Does having HIV affect the course of COVID-19, the disease caused by the new coronavirus? Are HIV-positive people at higher risk for bad outcomes or, perhaps counterintuitively, do HIV-positive people have better outcomes? Is there enough data available to even begin to tackle these and other important questions, such as about COVID-19 incidence in HIV-positive people?
My former associate Jose Lares-Guia, MD, has observed to date that HIV-positive people in his practice whom he has diagnosed with COVID-19 have had favorable clinical outcomes and relatively benign courses. (Click here to read a heartfelt, hopeful and personal account by Dr. Lares of his clinical observations.)
Dr. Lares has a very busy HIV medical practice, located in the heart of Greenwich Village. His practice serves many HIV-positive New Yorkers, particularly from Manhattan, Queens, Brooklyn and Northern New Jersey.
His practice is thus in one the epicenters of the COVID-19 epidemic, which lends potential importance to his observations.
And Dr. Lares is not alone in his observations about a possible more benign course of COVID-19 in HIV-positive people. His observations are being supported globally in other places that have significantly large populations of both people living with HIV and people affected by COVID-19.
Josep Llibre, MD, PhD, a highly regarded clinical researcher from Barcelona, Spain, has reported that so far in his clinic population of 3,200 people he has observed very little serious COVID-19 illness in his HIV-positive patients. Similar observations of a more benign COVID-19 course have been reported from Wuhan, China, and Geneva, Switzerland, and other places.
On the other hand, clinical researchers from a different medical center in Barcelona have not found that people living with HIV are doing better with COVID-19.
However, the sample size of all of these practices is not sufficient to draw any firm conclusions regarding HIV and COVID-19 coinfection.
There are critical gaps in our knowledge that need to be filled. We currently lack accurate information about the total number of people with COVID-19 who are living with or without HIV.
We don’t yet know the percentage of people with COVID-19 with and without HIV; who are asymptomatic; who have mild illness; who get very sick; who are hospitalized and who die.
It likely will require a database of thousands, if not tens of thousands, of HIV-positive people to answer important questions about HIV and COVID 19 coinfection.
It is crucial that doctors treating HIV and COVID-19 patients pool their data. There is a plan to pool such data in Europe and it would be important to do the same in the United States, given that we have the world’s largest population of people with COVID-19, including many in areas of high HIV incidence, such as New York City.
If it turns out that HIV-positive people have more benign COVID-19 courses, then this fact would be very reassuring for the HIV community who have been told that their risks might even be higher due to immune compromise, as well as other comorbidities.
It would likely be of global significance in the war on COVID-19 if HIV-positive people have more benign courses with COVID-19. There would be several possible explanations for these phenomena, if real, that could lead to new therapeutic approaches for COVID-19.
One possible explanation for good outcomes in HIV-positive people is that commonly used HIV drugs are somehow mitigating the COVID-19 disease process.
Jose Arribas, MD, the research director of HIV and infectious diseases at La Paz Hospital in Madrid, Spain, has observed relatively few HIV-positive people with COVID-19 in a large HIV practice.
Dr. Arribas is so impressed with this finding that he is initiating a clinical trial to see whether Truvada, a commonly prescribed HIV medication, may be used as pre-exposure prophylaxis (PrEP) for COVID-19 among health care workers. Truvada is already used as PrEP for HIV. He is testing Truvada, hydroxychloroquine and the combination of Truvada and hydroxychloroquine in a randomized placebo-controlled trial.
There is also the strong possibility that many people living with HIV have some degree of immune compromise that actually allows them to avoid the cytokine storm syndrome that seems to be what causes people with COVID-19 to get very sick and sometimes die.
Cytokine storm syndrome is apparently driven by excessive immune activation that may be mitigated in people living with HIV. At the same time, they likely still have sufficient immune function to fight off COVID-19 the way HIV-positive people routinely fight off many other infections, but without overdoing it.
If we can figure out the mechanisms of this phenomena of less severity and/or less incidence of COVID-19 in HIV-positive people it may help us enormously in identifying therapies for HIV-negative people who suffer serious illness from COVID-19.
It would, for example, suggest immune therapies designed to induce the similar alterations in HIV-negative people that are seen in HIV-positive people that may be protective.
Finally, it is of the utmost importance that no one in the HIV-positive community or in the public at large misconstrue these hopeful observations to justify any relaxing of the critical public health measures that are necessary to prevent COVID-19 spread and save lives.
People living with HIV have gotten sick and died of COVID-19 and like the general public have likely inadvertently spread COVID-19 when asymptomatic.
Social distancing, frequent handwashing and wearing a face mask in public and other public health recommendations must be strictly adhered by all people as they are issued by our public health authorities.
Paul Bellman, MD, is a retired physician who led a longtime private practice in New York City for people living with HIV. He was on the frontlines of the early AIDS epidemic.