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Coronavirus Disease 2019 (COVID-19) Infection Among People With Human Immunodeficiency Virus in New York City: A Population-Level Analysis of Linked Surveillance Data - Commentary & paper
50% Higher COVID Deaths, hospitalizations & ICU due to COVID for PLWH vs HIV-Neg in NYC
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Download the PDF here
Download the PDF here
We found that racial and ethnic inequities in the NYC COVID-19 pandemic overall are mirrored-and even more pronounced-among PWH with COVID-19. Efforts to eliminate racial/ethnic inequities among PWH and for other individuals affected by HIV are central to achieving the goals of NYC DOHMH's ending the HIV epidemic (EtE) strategy [15]. Given the exacerbating effects of the COVID-19 pandemic on health inequities, including among PWH, this is a critical time for the HIV public health and clinical community to strengthen services and support for people living with and affected by HIV to protect and accelerate progress made thus far toward the EtE strategy.
Clinical Infectious Diseases 15 June 2021
according to table 2 it appears 312 PLWH died, 1011 ever hospitalized, 124 ever in ICU; mostly men, mostly in 45-64 age group; mostly black and latino; mostly from higher poverty areas; disproportionate affect on those with a history of IDU; mostly with undetectable VL; with CD4 counts varying between <200 to >500; mostly with a history of AIDS diagnosis. Low nadir CD4 appears to increase risk.
• 13% with HIV Died vs 8% without HIV
• 42% were hospitalized with HIV vs 26% without HIV
• 5% went to ICU with HIV vs 3% without HIV
• PLWH who experienced these worse outcomes were more likely to be older, Black or Latino, in poverty, and people with a history of IDU were disproportionately affected.
• in table 2 it appears to suggest those with a history of IDS, perhaps lower nadir CD4, had a greater risk for bad outcomes.
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COMMENTARY by Triant & Gandhi.
When Epidemics Collide: Why People With Human Immunodeficiency Virus May Have Worse Coronavirus Disease 2019 Outcomes and Implications for Vaccination
The coronavirus disease 2019 (COVID-19) pandemic continues to accelerate, stressing healthcare systems and highlighting and exacerbating disparities. As the pandemic surges in the United States, it is increasingly important to identify patients at elevated risk of developing severe disease to inform management decisions, including COVID-19 vaccine prioritization. People with HIV (PWH) have been proposed to be at high risk for severe COVID-19 because of immunodeficiency, comorbidities, and/or societal inequities, such as poverty and lack of access to care. Several studies, including that of Braunstein et al in this issue of Clinical Infectious Diseases, are now finding that PWH have worse COVID-19 outcomes; determining why is of utmost importance.
A complex interplay of factors drives the course of COVID-19 [1-6]. Patients with immunodeficiency, such as organ transplant recipients, are at increased risk for severe COVID-19, and prolonged severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) replication has been reported in immunocompromised hosts [7, 8]. In PWH who are not receiving antiretroviral therapy (ART) or have low CD4 cell counts-that is, those who are immunodeficient-there has been concern that SARS-CoV-2 infection will cause severe disease, as is the case for influenza [9]. PWH who are receiving ART are typically not at high risk for other infections, but there are theoretical reasons why they may be more prone to severe COVID-19. PWH on ART continue to have excess inflammation, which has been linked to comorbidities, such as cardiovascular disease [10, 11]. Residual inflammation is most pronounced in PWH with low CD4 cell count nadirs, incomplete CD4 cell reconstitution, or persistently low CD4/CD8 ratios-an immune dysregulation "legacy effect." [12, 13]. Because elevated inflammatory markers have been linked to severe COVID-19 [4], it is important to determine whether the HIV legacy effect "primes the pump" for worse outcomes after SARS-CoV-2 infection. If this is the case, one would predict worse COVID-19 outcomes in PWH, particularly among those with low CD4 cell count nadirs, incomplete CD4 cell count reconstitution, or persistently low CD4/CD8 ratios.
