The following is a video and transcript excerpt from an interview conducted with David Alain Wohl, M.D., discussing highlights and clinical takeaway messages from the 2021 Conference on Retroviruses and Opportunistic Infections (CROI 2021), which took place in March. In this video, Wohl talks through updated data regarding the intersection of HIV and COVID-19, with a particular focus on SARS-CoV-2 susceptibility and disease severity.
I think, for most people who care for people living with HIV, there's been concern that COVID outcomes—and maybe even acquisition of SARS-CoV-2—could be worse among people who are HIV infected.
There's been some mixed data about this, as we've seen over the last few months, where it seems like maybe people who are HIV positive do suffer some worse outcomes. And there's also been some tantalizing evidence along the lines of what we've thought about before, where there might be this “accelerated” or pronounced aging of people living with HIV, in which people who are younger with HIV seem to be acting [clinically] like people who are older without HIV, as far as COVID goes. But it's been very unclear, and it's very hard to get a clean data set to look at.
SARS-CoV-2 Positivity Rates Similar Regardless of HIV Status
I think some things that were reassuring here—mostly—at this conference was that when we look at people living with and without HIV, there really didn't seem to be too many stark differences between the two. As it comes to being infected with COVID-19, there was a very nice presentation from, I think, a poorly named mega cohort called CIVET. Civet, if you remember, is the animal that has been implicated in the original coronavirus outbreak, SARS-1. But I guess it's sort of tongue-in-cheek.
This is a huge cohort of people that looked at people with and without HIV and they're testing for COVID-19, and found that people living with HIV tested more often in this very, very large cohort than people without HIV. But their positivity rate was about the same.
It didn't matter what cohort we were looking at. These are cohorts you know about: the MACS and WIHS, NA-ACCORD, data from the VA cohort. So, really, I think, impressive data. If there was a signal for higher risk of acquisition, I think we would have picked it up there, but there wasn't. There was just higher rates of testing among people living with HIV. Which has been something that's fascinating to me as a practitioner: just how attuned most of my patients are who live with HIV to their health, to taking care of themselves, to avoiding getting infected—more so, I think, than maybe the general public. So, good news there.
COVID-19 and HIV Hospitalization and Mortality: Data Are Reassuring, But Complicated
On the other end of the spectrum are hospitalized patients. Those are the data that are easier to get to, and that's why we saw those first. And again, reassuringly, we're not seeing tremendous differences between people living with and without HIV.
Some of the best data we do have come from the UK [United Kingdom], given that they were earlier in [experiencing] the massive impact of the pandemic there compared to here in the United States. And so, they've had more time to look at folks who are in the hospital, and look for differences between people, again, based upon their HIV status.
And there, too, by and large: There were some differences, but some of that may be explained by differences between people who live with HIV and people who don't live with HIV—more comorbidities, higher frailty scores, meaning more frailty. That may explain some of what we see as far as differences in time to get out of the hospital.
This is all really hard to dissect, because probably people living with HIV might be more inclined to get admitted when they present to an emergency room or are sick with COVID-19, just because I think providers may be more concerned about them. But by and large, especially when it comes to mortality, we are not seeing major differences.
Other data that were presented from the U.S. showed that, really, it's the non-HIV-related factors that have to do with doing poorly with COVID-19 for people living with HIV. So: age, obesity, things like that.
Low CD4 cell count did shake out in that one study. And that's, again, maybe wrapped up into a whole bunch of different things, because low CD4 cell count may reflect other things as well besides just having a lower T-cell count and lower immunity. How that translates directly into what happens with COVID-19, I think, is unclear.
Bottom line for me is: I was pretty reassured by the data that I saw at CROI that there weren't huge differences in the fates of people living with HIV who get COVID-19 compared to those who don't. And that's reassuring because very early on in the epidemic, I and others were really concerned that our patients may be more vulnerable biologically—not just structurally and sociologically, which they certainly are, given poverty levels, given essential work, etc.
But I am really encouraged that there are not significant differences, and really proud of how well most of those that I know who are living with the virus have taken the precautions that all of us really should be adapting, and really protected themselves—more so than anyone else, despite all their challenges.
Limited Data on Coronavirus Vaccine Efficacy and Safety in People Living With HIV
One thing, I think, we do have to see—and it's guaranteed we'll see it at some upcoming conference, whether that be CROI 2022 or some of the conferences later on this year—are outcomes related to vaccine efficacy and side effects among people living with HIV.
We do know that for some of the mRNA vaccines—Pfizer and Moderna—that people living with HIV were allowed in [to clinical trials]. It wasn't always the case, but there was advocacy, especially from the community advisers within the AIDS Clinical Trials Group, the NIH [National Institutes of Health]-funded network for HIV research, that led to opening up of the Moderna trial specifically to people living with HIV.
But there will be subgroup analyses, we're told, looking at responses to mRNA vaccine among people living with HIV. It wasn't a large proportion, but when you have a large study with tens of thousands of people, there are data that could be gleaned regarding subgroups, including those living with HIV. I think that will be really key. We'll have to look at whether CD4 cell count or viral suppression or things like that influence [vaccine response].
My suspicion is that people living with HIV will respond just fine to these vaccines. As far as side effects, nothing that we've seen that really can tease out who gets more side effects versus [fewer] in any realm for people living without HIV. We don't really see it, except for female sex.
The vast majority of the severe, which are very rare—severe side effects, like anaphylaxis, severe allergic reaction—has almost always been women, very few men. And I'm sitting right now in a large vaccine clinic where we vaccinate over 1,000 a day. And I could tell you, by and large, over 90% of any reaction of any type is among women, cis[gender] women rather than cis men, which is interesting and has to be further examined.