COVID-19 Vaccination and Hospitalization Among Persons Living With Diagnosed HIV in New York State : JAIDS Journal of Acquired Immune Deficiency Syndromes

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Epidemiology

COVID-19 Vaccination and Hospitalization Among Persons Living With Diagnosed HIV in New York State

Rosenthal, Elizabeth M. MPHa,b,c; Patterson, Wendy MPHd; Chicoine, Joyce BSd; Dorabawila, Vajeera PhDe; Adamashvili, Natalia MD, MPHa,f; Rajulu, Deepa T. MSd; Rosenberg, Eli S. PhDb,c,g; Tesoriero, James M. PhDa,b,c

Author Information

aCenter for Program Development, Implementation, Research and Evaluation, AIDS Institute, New York State Department of Health, Albany, NY;

bUniversity at Albany School of Public Health, State University at New York, Rensselaer, NY;

cCenter for Collaborative HIV Research in Practice and Policy, University at Albany School of Public Health, State University of New York, Rensselaer, NY;

dDivision of Epidemiology, Evaluation and Partner Services, AIDS Institute, New York State Department of Health, Albany, NY;

eDivision of Epidemiology, Center for Community Health, New York State Department of Health, Albany, NY;

fDepartment of Public Health, Faculty of Medicine, Tbilisi State University; and

gOffice of Public Health, New York State Department of Health, Albany, NY.

Correspondence to: Elizabeth M. Rosenthal, MPH, New York State Department of Health AIDS Institute, Empire State Plaza, Corning Tower, Room 342, Albany, NY 12237 (e-mail: [email protected]).

N.A. is supported by the Fogarty International Center and the National Institute of Alcohol Abuse and Alcoholism of the National Institutes of Health under Award Number D43 TW011532.

The authors have no conflicts of interest to disclose.

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

JAIDS Journal of Acquired Immune Deficiency Syndromes 93(2):p 92-100, June 1, 2023. | DOI: 10.1097/QAI.0000000000003177
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Abstract

INTRODUCTION

As of August 18, 2022, there have been more than 5.8 million cases of COVID-19 and more than 73,000 COVID-19–associated deaths in New York State (NYS).1 NYS ranks fourth in the United States in the number of cases of COVID-19 (as of January 6, 2023)2 and, at the end of 2020, ranked second in the number of persons living with diagnosed HIV (PLWDH) and first in the rate of HIV per 100,000 population, placing the state as an epicenter of both the US COVID-19 and HIV/AIDS epidemics.3 Approximately 83% of adults residing in NYS completed their COVID-19 vaccine series, and 45% were boosted as of March 7, 2022, though completion varied by demographics and region.4 Previous research has shown that COVID-19 vaccines remain effective against symptomatic infection and hospitalization across periods where the predominant SARS-CoV-2 variants included B.1.617.2 (Delta) and B.1.1.529 (Omicron) variants in NYS.5,6

There continues to be increasing evidence that COVID-19 vaccines are effective against severe outcomes. A multisite case–control study found that people who were hospitalized for COVID-19 were less likely to be vaccinated for COVID-19 (aOR 0.15, 95% CI: 0.13–0.18).7 Unvaccinated patients accounted for 94% of disease progression to death or invasive mechanical ventilation and 91% of deaths among patients with COVID-19. Recent studies found that hospitalization rates increased during Omicron circulation compared with those during Delta (38.4 vs. 15.5 per 100,000)8; however, COVID-19–related outcomes among hospitalized patients may have been worse during Delta circulation.9

Research suggests PLWDH may be at risk for more severe clinical outcomes of COVID-19 compared with persons who do not have HIV.10–16 PLWDH in NYS who were diagnosed with COVID-19 during March–June 2020 were more likely to be hospitalized compared with persons without diagnosed HIV.13 However, once hospitalized, mortality did not differ significantly between PLWDH and persons without diagnosed HIV.13,17 Nationally and in NYS, PLWDH were prioritized early for initial vaccine, booster, and additional doses; vaccines were available at no cost in NYS.18 However, our previous study demonstrates that early vaccination coverage among PLWDH through October 24, 2021 was lower than that of the general adult NYS population during the same time frame.19 Coverage was particularly low among PLWDH who were not virally suppressed or not in HIV care compared with PLWDH overall.