In addition to potential contributions of immune dysregulation, PWH may have worse COVID-19 outcomes because of comorbidities or social determinants of disease. Clinical and sociodemographic factors that are highly prevalent in people with HIV parallel risk factors for severe COVID-19. PWH are aging as a population [14], are frequently black or Hispanic, and have elevated rates of comorbidities including cardiometabolic risk factors (obesity, diabetes, hypertension) and cardiovascular disease [11, 15]; these factors closely mirror risk factors for development of severe COVID-19 [2-4, 16]. Studies of PWH with COVID-19 find high rates of factors that increase severe COVID-19 risk. In a study comparing COVID-19 outcomes in 404 PWH and 49 763 individuals without HIV, PWH had higher rates of obesity, hypertension, diabetes, and chronic kidney disease and were more likely to be African American [17]. PWH with COVID-19 have higher body mass index (BMI) and a higher proportion have at least 1 comorbidity compared with PWH without COVID-19 [18]; in addition, PWH have been shown to have high rates of comorbidities in several case series, including 64% with at least 1 comorbidity in an Italian cohort [19], 83% with at least 1 comorbidity in a Boston cohort [20], and half of patients with at least 5 comorbidities in an Atlanta case series [21].
With these potential contributors as background, what do we know about PWH who develop COVID-19? Several studies have failed to show an association of HIV with severe COVID-19 (Table 1). A large US-based study using a multicenter research network and a propensity-matched cohort of COVID-19 patients without HIV showed no difference in mortality after matching for demographics and comorbidities [17]. Several studies in which COVID-19 patients without HIV were compared with PWH with COVID-19 failed to show associations of HIV status with intensive care unit (ICU) admission [22, 23], mechanical ventilation [22-25], or mortality [22-25], although matching factors differed. An as-yet unpublished abstract from the Veterans Aging Cohort Study found that PWH had no increased risk of severe COVID-19 outcomes [26].
By contrast, several large population-based studies have found that PWH are at increased risk of severe COVID-19 (Table 1). Data from a large cohort in South Africa showed HIV to be associated with increased COVID-19 mortality (adjusted hazard ratio [aHR], 2.14), adjusting for some comorbidities but not for BMI, smoking, or socioeconomic status [27]. A United Kingdom population-based study encompassing 1 728 905 patients, including 27 480 with HIV, showed that HIV conferred a >2-fold increased risk of COVID-19 mortality (aHR, 2.59 [adjusting for deprivation, ethnicity, smoking, and obesity]) [28]. A prospective study of patients hospitalized with COVID-19 showed increased 28-day mortality in PWH after adjusting for age (aHR, 1.47); in patients under age 60, mortality rates were higher for PWH compared with HIV-uninfected COVID-19 patients (21.3% vs 9.6%) [29]. A New York City study that did not show an overall effect of HIV on severe COVID-19 showed a significant association of HIV with intubation and mortality among patients ≤50 years of age [23]. A separate New York State study in preprint form demonstrated a standardized mortality ratio for HIV of 1.23 for in-hospital mortality, but did not adjust for comorbidities [30].
Several factors merit consideration in interpreting studies investigating the impact of HIV on COVID-19 outcomes. First, the ability to adjust for comorbidities may profoundly impact results. Comorbidities are highly prevalent in PWH, typically at higher rates than in non-HIV comparator groups, and increase risk for severe COVID-19. A finding of increased risk of severe COVID-19 conferred by HIV may be attenuated or lose significance after adjustment for relevant comorbidities. Second, findings may reflect the selection of the study population. Studies limited to hospitalized patients may fail to detect a mortality signal if the at-risk group in question is hospitalized at higher rates. Third, by virtue of sociodemographic factors or occupation, some PWH may be at higher risk of COVID-19 exposure [20, 31]. Fourth, the role of inflammation in HIV and COVID-19 outcomes is likely to be complex and may impact outcomes. While several studies have shown higher C-reactive protein (CRP) values in PWH with COVID-19 compared with HIV-uninfected patients [22, 29], another large multicenter study showed no difference in inflammatory markers (CRP, lactate dehydrogenase, erythrocyte sedimentation rate, or ferritin) in PWH compared with HIV-uninfected patients with COVID-19 after propensity score matching [17]. The uncertainty regarding whether HIV affects the inflammatory response in COVID-19 underscores the need for additional research on the impact of inflammatory markers on risk stratification.
