COVID‐19 among adults living with HIV: correlates of mortality among public sector healthcare users in Western Cape, South Africa

Abstract

Introduction While a large proportion of people with HIV (PWH) have experienced SARS‐CoV‐2 infections, there is uncertainty about the role of HIV disease severity on COVID‐19 outcomes, especially in lower‐income settings. We studied the association of mortality with characteristics of HIV severity and management, and vaccination, among adult PWH. Methods We analysed observational cohort data on all PWH aged ≥15 years experiencing a diagnosed SARS‐CoV‐2 infection (until March 2022), who accessed public sector healthcare in the Western Cape province of South Africa. Logistic regression was used to study the association of mortality with evidence of antiretroviral therapy (ART) collection, time since first HIV evidence, CD4 cell count, viral load (among those with evidence of ART collection) and COVID‐19 vaccination, adjusting for demographic characteristics, comorbidities, admission pressure, location and time period. Results Mortality occurred in 5.7% (95% CI: 5.3,6.0) of 17,831 first‐diagnosed infections. Higher mortality was associated with lower recent CD4, no evidence of ART collection, high or unknown recent viral load and recent first HIV evidence, differentially by age. Vaccination was protective. The burden of comorbidities was high, and tuberculosis (especially more recent episodes of tuberculosis), chronic kidney disease, diabetes and hypertension were associated with higher mortality, more strongly in younger adults. Conclusions Mortality was strongly associated with suboptimal HIV control, and the prevalence of these risk factors increased in later COVID‐19 waves. It remains a public health priority to ensure PWH are on suppressive ART and vaccinated, and manage any disruptions in care that occurred during the pandemic. The diagnosis and management of comorbidities, including for tuberculosis, should be optimized.

The immune response to SARS-CoV-2 in people with HIV

“…For example, the results from a large American study using US National COVID Cohort Collaborative data showed that among PWH, individuals with a CD4 count lower than 200 cells/mm 3 had increased odds ratios (adjusted for demographics, lifestyle factors, and comorbidities) of 1.51, 2.73, and 3.1 for severe disease, hospitalization, and death, respectively. Similarly, Kassanjee et al reported a strong association between COVID-19-related mortality and suboptimal HIV control in a low-income, high-HIV-burden setting, even after adjusting for demographic characteristics, comorbidities, admission pressure, location, and time period [ 23 ]. In some studies, a low CD4 count (< 200 cells/mm 3 ) appeared to be a critical contributing factor to adverse COVID-19 outcomes, outweighing viral suppression as a significant contributor [ 20 , 25 ].…”