What people living with HIV should know about COVID-19 today

With the conspicuous lack of masks, even in hospitals, as well as people speaking of the COVID pandemic in the past tense if they speak of it at all, one might be lulled into believing that SARS CoV-2 is no longer a concern. But that’s not the case, and people living with HIV (PLWH), especially HIV that is not well controlled, should remain COVID aware and stay up-to-date on vaccine boosters, according to recent studies. 

Presenting data from a World Health Organization (WHO) study at the 12th IAS Conference on HIV Science (IAS 2023), Nathan Ford of the WHO said that while COVID deaths declined during the omicron wave starting in late 2021 (when vaccines were beginning to roll out), death rates declined less for PLWH with low CD4 counts. Using the WHO Global Clinical Platform, Ford and colleagues identified 821,331 patients hospitalized with COVID during the pre-delta, delta and omicron waves, and of these patients 5.3% were living with HIV.

Researchers evaluated the association of HIV with in-hospital mortality across three SARS CoV-2 waves: pre-delta, delta, and omicron. The variant periods were defined as timeframes when greater than 90% of cases from these variants. Over all waves, the death rate from COVID for PWH was 23% for PLWH compared to 19% for people without HIV (PWOH). But the differences became more stark during the omicron wave:

•   22% versus 24.2% respectively, for PLH and PLWH, pre-Delta

•   20.9% versus 23.4% during the Delta wave

•   9.8% versus 19.6% during the Omicron wave. 

Put another way, PLWH who had COVID-19 had a 54% higher risk of death pre-delta, a 56% higher risk during delta, and a 114% higher risk during omicron, as compared to PWOH. Risk factors for mortality for all groups were a severe COVID-19 infection requiring hospitalization and a CD count of less than 200 c/ML. Other risk factors included chronic kidney disease, older age and diabetes. 

The findings emphasize “the need to implement WHO recommendations for giving booster vaccine doses for all [PLWH],” Ford said. He added that study data showed a higher rate of death from COVID for people with unknown HIV status, which highlight “the need to offer HIV testing services for possible prioritization for possible therapeutic interventions and COVID-19 booster vaccines.”

A low CD4 count also puts PWH at greater risk of serious complications, including death, from mpox. 

Both Pfizer and Moderna have requested that the FDA approve their updated COVID boosters designed to target a newer subvariant, and if approved the boosters could be available sometime in the fall. But the uptake of COVID booster shots has been anemic: less than 20% of the U.S. population has received an updated booster, according to the CDC, and that’s an even bigger problem because vaccine immunity wanes rather quickly. A study published May 3 in JAMA Network Open concluded that effectiveness of the original two-dose mRNA vaccines (Moderna or Pfizer) dropped to as low as 9% after nine months. Boosters can bring protection levels back, but those levels wane as well—to as low as 13% nine months post-booster. The protein-based Novavax COVID vaccine is just as effective as the mRNA vaccines in minimizing the seriousness of initial COVID infections, though Novavax can be harder to find. The CDC notes that the all approved COVID vaccines are safe for people living with HIV. And while the current vaccines have not produced the kind of durable immunity many people hoped for, there are some nasal vaccines being developed that could provide a more robust fight against infection. 

Long COVID is a concern for everyone

Vaccines, so long as they’re up-to-date, have been proven effective in reducing the seriousness of acute COVID infections and reducing the possibility of death from an infection, but with rapidly mutating and increasingly infectious variants, they’re less effective in preventing transmission of the virus. And while most people get through an acute infection with symptoms no worse than a cold, some—an estimated one in ten—have severe symptoms that can last months or years, according to an analysis of the most recent data from the CDC. 

Long COVID, defined by the CDC as symptoms that can include neurological conditions, kidney failure, musculoskeletal conditions, blood clots and vascular issues, respiratory conditions and cardiovascular issues andcrippling fatigue. These symptoms may linger weeks, months, or longer, leaving some COVID “long haulers” unable to perform daily activities, or even get out of bed. It’s not clear why one person will end up as a long hauler and another one won’t. The antiviral Paxlovid can minimize the severity of the initial infection and decrease the risk of long COVID, but there is still no cure for long COVID.

Even if someone doesn’t suffer long COVID, people of any age who get COVID—whether they have HIV or any comorbidity—increase their chance of having multiple health problems, including chronic kidney disease, type two diabetes and a 72% greater risk of heart disease. The SARS CoV-2 virus is not unlike a trojan horse, doing long-term damage to multiple organs, including the brain, kidneys and a key organ for metabolizing antiretroviral drugs, the liver. The reasons are not yet clear, but researchers are looking at something familiar to people living with HIV: viral persistence. 

And in contrast to prevailing public beliefs, there’s no “herd immunity” to SARS-CoV-2, nor does being re-infected by SARS CoV-2 build your immune system. Just the opposite: each infection is more likely to produce T-cell exhaustion, according to several studies. And due to the rapid mutation of SARS CoV-2, there is no upper limit to the number of times a person can get COVID. The CDC recently acknowledged this point, changing its guidelines to state that re-infection can occur in as little as 90 days after initial infection, and that re-infections can sometimes be more severe. 

The very real possibility of being sidelined with long COVID, regardless of a person’s HIV status, comorbidities, or seriousness of COVID infection, puts every public interaction into question, especially with transmission rates (via wastewater surveillance) spiking in most places since early July. That’s why a doctor appearing on MSNBC recently urged Americans to start wearing masks again. On José Diaz-Balart Reports, MSNBC medical contributor Dr. Kavita Patel warned that crowded indoor spaces are especially problematic, partly because people can transmit COVID before they show any symptoms. “A mask can be your best friend,” Patel said. “Time to bring them out again, especially as the fall season starts.”