In terms of the impact of HIV disease stage or virologic suppression on COVID-19, data from several recent studies are beginning to shed light on this critical question. A study from the University of Missouri showed CD4 count <200 cells/mm3 to increase risk of a composite outcome of ICU admission, mechanical ventilation, or death >3-fold [32]; a South African population-based study showed CD4 count <200 cells/mm3 in hospitalized patients to be associated with COVID-19 death [27]; a New York State study showed CD4 count <200 cells/mm3 to be associated with increased risk of hospitalization [30]; and an Italian series showed nadir CD4 cell count to be lower in hospitalized patients in unadjusted analyses [33]. The New York State study also showed HIV viremia to be associated with increased risk of hospitalization [30].
The current study by Braunstein et al adds to this literature by demonstrating increased rates of severe COVID-19 in PWH. The population-level analysis matched records from the New York City (NYC) Health Department with those from the NYC HIV surveillance registry. Comparison groups included PWH with COVID-19 (n = 2410), PWH without COVID-19 (n = 113 907), and COVID-19 patients without HIV (n = 202 012). PWH with COVID-19 were more likely to be hospitalized (42% vs 26% of all cases), be admitted to the ICU (5% vs 3%), and to die (13% vs 8%) compared with all NYC patients with COVID-19. Among patients who experienced 1 of these 3 outcomes, PWH were older, lived in higher-poverty neighborhoods, and were more likely to be black or Hispanic when compared with all COVID-19 patients (although race/ethnicity data were missing for nearly half of HIV-uninfected COVID-19 patients). Comorbidities were common in PWH, with 64.3% reporting at least 1 comorbidity compared with 35.4% in HIV-uninfected COVID-19 patients; this difference persisted even when PWH who reported immunodeficiency as their single comorbidity were excluded. Notably, >90% of PWH who were admitted to the ICU or died had at least 1 comorbidity documented. While the majority of PWH were virally suppressed, a higher proportion of patients admitted to the ICU had a CD4 count <200 cells/mm3 compared with those hospitalized but not admitted to the ICU (34.7% vs 23.4%).
These findings corroborate results from several other studies indicating that PWH are at increased risk for severe COVID-19 [27-30]. Because it was not possible to adjust for potentially confounding variables, however, the factors driving this increased risk in HIV cannot be delineated in this study. Notably, higher rates of comorbidities might explain in part the increased risk of hospitalization, ICU admission, and death observed among PWH compared with the non-HIV COVID-19 comparator group. Because of the lack of adjustment and possibility of confounding, this study is certainly not the last word on whether HIV itself leads to worse COVID-19 outcomes.
Although the studies to date have been suggestive, it is important to emphasize that salient knowledge gaps remain regarding the role of HIV in COVID-19 course, and filling in these gaps is needed to inform critical medical and policy decisions, including COVID-19 vaccine prioritization. In particular, we do not have definitive data to answer critical questions, such as: (1) Is HIV a risk factor for severe COVID-19 and mortality independent of comorbidities and socioeconomic factors? and (2) To what extent do CD4 cell count and HIV RNA determine COVID-19 outcomes?
Despite these uncertainties, based on the currently available data, there is growing concern that PWH may be at increased risk for severe COVID-19; indeed, several large studies (but not all) point to a signal of increased COVID-19 mortality in individuals with HIV (Table 1). Exactly why PWH may have worse COVID-19 outcomes is not certain. Is it HIV's legacy effect on immune function or inflammation? Is it because of comorbidities? Is it because of societal inequities and disparities in access to care? Or is it because of a conglomeration of these and potentially other mechanisms? Large and rigorous studies that adequately account for immunologic function (including current and nadir CD4 cell count; CD4/CD8 ratio; and inflammation), comorbidities (including smoking, BMI, cardiovascular disease), and socioeconomic disparities are needed to once and for all disentangle and delineate what is driving COVID-19 outcomes in people with HIV.
While awaiting these necessary and critical studies to sort out exactly why PWH may have worse COVID-19 outcomes, we must make decisions today about how to apportion vaccines and how best to counsel and manage PWH. Even if increased risk of COVID-19 mortality in HIV is largely limited to individuals with lower CD4 cell counts or active viremia, we do not yet have the data to precisely identify which individuals in this population are at highest risk. Even if risk of severe COVID-19 is mostly driven by comorbidities, these are often underdiagnosed and underrecognized in PWH-particularly as they can manifest at younger ages in this group-and might not be adequately factored into COVID-19 risk stratification. Even if structural inequities long endured by many PWH influence COVID-19 outcomes (and they almost certainly do), this makes vaccination even more pressing because COVID-19 prevention-such as staying home and social distancing-is likely to be more challenging for many PWH due to employment, family obligations, or other unavoidable constraints. For all these reasons, we call for prioritization of people with HIV for COVID-19 vaccination into the same tier as people with other comorbidities that confer increased risk of severe COVID-19, such as those with cardiovascular or chronic pulmonary disease.
