COVID-19 in People Living With HIV

April 27, 2020

A hospital case series of patients with both COVID-19 and HIV describes recovery, but highlights the need to refine treatment.

In a clinical case series, 4 of the 5 patients with HIV who were hospitalized for coronavirus disease 2019 (COVID-19) recovered after receiving an array of medications for the coronavirus infection, and a change in their antiretroviral therapy (ART) to protease-inhibitor based regimens.

José Mirό, MD, PhD, from the University of Barcelona and colleagues of the COVID-19 in HIV Collaborative, reported what they characterize as the first single-center experience of COVID-19 in patients with HIV-1, in The Lancet HIV.

"This pandemic is a challenge affecting everyone," Mirό and colleagues asserted. "By generating information such as we present here, the management and prognosis of patients co-infected with HIV and SARS-CoV-2 might be improved."

The 5 patients with the co-infections were among 543 consecutive patients admitted to a hospital in Barcelona with COVID-19 as of March 9th. They ranged in age from 29 to 49 years; 2 of the 5 had an underlying illness (hypothyroidism and asthma, respectively).

Four of the patients were on ART, 2 patients with a protease-inhibitor and 2 with integrase-inhibitor. One patient was ART-naïve and was described as having very advanced late presentation. The 4 patients on ART had CD4 cell counts >445 cells/μl (range 445-1140), while the ART-naive patient had CD4 count of 13

The 2 patients on protease-inhibitor ART were admitted with upper respiratory tract infection. The 2 patients on an integrase-inhibitor and the ART-naïve patient were admitted with viral pneumonia; with 1 of these patients on ART and the ART-naïve patient admitted to intensive care. The patient on ART, and with hypothyroidism, admitted to the ICU was the only patient to require invasive mechanical ventilation.

Mirό and colleagues advise that patients with advanced, late presentation of HIV will require differential diagnosis and initial antimicrobial treatment to address pulmonary opportunistic infections such as pneumocystis jiroveci, which was detected in their ART-naive patient.

The treatment of COVID-19 varied between patients, but could include interferon-beta-1b, hydroxychloroquine, antibiotics, corticosteroids and/or tocilizumab. The ART regimen for each patient was either maintained as or converted to a protease-inhibitor for the duration of hospitalization, and changed back to their original treatment on discharge from the hospital.

"...we were making a transitional change in their regimen on the basis of the fact that HIV protease inhibitors might have activity against the coronavirus protease," Mirό and colleagues explained.

All patients except the patient requiring mechanical ventilation had recovered and were discharged at the time of the report, within a range of 1-4 days, and 12 days for the patient who had been ART-naïve, followed by periods of supervised "home-hospitalization".

Mirό and colleagues acknowledge that a possible benefit of the protease inhibitor ART in COVID-19 is hypothetical, and that one trial in China found that lopinavir-boosted ritonavir was ineffective as a monotherapy against severe pneumonia associated with COVID-19. They also note data from Janssen Pharmaceuticals indicate that darunavir was ineffective against SARS-CoV-2 due to low affinity to coronavirus protease.

"Therefore, investigation of the efficacy of this treatment in patients with COVID-19 in combined therapy in earlier stages of the disease is needed," they said.

Mirό and colleagues are awaiting results with remdesivir, which they characterize as the most active in-vitro and in-vivo antiviral drugs against coronavirus to date. In addition to hoping that it will be found effective, they point out that remdesivir does not appear to have pharmacokinetic interactions with ART medications.