SARS-COV2 infection in 30 HIV-infected patients followed-up in a French University Hospital

Open AccessPublished:September 25, 2020DOI:https://doi.org/10.1016/j.ijid.2020.09.1436

      Highlights

      • An acute respiratory disease caused by a novel coronavirus (SARS-COV2) has been spreading from China since January 2020. Surprisingly, few cases of Covid-19 have been reported in people living with HIV (PLWHIV).
      • We present a series of 30 PLWHIV diagnosed with SARS-COV2 infection.
      • The most common comorbidities in our population were cardiovascular disease, hypertension, diabetes, obesity and chronic renal disease.
      • Mortality was 6,7%. Poorest outcomes and death were observed in patients with a high comorbidity score.
      • Most of the patients were virologically suppressed with CD4 > 500 mm3. Risk factors were the same as those described in other SARS-COV2 series, suggesting that HIV infection is probably not an independent risk factor for covid-19.

      Abstract

      Introduction

      An acute respiratory disease caused by a novel coronavirus (SARSCOV2) is spreading from China since January 2020. Surprisingly, few cases of Covid-19 have been reported in people living with HIV (PLWHIV).

      Methods

      Here we present a series of 30 PLWHIV diagnosed for SARS-COV2 infection. The principal outcome was to describe clinical characteristics of this population.

      Results

      Eighteen (60%) patients were men, 10/30 (33,3%) women and 2/30 (6,7%) transgender women. Median age was 53,7 years (range 30–80 years) and 23/30 patients (76,7%) were born in a foreign country (out of France). The most common comorbidities were cardiovascular disease (11/30, 36,7%), hypertension (11/30, 36,7%), diabetes (9/30,30%) obesity (7/30, 23%) and chronic renal disease (5/30, 16,7%). Twenty (66,7%) patients presented overweight. Five patients (16,7%) had a Charlson comorbidity (Quan et al., 2011) score ≥3. Twenty-seven (90%) patients were virologically suppressed.CD4 count was >500 cell/mm 3 in 23/30 (76,6%) patients. An antiviral treatment for SARS-COV2 was administered, in addition to HIV treatment, in 5/30 patients (16,3%). Twenty-four patients (80%) recovered from covid-19, 3/30 (10%) required invasive mechanical ventilation, 2/30 (6,7%) patients died and 4/30 (13,3%) patients were still hospitalized.

      Conclusions

      Most of the patients were virologically suppressed with CD4>500 mm3. Risk factors were the same as those described in other SARS-COV2 series, suggesting that HIV infection is probably not an independent risk factor for covid-19.

