total visits did not fully rebound to pre-pandemic levels. Other research has echoed this with one analysis of 8 clinical sites finding that outpatient office visits for HIV care declined 78% between January and June 2020, even when accounting for telehealth visits.Researchers in Oregon found that public sector HIV and bacterial STI testing declined substantially in the state in the wake of COVID related distancing measures but once testing rebounded to a certain extent, primary and secondary syphilis diagnoses increased, “indicating ongoing sexual risk during physical distancing.”
• ARVs (for treatment and prevention): Data from Gilead, the company supplying ARVs to the majority of people with HIV in the U.S., show that sales for HIV medications (presumably for both prevention and treatment) dropped initially in 2020 and picked up by the end of the year but had not fully recovered.One San Francisco clinic found that the share of patients with viral load suppression declined 30% during the pandemic, suggesting lack of access to or adherence with ARVs.A CDC analysis found that PrEP prescriptions in the U.S. declined 21%, and that there was a 28% drop in new PrEP starts, between March and September 2020, compared to what was expected. Decreases were sharpest for younger people, those paying with cash or using patient assistance programs, and those in certain states.

  Analysis of prescription data from GoodRx point to declines in prescriptions for the medications used for PrEP during early months of the pandemic. While those drugs are also sometimes used for treatment, other non-PrEP treatment drugs saw a smaller, though still detectable decline.  Prescriptions for the medications used for PrEP declined 18% compared to baseline while other drugs used for HIV treatment declined 5% compared to baseline.

In addition, for many with and at risk for HIV, meeting basic needs is a common struggle and for some, this was heighted during the pandemic. There have been reports that some people with HIV and HIV service organizations faced delays in access to food and financial assistance during the pandemic. Lack of basic security for key resources such as food, housing, and economic stability, can undermine people’s ability to access and engage in HIV care, treatment, and prevention.