This Week in HIV Research: The Real-World Effects of COVID-19

During the COVID-19 pandemic, people living with HIV (PLWH) who typically receive care at a safety-net clinic have experienced severe challenges with maintaining viral suppression, researchers reported in AIDS.

Ward 86, a large HIV clinic in San Francisco, California, immediately moved to telehealth when a shelter-in-place order was announced earlier this year. Clinic visits were held by phone and viral load tests were scheduled as rapid lab visits.

The proportion of clients who did not show up for scheduled appointments did not change appreciably between pre-lockdown in-person and post-lockdown phone visits. However, the odds of not being virally suppressed increased 31% after the city’s COVID shutdown. This may be in part due to the unavailability of social support services normally provided at the clinic, the authors hypothesized.

Viral suppression rates dropped even lower among people who experienced homelessness. The emptying of shelters due to COVID-19 and the economic impact of the lockdown may have caused more pressing survival needs to be prioritized over HIV care, study authors suggested.

“Telemedicine may facilitate retention-in-care in the context of shelter-in-place for those without a digital divide, but is unlikely to compensate for the loss in clinic-based social services and support for [PLWH] with vulnerabilities,” they wrote.

A phenomenon dubbed “repliclones” may help explain unsuppressed viral loads in PLWH who take their medications and whose virus is not resistant to their current drug regimen, a small study published in The Journal of Clinical Investigation found.

Researchers sequenced HIV from eight individuals who had been previously virally suppressed, were adherent to their HIV medications, and were not resistant to their current antiretroviral regimen. They found identical viral RNA sequences that didn’t change over time in the plasma of each participant—an indication that these were clones of HIV-1-infected cells, rather than virus spreading between cells (which would have led to some mutations). In half of the samples, the virus could reproduce.

The clone clusters were quite large (50 million to 350 million cells), but still comprised a small fraction of infected cells.

This discovery raises some questions, such as: How and why do these repliclones develop? How many people are affected? What does this mean for HIV care?

One thing is clear, however: If repliclones are the underlying cause of a person’s lack of viral suppression, changing that person’s drug regimen or providing additional adherence counseling will have no effect. This means patients who are viremic despite antiretroviral treatment adherence and no resistance mutations would require close monitoring rather than having their regimen changed, study author John Mellors, M.D., counseled in a press release.

The findings could also complicate HIV cure research, since these sets of cloned cells may represent a previously unappreciated viral reservoir that needs to be addressed for a “shock and kill” strategy to work.

Providing rapid testing for HIV and hepatitis C (HCV) at a person’s point of care (e.g., a drug detoxification center) is a far more reliable way to ensure that people actually receive their results than sending samples to a lab, a study published in The Journal of Infectious Diseases showed. While the results may seem intuitive, they come amidst the reality that roughly half of U.S. state health department sites utilize lab testing (which can spot acute infections) instead of rapid testing (which cannot).

Two hundred people at a drug/alcohol detoxification center in Boston were randomized to receive rapid (n=98) or laboratory-based (n=102) testing. Ninety-six percent of participants in the rapid testing arm received their results compared to 42% in the lab-based arm. Overall, 0.5% received a new HIV diagnosis and 48% were seropositive for HCV.

The study also highlighted issues further down the continuum of care: Once notified, only 6% of participants who tested positive were linked to care within four months. Emergency department visits after leaving the detox center would have been an opportunity for linkage to care had the center’s test results been available to the ED, study authors noted.

This already-low follow-up rate has likely worsened in the wake of COVID-19, a press release noted. "We hope that these findings will encourage changes in local and national HIV and HCV testing practices and policy at non-hospital-based settings caring for populations at-risk during the opioid epidemic," study author Sabrina Assoumou, M.D., M.P.H., stated in the release.

It makes little difference which modern antiretroviral regimen people living with HIV start taking, as long as they begin treatment soon after seroconversion, a retrospective cohort study published in AIDS found.

Researchers compared thethree-year efficacy of protease inhibitor-based (n=28), integrase strand transfer inhibitor-based (n=87), and non-nucleoside reverse transcriptase inhibitor-based (n=22) regimens initiated during acute or early HIV. Overall, 96% of participants were virally suppressed after one year and 99% after three years. Viral suppression rates one and three years later were comparable across arms, as was CD4 cell reconstitution. Starting antiretroviral treatment at an earlier Fiebig stage (which is used to measure HIV disease progression) was associated with a higher rate of people who have a CD4 cell count over 900 cells/µL.

The findings are especially important for resource-limited settings, where NNRTI-based regimens are still a common first-line treatment, study authors noted. Results show that this older antiretroviral treatment is just as effective as the newer INSTIs, although they did note that INSTIs were generally better tolerated than PIs or NNRTIs.

Study limitations included the small number of participants and the fact that few women were included in the study.