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SARS-CoV-2 Infection Among People Living With HIV Compared With People Without HIV: Survey Results From the MACS-WIHS Combined Cohort Study
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JAIDS Jan 1 2022
SARS-CoV-2 positivity was higher among PLWH than among SN individuals (9.4% vs 4.8%, P = 0.003).
Despite similar SARS-CoV-2 testing rates, a higher proportion of PLWH in our study tested positive for SARS-CoV-2 infection compared with SN participants. This suggests that PLWH may have increased susceptibility or have had greater non–HIV-related risks for SARS-CoV-2 infection. Our findings are similar to a large study of more than 280,000 people tested by the San Francisco Department of Public Health, which reported higher SARS-CoV-2 test positivity among PLWH than among SN individuals (4.5% vs 3.5%).14 However, our findings differ from several other studies that reported similar risk of infection with SARS-CoV-2 in PLWH and SN individuals.15–17
Abstract
Background:
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (COVID-19) symptoms among people living with HIV (PLWH) are not well described.
Setting:
Longitudinal survey within the MACS/WIHS Combined Cohort Study (MWCCS) of PLWH compared with similar HIV-seronegative (SN) individuals.
Methods:
Telephone-administered survey of MWCCS participants at 13 clinical research sites across the United States addressing COVID-19 symptoms, SARS-CoV-2 testing, and pandemic impact on social distancing and antiretroviral therapy (ART) use. Primary data collection occurred during May (wave 1), June–July (wave 2), and August–September, 2020 (wave 3).
Results:
One-third of MWCCS participants were tested for SARS-CoV-2 infection; 10% was tested ≥2 times. Similar proportions of PLWH and SN participants were tested, but SARS-CoV-2 positivity was higher among PLWH than among SN individuals (9.4% vs 4.8%, P = 0.003). Odds of SARS-CoV-2 positivity remained higher among PLWH after adjusting for age, sex, race/ethnicity, and study site (adjusted odds ratio = 2.0, 95% confidence interval = 1.2 to 3.2). SARS-CoV-2 positivity was not associated with CD4 cell counts among PLWH. Among SARS-CoV-2 positive participants, 9% had no symptoms, 7% had 1–2 mild symptoms, and 84% had ≥3 symptoms. Most of the (98%) participants reported physical distancing during all survey waves; self-reported ART adherence among PLWH was not adversely affected during the pandemic compared with the previous year (similar adherence in 89% of participants, improved in 9% of participants, and decreased in 2% of participants).
Conclusions:
Despite similar SARS-CoV-2 testing and physical distancing profiles by HIV serostatus among MWCCS participants, PLWH who reported SARS-CoV-2 testing were more likely to have a positive test result. Additional studies are needed to determine whether and why PLWH are at increased risk of SARS-CoV-2 infection.
INTRODUCTION
Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), the virus responsible for coronavirus disease 2019 (COVID-19), manifests itself with a variety of clinical symptoms during infection. Although most people who become infected are either asymptomatic or experience mild symptoms, the illness can be severe and/or life-threatening.1 Between March and September 2020, with infection levels surging across the United States,2 more than 7 million people tested positive for SARS-CoV-2 and 200,000 people died.3,4 In an effort to mitigate the impact of the pandemic, many states mandated policies of social distancing and closures of businesses and other venues.5
COVID-19 severity increases among adults with each decade of advancing age6 and among those with certain underlying health conditions and comorbidities. It is unclear whether SARS-CoV-2 infection is higher among people living with HIV (PLWH); however, some recent studies suggest that PLWH may have increased disease severity and risk of hospitalization.7 A recent review of SARS-CoV-2 cases among PLWH indicated that although documented combined HIV and SARS‐CoV‐2 coinfection was uncommon globally, greater HIV‐related immunosuppression predisposed PLWH to more severe COVID‐19 disease.8,9 Analysis of 192 PLWH suggested that a CD4 count <200 cells/µL (vs ≥200 cells/µL) was associated with a 4.9-fold higher odds of progression to severe COVID-19.8Currently, recommendations for prevention of SARS‐CoV‐2 infection and COVID-19 management among PLWH are no different than those for the general population. The US Centers for Disease Control and Prevention (CDC) recommend that “until more is known, additional caution for all PLWH, especially those with advanced or poorly controlled HIV, is warranted” and that PLWH should follow CDC prevention recommendations.10 However, PLWH are more likely than the general population to have risk factors associated with greater SARS-CoV-2 exposure and/or worse COVID-19 outcomes, including higher prevalence of adverse social determinants of health (eg, unstable housing and public transportation use) and comorbidities (eg, cardiovascular disease, obesity, and smoking).11 PLWH in the United States are also disproportionately represented among racial minorities and groups hit hardest by the SARS-CoV-2 pandemic.
