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  AIDS 2022
July 29 - Aug 2
24th Intl AIDS Conference
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COVID Hospital Death Risk 50% Higher With HIV, WHO Says- Risk Factors Are Under 200 CD4s, CKD, Diabetes, Hypertension
  AIDS 2022, July 29-August 2, Montreal
Mark Mascolini
Compared with HIV-negative inpatients with COVID, those with HIV have a 50% higher chance of dying in the hospital, according to a World Health Organization (WHO) analysis of 362,941 inpatients with COVID in 42 countries [1]. The study also pinpointed several independent risk factors for in-hospital mortality in people with HIV, including older age, CD4 count below 200, chronic kidney disease (CKD), diabetes, and hypertension-the last 3 being HIV-related comorbidities well known in the HIV community for many years.
The WHO’s Silvia Bertagnolio analyzed 13 systematic reviews of COVID mortality with versus without HIV, noting that 8 of them found a higher death risk with HIV, 5 found a similar death risk with and without HIV, and none found a lower death risk with HIV. A meta-analysis reported at AIDS 2022 (reported separately by NATAP) estimated a 30% higher risk of in-hospital mortality with versus without HIV [2].
WHO statisticians used multivariable regression analysis to identify risk factors for 21-day in-hospital mortality. They adjusted models for clustering at the country level and for hypertension, TB, diabetes, cancer, cardiac disease, chronic pulmonary disease, CKD, age, gender, CD4 count, and HIV viral load. They excluded records with missing data.
For this analysis, Bertagnolio turned to data on 629,729 in-hospital COVID cases in 50 countries across the world from January 2020 to May 2022. The group included 362,941 people in 42 countries with known HIV status, of whom 29,530 (8.1%) were people with HIV. Overall, most participants, 97%, were African.
Compared with HIV-negative people admitted to the hospital with COVID, people with HIV had several classic COVID symptoms more often: fever, shortness of breath, fatigue, headache, chest pain, loss of smell, and myalgia (muscle pain). Cough was less frequent in HIV-positive people with COVID than in the HIV-negative group. More than half of in-hospital COVID patients with HIV, 59%, had 1 or more underlying conditions, compared with 45% of HIV-negative people, a highly significant difference (P < 0.0001).
Adjusted analysis determined that HIV-positive people admitted to the hospital with COVID had a 50% higher risk of dying in the hospital with COVID (adjusted hazard ratio [aHR] 1.51, 95% confidence interval [CI] 1.46, to 1.56).
An HIV load above 1000 copies with a CD4 count below 200 doubled COVID death risk (aHR 1.96, 95% CI 1.81 to 2.12). Other HIV load/CD4 combinations that heightened risk of in-hospital COVID mortality were viral below 1000/CD4s below 200 (aHR 1.62, 95% CI 1.52 to 1.73), viral load below 1000/CD4s above 200 (aHR 1.29, 95% CI 1.21 to 1.37), and viral load above 1000/CD4s above 200 (aHR 1.12, 95% CI 1.04 to 1.22).
Among people with HIV, adjusted analysis identified several age-related independent predictors of in-hospital COVID mortality: age 18 to 45 years (aHR 2.40, 95% CI 1.33 to 4.32), age 45 to 65 (aHR 4.37, 95% CI 2.42 to 7.89), age 65 to 75 (aHR 6.84, 95% CI 3.73 to 12.56), and age older than 75 (aHR 5.73, 95% CI 2.81 to 11.69). Other independent predictors were CD4 count below 200 (aHR 1.46, 95% CI 1.33 to 1.60) (but not viral load above 1000), CKD (aHR 1.65, 95% CI 1.42 to 1.93), diabetes (aHR 1.34, 95% CI 1.19 to 1.50), and hypertension (aHR 1.17, 95% CI 1.06 to 1.31). Gender did not affect death risk in this analysis.
Dominant circulation of the delta SARS-CoV-2 variant followed by the omicron variant changed in-hospital mortality risk with versus without HIV. When delta held sway, 19.4% of people without HIV versus 21.8% of people with HIV died, results that translated into a 55% higher death risk with HIV (aHR 1.55, 95% CI 1.43 to 1.67). Mortality waned significantly to 8.1% with the arrival of omicron in the HIV-negative group (absolute mortality difference from delta 13.0%, P < 0.0001). Mortality also dipped in HIV-positive people when omicron arrived, to 17.6%. That decline was significant (P < 0.0001) but much less marked than in HIV-negative people (absolute difference from delta 4.8%). And HIV infection independently conferred an even higher risk of in-hospital mortality in the omicron era (aHR 2.47, 95% CI 2.27 to 2.68).
The WHO investigators stressed that COVID vaccine coverage remains unacceptably low in Africa compared with the rest of the world (about 18% versus 62%) and urged health authorities to prioritize SARS-CoV-2 vaccination and other pharmacological measures in people with HIV, especially those with advanced HIV infection or comorbidities.
1. Bertagnolio S. Are people living with HIV at higher risk of severe and fatal COVID-19? AIDS 2022, July 29-August 2, Montreal. Abstract OAB0404. 2. Tang Y, Xie Y, Hu S, et al. Systematic review and meta-analyses of the interaction between HIV infection and COVID-19: two years' evidence summary. AIDS 2022, July 29-August 2, Montreal. Abstract EPC080.