Many studies of COVID-19 breakthrough infections have focused on the general population,5–7,20 though a few have compared outcomes among patients with immunocompromised conditions, including HIV, before Omicron variant predominance. Immunocompromised patients had increased odds of COVID-19 breakthrough infections, severe COVID-19 breakthrough illness, and hospitalization.21–24 Two large cohort studies observed higher breakthrough infection rates among PLWDH compared with those among persons living without HIV and persons without immune dysfunction.23,25 In addition, a multisite case–control study found a weaker association between COVID-19 vaccination and a decreased risk of COVID-19 hospitalization in immunocompromised patients compared with that in immunocompetent patients, indicating potentially reduced vaccine effectiveness among immunocompromised persons generally.7 As new SARS-CoV-2 variants emerge, it is important to continue to assess the impact of the COVID-19 vaccination and different variants on immunocompromised persons and particularly, PLWDH. The purpose of this study was to update early vaccination coverage estimates19 among PLWDH in NYS and compare coverage with that of the adult NYS population to determine whether this coverage increased over time. In addition, we compared COVID-19–associated hospitalizations among PLWDH by vaccination status during periods of B.1.617.2 (Delta) and B.1.1.529 (Omicron) variant predominance in NYS.

METHODS

Data Sources

This is a retrospective cohort study of PLWDH aged 18 years or older who reside in NYS. This cohort was constructed based on matches of 4 surveillance databases: (1) NYS HIV surveillance registry, which is composed of name-based reports for all HIV-related laboratory tests among persons who reside or receive HIV-related care in NYS; (2) New York City (NYC) Citywide Immunization Registry (CIR), which collects data on COVID-19 vaccinations for persons who reside in NYC; (3) New York State Immunization Information System (NYSIIS), which collects vaccination data for persons residing in the rest of the state (ROS) with the exception of vaccinations reported directly to a federal system, such as for veterans, military personnel, or American Indian Health Program enrollees; and (4) Health Electronic Response Data System, which includes data on new hospital admissions of persons with laboratory-confirmed COVID-19 diagnoses through an electronic survey of all inpatient facilities in NYS.

The CIR and NYSIIS COVID-19 vaccination data were combined and deduplicated by first name, last name, date of birth, and zip code following previously reported methodology.20 The combined vaccination data (vaccinations through February 22, 2022) were matched with the NYS HIV surveillance registry (PLWDH through December 31, 2020) using a deterministic matching algorithm (matched on first name, last name, date of birth, and zip code) in SAS DataFlux. Data were matched to Health Electronic Response Data System using first and last initials, sex, date of birth, and zip code.

HIV surveillance registry data were used to compare demographic and HIV-related characteristics of PLWDH by vaccination status. Demographic characteristics included age at the end of 2020 (persons aged 18–49 years, 50–64 years, and 65 years or older), current gender (women, men, or nonconforming or nonbinary persons), race/ethnicity (non-Hispanic Black, non-Hispanic White, Asian/Pacific Islander, Hispanic, Multiracial, Native American, or unknown), and residence reported by the end of 2020 (NYC or ROS). HIV-related characteristics included viral suppression of <200 copies/mL at last test in 2020 and evidence of HIV care in 2020 (any CD4, viral load or genotype test reported to the NYS HIV surveillance registry in 2020). Consultation with the NYS Department of Health Institutional Review Board indicated that this work constitutes public health surveillance. We followed STROBE reporting guidelines.26