      Short communication

      An acute respiratory and potentially fatal disease caused by a novel coronavirus (SARS-COV2) has been spreading from China since January 2020.
      Surprisingly, few cases of Covid-19 have been reported in people living with HIV (PLWHIV).
      As of April 27th 2020, with a total of 5327 PLWHIV followed-up at Bichat University Hospital in Paris, 30/5327 (0,5%) patients have been diagnosed with Covid-19, of whom 21/30 (70%) were inpatients and 9/30 (30%) were outpatients, assessed in telemedicine clinics set up during the outbreak lock down. Most SARS-COV2 infected outpatients with mild symptoms were probably not diagnosed or not referred to the hospital.
      A total of 390 patients have been admitted to the Infectious Diseases department with a diagnosis of SARS-COV2, of whom 21 (5,4%) were PLWHIV.
      All participants gave their written consent to have their medical chart recorded in the electronic medical record system Nadis®, from which we extracted anonymized data.
      Clinical characteristics and outcomes of the study population are reported in Table 1.
      Table 1Clinical characteristics and outcomes of HIV patients diagnosed with covid-19.
      Comorbidities (Charlson score)
      • Quan H.
      • Li B.
      • Couris C.M.
      • Fushimi K.
      • Graham P.
      • Hider P.
      • Januel J.M.
      • Sundararajan V.
      Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries.
      )
      BMI kg.m-2CD4 cells/ μLHIV viral load Copies/mLART-regimen before admissionSARS-COV2 PCRClinical status* D30Outcomes
      Patient 1Hypertension, dyslipidemia, hypertensive cardiomyopathy, chronic renal failure (1)36.2350<20abacavir + lamuvidine + raltegravir + darunavir + ritonaviryes1Cured
      Patient 2None (0)34.91010<20tenofovir alafenamide + emtricitabine + elvitegravir + cobicistatyes1Cured
      Patient 3None (0)23.9720<20dolutegravir + rilpivirineyes1Cured
      Patient 4None (0)24.8620<20tenofovir alafenamide + emtricitabine + elvitegravir + cobicistatyes1Cured
      Patient 5None (0)29.31020<20rilpivirine + emtricitabine + tenofovir alafenamideyes1Cured
      Patient 637 weeks pregnancy, recurrent herpetic infection (0)26.6640<20abacavir + lamuvidine + nevirapineyes1Cured
      Patient 7Hypertension, diabetes, disseminated Cryptococcus (4)21.14014,164bictegravir + emtricitabine + tenofovir alafenamide + darunavir + ritonavir + atazanavir + dolutegraviryes1Cured
      Patient 8Hypertension, diabetes, stroke (1)22.3460<20tenofovir disoproxil + raltegravir + darunavir + ritonaviryes1Cured
      Patient 9Hypertension, hypertrophic cardiomyopathy, kidney transplantation (1)26.6220<20bictegravir + emtricitabine + tenofovir alafenamideyes1Cured
      Patient 10Kidney transplantation, stroke, pulmonary embolism (5)24.6140<20abacavir + lamuvidine + dolutegraviryes1Cured
      Patient 11None (0)29.5460<20abacavir + lamuvidine + dolutegraviryes1Cured
      Patient 12Hypertension (0)39.8910<20rilpivirine + emtricitabine + tenofovir alafenamideyes1Cured
      Patient 13None (0)29.0900<20tenofovir alafenamide + emtricitabine + elvitegravir + cobicistatyes1Cured
      Patient 14Diabetes, hypertension, chronic renal failure, dialysis (2)40.0870<20abacavir + lamivudine + dolutegraviryes7Death
      Patient 15Pulmonary tuberculosis (0)23.1980<20tenofovir alafenamide + emtricitabine + elvitegravir + cobicistatyes1Cured
      Patient 16Hypertension, diabetes, atrial fibrillation, ischemic stroke, prostatic adenocarcinoma (1)32.8390<20tenofovir alafenamide + emtricitabine + elvitegravir + cobicistatyes1Cured
      Patient 17Diabetes with microangiopathic complications, dementia (3)31.6620<20abacavir + lamuvidine + dolutegraviryes1Cured
      Patient 18None (0)29.8910<20tenofovir disoproxil + nevirapineyes1Cured
      Patient 19Hypertension, diabetes, ischemic stroke, chronic renal failure, COPD, pulmonary embolism (3)28.1570<20abacavir + lamuvidine + dolutegraviryes7Death
      Patient 20Dilated cardiomyopathy (1)29.3810<20rilpivirine + emtricitabine + tenofovir alafenamideNeg1Cured
      Patient 21Severe cervical dysplasia, esophageal ulcer (0)28.71109<20tenofovir disoproxil + doravirine + lamuvidineND1Cured
      Patient 22Diabetes, ischemic stroke (1)29.7240<20rilpivirine + emtricitabine + tenofovir disoproxilNeg3Hosp
      Patient 23Hypertension (0)24.6830<20tenofovir alafenamide + emtricitabine + elvitegravir + cobicistatND1Cured
      Patient 24Bipolar disorder (0)28.4770<20rilpivirine + emtricitabine + tenofovir disoproxilND1Cured
      Patient 25None (0)28.7119039tenofovir disoproxil + emtricitabine + elvitegravir + cobicistatyes1Cured
      Patient 26Alcoholism, delirium tremens, dilated cardiomyopathy (1)31.620065maraviroc + darunavir + ritonavir + dolutegraviryes3Hosp
      Patient 27Depressive disorder (0)24.1650<20rilpivirine + emtricitabine + tenofovir alafenamideND1Cured
      Patient 28None (0)21.0585<20lamivudine + dolutegraviryes1Cured
      Patient 29Hypertension, diabetes, stroke, aphasia, ischemic heart disease (1)21.2630<20zidovudine etravirine + raltegravir + darunavir + ritonaviryesNAHosp
      Patient 30Hypertension, diabetes, carotid stenosis (1)28.7627<40tenofovir disoproxil + doravirine + lamuvidineyes6Hosp
      The 7-point ordinal scale is an assessment of the clinical status (
      • Peterson R.L.
      • Vock D.M.
      • Powers J.H.
      • Emery S.
      • Cruz E.F.
      • Hunsberger S.
      • et al.
      Analysis of an ordinal endpoint for use in evaluating treatments for severe influenza requiring hospitalization.
      ). The scale is as follows.
      1. Not hospitalized, no limitations on activities, 2. Not hospitalized, limitation on activities, 3. Hospitalized, not requiring supplemental oxygen; 4. Hospitalized, requiring supplemental oxygen;
      5. Hospitalized, on non-invasive ventilation or high flow oxygen devices, 6. Hospitalized, on invasive mechanical ventilation or ECMO, 7. Death.
