Breakthrough COVID-19 Infection More Likely in Adults with HIV

Adults living with HIV were more likely to have a breakthrough COVID-19 infection after vaccination, suggesting a need for additional vaccine doses in this population.

mRNA COVID-19 vaccination is highly effective against severe or fatal disease, but persons who are immunocompromised may require additional protection. As such, investigators are researching the necessity of additional booster doses for the most vulnerable populations.

People living with HIV are one such immunocompromised population. Currently, additional COVID-19 vaccine doses are only recommended for people with advanced HIV infection or unsuppressed viral load. One study, published today in the Journal of the American Medical Association, sought to evaluate the risk of COVID-19 infection after vaccination in people living with HIV.

The investigators compared the risk and rate of breakthrough infection after receiving all recommended COVID-19 vaccine doses in people with HIV and people without HIV in the US. They hoped this work would inform vaccination guidelines for highly immunocompromised and immunosuppressed persons.

This cohort study used the Corona-Infectious-Virus Epidemiology Team (CIVET)-II database, part of a conglomerate of 4 prospective electronic health record-based cohorts from integrated health systems and academic medical centers. The study included adults living with HIV who were fully vaccinated against COVID-19 as of June 30, 2021. They were matched with HIV-negative adults by date of full vaccination, age, sex, race, and ethnicity. Follow-up for cohorts continued until December 31, 2021.

The study included 113994 patients, 33029 HIV-positive and 80965 HIV-negative. Among both cohorts, 70% were 55 years or older, 92% were male, 41% were non-Hispanic Black, and 38% were non-Hispanic White. The primary outcome of interest was COVID-19 breakthrough infection, defined as laboratory evidence of a COVID-19 diagnosis after a patient was fully vaccinated.

The cumulative incidence of breakthrough COVID-19 infection at 9 months after a complete vaccine series was low, but higher in people living with HIV than in people without HIV. HIV-positive people had 55 cases per 1000 person-years (4.4%), and HIV-negative people had 43 cases per 1000 person-years (3.5%). The adjusted results showed people living with HIV were 28% more likely to have a breakthrough COVID-19 infection.

Among people living with HIV, age younger than 45 years, prior history of COVID-19, and not receiving an additional vaccine dose were associated with an increased risk of COVID-19 breakthrough infection. Notably, there was no association between breakthrough infection and HIV viral load suppression, but a high CD4 count (≥500 cells/mm3) reduced the risk of COVID-19 infection after vaccination.

The investigators concluded that COVID-19 vaccination, especially with a booster dose, was effective against infection with the COVID-19 strains circulating through December 31, 2021. Because people living with HIV were more likely to contract HIV, the investigators recommended additional “booster” doses of COVID-19 vaccines be expanded to this known immunocompromised population.