Study Cohorts

NYS implemented a phased approach to COVID-19 vaccination eligibility, prioritizing residents based on age, occupation, setting, and comorbidity, beginning in December 2020. On February 15, 2021,27 HIV became a qualifying condition for prioritized vaccination. PLWDH were categorized into 4 mutually exclusive closed exposure cohorts based on vaccination status during the period of interest: (1) an additional or booster dose beyond full vaccination of the Food and Drug Administration–authorized or approved Ad.26.COV2.S (Janssen [Johnson & Johnson]), BNT162b2 (Pfizer-BioNTech), or mRNA-1273 (Moderna); (2) full vaccination; (3) partial vaccination; or (4) having no matching vaccine record during the period of interest (unvaccinated). Booster dose was defined as ≥14 days since receipt of a dose of Pfizer-BioNTech or Moderna after prior full vaccination. Full vaccination was defined as ≥14 days since receipt of either a single dose of Johnson & Johnson or 2 doses of Pfizer-BioNTech or Moderna. Partial vaccination was defined as ≥14 days since receipt of only the first of a 2-dose series vaccine (Pfizer-BioNTech or Moderna) or <14 days since receipt of either a single dose of Johnson & Johnson or second dose of Pfizer-BioNTech or Moderna. Analyses did not differentiate between the type of vaccine received. However, there was a 99% agreement between the first and second vaccine types, and among PLWDH who received an additional or booster dose beyond full vaccination, there was an 88% agreement between the primary series type and additional booster type. PLWDH who were possible but not confirmed matches to the vaccination registries were excluded from analyses (n = 478).

To assess characteristics of PLWDH by COVID-19 vaccination status, cohorts included vaccination status for the entire study population as of March 4, 2022. To assess the outcome of COVID-19 hospitalizations among PLWDH during the period in which Delta variant prevalence was >50% (June 26, 2021–December 17, 2021 in Region 2), cohorts included vaccination status as of June 25, 2021.2 To assess COVID-19 hospitalizations among PLWDH during the period in which Omicron variant prevalence was >50% (December 18, 2021–February 24, 2022 in Region 2), cohorts included vaccination status as of December 17, 2021.

Statistical Analysis

The 4 vaccination status cohorts were analyzed by demographic groups for the entire study population, and separated into the 2 hospitalization time periods (Delta and Omicron) by calculating frequencies of the number of people in each vaccine cohort divided by the entire study population. Hospitalization rates were expressed as rates per 10,000 individuals by dividing the number of people with a hospitalization by the vaccine cohort population and multiplying by 10,000. All analyses were conducted using SAS software, version 9.4 (SAS Institute).

RESULTS

Vaccination Coverage

As of March 4, 2022, 39,655 (39%) of the 101,205 PLWDH included in the study received a booster dose, 29,482 (29%) were fully vaccinated without additional doses, 3813 (4%) received partial vaccination, and 28,255 (28%) were unvaccinated (Table 1).

TABLE 1. - Characteristics of Persons Living With Diagnosed HIV Infection in 2020 and COVID-19 Vaccination Status, New York, as of March 4, 2022*
Received 1 Dose of Janssen Vaccine or 2 Doses of Pfizer-BioNTech or Moderna Vaccine, Additional Dose or Booster Dose Received 1 Dose of Janssen Vaccine or 2 Doses of Pfizer-BioNTech or Moderna Vaccine Received Only 1 Dose of Pfizer-BioNTech or Moderna Vaccine Not Vaccinated Total
N (%) No. (%) No. (%) No. (%) No.
Total 39,655 (39) 29,482 (29) 3813 (4) 28,255 (28) 101,205
Age†
 18–49 yrs 11,471 (27) 14,138 (33) 2109 (5) 14,996 (35) 42,714
 50–64 yrs 20,096 (46) 11,945 (28) 1314 (3) 10,073 (23) 43,428
 65+ yr 8088 (54) 3399 (23) 390 (3) 3186 (21) 15,063
Current gender‡
 Men 29,408 (42) 19,391 (27) 2550 (4) 19,287 (27) 70,636
 NCNB 29 (31) 31 (33) 1 (1) 32 (34) 93
 Women 10,218 (34) 10,060 (33) 1262 (4) 8936 (29) 30,476
Race/ethnicity
 Hispanic 11,202 (39) 8813 (30) 1046 (4) 8014 (28) 29,075
 Non-Hispanic Black 15,065 (33) 14,672 (32) 2083 (5) 13,714 (30) 45,534
 Asian/Pacific Islander 1155 (46) 646 (26) 52 (2) 666 (26) 2519
 Multirace 212 (36) 167 (28) 25 (4) 186 (32) 590
 Native American 75 (39) 54 (28) 4 (2) 57 (30) 190
 Non-Hispanic White 11,894 (51) 5116 (22) 599 (3) 5599 (24) 23,208
 Unknown 52 (58) 14 (16) 4 (4) 19 (21) 89
Residence in 2020§
 New York City 30,557 (38) 23,401 (29) 3117 (4) 22,358 (28) 79,433
 ROS 9098 (42) 6081 (28) 696 (3) 5897 (27) 21,772
Virally suppressed in 2020 ¦
 No 4799 (19) 6263 (25) 1326 (5) 12,919 (51) 25,307
 Yes 34,856 (46) 23,219 (31) 2487 (3) 15,336 (20) 75,898
In care in 2020
 No 2092 (15) 2648 (18) 489 (3) 9186 (64) 14,415
 Yes 37,563 (43) 26,834 (31) 3324 (4) 19,069 (22) 86,790
*Vaccination status determined based on status ≥14 days since receipt of most recent dose.
†Age was determined as of the end of 2020.
‡Current gender was determined as of the end of 2020 based on gender reported to the New York State HIV surveillance registry.
§Residency was determined as last known residence in 2020.
¦Viral suppression is defined as <200 HIV RNA copies/mL at the last viral load test reported to the New York State HIV surveillance registry in 2020.
HIV care was defined as any CD4, viral load, or genotype test reported to the New York State HIV surveillance registry in 2020.
NCNB, nonconforming or nonbinary.