The intersecting epidemics of HIV and COVID-19 pose a clear challenge over the coming months. What is our charge in caring for PWH during the COVID-19 era? Maintaining a high degree of vigilance for COVID-19 symptoms and disruptions to care, facilitating frequent communication and outreach, and ensuring equitable and timely access to testing, therapeutics, clinical trial participation, and COVID-19 vaccination must be our highest priorities to reduce disparities and promote the well-being of this vulnerable population.
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Coronavirus Disease 2019 (COVID-19) Infection Among People With Human Immunodeficiency Virus in New York City: A Population-Level Analysis of Linked Surveillance Data
Clinical Infectious Diseases 15 June 2021
2410 PLWH were diagnosed with COVID, 90% were Black & Latino, most were in high or very high poverty areas; while more MSM were diagnosed with COVID the proportions with a history of IDU were much more impacted (see tables 1 and 2).
The scientific community has conjectured that PWH may be especially vulnerable to poor outcomes after SARS-CoV-2 infection due to immunosuppression and/or the presence of other conditions-or, conversely, that PWH could potentially experience protection from the most serious sequelae of COVID-19 because of their history of immune response and/or because of the potential anti-SARS-CoV-2 activity of HIV antiretroviral treatments [12]. In our study, we did find that PWH who experienced poor COVID-19-related outcomes, particularly those who had been admitted to the ICU or died, had lower CD4 counts (majority had <500 cells/μL), and that PWH who had been diagnosed with HIV prior to the year 2000 were more heavily represented among those with poor COVID-19-related outcomes. Those with longer time since HIV diagnosis are more likely to be older and have other comorbid conditions, which could put them at higher risk for poor COVID-19-related outcomes. We also found a high prevalence of other comorbidities among PWH with COVID-19, which has been identified in other cohorts [13, 14]. We also saw high levels of HIV viral control in our population of PWH with COVID-19, which suggests high levels of antiretroviral coverage, and a relatively low proportion with very low CD4 cell counts.
CONCLUSIONS: This large-scale, combined analysis of NYC COVID-19 and HIV surveillance data should inform the public health response to COVID-19 and shape approaches to service delivery and programming for people with and at risk for HIV and COVID-19 in NYC, and potentially in other jurisdictions as applicable. Even if PWH are not overrepresented among NYC COVID-19 cases thus far, their experience as a community of racism and other forms of structural oppression; their frequent exposure to poverty, housing insecurity, and other adverse socioeconomic conditions; the high prevalence of comorbid conditions; and other challenges and vulnerabilities underscore the need to assess and respond to community needs during this time. Additional epidemiologic research on the intersection of HIV and COVID-19 is needed to inform the response, including to quantify risk for SARS-CoV-2 infection among PWH, and to identify risk factors associated with specific COVID-19-related outcomes among PWH.
Compared with all NYC COVID-19 cases, a higher proportion of PWH with COVID-19 experienced COVID-19-related hospitalization, admission to an ICU, and death during this period (Table 2). Forty-two percent of PWH with COVID-19 were hospitalized (vs 26% of all cases), 5% were admitted to the ICU (vs 3% of all cases), and 13% died (vs 8% of all cases) (Figure 2).
Generally, compared with all NYC COVID-19 cases, PWH with COVID-19 who experienced these COVID-19 outcomes were more likely to be older, Black or Latino/Hispanic, and living in high-poverty NYC neighborhoods. Compared with their representation among all PWH with COVID-19, higher proportions of Bronx residents experienced hospitalization, ICU admission, and death, and lower proportions of Manhattan and Queens residents experienced ICU admission and death; lower proportions of MSM experienced hospitalization, ICU admission, and death, while higher proportions of PWH with a history of IDU experienced hospitalization, ICU admission, and death. Compared with their proportions among all PWH with COVID-19, higher proportions of PWH who were hospitalized, admitted to the ICU, and died had earlier HIV diagnoses (eg, before 1990 or from 1991 to 1999); relatively small proportions of PWH diagnosed with HIV in the most recent decade (2010-2020) experienced these adverse COVID-19 outcomes (Table 2).
