New research was presented at AIDS 2020: Virtual, the 23rd International AIDS Conference, from July 6-10, much of it focused on the intersection of COVID-19 and HIV. The features below highlight some of the studies focused on COVID-19 that emerged from the conference.
COVID-19 & HIV Susceptibility in LGBTI+ Communities
With evidence suggesting that COVID-19 and the public health response to it have exacerbated prevailing inequalities and the hypothesis that their combination may worsen economic circumstances of lesbian, gay, gay, bisexual, transgender, intersex and other sexuality, sex and gender diverse (LGBTI+) people—including a possible increase in HIV exposure—researchers conducted a cross-sectional online survey that was broadcasted online among LGBTI+ social networks. Among 13,562 LGBTI+ participants from 138 countries/territories, approximately 91% were party or entirely confined. Among the 26% of participants with HIV who had experienced interrupted or restricted access to refills of ART medication, 55% had 1 month’s stock supply or less of ART available. Loss of employment was expected by 47% of those currently working, and 12.6% had already lost it. Among the 45% of respondents facing economic difficulty, 73% count not meet basic needs and 37% had to skip or reduce the size of meals. Overall, 1% of respondents (n = 1,532) were pushed into engaging in sex work by the pandemic, among whom COVID-19 reduced the capacity to negotiate safe sex practices—more condomless relations (3%), taking more risks (7%)—and thus increasing HIV exposure. The pandemic also reduced access to safe injection equipment for the 36% who inject drugs and limited access to opioid substitution therapy for the 26% of those who needed it.
The Impact of COVID-19 on PrEP Care
In order to describe the impact of COVID-19 on HIV pre-exposure prophylaxis (PrEP) care at a health center specializing in sexual healthcare, investigators extracted electronic healthcare data for patients with at least one active PrEP prescription from January-April 2020. The study team assessed trends in PrEP initiations and refill lapses, testing for gonorrhea/chlamydia (GC/CT) and HIV, and telehealth use. Among more than 3,500 participants with a mean age of about 37 who were 72.7% white, 13.6% Latinx, 92.1% cisgender men, and 12.9% publically insured, PrEP initiations decreased 72.1% during the study period, from 122 to 34 per month. Refill lapses increased 278%, from 140 to 407 per month, while the number of PrEP patients decreased 17.9%. GC/CT and HIV tests each decreased by 85.1% (1058/month to 158/month for GC/CT and 1014/month to 151/month for HIV), while GC/CT test positivity rates increased slightly (12.3%-15.8%). Clinical encounters decreased 26.3% and transitioned from 0% to 97.7% telehealth.
The Immunologic Impact of COVID-19 in PLWHIV
Because data on the immunologic impact of COVID-19 co-infection in people living with HIV (PLWHIV) are limited, researchers conducted a retrospective study of clinical and immunologic outcomes of COVID-19 in 93 PLWHIV presenting to five New York City emergency departments who tested positive for COVID-19. At presentation, PLWHIV with COVID-19 demonstrated significant lymphopenia and decreased CD4 cell counts. Inflammatory marker levels were commonly elevated. Serum cytokine profiles during acute COVID-19 were characterized by elevated interleukin (IL)-6, IL-8, and TNF-alpha, but not IL-1b. Among those hospitalized with COVID-19, 22.2% died, 66.7% recovered, and 11.1% remained hospitalized at the time of the analysis. When compared with those who recovered, those who died had significantly lower nadir absolute lymphocyte counts during COVID-19. Peak inflammatory markers, including C-reactive protein, IL-6, and fibrinogen were significantly higher in those who died. Those who died also had non-significant trends toward IL-8 and TNF-alpha elevations. A greater proportion in the recovered group was on a regimen containing tenofovir, but the difference was not statistically significant. “Our findings indicate that a subset of PLWHIV are capable of mounting profound inflammatory responses that have been noted to correlate with poor outcomes in people without HIV,” write the study authors.
Outcomes in Patients With COVID-19 by HIV Status
With data lacking on whether people living with HIV (PLWHIV) are at great risk for adverse outcomes due to COVID-19 that those without HIV—or, if outcomes differ by CD4 count and viral suppression among PLWHIV—researchers conducted a retrospective cohort study of COVID-19+ patients admitted to a large tertiary academic health system between March 10 and May 11, 2020. Among 4,662 patients with a median age of 65, 1.7% were PLWHIV. Intubation occurred in 13% of PLWHIV and 14% of those without HIV. Among PLWHIV, 38% developed AKI, compared with 41% of those without HIV. In-hospital mortality rates were 18% among PLWHIV and 23% among those without HIV. Among both groups, hospital length of stay was 5 days (3-9) for those who were discharged. An exploratory analyses of PLWHIV who had CD4 counts available found that higher count was associated with intubation (adjusted odds ratio, 1.36 per 100 cells/ uL). Zero viremic PLWHIV were intubated, compared with 18% of those with suppressed HIV. “Our preliminary findings regarding intubation among PLWH warrant further examination,” write the study authors.
COVID-19 & HIV Service Interruption in MSM
Researchers have hypothesized that the range of population-based measures meant to stem the spread of COVID-19 infection and reduce related morbidity and mortality may be associated with disruptions to other health services, including for men who have sex with men (MSM) who are at risk for or living with HIV. To assess the relationship between intensity and breadth of COVID-19 mitigation strategies and interruptions to HIV prevention and treatment services for MSM, they collected data from a COVID-19 disparities survey implemented by the gay social networking app Hornet between April 16 and May 4, 2020. Each of eight countries received a 0-100 score based on the number and strictness of nine indicators related to school and workplace closures and travel bans. Participants had a mean age of 36, included 13% who were living with HIV, and lived in countries with a mean stringency score of 70.5, ranging from 29.4 in Taiwan to 89.4 in France. For each indicator of prevention, increasing stringency of response was associated with decreased access to services. Every 1-point increase in stringency was associated with a 4% reduction in odds of access to in-person testing and a 3% reduction in odds of access to self-testing, PrEP, and condoms. Health insurance—government (adjusted odds ratio [aOR], 4.86) or private (aOR, 4.47)—was independently associated with access to ART. “Innovative strategies, like mobile-service delivery or telehealth, may be needed to minimize the service interruptions from these types of government responses on MSM communities and ensure continuity of care,” write the study authors.