To the Editors:
As our understanding of the coronavirus disease 2019 (COVID-19) improves through emerging data from the general population affected with COVID-19, there is a paucity of information regarding the management and prognosis of patients with HIV infection who may be at an increased risk for morbidity and mortality.1
Here, we describe our experience with the management of COVID-19 in patients with HIV at a health care facility in Newark, the center of the HIV epidemic of New Jersey.2 We included all patients with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection defined as a positive result on a reverse transcriptase polymerase chain reaction assay of a specimen collected on a nasopharyngeal swab.
We identified 27 patients who had a known history of HIV at the time of presentation. Of these, 51% (n = 14) were managed in the ambulatory setting, whereas the rest were hospitalized. The median age was 58 years, there were 15 men and 12 women, and 93% (n = 25) were black or African Americans. The top 4 common symptoms at presentation were fever (67%), cough (63%), dyspnea (63%), and fatigue (48%), which had started over a median duration of 3 days before presentation. More than half of the patients had a history of systemic hypertension (59%), and about one-third reported diabetes mellitus (33%) or chronic kidney disease (27%) (Table 1).
Ambulatory patients were hemodynamically stable at the time of presentation and demonstrated an oxygen saturation of 94–100% on ambient air. They were discharged home with no medical therapy but with the following recommendations: (1) self-quarantine for at least 2 weeks, (2) return to the emergency department for management in case of new-onset symptoms such as fever and dyspnea, and (3) adherence to antiretroviral therapy. Ambulatory patients were followed up with phone calls through a telemedicine platform over a median duration of 14 days.
Patients were hospitalized and managed in the inpatient setting if they (1) had signs of sepsis or septic shock defined by the 2016 Third International Consensus Definitions for Sepsis and Septic Shock3 and (2) reported dyspnea requiring a step up in oxygenation therapy to maintain an oxygen saturation between 88% and 94%.
Major laboratory markers and immunological data of their HIV status are given in Table 1. The median lymphocyte count was 17%, with a serum d-dimer and procalcitonin of 1.9 ng/mL and 0.26 μ/L, respectively. Patients reported a median CD4 count of 551, and the viral load was <120 in 96% (n = 26) of the patients. Data on antiretroviral regimen before presentation were unavailable in 15% (n = 4) of the patients. Among those with full data, integrase-based regimen was used in 33% (n = 9), nonnucleoside reverse transcriptase inhibitor (NNRTI) in 19% (n = 7), protease inhibitor (PI) + integrase in 19% (n = 7), NNRTI + integrase in 7% (n = 3), and PI based in only 1 patient.
Of the hospitalized patients, 26% (n = 7) received hydroxychloroquine and 30% (n = 6) were managed with empiric antibiotics for suspected community-acquired pneumonia. Antiretroviral therapy was held during hospitalization. None of the patients had a superimposed infection, defined as an isolated organism in a positive sputum, urine, or blood culture. After a median hospital course of 10 days, 3 patients required intensive unit level of care and 2 of them had died. The deceased subjects were elderly patients, with multiple coexisting conditions whose course was complicated by septic shock and multiorgan dysfunction syndrome. There were no cases of hospital admission for patients who were managed in the ambulatory setting.
In this series of HIV patients with COVID-19, we found a similarity in presentation with what has been reported for the general population. Half of the patients were managed in the ambulatory setting with no reported mortality or morbidity. In-hospital survival was 85% and 23% required intensive care unit admission. Of note, all 27 patients had well-controlled HIV infection evidenced by elevated CD4 count levels and low viral loads. As the challenge involving the management of COVID-19 evolves, large-scale studies are necessary to better understand the management and prognosis of patients with HIV who present with COVID-19.
1. CDC. Coronavirus Disease 2019 (COVID-19) in People with HIV [Internet]. Centers for Disease Control and Prevention. 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/hiv.html
. Accessed May, 2, 2020.
2. Martin EG, Salaru G, Mohammed D, et al. Finding those at risk: acute HIV infection in Newark, NJ. J Clin Virol. 2013;58:e24–e28.
3. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315:801–810.