What We Know About HIV & COVID-19
More Questions than Answers Abound
by Jeannie Wraight

As we navigate our way through a brand new pandemic, far more questions than answers in regard to COVID-19 arise. In the earliest days of the novel coronavirus pandemic, researchers believed that only the very elderly and people with serious underlining conditions were at risk. However, as the weeks and months pass, we’re finding this may not be the case and although less frequent, serious illness and death from COVID-19 is somewhat of a crap shoot with the illness becoming severe in people of all ages and health, including (though infrequent) children and teen- agers. However, certain groups of people are at a definitive higher risk. Does this include people with HIV? Here’s what we know so far.

Are people with HIV at a higher risk of severe illness with COVID- 19?
The simple answer is, as far as we know, no. However, that’s a murky no. If a person’s on antiretrovirals (ARVs), virally suppressed with a strong immune system and otherwise healthy, there’s no evidence of a greater risk of severe illness or death. However, this classification does not define a large portion of PLWH. So what makes a person with HIV at higher risk?

Immune dysfunction and COVID- 19
Many people living with HIV in the U.S. are not adequately virally suppressed, which places them at risk of a compromised immune system. In fact, the most recent data shows that approximately 20% of PLWH in the U.S. are not virally suppressed. Experts currently believe a compromised immune system may leave the body unable to effectively fight SARS- CoV- 2. Smoking cigarettes is another factor that may compromise immune function. It’s estimated that 40% of HIV- positive people currently smoke cigarettes, a rate much higher than the general population at 13.7%. However, currently we are still learning about COVID-19 and how it affects the body. One interesting new study suggests that we may not know the whole story when it comes to immune function and COVID-19.

A mathematical model by the University of California described how suppressing the immune system early after infection with the novel coronavirus, might actually prevent serious illness. The authors explained that when a virus is introduced into the body, two lines of immune defense are dispatched——first the innate immune response and then the adaptive immune response. The innate immune response quickly kills off any virus and cells already infected by the virus. Then a few days later, the adaptive immune response kicks in with T cells and B cells, takes what the innate response learned about the virus and uses it to kill off any remaining virus. However, with SARS- CoV-2, sometimes both lines of defense are deployed simultaneously. In a flurry of immune activation, the immune system not only attacks the virus and infected cells but may also kill healthy cells causing tissue damage. This creates a severe immune response resulting in what is called a cytokine storm. People who experience this immune overreaction tend to become severely ill and at risk of death. The authors suggest that immune suppressing drugs, very early on in infection, may prevent this immune reaction, thus preventing severe illness. The authors did not mention whether natural immune suppression may also have the same effect. However, this study does show us that we have a lot to learn about COVID-19, in this case, how the status of a person’s immune system comes into play.

Age is a factor
Older age places a person at greater risk. The current observation is that age plays a strong factor in who may become very sick. Many experts have suggested that people fifty-five and older are at increased risk with that risk growing the older a person is. In the United States, 50% of people living with HIV are over age fifty.

Some HIV-related comorbidities put a person at greater risk
Heart disease, diabetes, liver disease and severe kidney disease are comorbidities common in people living with HIV that place individuals at a higher risk of illness with COVID-19.

Does being on HIV antiretrovirals give you an advantage against COVID-19?
At the current time, there is no evidence that ongoing treatment with ARVs in people living with HIV or those taking PrEP either prevents infection of SARS-CoV-2 or lessens the severity of symptoms. However, as not all drugs and regimens are being studied and others are in ongoing studies, we simply don’t know if any HIV regimens provide protection. These are the ARVs being studied and what is currently known.

The medications people with HIV take to suppress viral load belong to a group of drugs called antivirals. Some antivirals work against not just one virus but possibly others. As such, researchers are studying if some ARVs used for HIV would be effective against COVID-19. As of yet, no data has shown a definitive benefit. However, there are numerous clinical trials of HIV ARVs registered including over 30 trials of lopinavir boosted with ritonavir (LPV/r). To date, although LPV/r did show antiviral activity against SARS CoV- 2 in vitro (in a petri dish), no human studies have shown evidence that this combination is effective at treating COVID-19. Kaletra, emtricitabine/tenofovir disoproxil, and darunavir and cobicistat are all being studied for COVID-19 as well.

Although PLWH in general are not at an increased risk of severe COVID-19, many sub-populations of PLWH may be. We need to ask many questions and seek answers before some PLWH can feel fully comfortable rejoining society before a vaccine is available.

Jeannie Wraight is the former editor-in-chief and co-founder of HIV and HCV Haven (www.hivhaven.com) and a blogger and writer for TheBody.com. She is a member of the Board of Directors of Health People, a community-based organization in the South Bronx and an advisor to TRW (Teach me to Read and Write), a community-based organization in Kampala, Uganda. She lives with her husband in New York City.