People living with HIV with and without diagnosed COVID-19 were generally older than NYC COVID-19 cases overall-with, for example, 56.1% and 53.5% of PWH with and without COVID-19, respectively, aged 45-64 years versus 36.1% of all NYC COVID-19 cases; notably, however, a higher proportion of all NYC COVID-19 cases were in the oldest age group of 75 years and older (11.8%) compared with PWH with COVID-19 (5.2%). Among individuals with known race/ethnicity across all 3 groups, Black and Latino/Hispanic individuals were overrepresented. This disparity was pronounced among PWH with COVID-19, with 86.1% of PWH with COVID-19 identified as Black or Latino/Hispanic compared with 78.6% of PWH without COVID-19 and 62.5% of all NYC COVID-19 cases;
By HIV viral suppression status, the vast majority of PWH who were hospitalized, admitted to the ICU, and died were virally suppressed at last HIV viral load. By latest CD4+ cell count, among PWH with a history of hospitalization, most had 500 or more cells/μL; among those with a history of ICU admission, most PWH had less than 200 cells/μL. The majority of PWH with COVID-19 with these outcomes had a history of AIDS diagnosis per the HIV surveillance registry. Finally, the majority of PWH who were hospitalized and especially those who experienced ICU admission or death due to COVID-19 had at least 1 underlying condition documented in the COVID-19 surveillance database (88.3%, 93.6%, and 93.6%, respectively).
Abstract
Background
New York City (NYC) was hard-hit by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic and is also home to a large population of people with human immunodeficiency virus (PWH).
Methods
We matched laboratory-confirmed coronavirus disease 2019 (COVID-19) case and death data reported to the NYC Health Department as of 2 June 2020 against the NYC HIV surveillance registry. We describe and compare the characteristics and COVID-19-related outcomes of PWH diagnosed with COVID-19 with all NYC PWH and with all New Yorkers diagnosed with COVID-19.
Results
Through 2 June, 204 583 NYC COVID-19 cases were reported.
The registry match identified 2410 PWH with diagnosed COVID-19 eligible for analysis (1.06% of all COVID-19 cases).
Compared with all NYC PWH and all New Yorkers diagnosed with COVID-19, a higher proportion of PWH with COVID-19 were older, male, Black, or Latino, and living in high-poverty neighborhoods. At least 1 underlying condition was reported for 58.9% of PWH with COVID-19. Compared with all NYC COVID-19 cases, a higher proportion of PWH with COVID-19 experienced hospitalization, intensive care unit admission, and/or death; most PWH who experienced poor COVID-19-related outcomes had CD4 <500 cells/μL.
Conclusions
Given NYC HIV prevalence is 1.5%, PWH were not overrepresented among COVID-19 cases. However, compared with NYC COVID-19 cases overall, a greater proportion of PWH had adverse COVID-19-related outcomes, perhaps because of a higher prevalence of factors associated with poor COVID-19 outcomes. Given the pandemic's exacerbating effects on health inequities, HIV public health and clinical communities must strengthen services and support for people living with and affected by HIV.
Early in the human immunodeficiency virus (HIV) epidemic in the United States, New York City (NYC) was the epicenter of HIV, and while the US epicenter has shifted geographically since the beginning of the epidemic, NYC remains home to an estimated 92 000 people living with HIV (PWH) in 2018 [1], representing 9% of the 1 million PWH nationally [2]. As the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic hit the United States, NYC became the early epicenter. Through 8 July 2020, 214 570 New Yorkers were diagnosed with coronavirus disease 2019 (COVID-19) infection and 23 224 deaths were attributed to COVID-19 [3].
