Scientists study intersection of COVID-19 and HIV

July / August 2020 | Volume 19, Number 4

July / August 2020 Global Health Matters newsletter [PDF <1M]

Female researcher working wearing lab coat and gloves examines testing supplies in front of lab equipment in a CAPRISA lab.
Photo courtesy of CAPRISA

Rapid testing for COVID-19 is available at
the CAPRISA clinic in South Africa, where
patients testing positive often have
comorbidities, such as diabetes, HIV and TB.

By January W. Payne

Although studies in high-income countries don’t indicate greater health risks for people with HIV who develop COVID-19, there is not enough information to know whether that holds true in low- and middle-income countries. In Kenya - where coronavirus transmission has been light - hypertension and diabetes are much more frequently associated with COVID deaths than HIV/AIDS, according to health ministry reports. Meanwhile, early data from one region in South Africa where COVID is more common suggests people with HIV (PWH) may have double the risk of dying from coronavirus. Additionally, current and previous tuberculosis (TB) infection also seems to increase COVID mortality.

“What’s new from our data is that we’ve been able to quantify the effect of HIV and tuberculosis, which until now we haven’t known,” said University of Cape Town researcher Dr. Mary-Ann Davies, during a recent webinar. “We might’ve expected that effect to really be very large, but in fact what we are seeing is very modest - around a 2.5 times increased risk of COVID death - with these conditions.” In Davies’ NIH-supported analysis of COVID deaths, published as a preprint by medRxiv, she also noted “that risk might be overestimated if we haven’t fully disentangled all of the comorbidities and risks that drive COVID death.” For instance, diabetes was a factor in 52% of COVID deaths in the study.

“The small contribution of HIV and TB to COVID-19 mortality is mainly due to these deaths occurring in older people, in whom HIV and active TB are not common,” observed Fogarty grantees Drs. Quarraisha Abdool Karim and Salim S. Abdool Karim in a Science article. Integrated medical care for these three conditions will be important as COVID patients with comorbidities begin seeking health care services in greater numbers, they added.

Impact of COVID-19 on HIV testing

Scientists are also concerned about the impact COVID is having on the diagnosis, treatment and prevention of HIV as services and supply chains are disrupted. For instance, HIV testing of exposed partners has decreased by about 50% in some areas of western Kenya, according to recent paper published in AIDS and Behavior. During the pandemic, testing is only possible at clinics, which is less desirable due to stigma, lack of transportation and other difficulties.

“There is growing concern that COVID-19 will result in services disruptions for HIV testing and treatment, resulting in excess HIV-related deaths and onward transmission leading to increased HIV incidence,” according to co-author Dr. Sarah Masyuko, a Fogarty trainee and Ph.D. candidate at the University of Washington (UW).

To avoid disruption of ART during the pandemic, people living with HIV are being given 3-6 month supplies, Masyuko said. However, the downside is that patients may be seen less often by providers, which can decrease the frequency of viral load checks.

Dr. Carey Farquhar, senior author and Fogarty principal investigator at UW is also worried COVID is increasing HIV transmission. “We are concerned because testing has dropped off dramatically in the clinics where we are doing our study,” she said. “If people can’t get tested for HIV, they can’t start treatment and will do less well in the short and long run. They also will be able to transmit HIV to others if they aren’t on treatment.”

Another interesting finding from Davises' South Africa study is that one type of antiretroviral seems to offer more protection against COVID death than others. Coronavirus patients with HIV who were taking tenofovir disoproxil fumarate (TDF) fared better than those on different versions of ART, concurring with similar findings from a study in Spain.

Learning from people with HIV

As the research community plans its response to COVID-19 in sub-Saharan Africa, it should begin by listening to PWH, according to a recent AIDS and Behavior paper by several NIH-supported authors. “COVID-19 is new; but the fear, stigma and poverty that determine health for much of the world, are not,” they noted. PWH have likely faced similar challenges before and “have solutions that are more likely to be successful in their context than global mandates designed for different settings, cultures and resources.”

COVID-19 generates anxiety and fatalism in many people, but especially among PWH. “The lack of understanding of coronavirus and its effects on HIV leads people living with HIV to be more fearful, given what they know about their condition. This stress and sense of impending doom can lead to a fatalism that is reminiscent of the advent of the HIV epidemic,” said co-author Dr. Robert N. Peck, a Fogarty grantee at Weill Cornell Medical College. “‘If God wills it, I will die from the coronavirus,’ we were told by more than one person living with HIV.”

Similar feelings of hopelessness debilitated people living with HIV and their families for decades at the beginning of the AIDS epidemic. In some patients, such as adolescents, counseling is more effective if conducted in groups. As such, some clinics are planning group counseling and support sessions when the clinic is otherwise empty to allow for physical distancing and honest conversations.

Stigma is another concern that has arisen anew during COVID, with many people afraid of being tested. “They're fearful that if they are infected, or known to be infected publicly, they'll be stigmatized or ostracized because we have made it sound like a death sentence. We’ve made it sound like a cause of quarantine and isolation, and not like a manageable disease,” said co-author Dr. Mark J. Siedner, an NIH grantee at Harvard Medical School. “We need to focus on communicating about this disease in a way that’s not terrifying and does not stigmatize the people who are infected.”