We previously reported similar prevalences and types of COVID-19 symptoms among PLWH and similar HIV-seronegative (SN) adults in the MACS/WIHS Combined Cohort Study (MWCCS) during Spring 2020.12(p1) In this analysis, we characterize the evolving pandemic among MWCCS participants by extending our initial report to include additional waves of data collection through September 2020, after the surge of COVID-19 that occurred in the United States in the Spring and Summer of 2020.
DISCUSSION
Despite similar SARS-CoV-2 testing rates, a higher proportion of PLWH in our study tested positive for SARS-CoV-2 infection compared with SN participants. This suggests that PLWH may have increased susceptibility or have had greater non–HIV-related risks for SARS-CoV-2 infection. Our findings are similar to a large study of more than 280,000 people tested by the San Francisco Department of Public Health, which reported higher SARS-CoV-2 test positivity among PLWH than among SN individuals (4.5% vs 3.5%).14 However, our findings differ from several other studies that reported similar risk of infection with SARS-CoV-2 in PLWH and SN individuals.15–17
The prevalence of self-reported COVID-19 symptoms and symptom severity was similar by HIV serostatus in the MWCCS. The proportion of SARS-CoV-2 positive participants who reported symptoms in our study was high (92%). However, most of the months that our surveys were conducted, SARS-CoV-2 testing was of limited availability and sought primarily by persons who were symptomatic or had a known exposure. Reasons for SARS-CoV-2 testing were not collected in this study, so could not be evaluated. COVID-19 symptoms did not differ by HIV serostatus, although some previous studies reported that immunosuppression in PLWH was associated with more severe COVID‐19 symptoms.8 Several large studies have reported higher rates of COVID-19 hospitalization and mortality among PLWH than among SN cases,7,18 raising concern that PLWH may be at increased risk of severe outcomes from COVID-19.
The impact of the pandemic on MWCCS participants was dramatic, prompting almost ubiquitous physical distancing and high reported self-isolation. Impacts on ART adherence were more modest, with disruptions in use reported by 9% of participants; however, these seemed short-lived. Only 2% of PLWH reported lower ART adherence during the pandemic compared with prepandemic, and 9% reported higher ART adherence during the pandemic. This is consistent with studies reporting some disruptions in HIV care but care engagement not being seriously disrupted19,20 and adherence increasing in some PLWH during the pandemic.21
Our study had several strengths. First, the MWCCS included study sites across the United States and collected data on PLWH and similar HIV SN individuals for comparison. In addition, the same survey was administered across all study sites by well-trained staff who knew the participants well. Third, a high proportion of participants completed the survey. Finally, the survey was administered multiple times over a 5-month timeframe and, thus, was able to capture updated, real-time, and changing information about social distancing practices, self-reported COVID-19 symptoms, and SAR-CoV-2 testing. Our study also has some limitations. First, we relied on participants' self-report of COVID testing and test results because medical records were not readily available for all cases.
However, people generally are likely to recall experiencing a nasopharyngeal or oropharyngeal swab, and during the early months of the COVID-19 pandemic, these specimens were unlikely to have been obtained for reasons other than COVID-19 testing. Medical records were obtained for more than half of the self-reported SARS-CoV-2 positive participants. Among self-reported cases for which test data were obtained, all cases were confirmed based on test results. MWCCS participants are used to reporting medical results, and the study has a system in place for medical information collection; however, the array of locations/testing sites and noncentralized testing methods/locations rolled out to provide access to SARS-CoV-2 testing increased the challenges associated with this process. Furthermore, some rapid SARS-CoV-2 testing sites did not provide written results and/or did not have centralized documentation of test results that could be requested, limiting confirmation. Second, we lacked information concerning access to and reasons for testing. Systematic differences in the distribution of reasons for testing could have affected the proportions of positive SARS-CoV-2 tests observed among PLWH and SN participants. We anticipate that most SARS-CoV-2 tests were prompted by the presence of COVID-19 symptoms because there were few self-reported asymptomatic COVID-19 cases; however, asymptomatic cases are underreported everywhere. Another limitation was that we did not have confirmed information on COVID-related hospitalizations and deaths, although collection of those medical records is planned in the future. In addition, because most participants are on effective therapies, we had a limited number of severely immunosuppressed subjects, so we were not well powered to explore infection among those with very low CD4 cell counts.
In our large, prospective, multicenter US observational cohort of people with and without HIV infection, one-third of participants reported SARS-CoV-2 testing between April and September 2020, and the proportion of self-reported SARS-CoV-2 positive tests was twice as high among PLWH than SN participants. Higher SARS-CoV-2 positivity among PLWH was observed in each of the 3 administration cycles of the MWCCS COVID-19 survey and remained after adjusting for age, sex, race, and clinical research site. COVID-19 symptom type, prevalence, and severity were similar by HIV serostatus. These data suggest that PLWH may be at increased risk of acquisition of SARS-CoV-2 infection compared with HIV SN persons; however, because not all participants were tested, further research is needed to support this finding.
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