Clinical features and outcomes of COVID-19 admissions in a population with a high prevalence of HIV and tuberculosis: a multicentre cohort study

Abstract

Background There is still a paucity of evidence on the outcomes of coronavirus disease 2019 (COVID-19) among people living with human immunodeficiency virus (PWH) and those co-infected with tuberculosis (TB), particularly in areas where these conditions are common. We describe the clinical features, laboratory findings and outcome of hospitalised PWH and human immunodeficiency virus (HIV)-uninfected COVID-19 patients as well as those co-infected with tuberculosis (TB). Methods We conducted a multicentre cohort study across three hospitals in Cape Town, South Africa. All adults requiring hospitalisation with confirmed COVID-19 pneumonia from March to July 2020 were analysed. Results PWH comprised 270 (19%) of 1434 admissions. There were 47 patients with active tuberculosis (3.3%), of whom 29 (62%) were PWH. Three-hundred and seventy-three patients (26%) died. The mortality in PWH (n = 71, 26%) and HIV-uninfected patients (n = 296, 25%) was comparable. In patients with TB, PWH had a higher mortality than HIV-uninfected patients (n = 11, 38% vs n = 3, 20%; p = 0.001). In multivariable survival analysis a higher risk of death was associated with older age (Adjusted Hazard Ratio (AHR) 1.03 95%CI 1.02–1.03, p < 0.001), male sex (AHR1.38 (95%CI 1.12–1.72, p = 0.003) and being “overweight or obese” (AHR 1.30 95%CI 1.03–1.61 p = 0.024). HIV (AHR 1.28 95%CI 0.95–1.72, p 0.11) and active TB (AHR 1.50 95%CI 0.84–2.67, p = 0.17) were not independently associated with increased risk of COVID-19 death. Risk factors for inpatient mortality in PWH included CD4 cell count < 200 cells/mm3, higher admission oxygen requirements, absolute white cell counts, neutrophil/lymphocyte ratios, C-reactive protein, and creatinine levels. Conclusion In a population with high prevalence of HIV and TB, being overweight/obese was associated with increased risk of mortality in COVID-19 hospital admissions, emphasising the need for public health interventions in this patient population.

Screening performance of C-reactive protein for active pulmonary tuberculosis in HIV-positive patients: A systematic review with a meta-analysis

“…concluded that higher values of CRP were measured in patients diagnosed with all three infections: TB, HIV, and COVID-19 ( 67 ). However, researchers recommend CRP as a monitoring and prognosis tool in patients diagnosed with both TB and COVID-19, rather than as a rule-out screening test ( 68 ). Multiple investigations are required in order to generalize our results in those individuals.…”

COVID-19 severity and in-hospital mortality in an area with high HIV prevalence

“…This cohort’s prevalence of HIV infection was within the range for other reported estimates and is likely to be broadly representative of similar hospital cohorts in South Africa. 6 , 41 , 42 Approximately one-third of PLWH in this study did not have HIVVLs measured which may have biased the comparison between detectable versus undetectable HIVVL participants. Strengths of our study include prospective data collection, a validated method for quantifying respiratory disease severity on a continuum, many patients with laboratory biomarkers during admission, and PLWH well characterised in terms of other comorbidities.…”

The severity of COVID-19 across the spectrum of HIV

“…Although there was a trend toward increased rates of ICU admission, mechanical ventilation, and mortality in PWH compared with their HIV-uninfected counterparts, these outcomes were not statistically significant within their small sample size. Another study from South Africa compared patients with and without HIV who were hospitalized with COVID-19 and did not find a clear increase in mortality associated with HIV, though having a CD4 cell count less than 200 cells/μl was a separate mortality risk factor [10 ▪ ].…”

“…An exploratory subgroup analysis of the recent large WHO Clinical Platform study found that HIV RNA greater than 1000 copies/ml and CD4 cell count less than 200 cells/ml nearly doubled the risk of in-hospital mortality compared with those with well controlled HIV [18 & ]. Another cohort study from South Africa also found that CD4 cell count less than 200 cells/ml was independently associated with increased risk of COVID-19 mortality [10 ]. A third recent South African cohort study found that among PWH, COVID-19 mortality was associated with lower recent CD4 count, high HIV RNA, and no evidence of recent antiretroviral prescription [19…”