Given that HIV can compromise the immune system and that a rapidly growing number of people are being diagnosed with COVID-19, there is concern about whether PWH could be at higher risk for SARS-CoV-2 infection and that, compared with people without HIV, PWH could experience worse COVID-19-related clinical outcomes. Older age and coexisting chronic medical conditions, including those that affect the immune system such as diabetes mellitus, have been identified as potential risk factors for poor clinical outcomes after diagnosis with SARS-CoV-2 infection [4-6]. People living with HIV are aging and older compared with the general population, and medical comorbidities are common among PWH [7-9]. However, the intersection between HIV and COVID-19 has not yet been described at the population level. Such an analysis would be critical for several reasons. First, it would enable a comprehensive characterization of the sociodemographic characteristics and clinical outcomes of PWH who acquire SARS-CoV-2. Second, such a study would inform additional analyses to quantify the risk for COVID-19 among PWH, particularly in geographic areas and communities hard-hit by both conditions. Third, it would identify differences in COVID-19 clinical outcomes for people with and without diagnosed HIV infection. These reasons are even more compelling given the disproportionate impact of both HIV and COVID-19 on Black and Latino communities. Here we present results of a descriptive, population-level analysis of linked data from the NYC HIV surveillance and COVID-19 surveillance systems.
RESULTS
Among a total of 204 583 COVID-19 cases reported to DOHMH as of 2 June 2020, we identified 2447 people with diagnosed HIV reported to the HIV surveillance registry. After removing PWH whose current residence was outside NYC or unknown and duplicate records, a total of 2410 PWH with diagnosed COVID-19 infection were eligible for the analysis. The comparison populations were all NYC PWH excluding those diagnosed with COVID-19 infection (N = 113 907) and all NYC residents with diagnosed COVID-19 infection and without diagnosed HIV infection (N = 202 012). The age-adjusted prevalence of diagnosed HIV among confirmed NYC COVID-19 cases was 1.06%. There was no apparent difference in the timing with which COVID-19 diagnoses were made among PWH compared with people without diagnosed HIV infection in NYC (Figure 1).
Nearly three-quarters of PWH with and without diagnosed COVID-19 were assigned male sex at birth compared with just over half of all NYC COVID-19 cases (Table 1). People living with HIV with and without diagnosed COVID-19 were generally older than NYC COVID-19 cases overall-with, for example, 56.1% and 53.5% of PWH with and without COVID-19, respectively, aged 45-64 years versus 36.1% of all NYC COVID-19 cases; notably, however, a higher proportion of all NYC COVID-19 cases were in the oldest age group of 75 years and older (11.8%) compared with PWH with COVID-19 (5.2%). Among individuals with known race/ethnicity across all 3 groups, Black and Latino/Hispanic individuals were overrepresented. This disparity was pronounced among PWH with COVID-19, with 86.1% of PWH with COVID-19 identified as Black or Latino/Hispanic compared with 78.6% of PWH without COVID-19 and 62.5% of all NYC COVID-19 cases; including cases with unknown race/ethnicity, 33.1% of all NYC COVID-19 cases were Black or Latino/Hispanic. The distribution of NYC borough of residence also varied across the groups: a higher proportion of PWH with and without COVID-19 were residents of the Bronx and Manhattan compared with all NYC COVID-19 cases, and a lower proportion of PWH with and without COVID-19 were residents of Queens compared with all NYC COVID-19 cases. People living with HIV with COVID-19 were more likely to be living in areas with high and very high poverty levels (56.9%) compared with 51.4% of PWH without COVID-19 and 39.9% of all NYC COVID-19 cases.
Most PWH with and without diagnosed COVID-19 had male-to-male sexual contact (MSM), heterosexual contact, or a history of injection drug use (IDU) as their documented HIV transmission risk prior to HIV diagnosis. Compared with PWH without COVID-19, a lower proportion of PWH with COVID-19 were MSM (33.9% vs 41.4%) and a higher proportion had a history of IDU (15.1% vs 11.5%). In both groups of PWH, the majority (61.4% and 63.8%, respectively) had been diagnosed with HIV in the year 2000 or later.
Compared with all NYC COVID-19 cases, a substantially higher proportion of PWH with COVID-19 had documentation of at least 1 underlying condition (64.3% vs 35.4%). The frequency of specific underlying conditions varied across the 2 groups, and the rankings of most common conditions differed somewhat. The most common specific underlying conditions among PWH with COVID-19 after the general "immunodeficiency" category were heart disease, diabetes mellitus, hepatic disease, hypertension, and lung disease. Excluding PWH with only immunodeficiency documented, which was likely documented due to HIV status, 58.9% of PWH with COVID-19 had at least 1 underlying condition reported. Among all NYC COVID-19 cases, the most common specific underlying conditions were diabetes, heart disease, hypertension, and lung disease.
