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Clinical features and outcome of HIV/SARS-CoV-2 co-infected patients in the Bronx, New York City
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Caution is needed when interpreting the incidence of COVID-19 in people living with HIV compared with the HIV-negative population.
Challenges in understanding the true frequency of COVID-19 in people with HIV include the overall limited testing that has happened so far, particularly for patients not needing hospitalisation, the admission of patients in hospitals external to where the individual might access their HIV care, and the fact that people with HIV might be more vigilant at shielding and self-isolation because of the propagation of fears of higher acquisition rates and a poorer outcome of SARS-CoV-2 infection in people living with HIV.
Finally, appropriately powered and designed studies are needed to draw conclusions on the effect of COVID-19 in people with chronic diseases, including HIV infection. HIV infection is itself characterised by various clinical scenarios, ranging from viral suppression and good quality of life to HIV-associated comorbidities or virological failure with or without immunosuppression.5
https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(20)30139-9/fulltext
BHIVA, DAIG, EACS, GESIDA & Polish Scientific AIDS Society Statement on risk of COVID-19 for people living with HIV (PLWH).....https://www.bhiva.org/BHIVA-DAIG-EACS-GESIDA-Polish-Scientific-AIDS-Society-statement-on-risk-of-COVID-19-for-PLWH
Case series of HIV-patients with COVID-19 have been published from China, Spain, Germany, Italy and the United States (1-6). So far there is no clear evidence for a higher COVID-19 infection rate or different disease course in people with HIV than in HIV-negative people.
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Clinical features and outcome of HIV/SARS-CoV-2 co-infected patients in the Bronx, New York City
Jnl of Med Virology May 28 2020 Kulachanya Suwanwongse1, MD, MSc, Nehad Shabarek1, MD
1 Department of Internal Medicine, Lincoln medical center, 234E 149th Street, the Bronx, NY, USA
https://onlinelibrary.wiley.com/doi/abs/10.1002/jmv.26077
Abstract
Coronavirus disease 2019 (COVID-19) is a highly contagious disease with millions of people have been infected. However, there is limited data regarding clinical features, disease courses and outcomes of COVID-19 in patients with human immunodeficiency virus (HIV). Herein, we presented the demographic data, clinical characteristics and outcomes of nine confirmed COVID-19 patients with HIV infection admitted to our hospital located in south Bronx, New York City. Our study revealed very high mortality rate at 78%, which may contradict to the hypothesis that immunosuppression from HIV infection prevents against severe COVID-19. More research is needed to determine the impact of HIV on the clinical course of COVID-19.
To the editor
Currently, coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a public health crisis, with almost five million people, have been infected and of which more than 300,000 died [1]. Older ages and several comorbidities, such as hypertension, diabetes mellitus, and cardiovascular diseases, are identified as risk factors for developing severe COVID-19 and deaths [2,3]. It is estimated that 40 million people worldwide have human immunodeficiency virus (HIV) infection [4]. Thus, we are expecting to encounter a significant number of HIV patients with SARS-CoV-2 infection. However, there is limited evidence regarding the impact of HIV infection on the severity and mortality related to COVID-19. Several case reports and case series showed that the mortality and severity of COVID-19 were not increased in HIV patients [5-7]. In contrast, HIV/SARS-CoV-2 co-infected patients may have mortality benefits from the immunosuppressive state [8]. However, the data from our institution showed contradictory results. Herein, we presented the case series of hospitalized HIV patients with COVID-19 in a single hospital in the South Bronx, the area that is well-known for its most poverty, least education, highest criminal, and poorest health outcomes in New York. The clinical features and outcomes of nine HIV/SARS-CoV-2 co-infected patients admitted to our hospital from March 25 to April 20, 2020, are discussed.
Table 1 provided demographic data, clinical features, and outcomes of each patient. The median age of the patients was 58 years-old (ranges 31-76). Seven were males, and two were females. All patients had multiple comorbidities. The diagnosis of COVID-19 was confirmed by a positive SARS-CoV-2 RT-PCR test from nasopharyngeal swab specimens. Most recent patients CD4+ T cell count ranged from 179 to 1827 per mm3. HIV viral load was very low to undetectable. Eight patients were on highly active antiretroviral therapy (HAART), of which six reported medication compliances. HAART was discontinued during hospital admission in four patients, two of which was due to acute kidney injury (AKI), and the other two were for an unclear reason. Fever, cough, and dyspnea are the most common presenting symptoms among all patients. One patient initially presented with gastrointestinal tract symptoms, including nausea, vomiting, and watery diarrhea. Chest x-ray (CXR) abnormalities compatible with COVID-19 pneumonia were found in eight patients (89%) and correlated with disease severity. All patients' blood cultures were negative. Seven patients eventually died (78%), of which four due to hypoxemic respiratory failure and three from septic shock and multi-organ failures.
Recent evidence demonstrated that several clinical features, including older age, lymphopenia, elevated inflammatory markers, and CXR abnormalities are predictive factors for severe COVID-19 and death [2,3,9]. We found a similar pattern in HIV/SARS-CoV-2 co-infected patients. Also, typical CXR abnormalities representing COVID-19 pneumonia were similar among all HIV patients regardless of their CD4 count.
Compare to previous studies [5-7,10]; our patients had significantly lower CD4+ cells count but showed a higher mortality rate. The inverse relationship between CD4+ cell count and mortality rate contradicts the hypothesis that HIV/SARS-CoV-2 co-infected patients have favorable prognoses because of paradoxical prevention from robust cytokine storms due to their immunosuppressive states and HIV-related lymphopenia [8]. Moreover, the extremely high mortality rate observed in our case series raises the concern that HIV infection and low CD4+ cell counts may negatively impact on COVID-19 outcomes.
It was clear from our case series that immunocompromised state from HIV-related lymphopenia, unfortunately, cannot prevent against progression to severe COVID-19 and death, as opposed to B-cell suppression in some specific population, such as patients taking B-cell depleting medication [8,9]. We proposed two possible explanations. First, host immunity response to SARS-CoV-2 requires T lymphocytes. HIV-related lymphopenia, therefore, delay the clearance of viruses and promote the progression of the disease. Second, the key pathogenesis of cytokines storms in severe COVID-19 may stem from the dysregulation of B lymphocytes so that HIV-related T-cell suppression does not confer any protective role against severe COVID-19.
Our report had several limitations. Firstly, the results were based on only nine patients. Secondly, all patients had several comorbidities that negatively impact the COVID-19 prognoses. Thus, further large observational studies are needed to verify our results. Understanding the clinical course and mechanism of COVID-19 in HIV patients will help elucidate the pathogenesis of SARS-CoV-2 infection and the progression to severe disease, which will help in better management and prevention of COVID-19 in HIV patients and perhaps in general.
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