Receipt of at least full vaccination (full vaccination with or without booster dose) increased with age, including 60% of PLWDH aged 18–49 years, 74% of PLWDH aged 50–64 years, and 76% of PLWDH aged 65 years or older (Table 1). Receipt of a booster dose varied even more, ranging from 27% of PLWDH aged 18–49 years to 54% of PLWDH aged 65 years or older. While the receipt of vaccine short of booster doses varied slightly by current gender, it varied more in the receipt of a booster dose, including 42% of male individuals, 34% of women, and 31% of nonconforming or nonbinary persons. Among persons with known race/ethnicity, the percent of PLWDH who received at least full vaccination was highest among non-Hispanic White (73%) and Asian/Pacific Islander (71%) and lowest among multiracial (64%) and non-Hispanic Black PLWDH (65%). Racial and ethnic differences were more pronounced in the receipt of a booster dose. Significantly more non-Hispanic White PLWDH received booster doses (51%) compared with all other racial and ethnic groups, with the largest disparities observed for multiracial (36%) and non-Hispanic Black PLWDH (33%). Full vaccination coverage (with or without booster dose) and booster dose coverage were slightly higher among residents in ROS (70% and 42%, respectively) compared with that among residents of NYC (68% and 38%, respectively).

Receipt of at least full vaccination and receipt of a booster dose were both substantially higher among PLWDH who were virally suppressed at the end of 2020 (77% and 46%, respectively) compared with PLWDH who were not virally suppressed (44% and 19%, respectively) (Table 1). Similarly, PLWDH who were in care at the end of 2020 were more often to be at least fully vaccinated (74%) and to have received a booster dose (43%) compared with PLWDH without evidence of care (33% at least fully vaccinated and 15% received a booster dose).

Hospitalizations During Delta Predominance (June 26, 2021–December 17, 2021)

Table 2 summarizes hospitalization rates among PLWDH by vaccination status during Delta predominance. There were a total of 162 COVID-19 hospitalizations among PLWDH between June 26, 2021 and December 17, 2021. Unvaccinated PLWDH had greater hospitalization rates (24/10,000) compared with those with partial (15/10,000) and full vaccination (10/10,000). Older PLWDH were more often to be hospitalized, with total hospitalization rates of 28/10,000 among PLWDH aged 65 years or older compared with 9/10,000 among PLWDH aged 18–49 years. The direct relationship between increasing age group and higher hospitalization rates was realized within each vaccination status.

