ID Week 2020: Updates in HIV - Episode 1

Screening Trends and HIV Status Effects on COVID-19 Outcomes

An infectious disease expert discusses the impact on HIV screening caused by the COVID-19 pandemic as well as the effects of HIV status on COVID-19 outcomes.

Moti Ramgopal, MD, FACP, FIDSA, CPI: This study in Chicago that was done [on patients with HIV] in emergency [department care] was quite interesting. At the time this study was done, there was the question: are we going to see less or more testing as a result of COVID-19 [coronavirus disease 2019]? The study mimics the trends we are seeing nationally, whereby patients are not being screened routinely. This change in testing has been because of the risk of exposure of testers, as well as the shifting of resources away from HIV toward COVID. This study revealed that there was a significant increase in the number of patients with acute HIV infections who sought treatment in the emergency department. This is possibly a result of fear of COVID, also a result of many providers shifting away to telemedicine, telemedicine visits, reducing the availability of hospital visits. It’s interesting that this has occurred.

What has been surprising about the rate of these acute HIV diagnoses, and why is this? The rate of acute HIV infections in these emergency departments was seen to be significantly higher in the first 8 months of 2020 compared to the prior 4 years. These patients now comprise a quarter of all new diagnoses, the highest percentage ever. This has to reflect the lack of testing, the lack of people going out in the community to do the testing, and now patients not finding the right place to go to be treated and to be seen. The big question is, how might this impact HIV screening in the future? I looked at this as an opportunity, that the COVID pandemic can actually increase testing, and it can be incorporated into COVID-19 testing programs.

It’s like a piggyback, you come in for COVID testing and you are offered the HIV test at the same time. I think this piggybacking of HIV tests can reach out to a lot of people since, as you can clearly see, we’re doing a significant amount of COVID testing today. It’s important to recognize that emergency departments are not established to treat patients. Even though patients have gone to the emergency department for early treatment and treatment intervention, these emergency departments would not be able to sustain care over a long period. Not only does this impact HIV screening in the future, it also can impact HIV treatment strategies as well.

The COVID pandemic is actually allowing us to increase HIV testing. Then this practice that was seen in the Chicago emergency department, it can be replicated in other emergency department settings in the COVID pandemic. However, it’s important that these emergency departments now have someone or some clinic where [patients] can have continuum of care—urban, suburban, rural, nationwide, wherever this test is done—so we can connect the patients to care. This is such an important aspect of HIV care presently.

The interesting question is, what was the effect of HIV status shown on COVID-19 outcomes? When COVID-19 started developing and evolving, as an HIV provider, we were concerned. Our patients can get sick. They can develop COVID and get truly sick from it. Is there any protectivity with the HIV medications? These were some interesting questions we pondered at an early time, and this study addressed some of these.

The study looked at 1469 patients with HIV, of which 94 or 6.4%, were tested for SARS-CoV-2, and 40 were positive. Then 50% of those who were positive were woman, 65% were 50 years and older. These are some of the risk factors associated with hospitalization. Let’s look at those; 65% were black, 65% were former active smokers, and 40% were active alcohol or substance users. Majority, 9%, were in treatment of ART [antiretroviral therapy], and 87.5% had HIV viral suppression of less than 50 copies [per mL].

When we looked at the comorbidities, 50% had hypertension, 42% had chronic lung disease with cardiovascular disease, 42% had obesity and diabetes and chronic kidney failure. When we do look at our patients with COVID, who are those that were admitted to the hospital? Who are those patients that were doing poorly? Those are patients with cardiac disease, obesity, and diabetes. When we look at this cohort of patients, hospitalization occurred in 19 patients, or 4.7% of those, and 4 of those required escalation of care.

What does this look like with those patients? Those who are hospitalized are more likely to be greater than 50 years of age, they have cardiac disease, diabetes, and chronic kidney disease, or have multiple comorbidities compared to those managed as outpatient. The median length of stay in the hospital was 12 days. The study reflected a patient with HIV at favorable short-term outcomes in spite of age and comorbidities not related to HIV. These are good data to look at; there are other data studies out there that look at New York patients and patients in different cohorts, but at least we have some data that we can reflect on and appreciate.