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HIV, Dementia, Cognitive Concerns Tied to Death in COVID Patients
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HIV, Dementia, Cognitive Concerns Tied to Death in COVID Patients
IDWeek 2022, October 19-23, 2022, Washington, DC
Mark Mascolini
A case-control study of COVID patients with and without HIV linked HIV and cognitive concerns to higher odds of death [1]. Dementia predicted death in the entire study group but not in the subset with HIV infection.
Large population studies suggest that people with HIV infection run a higher risk of severe disease and death than the general population when admitted to the hospital with COVID. Much research before the COVID pandemic confirmed persistent neurologic disorders in HIV-positive people despite a good response to antiretroviral therapy. Yet prevalence of neurologic disorders has been surprisingly low in some studies of HIV-positive people with COVID [2,3].
Researchers at Massachusetts General Hospital conducted this study to take a closer look at whether dementia heightens death risk in COVID patients with or without HIV. They also wanted to determine whether dementia, cognitive concerns, and death have unique relations in HIV-positive people with COVID.
The study group consisted of 64 people with HIV and 463 HIV-negative individuals, all diagnosed with COVID and similar in average age (53.4 and 53.3) and proportions of females (39.1% and 43.4%), blacks (42.2% and 34.8%), and Hispanics (25.0% and 25.7%). Researchers also matched the HIV and non-HIV groups by zip code. The HIV group included a significantly higher proportion with a history of dementia determined by ICD-10 code (15.6% vs 6.0%, P = 0.01) and a higher proportion with cognitive concerns established by clinical review (21.9% vs 15.8%, P = 0.04).
The 64 people with HIV and COVID included 49 inpatients and 15 outpatients. The inpatient group was older (average 55.4 vs 46.8) and had a higher proportion with a CD4 count below 200 (24.5% vs 0). Inpatients and outpatients were similar in proportions with antiretroviral therapy documented in their electronic health records (87.8% and 93.3%) and with a viral load below 200 copies (87.8% and 86.7%).
Compared with the 463 HIV-negative people, the 64 with HIV had a higher proportion whose highest level of care was hospital admission (76.6% vs 63.3%, P = 0.052) and a higher proportion who died in the hospital (17.2% vs 6.3%, P = 0.004). Among people who died, those with HIV died at a younger age (average 57.95 vs 66.23, P = 0.03). Death could be attributed to COVID in 63.6% with HIV and 72.4% without HIV, a nonsignificant difference (P = 0.637).
In an unadjusted analysis of the whole study group, age, sex, race, and body mass index did not affect odds of death, but four factors did: HIV infection (odds ratio [OR] 3.11, 95% confidence interval [CI] 1.41 to 6.43, P = 0.003), history of dementia (OR 5.46, 95% CI 2.34 to 12.03, P < 0.001), cognitive concerns (OR 4.96, 95% CI 2.41 to 10.31, P < 0.001), and cerebrovascular disease (OR 3.24, 95% CI 1.56 to 6.51, P = 0.001).
The VACS (Veterans Aging Cohort Study) 2.0 index estimates 5-year risk of death from any cause in people with HIV [4]. It incorporates basic demographic variables and easily obtained lab measures like HIV load, platelets, and estimated glomerular filtration rate [4]. In the full cohort of the dementia study, VACS 2.0 significantly predicted level of care (outpatient vs hospital, outpatient vs ICU, and outpatient vs death, P < 0.001 for all differences). Compared with HIV-negative people, those with HIV had significantly higher (worse) VACS scores among outpatients and ICU patients (P < 0.05 for both) but not for in-hospital patients or death.
The main drivers of higher odds of death in VACS 2.0 were older age and liver function markers-AST, ALT, and FIB-4. Compared with a VACS score below 40, a score of 40 to 59 raised odds of death more than 8-fold (OR 8.19, 95% CI 2.17 to 53.43, P = 0.007), a score of 60 to 79 boosted death odds more than 37-fold (37.55, 95% CI 10.35 to 241.59, P < 0.001), and a score of 80 to 100 made mortality odds almost 50-fold higher (OR 49.64, 95% CI 8.92 to 393.70, P < 0.001). Confidence intervals were wide for all these associations.
In all 527 study participants, an analysis adjusted for VACS 2.0 [4] determined that preexisting cognitive concern (vs no concern) more than doubled odds of death (OR 2.39, 95% CI 1.09 to 5.27, P = 0.02). This association was similar to that of the impact of a dementia diagnosis in the whole study group (OR 2.42, 95% CI 0.96 to 5.75, P = 0.05). In the 64 people with HIV, preexisting cognitive concern almost quadrupled odds of death in an association that stopped short of statistical significance (OR 3.92, 95% CI 0.81 to 20.09, P = 0.09). But in the HIV group alone, dementia was not associated with death in people with COVID.
The Massachusetts General team concluded that in this matched HIV-positive/negative group with COVID, people with HIV were more likely to die (17.2% vs 6.3%) and to die at a significantly younger age (58 vs 66). They proposed that the VACS 2.0 index may help predict death in all people with COVID. Preexisting dementia based on ICD-10 coding, or cognitive concerns based on note review, were linked to higher odds of death in the combined group with or without HIV. But in the HIV group alone, cognitive concerns but not dementia were tied to higher odds of death.
References
1. Mukerji SS, Wilcox DR, Rudmann EA, et al. Dementia and cognitive concerns are risk factors for mortality in people with human immunodeficiency virus and COVID-19. IDWeek 2022, October 19-23, 2022, Washington, DC.
2. Bhaskaran K, Rentsch CT, MacKenna B, et al. HIV infection and COVID-19 death: a population-based cohort analysis of UK primary care data and linked national death registrations within the OpenSAFELY platform. Lancet HIV. 2021;8:e24-e32. doi: 10.1016/S2352-3018(20)30305-2.
https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(20)30305-2/fulltext
3. Bertagnolio S, Thwin SS, Silva R, et al. Clinical features of, and risk factors for, severe or fatal COVID-19 among people living with HIV admitted to hospital: analysis of data from the WHO Global Clinical Platform of COVID-19. Lancet HIV. 2022;9:e486-e495. doi: 10.1016/S2352-3018(22)00097-2.
https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(22)00097-2/fulltext
4. mdcalc.com. Veterans Aging Cohort Study (VACS) 2.0 Index. https://www.mdcalc.com/calc/10402/veterans-aging-cohort-study-vacs-2.0-index
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