TABLE 2. - COVID-19 Hospitalizations Among Persons Living With Diagnosed HIV Infection During Delta Predominance Period (June 26, 2021–December 17, 2021) by Vaccination Status*
Received 1 Dose of Janssen Vaccine or 2 Doses of Pfizer-BioNTech or Moderna Vaccine Received Only 1 Dose of Pfizer-BioNTech or Moderna Vaccine Not Vaccinated Total
Persons Hospitalizations Persons Hospitalizations Persons Hospitalizations Persons Hospitalizations
No. Rate per 10,000 No. Rate per 10,000 No. Rate per 10,000 No. Rate per 10,000
Total 53,509 53 10 6088 9 15 41,608 100 24 101,205 162 16
Age†
 18–49 yrs 17,524 6 3 2776 2 7 22,414 30 13 42,714 38 9
 50–64 yrs 25,927 31 12 2569 5 19 14,932 46 31 43,428 82 19
 65+ yr 10,058 16 16 743 2 27 4262 24 56 15,063 42 28
Current gender‡
 Men 39,437 41 10 4025 4 10 27,174 44 16 70,636 89 13
 NCNB 43 0 0 4 0 0 46 0 0 93 0 0
 Women 14,029 12 9 2059 5 24 14,388 56 39 30,476 73 24
Race/Ethnicity
 Hispanic 15,755 16 10 1888 5 26 11,432 23 20 29,075 44 15
 Non-Hispanic Black 20,694 22 11 2967 3 10 21,873 63 29 45,534 88 19
 Asian/Pacific Islander 1530 1 7 131 0 0 858 0 0 2519 1 4
 Multirace 300 2 67 39 1 256 251 1 40 590 4 68
 Native American 102 0 0 10 0 0 78 0 0 190 0 0
 Non-Hispanic White 15,069 12 8 1051 0 0 7088 13 18 23,208 25 11
 Unknown 59 0 0 2 0 0 28 0 0 89 0 0
Residence in 2020§
 New York City 41,102 31 8 4912 7 14 33,419 61 18 79,433 99 12
 ROS 12,407 22 18 1176 2 17 8189 39 48 21,772 63 29
Virally suppressed in 2020 ¦
 No 7160 15 21 1372 9 66 16,775 27 16 25,307 46 18
 Yes 46,349 38 8 4716 0 0 24,833 73 29 75,898 116 15
In care in 2020
 No 3142 7 22 511 1 20 10,762 10 9 14,415 18 12
 Yes 50,367 46 9 5577 8 14 30,846 90 29 86,790 144 17
*Vaccination status determined as of June 25, 2021, based on status ≥14 days since receipt of most recent dose.
†Age was determined as of the end of 2020.
‡Current gender was determined as of the end of 2020 based on gender reported to the New York State HIV surveillance registry.
§Residency was determined as last known residence in 2020.
¦Viral suppression is defined as <200 HIV RNA copies/mL at the last viral load test reported to the New York State HIV surveillance registry in 2020.
HIV care was defined as any CD4, viral load, or genotype test reported to the New York State HIV surveillance registry in 2020.
NCNB, nonconforming or nonbinary.

The overall hospitalization rate was nearly twice as high among women (24/10,000) than among men (13/10,000) (Table 2). This trend was contingent on vaccination status, occurring among PLWDH with either no or partial vaccination, but not among PLWDH achieving full vaccination. More than 80% of hospitalizations were among Hispanic (n = 44) and non-Hispanic Black (n = 88) PLWDH. Persons in these groups also exhibited higher hospitalization rates relative to non-Hispanic White PLWDH. The hospitalization rate varied by region and was significantly greater among PLWDH residing outside NYC (29/10,000) compared with those residing within NYC (12/10,000). This difference persisted within each category of vaccination status.

Those who were virally suppressed at the end of 2020 had lower hospitalization rates compared with PLWDH who were not virally suppressed, overall, and among those with any vaccination history. (Table 2). However, among unvaccinated PLWDH, those who were virally suppressed had higher hospitalization rates (29/10,000) compared with unsuppressed and unvaccinated PLWDH (16/10,000).

