The global outbreak of SARS-CoV-2 infection raised concern that people living with HIV (PLHIV) may be at high risk of infection or developing severe clinical manifestations. PLHIV should be considered particularly vulnerable to COVID-19 due to their immune-compromised status. However, little is known about the impact of SARS-CoV-2 in PLHIV.
The Joint United Nations Programme on HIV/AIDS (UNAIDS) reported that approximately 37.9 million PLHIV worldwide are at risk of COVID-19, and the number of PLHIV aged over 50 years old has increased, representing 1/5 of PLHIV globally. PLHIV have a higher risk of comorbidity compared with the general population due to chronic inflammation and immune activation from HIV, side effects of antiretroviral therapy (ART), and common risk factors such as alcohol, and tobacco use.
Based on limited data, people with immunocompromised status and COVID-19 could have an increased risk of severe disease and death . A systematic review with meta-analysis did not show that immunosuppression and immunodeficiency increased the risk of COVID-19 severe clinical course of.
No study reported the proportion of patients with COVID-19 and HIV infection. presently, it is not possible to estimate the incidence of two viral infections occurring in the same patient. PLHIV seemed to be similarly affected by SARS-CoV-2 compared with the general population in terms of clinical presentation. In line with large-scaled studies, fever, myalgia, cough, fatigue were common symptoms of COVID-19.
The SARS-CoV-2 infection prevalence in PLHIV is about 1%, similar in various published cohorts studies. Probably, these reports underestimate the real incidence of SARS-CoV-2 infection in PLHIV because of the low number of completed SARS-CoV-2 tests and inadequate case reporting.
The knowledge about the role of immune system in COVID-19 could explain the possible risk related to immunosuppression, and it is essential for the identification and design of effective therapy.
The immune system is involved in the pathological process of COVID-19 and activated T and B cells against SARS-CoV-2 are detected in the blood one week after the onset of COVID-19 symptoms. CD4+ T cells play a central role, and PLHIV might be at an increased risk of SARS-CoV-2 infection or severe disease, especially individuals with comorbidities, lower CD4 cell counts, or high HIV RNA viral load. However low CD4 counts were not associated with the incidence of COVID-19 and immunosuppression was not related to disease severity. As hypothesised by Romanelli et al, a good clinical outcome in HIV patients could be related to the immunosuppressive status. The activation of the immune system could enhance the injury caused by SARS-CoV-2 infection, related to worst outcome. In fact, the activation of the immune system and T cells could represent a landmark of the histological picture of lung injury related to COVID-19. In addition, overactivation of T cells accounts partially for the severe immune injury.
Zhu et al. reported the first case of SARS-CoV-2 infection in a naïve-HIV patient, with a good clinical outcome. As noted by Joob et al., the patient did not receive antiviral therapy, and this is interesting because it seems that naïve HIV patient, despite impairment in lymphocyte count and function, could have a better clinical outcome during SARS-CoV-2 infection. HIV-related lymphopenia in naive patient, due to uncontrolled viral replication, alters the hyperactive response of the immune system to SARS-CoV-2 infection. The relationship between HIV-infection naive status, SARS-CoV-2 infection and clinical outcomes requires further studies.
Knowledge about the efficacy of different antiviral treatments against SARS-CoV-2 is evolving rapidly. Local protocols and guidelines have been periodically updated, even if the therapeutic approach of PLHIV does not differ from the general population.
Analysing published cases of co-infection HIV/SARS-CoV-2, we observed that the authors usually did not switch the previous ART in PLHIV during SARS-CoV-2 infection. It happens because currently neither drug combination is the first-line choice.
In conclusion, PLHIV should not be considered protected from SARS-CoV-2 infection or with a lower risk of severe disease. It is unclear if those with low CD4 cell counts could have worse outcomes than individuals with restored immunity. Globally, in absence to evidence, PLHIV should receive the same treatment approach as that applied to the general population. Further studies are needed to elucidate these aspect.
Direttore UOC Immunodeficienze e Malattie Infettive di Genere
P.O. Cotugno – AO dei Colli – Napoli