Compared with all NYC COVID-19 cases, a higher proportion of PWH with COVID-19 experienced COVID-19-related hospitalization, admission to an ICU, and death during this period (Table 2). Forty-two percent of PWH with COVID-19 were hospitalized (vs 26% of all cases), 5% were admitted to the ICU (vs 3% of all cases), and 13% died (vs 8% of all cases) (Figure 2). Generally, compared with all NYC COVID-19 cases, PWH with COVID-19 who experienced these COVID-19 outcomes were more likely to be older, Black or Latino/Hispanic, and living in high-poverty NYC neighborhoods. Compared with their representation among all PWH with COVID-19, higher proportions of Bronx residents experienced hospitalization, ICU admission, and death, and lower proportions of Manhattan and Queens residents experienced ICU admission and death; lower proportions of MSM experienced hospitalization, ICU admission, and death, while higher proportions of PWH with a history of IDU experienced hospitalization, ICU admission, and death. Compared with their proportions among all PWH with COVID-19, higher proportions of PWH who were hospitalized, admitted to the ICU, and died had earlier HIV diagnoses (eg, before 1990 or from 1991 to 1999); relatively small proportions of PWH diagnosed with HIV in the most recent decade (2010-2020) experienced these adverse COVID-19 outcomes (Table 2).
By HIV viral suppression status, the vast majority of PWH who were hospitalized, admitted to the ICU, and died were virally suppressed at last HIV viral load. By latest CD4+ cell count, among PWH with a history of hospitalization, most had 500 or more cells/μL; among those with a history of ICU admission, most PWH had less than 200 cells/μL. The majority of PWH with COVID-19 with these outcomes had a history of AIDS diagnosis per the HIV surveillance registry. Finally, the majority of PWH who were hospitalized and especially those who experienced ICU admission or death due to COVID-19 had at least 1 underlying condition documented in the COVID-19 surveillance database (88.3%, 93.6%, and 93.6%, respectively).
DISCUSSION
Our population-level analysis of matched surveillance data on HIV and SARS-CoV-2 infection in NYC found that people with diagnosed HIV comprised 1.06% of all confirmed COVID-19 cases in the first 14 weeks of the city's outbreak. Given that the overall prevalence of HIV in the NYC population was 1.5% in 2018 [11], this finding suggests that, compared with people without HIV, PWH might not be disproportionately vulnerable to SARS-CoV-2 infection. However, despite this encouraging finding, our analysis demonstrated that, compared with all NYC COVID-19 cases, a higher proportion of NYC PWH with COVID-19 were hospitalized for COVID-19, admitted to the ICU, and died due to COVID-19. This may not be due to HIV itself but to the fact that NYC PWH have characteristics in common with people who have been diagnosed with COVID-19 and had poor outcomes. Further analysis beyond this descriptive one is required to identify whether HIV infection is an independent risk factor for poor COVID-19-related outcomes. We also found that, compared with all NYC COVID-19 cases, a higher proportion of PWH with COVID-19 were male, older, and Black, and Latino/Hispanic, which is reflective of NYC PWH overall. However, compared with PWH without COVID-19, PWH with COVID-19 were more likely to be Latino and less likely to be White, suggesting pronounced inequities among PWH with COVID-19. More PWH with COVID-19 lived in the Bronx, an NYC borough hit particularly hard by the NYC COVID-19 outbreak thus far.
Our study contributes to the limited published literature on the intersection of HIV and SARS-CoV-2 infection. The scientific community has conjectured that PWH may be especially vulnerable to poor outcomes after SARS-CoV-2 infection due to immunosuppression and/or the presence of other conditions-or, conversely, that PWH could potentially experience protection from the most serious sequelae of COVID-19 because of their history of immune response and/or because of the potential anti-SARS-CoV-2 activity of HIV antiretroviral treatments [12]. In our study, we did find that PWH who experienced poor COVID-19-related outcomes, particularly those who had been admitted to the ICU or died, had lower CD4 counts (majority had <500 cells/μL), and that PWH who had been diagnosed with HIV prior to the year 2000 were more heavily represented among those with poor COVID-19-related outcomes. Those with longer time since HIV diagnosis are more likely to be older and have other comorbid conditions, which could put them at higher risk for poor COVID-19-related outcomes. We also found a high prevalence of other comorbidities among PWH with COVID-19, which has been identified in other cohorts [13, 14]. We also saw high levels of HIV viral control in our population of PWH with COVID-19, which suggests high levels of antiretroviral coverage, and a relatively low proportion with very low CD4 cell counts. While we found that PWH and COVID-19 were more likely to have worse outcomes than COVID-19 cases overall, in a relatively small group of PWH hospitalized for COVID-19 infection in NYC Sigel et al [13] found no difference in the frequency of poor outcomes, including mechanical ventilation and death, for hospitalized PWH and non-PWH. Consistent with other studies, we found that PWH do not appear to be overrepresented among those who acquire SARS-CoV-2 infection, and in fact, the prevalence of HIV among NYC COVID-19 cases was slightly lower than NYC's overall HIV prevalence. This analysis did not examine risk for COVID-19 infection and whether risk among PWH may be influenced by differences in their likelihood to self-quarantine, especially if immunosuppressed.