PLWDH who were in care at the end of 2020 had higher hospitalization rates (17/10,000) compared with PLWDH who were not in care at the end of 2020 (12/10,000) (Table 2). This overall trend was driven among the unvaccinated PLWDH, where the hospitalization rates among those in care (29/10,000) and not in care (9/10,000) differed the greatest. Fully vaccinated and partially vaccinated PLWDH who were in care had lower hospitalization rates (9/10,000 and 14/10,000, respectively) compared with those not in care (22/10,000 among fully vaccinated and 20/10,000 among partially vaccinated).

Hospitalizations During Omicron Predominance (December 18, 2021–February 24, 2022)

Table 3 summarizes hospitalization rates among PLWDH by vaccination status during Omicron predominance. Between December 18, 2021, and February 24, 2022, there were a total of 425 hospitalizations among PLWDH, for an overall hospitalization rate of 42/10,000. This rate was nearly 3 times that observed during Delta predominance (16/10,000). The lowest overall rates were among boosted PLWDH (25/10,000); however, the highest were observed among partially vaccinated PLWDH (77/10,000) rather than the unvaccinated (52/10,000) (Fig. 1). There were similar trends in hospitalizations by age, gender, and race/ethnicity in both Delta and Omicron predominance periods. One exception was that among partially vaccinated PLWDH, the highest hospitalization rates during Omicron predominance were among PLWDH aged 50–64 years (124/10,000). Hospitalization rates were more similar between PLWDH outside NYC (45/10,000) and PLWDH in NYC (41/10,000) during Omicron than Delta predominance period.

TABLE 3. - COVID-19 Hospitalizations Among Persons Living With Diagnosed HIV Infection During Omicron Predominance Period (December 18, 2021–February 24, 2022) by Vaccination Status*
Received 1 Dose of Janssen Vaccine or 2 Doses of Pfizer-BioNTech or Moderna Vaccine, Additional Dose or Booster Dose Received 1 Dose of Janssen Vaccine or 2 Doses of Pfizer-BioNTech or Moderna Vaccine Received Only 1 Dose of Pfizer-BioNTech or Moderna Vaccine Not Vaccinated Total
Persons Hospitalizations Persons Hospitalizations Persons Hospitalizations Persons Hospitalizations Persons Hospitalizations
n Rate per 10,000 N Rate per 10,000 n Rate per 10,000 n Rate per 10,000 n Rate per 10,000
Total 27,285 69 25 39,516 167 42 4432 34 77 29,972 155 52 101,205 425 42
Age, yr†
 18–49 6794 14 21 17,460 24 14 2441 11 45 16,019 51 32 42,714 100 23
 50–64 14,045 30 21 17,178 95 55 1538 19 124 10,667 75 70 43,428 219 50
 65+ 6446 25 39 4878 48 98 453 4 88 3286 29 88 15,063 106 70
Current gender‡
 Men 21,108 53 25 26,302 88 33 2920 22 75 20,306 89 44 70,636 252 36
 NCNB 17 0 0 36 0 0 5 0 0 35 0 0 93 0 0
 Women 6160 16 26 13,178 79 60 1507 12 80 9631 66 69 30,476 173 57
Race/Ethnicity
 Hispanic 7404 22 30 12,057 42 35 1171 10 85 8443 35 41 29,075 109 37
 Non-Hispanic Black 9434 36 38 18,873 93 49 2437 17 70 14,790 92 62 45,534 238 52
 Asian/Pacific Islander 783 3 38 979 1 10 68 1 147 689 0 0 2519 5 20
 Multirace 137 0 0 229 1 44 27 0 0 197 3 152 590 4 68
 Native American 50 0 0 72 2 278 5 0 0 63 0 0 190 2 105
 Non-Hispanic White 9435 8 8 7284 28 38 719 6 83 5770 25 43 23,208 67 29
 Unknown 42 0 0 22 0 0 5 0 0 20 0 0 89 0 0
Residence in 2020§
 New York City 21,029 57 27 31,035 130 42 3611 23 64 23,758 116 49 79,433 326 41
 ROS 6256 12 19 8481 37 44 821 11 134 6214 39 63 21,772 99 45
Virally suppressed in 2020 ¦
 No 3014 13 43 7369 46 62 1459 16 110 13,465 61 45 25,307 136 54
 Yes 24,271 56 23 32,147 121 38 2973 18 61 16,507 94 57 75,898 289 38
In care
 No 1341 4 30 3109 7 23 546 3 55 9419 13 14 14,415 27 19
 Yes 25,944 65 25 36,407 160 44 3886 31 80 20,553 142 69 86,790 398 46
*Vaccination status determined as of December 17, 2021, based on status ≥14 days since receipt of most recent dose.
†Age was determined as of the end of 2020.
‡Current gender was determined as of the end of 2020 based on gender reported to the New York State HIV surveillance registry.
§Residency was determined as last known residence in 2020.
¦Viral suppression is defined as <200 HIV RNA copies/mL at the last viral load test reported to the New York State HIV surveillance registry in 2020.
HIV care was defined as any CD4, viral load, or genotype test reported to the New York State HIV surveillance registry in 2020.
NCNB, nonconforming or nonbinary.

