Racial and ethnic disparities in coronavirus disease 2019 disease incidence independent of comorbidities, among people with HIV in the United States

Abstract

Objectives: To define the incidence of clinically detected coronavirus disease 2019 (COVID-19) in people with HIV (PWH) in the United States and evaluate how racial and ethnic disparities, comorbidities, and HIV-related factors contribute to risk of COVID-19.

Design: Observational study within the CFAR Network of Integrated Clinical Systems cohort in seven cities during 2020.

Methods: We calculated cumulative incidence rates of COVID-19 diagnosis among PWH in routine care by key characteristics including race/ethnicity, current and lowest CD4+ cell count, and geographic area. We evaluated risk factors for COVID-19 among PWH using relative risk regression models adjusted with disease risk scores.

Results: Among 16 056 PWH in care, of whom 44.5% were black, 12.5% were Hispanic, with a median age of 52 years (IQR 40-59), 18% had a current CD4+ cell count less than 350 cells/μl, including 7% less than 200; 95.5% were on antiretroviral therapy (ART), and 85.6% were virologically suppressed. Overall in 2020, 649 PWH were diagnosed with COVID-19 for a rate of 4.94 cases per 100 person-years. The cumulative incidence of COVID-19 was 2.4-fold and 1.7-fold higher in Hispanic and black PWH respectively, than non-Hispanic white PWH. In adjusted analyses, factors associated with COVID-19 included female sex, Hispanic or black identity, lowest historical CD4+ cell count less than 350 cells/μl (proxy for CD4+ nadir), current low CD4+ : CD8+ ratio, diabetes, and obesity.

Conclusion: Our results suggest that the presence of structural racial inequities above and beyond medical comorbidities increased the risk of COVID-19 among PWH. PWH with immune exhaustion as evidenced by lowest historical CD4+ cell count or current low CD4+ : CD8+ ratio had greater risk of COVID-19.

Fig. 1.

Cumulative incidence of coronavirus disease 2019 cases in 2020 by: (a) geographic area, (b) race/ethnicity, (c) lowest historical CD4R T-cell count, and (d) current CD4R T-cell count. Sites were anonymized based on regulatory requirements of this cohort to not present individual site data. y-axes are cumulative incidences, presented as the proportion of the population under study. Results for current or lowest historical CD4þ T-cell count were not different when stratified using 200 cells/ml as the cutoff.

Fig. 2.

Relative risk of coronavirus disease 2019 among people with HIV by key characteristics. ASCVD, atherosclerotic cardiovascular disease; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; eGFR, estimated glomerular filtration rate; FIB-4, fibrosis-4 scoring system for liver fibrosis; HCV, hepatitis C virus; PWH, people with HIV; RR, relative risk VL, viral load. a Relative risk regression models adjusted for demographic and clinical characteristics using disease risk scores, except for the ASCVD risk score analysis, which is unadjusted. Disease risk scores were constructed independently for each exposure variable of interest using all nonduplicative covariates.