      ND : not done; NA : not applicable; Hosp : still hospitalized patients.
      Eighteen (60%) patients were men, 10/30 (33,3%) were women and 2/30 (6,7%) were transgender women. Median age was 537 years (range 30–80 years) and 23/30 patients (767%) were born in a foreign country (out of France). The most common comorbidities were cardiovascular disease (11/30, 36,7%), hypertension (11/30, 36,7%), diabetes (9/30,30 %) obesity (7/30, 23 %) and chronic renal disease (5/30, 167%). Twenty (66,7%) patients presented overweight. Five patients (167%) had a Charlson comorbidity (
      • Quan H.
      • Li B.
      • Couris C.M.
      • Fushimi K.
      • Graham P.
      • Hider P.
      • Januel J.M.
      • Sundararajan V.
      Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries.
      ) score ≥3.
      Twenty-seven (90%) patients were virologically supressed, 2/30 patients (6,7%) had a low level plasma HIV-RNA viral load (>20 and <70 copies/mL) and only 1/30 patients had a viral load > 10,000 copies/mL. CD4 count was >500 cell/mm3 in 23/30 (76,6%) patients.
      Positive SARS-COV2 protein chain reaction (PCR) was confirmed in 24/30 (80%) patients, 2/30 (6,7%) patients had negative SARS-COV2 PCR and typical covid-19 chest CT findings, while diagnosis was based on typical clinical presentation (anosmia and/or ageusia) in 3/30 (10%) patients (nasopharyngeal swab not done).
      Median delay between symptoms onset and diagnosis was 7 days (range 1–16 days).
      Antiretroviral treatment was modified during hospitalization in only one patient (switch from a TDF to a TAF-containing regimen in order to prevent renal failure in a critical patient).
      An antiviral treatment for SARS-COV2 was administered, in addition to HIV treatment, in 5/30 patients (163%): 3/30 (10%) patients received lopinavir/ritonavir and 2/30 (6,6%) hydroxychloroquine. Moreover, 5/30 (166%) patients received dexamethasone and 1/30 (3,3%) tocilizumab.
      Twenty-four patients (80%) recovered from covid-19, 3/30 (10%) required invasive mechanical ventilation, 2/30 (6,7%) patients died and 4/30 (13,3%) patients are still hospitalized.
      Study population reflects the characteristics of the population routinely followed-up at our center, with a high percentage of migrant patients (65, 1% in PLWHIV routinely followed up, 767% in the study population). Main comorbidities were cardiovascular disease, hypertension, diabetes, obesity, and chronic renal disease, all being classic covid-19 risks factors described in others studies (
      • Richardson Safiya
      • et al.
      Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area.
      ,
      • Hu Ling
      • et al.
      Risk Factors Associated with Clinical Outcomes in 323 COVID-19 Hospitalized Patients in Wuhan, China.
      ,
      • Grasselli Giacomo
      • et al.
      Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy.
      ,
      • Mehra M.D.
      • Mandeep R.
      • et al.
      Cardiovascular Disease, Drug Therapy, and Mortality in Covid-19.
      ,
      • Zheng Zhaohai
      • et al.
      Risk Factors of Critical & Mortal COVID-19 Cases: A Systematic Literature Review and Meta-Analysis.
      )
      In a recent publication of 57.000 patients hospitalized with SARS-COV2 infection in 12 hospitals in the New York City area, the median score of the Charlson Comorbidity Index was 4. (
      • Richardson Safiya
      • et al.
      Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area.
      )
      In our population, only five patients (167%) had a Charlson comorbidity score ≥3, but we also included outpatients and the median age was lower (53 vs 68 years).
      In the same study, percentage of patients requiring mechanical ventilation was 12.2%, similar to that observed in our study (10%), but mortality was higher (21% vs 6,7%), in line with a higher comorbidity score.
      In our series, the poorest outcomes and death were observed in patients with a high comorbidity score.
      Most patients (90%) were virologically suppressed, with a CD4 > 500 (766%), suggesting a role of already described risk factors, rather than immunosuppression, for SARS-COV2 infection.
      Compared to other series of PLWHIV SARS-COV2 infected patients (
      • Blanco Jose L.
      • et al.
      COVID-19 in Patients with HIV: Clinical Case Series.
      ,
      • Vizcarra P.
      • Pérez-Elías M.J.
      • Quereda C.
      • Moreno A.
      • Vivancos M.J.
      • Dronda F.
      • et al.
      Description of COVID-19 I.D.n HIV-infected individuals: a single-centre, prospective cohort.
      ), a lower percentage of patients had specific antiviral treatment for Covid-19 (163%). Based on local guidelines, antiviral treatment was indicated only in hospitalized patients with severe disease (oxygen requirement > 3lpm).
      Five patients in our study population were treated with an antiretroviral combination containing a non lopinavir/r protease inhibitor (darunavir).
      In conclusion, most of the patients in our study were virologically suppressed with CD4 > 500 mm3. Risk factors were the same as those described in other SARS-COV2 series, suggesting that HIV infection is probably not an independent risk factor for covid-19 infection. Mortality was 6,7%. Poorest outcomes and death were observed in patients with a high comorbidity score. Further studies are needed to investigate risk factors, clinical outcome and treatment options of SARS-COV2 in PLWHIV.
      The authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter discussed in this manuscript.
      The authors received no specific funding for this work.
      The participants enrolled in this study gave their written consent to have their medical charts recorded in the medical record system NAdis. The CNIL approved anonymized data extraction from electronic medical records (CNIL number 1171457, 24 May 2006). No further ethical approval is needed for French law on personal data protection.