F1
FIGURE 1.:
COVID-19 hospitalization rates among infection during Deltaa and Omicronb predominance periods by vaccination status. aDelta variant predominance period (June 26, 2021–December 17, 2021). bOmicron variant predominance period (December 18, 2021–February 24, 2022). cVaccination status cohorts varied based on COVID-19 variant predominance period. Vaccination status cohorts during Delta variant predominance period was defined by vaccination status determined as of June 25, 2021, based on status ≥14 days since receipt of most recent dose. Vaccination status cohorts during Omicron variant predominance period was defined by vaccination status determined as of December 17, 2021, based on status ≥14 days since receipt of most recent dose.

PLWDH who were virally suppressed had lower hospitalization rates (38/10,000) compared with PLWDH who were not virally suppressed (54/10,000) (Table 3). Similarly, PLWDH who were boosted, fully vaccinated, and partially vaccinated had lower hospitalization rates if they were virally suppressed. Unvaccinated PLWDH who were virally suppressed had higher hospitalization rates (57/10,000) compared with unvaccinated PLWDH who were not virally suppressed (45/10,000). Overall and among nonboosted cohorts, PLWDH who were in care had higher hospitalization rates compared with PLWDH who were not in care. However, boosted PLWDH who were in care had slightly lower hospitalization rates (25/10,000) compared with PLWDH who were not in care (30/10,000).

DISCUSSION

COVID-19 vaccination coverage among PLWDH in NYS increased only 5 percentage points since October 24, 2021.19 Although there were modest declines in the percentage of PLWDH who were unvaccinated in every race/ethnicity category, previously reported disparities still exist and at similar levels. One exception was a slightly greater improvement (6%) in vaccination coverage among non-Hispanic Black PLWDH compared with non-Hispanic White (2%) and Hispanic (2%) PLWDH. More than 25% of PLWDH remain unvaccinated, and PLWDH still had lower full vaccination coverage (68%) compared with the general adult population (83%) as of March 7, 2022.1 Differences in the demographic composition of PLWDH compared with the general NYS population might account for some of this lower coverage; however, coverage was lower than 83% across all PLWDH categories, as listed in Table 1. Socioeconomic status and other unmeasured variables might help to further explain coverage differences between PLWDH and the overall NYS population.

In both the Delta and Omicron predominance periods, the hospitalization rates among PLWDH increased by age and were also higher for women and persons of color, excepting Asian/Pacific Islander adults during Delta predominance period. These age and racial/ethnic disparities are consistent with higher hospitalizations among older adults and persons of color in the general population.8,28 Disparities may be explained by uncontrolled variables such as social determinants. As expected, hospitalization rates in both periods were lowest among fully vaccinated PLWDH. Hospitalization rates increased between Delta and Omicron for all groups except multiracial PLWDH.

