Risk Factors for SARS-CoV-2 Infection and Severe Outcomes Among People With Human Immunodeficiency Virus: Cohort Study

Abstract

Background: Studies on COVID-19 in people with HIV (PWH) have had limitations. Further investigations on risk factors and outcomes of SARS-CoV-2 infection among PWH are needed.

Methods: This retrospective cohort study leveraged the national OPTUM COVID-19 data set to investigate factors associated with SARS-CoV-2 positivity among PWH and risk factors for severe outcomes, including hospitalization, intensive care unit stays, and death. A subset analysis was conducted to examine HIV-specific variables. Multiple variable logistic regression was used to adjust for covariates.

Results: Of 43 173 PWH included in this study, 6472 had a positive SARS-CoV-2 result based on a polymerase chain reaction test or antigen test. For PWH with SARS-CoV-2 positivity, higher odds were found for those who were younger (18-49 years), Hispanic White, African American, from the US South, uninsured, and a noncurrent smoker and had a higher body mass index and higher Charlson Comorbidity Index. For PWH with severe outcomes, higher odds were identified for those who were SARS-CoV-2 positive, older, from the US South, receiving Medicaid/Medicare or uninsured, a current smoker, and underweight and had a higher Charlson Comorbidity Index. In a subset analysis including PWH with HIV care variables (n = 5098), those with unsuppressed HIV viral load, a low CD4 count, and no antiretroviral therapy had higher odds of severe outcomes.

Conclusions: This large US study found significant ethnic, racial, and geographic differences in SARS-CoV-2 infection among PWH. Chronic comorbidities, older age, lower body mass index, and smoking were associated with severe outcomes among PWH during the COVID-19 pandemic. SARS-CoV-2 infection was associated with severe outcomes, but once we adjusted for HIV care variables, SARS-CoV-2 was no longer significant; however, low CD4 count, high viral load, and lack of antiretroviral therapy had higher odds of severe outcomes.

Keywords: COVID-19; SARS-CoV-2; electronic health records; human immunodeficiency virus; risk factors.

Figure 1.

The study's cohort selection process for the primary and subset analyses. ART, antiretroviral therapy; PrEP, pre-exposure prophylaxis; VL, viral load.

Figure 2.

Adjusted odds ratios and 95% CIs from the multivariable logistic regression models in the primary analysis. A, Risk factors for SARS-CoV-2 test positivity among people with HIV in the United States. B, Risk factors for severe outcomes within 30 days of SARS-CoV-2 testing (positive and negative) among people with HIV. BMI, body mass index.

Figure 3.

Adjusted odds ratios and 95% CIs from the multivariable logistic regression models in a subset of PWH who had available CD4 count, HIV VL, and ART data in the 12 months preceding their SARS-CoV-2 test in the electronic health record repository. A, Risk factors for SARS-CoV-2 test positivity among PWH in the United States, accounting for CD4 count, HIV VL, and ART. B, Risk factors for severe outcomes within 30 days of SARS-CoV-2 testing (positive and negative) among PWH in the United States, accounting for CD4 count, HIV VL, and ART. ART, antiretroviral therapy; BMI, body mass index; PWH, people with HIV; VL, viral load.