People with HIV and Low CD4 Could Experience Less Severe COVID-19

Reviewers attribute less severe COVID-19 symptoms in patients with HIV and low CD4 count to reduced capacity for immune reactions including cytokine storm.

Persons living with HIV (PLWH) do not appear to be among those who are at heightened risk for severe COVID-19 for having a pre-existing chronic medical condition, according to a systematic review of studies of the course of COVID-19 in cohorts that have included PLWH

The corresponding author, Esmaeil Mehraeen, PhD, Department of Health Information Technology, Khalkhal University of Medical Sciences, Khalkhal, Iran, and colleagues did not find PLWH to be at greater risk for severe COVID-19 symptoms than the general population; and they suggest that those who also have low CD4 could be spared from heightened immune response to SARS-CoV-2, including cytokine storm.

"We found that HIV patients at advanced stages of the disease with low CD4 count and weak immune systems show less severe COVID-19 symptoms," Mehraeen and colleagues state.

They hypothesized that the immunocompromised patients with CD4 count of less than <500 are unable to produce the heightened and damaging immune response to SARS-CoV-2, and might parallel patients with COVID-19 who are not immunocompromised but receive treatment with steroids or agents like canakinumab, a monoclonal antibody targeting IL-1β, to suppress immunoresponse.

The reviewers acknowledge, however, encountering incomplete or contradicting evidence for this determination."The main reason for these contradictory results was the scarcity of existent literature and inconsistency of evidence...," Mehraeen and colleagues indicated."This may also be due to simultaneous symptoms and underlying comorbidities that come along at advanced stages of HIV infections and could perplex and obscure the typical presentation of COVID-19 in such patients."

The review included 36 clinical studies that assessed COVID-19 status in cohorts that included PLWH.The studies were conducted between January and December 2020, and ranged from single patient case reports to large, nationwide population studies.

Studies were excluded if published as letter to the editor; or presented as abstracts, or were otherwise without full text; if they were ongoing; or if they incorporated non-original data.The quality of the studies was assessed with an NIH measure, with 25 of the 37 initially identified judged to be of good quality and the remainder determined to be of fair quality.

All of the studied population was 20 years or older, with 72% male. Of the total 3,993,400 patients with COVID-19 included in the studies, 89,343 were PLWH. The investigators indicated that "most" of the patients had comorbidities such as hypertension, diabetes mellitus, asthma, renal insufficiency, and cardiovascular disease.In 8 studies, mortality was reported ranging from 1% to 36%.

Mehraeen and colleagues found that "in most of the studies, all PLWH patients completely recovered from the COVID-19 infection." These patients, they noted, did demonstrate the elevated inflammatory markers characteristic of other patients with COVID-19.The most common symptoms were fever, cough, myalgia and headache.

"This review...found an unexpected high recovery rate in these patients after COVID-19 infections, which contradicts the common knowledge of higher morbidity and mortality rate in immunocompromised patients," Mehraeen and colleagues observe.