Management of COVID-19 in PLWH

Introduction

Epidemiology of COVID-19 among PLWH

  • SARS-CoV-2 infection incidence in PLWH seems to be similar to that reported in the general population

Risk factors for severe COVID-19 and outcomes among PLWH

  • No clear evidence for more severe disease course in PLWH, compared to the general population. Among hospitalized COVID-19 patients, most studies reported a younger age of PLWH vs. HIV-negative patients, but higher rates of co-morbidities among PLWH. Severe COVID-19 has also been described in patients with concomitant TB and/or PcP. PLWH with CD4 count < 200 cells/μL and co-morbidities might have poorer outcomes, however the evidence is scarce

HIV care during COVID-19 epidemic

  • It is important to ensure continuum of HIV-care during lock-down and isolation due to COVID-19
  • Switching ARVs is not recommended, and may occur only in critical situations, e.g. virological failure
  • It is recommended to develop local country-specific strategies to prevent disruption in HIV care, including teleconsultation and tele-pharmacy, and ensure continuous ART supply
  • Position of EACS on SARS-CoV-2 risk and prevention in PLWH can be consulted here

Management of COVID-19 in PLWH

Diagnostic approach

  • The same approach, as for general population should be applied, according to the national or international recommendations (RT-PCR, SARS-CoV-2 antibodies and antigen detection). For details, see WHO recommendations

Differential diagnosis

  • For PLWH, particularly for those with poor immune status, other respiratory diseases (e.g. PcP, and TB) should be considered as differential diagnosis. Consider BAL to obtain sufficient material for microbiological investigation

Treatment approach

Management of HIV infection while on treatment for COVID-19

  • ART should neither be stopped, nor modified, unless strictly necessary (no proven activity of any ARV drugs against SARS-CoV-2, studies are ongoing)
  • For persons who are unable to swallow their usual ART (such as those on mechanical ventilation or ECMO therapy), the ART regimen may be adapted. see Administration of ARVs in PLWH with Swallowing Difficulties
  • CD4 count may decrease during COVID-19; in these cases, consider appropriate OI prophylaxis, see Primary Prophylaxis of OIs According to stage of Immunodeficiency
  • HIV-RNA blips have been described during COVID-19, their clinical relevance is currently unknown
  • In case of lockdowns, ARVs provision should be assured and tele-pharmacy can be considered; provide ART supply for at least 3 months at a time
  • New development or worsening of mental health problems (anxiety, depression, increased loneliness and stigma) have been very common during pandemic waves and following social distancing and lockdowns; psychological and social support should be actively offered to PLWH
  • Telemedicine and phone visits can be used for chronically stable persons, not requiring ART or co-medications changes. Retain in-person visits for persons complaining of acute problems, adverse effects due to ART, STIs or other complains/ co-morbidities requiring clinical evaluation
  • Co-morbidities and co-infections should be managed as indicated in specific sections of the Guidelines, see Prevention and Management of Co-mobidities in PLWH, Viral hepatitis co-infections (HBV, HCV, HDV-HEV), Opportunistic infections
  • Accessibility to specialist consultations should be evaluated and well-being (diet/ exercise) recommendations should be intensified

Management of long-term symptoms and sequelae of COVID-19

Prophylaxis of COVID-19

SARS-CoV-2 Vaccines

  • Numerous COVID-19 vaccine candidates are in development and several have been approved in Europe and other countries worldwide
  • There are multiple vaccine platforms including mRNA vaccines, adenovirus-vectored (Ad)-DNA vaccines and protein (subunit) vaccines
  • Overall efficacy of different vaccines varies, although their direct comparison is lacking, and data for PLWH is limited
  • It is recommended for all PLWH to be vaccinated against SARS-CoV-2. Priority should be given to those with immunosuppression (CD4 count < 350 cells/μL), if access to vaccines is limited. There is no data to recommend a specific vaccine and the choice depends on the availability in individual countries. As with other vaccines, response in PLWH could be poorer compared to the general population (particularly in those with low CD4 count and high HIV-VL); however, there have so far been no safety concerns with SARS-CoV-2 vaccines in PLWH and vaccination schedule is the same as for the general population. Serological testing before vaccination is not required
  • Other vaccines (particularly S. pneumoniae and influenza) should be given as scheduled, but at least 1 week before or after SARS-CoV-2 vaccines

Monoclonal antibodies

  • Passive immunization with antibodies against the SARS-CoV-2 spike protein is currently being considered as SARS-CoV-2 infection pre-exposure prophylaxis and to prevent progression of an initial SARS-CoV-2 infection. The approach may be useful and appropriate for immunocompromised PLWH but currently there are no available recommendations
  • Links to an overview of available vaccines and information regarding SARS-CoV-2 vaccination in PLWH: WHO, BHIVA, EACS