This study's findings have important implications for the care of PWH. We found that racial and ethnic inequities in the NYC COVID-19 pandemic overall are mirrored-and even more pronounced-among PWH with COVID-19. Efforts to eliminate racial/ethnic inequities among PWH and for other individuals affected by HIV are central to achieving the goals of NYC DOHMH's ending the HIV epidemic (EtE) strategy [15]. Given the exacerbating effects of the COVID-19 pandemic on health inequities, including among PWH, this is a critical time for the HIV public health and clinical community to strengthen services and support for people living with and affected by HIV to protect and accelerate progress made thus far toward the EtE strategy. More rigorous exploration of COVID-19 outcomes among PWH compared with people without HIV is needed to understand which factors-older age, higher prevalence of comorbidities, and/or HIV itself-may be contributing to worse clinical outcomes. Additionally, the extent to which older age and accelerated aging related to HIV infection may contribute to these outcomes merits further investigation.
To our knowledge, this is among the largest population-level analyses to draw on data collected by surveillance systems for HIV and COVID-19, and its robustness and comprehensiveness are major strengths. Several limitations of the analysis are also noted. First, reporting lags in COVID-19 case and death data mean that very recently diagnosed individuals and deaths may have been missing from the 2 June dataset. Second, SARS-CoV-2 testing availability was not consistent throughout the analytic period; early COVID-19 cases are presumed to be under-ascertained. However, SARS-CoV-2 infection among PWH may have been more likely to be detected given their connection to healthcare. Third, there are important gaps in data collection and availability for NYC COVID-19 cases given that DOHMH is not able to investigate all cases to collect ancillary data; instead, COVID-19 laboratory test results are the primary data source and these data typically only contain limited personal information. Importantly, race/ethnicity is missing for 47% of cases in the COVID-19 surveillance dataset. We acknowledge the possibility that data are missing differentially for different race/ethnic groups depending on the data sources available (patient interview or electronic medical record if hospitalized [more complete] vs laboratory test result only [less complete]). In addition, information on underlying conditions is likely incomplete since this information is captured from clinical data, hospital records, or patient interview when available; the fact that only 39% of PWH with COVID-19 had information indicating immunodeficiency despite confirmed HIV status via the registry match suggests potentially substantial under-ascertainment of coexisting conditions in this dataset. Differential ascertainment of comorbidities is possible if PWH are more likely to be diagnosed with comorbidities since most are in continuous medical care that routinely screens for a range of comorbidities. Last, as this is a population-level analysis, we do not have data on potential differences in clinical practices that may exist across NYC hospitals with respect to criteria for hospitalization and ICU admission for COVID-19.
Conclusions
This large-scale, combined analysis of NYC COVID-19 and HIV surveillance data should inform the public health response to COVID-19 and shape approaches to service delivery and programming for people with and at risk for HIV and COVID-19 in NYC, and potentially in other jurisdictions as applicable. Even if PWH are not overrepresented among NYC COVID-19 cases thus far, their experience as a community of racism and other forms of structural oppression; their frequent exposure to poverty, housing insecurity, and other adverse socioeconomic conditions; the high prevalence of comorbid conditions; and other challenges and vulnerabilities underscore the need to assess and respond to community needs during this time. Additional epidemiologic research on the intersection of HIV and COVID-19 is needed to inform the response, including to quantify risk for SARS-CoV-2 infection among PWH, and to identify risk factors associated with specific COVID-19-related outcomes among PWH.
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