One important finding from this study concerns the much smaller difference in hospitalization rates between fully vaccinated (with or without booster dose) and unvaccinated PLWDH compared with those in all New Yorkers. In the overall NYS population, unvaccinated persons had hospitalization rates approximately 10 times higher than fully vaccinated persons in both the Delta (10.9) and Omicron (9.6) predominance periods.1 Among PLWDH in our study, unvaccinated persons had hospitalization rates approximately 2 times higher than those fully vaccinated during Delta (2.4) and Omicron (1.5) predominance periods. Of importance, this difference is being driven by higher hospitalization rates among vaccinated PLWDH. For example, during Omicron predominance period, hospitalization rates among unvaccinated PLWDH (52/10,000) were somewhat higher than those among all unvaccinated New Yorkers (29/10,000); however, rates among fully vaccinated PLWDH (35/10,000) were more than 10 times greater than rates among all fully vaccinated New Yorkers (3/10,000). Time since vaccination between PLWDH and all New Yorkers may differ; however, results support previous findings of greater COVID-19 hospitalizations among PLWDH,13,21–23 and vaccination may have reduced protective effects against hospitalization among immunocompromised populations compared with the general population.7

During Delta predominance, PLWDH with at least some vaccination history who were in care had lower hospitalization rates compared with those not in care. However, during Omicron predominance, only boosted PLWDH in care had lower hospitalization rates compared with those out of care. PLWDH who are in care may be more engaged in healthcare services and may be more likely to access the hospital than those not in care. In addition, PLWDH have a high prevalence of comorbidities that increase the risk of severe COVID-19 infection,29–33 so it is plausible that PLWDH with comorbidities may be more engaged in the healthcare system in general and thus more likely to have access to hospitalization. This study did not assess COVID-19 diagnoses among all PLWDH, so we are unable to determine the extent to which SARS-CoV-2 infection varied by vaccination status. However, it is likely that COVID-19 diagnoses among PLWDH were greater during the Omicron predominance period, similar to reports of increased COVID-19 incidence nationally,34 which contributed to increased hospitalization rates during this period.

Addressing the expansive gap in vaccination coverage by HIV care and viral suppression status is critical, given the increased risk and/or prevalence of severe COVID-19 outcomes among immunocompromised persons, including PLWDH,10–16,21–23,25 and CDC recommendations for these persons to stay up to date with COVID-19 vaccines.35 However, there is limited research on effective interventions to increase vaccination coverage among PLWDH or members of the general population who remain unvaccinated. Reminder notifications can address scheduling-related barriers, resulting in increased appointment and vaccination rates.36 Disparities in COVID-19 vaccination coverage among PLWDH may be reduced by incorporating COVID-19 vaccination into existing HIV programming and services.19 For example, HIV providers can be leveraged to promote vaccination and subsequent booster and additional shots, as relevant, and promoting vaccination could be incorporated into existing HIV and STI partner services activities, such as Data to Care.37

LIMITATIONS

Vaccination status was limited to reports to NYSIIS and CIR during this study. PLWDH were categorized as unvaccinated when there was an absence of a matching vaccination record during matching. This may include PLWDH who were vaccinated outside of NYS and not reported to NYSIIS or CIR, PLWDH who were unmatched during matching, or PLWDH who died after December 31, 2020. Death data were available only through December 2020; thus, deaths reported in previous years in NYS, including 2020, were used to estimate the number of PLWDH aged 18 years or older who were alive as of March 4, 2022. This analysis likely includes 2000 PLWDH who died during 2021 and early 2022; these decedents may have died before they were able to begin or complete vaccination, which may have resulted in a slight misclassification of vaccination status.

CONCLUSIONS

Fifteen months after vaccines became available, more than 25% of PLWDH in NYS remained unvaccinated for COVID-19. Differences in vaccination status were most pronounced within categories of race/ethnicity, viral suppression, and HIV care status. Lower vaccination rates among non-Hispanic Black and Hispanic PLWDH could magnify already higher diagnosis rates and more severe COVID-19 outcomes experienced in these communities.28,38 More research is needed to understand why PLWDH are less likely to be vaccinated for COVID-19, and why PLWDH, particularly vaccinated PLWDH, have significantly higher hospitalizations rates compared with those in New Yorkers overall.

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Keywords:

HIV; COVID-19; COVID-19 vaccines; vaccination coverage; hospitalization

Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.