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, you might be lulled into believing that an infection with SARS CoV-2 is no longer a concern. But that’s not the case, and people living with HIV (PLWH), especially if HIV 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 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 were from these variants. Across all waves, the death rate from COVID for PLWH was 23% for PLWH compared to 19% for people without HIV (PWOH). But the differences became more stark during the omicron wave: PLWH with 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 were a severe COVID-19 infection requiring hospitalization and a CD4 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, as well as “the need to offer HIV testing services for possible prioritization for possible therapeutic interventions and COVID-19 booster vaccines.”

Both Pfizer and Moderna have requested that the U.S. Food and Drug Administration approve their updated COVID boosters designed to target a newer subvariant and if approved the boosters could be available sometime in the fall of 2023. 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 Centers for Disease Control and Prevention (CDC) notes that all the approved COVID vaccines are safe for people living with HIV. 

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 1 in 10—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, and crippling 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 reduce 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 2 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. The reasons are not yet clear, but researchers are looking at something familiar to people living with HIV: viral persistence.

More bad news: 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 reinfection can occur in as little as 90 days after initial infection, and that reinfections can sometimes be more severe. While the COVID-19 death rate—at least from an initial infection—is low, the very real possibility of being sidelined with long COVID puts every public interaction into question, especially with transmission rates (via wastewater surveillance) spiking in most places since early July 2023.