      References

        • Blanco Jose L.
        • et al.
        COVID-19 in Patients with HIV: Clinical Case Series.
        Lancet HIV. 2020; (p. S2352301820301119. DOI.org (Crossref) avril)https://doi.org/10.1016/S2352-3018(20)30111-9
        • Grasselli Giacomo
        • et al.
        Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy.
        JAMA. 2020; 323 (DOI.org (Crossref) avril): 1574https://doi.org/10.1001/jama.2020.5394
        • Hu Ling
        • et al.
        Risk Factors Associated with Clinical Outcomes in 323 COVID-19 Hospitalized Patients in Wuhan, China.
        Clin Infect Dis. 2020; (p. ciaa539. DOI.org (Crossref) mai)https://doi.org/10.1093/cid/ciaa539
        • Mehra M.D.
        • Mandeep R.
        • et al.
        Cardiovascular Disease, Drug Therapy, and Mortality in Covid-19.
        N Engl J Med. 2020; (p. NEJMoa2007621. DOI.org (Crossref) mai)https://doi.org/10.1056/NEJMoa2007621
        • Peterson R.L.
        • Vock D.M.
        • Powers J.H.
        • Emery S.
        • Cruz E.F.
        • Hunsberger S.
        • et al.
        Analysis of an ordinal endpoint for use in evaluating treatments for severe influenza requiring hospitalization.
        Clin Trials. 2017; 14: 264-276
        • Quan H.
        • Li B.
        • Couris C.M.
        • Fushimi K.
        • Graham P.
        • Hider P.
        • Januel J.M.
        • Sundararajan V.
        Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries.
        Am J Epidemiol. 2011; 173: 676-682
        • Richardson Safiya
        • et al.
        Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area.
        JAMA. 2020; (Apr 22)
        • Vizcarra P.
        • Pérez-Elías M.J.
        • Quereda C.
        • Moreno A.
        • Vivancos M.J.
        • Dronda F.
        • et al.
        Description of COVID-19 I.D.n HIV-infected individuals: a single-centre, prospective cohort.
        Lancet HIV. 2020; S2352-3018: 30164-30168https://doi.org/10.1016/S2352-3018(20)30164-8
        • Zheng Zhaohai
        • et al.
        Risk Factors of Critical & Mortal COVID-19 Cases: A Systematic Literature Review and Meta-Analysis.
        J Infect. 2020; (p. S0163445320302346. DOI.org (Crossref) avril)https://doi.org/10.1016/j.jinf.2020.04.021