HIV and SARS CoV-2 coinfection: A retrospective, record-based, case series from South India.

Dear Editor,

Coronavirus disease 2019 (COVID‐19) is wreaking havoc across the world, with 10 021 401 cases and 499 913 deaths reported as on 29 June 2020. With 37.9 million people living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (PLHA) around the world, it is one of the comorbidities to be looked in relation with COVID‐19, as the infected are immunodeficient. Although per se, HIV has not been found to have increased the risk of COVID‐19 acquisition or its course, PLHA whose disease is not under control, are at high risk for COVID‐19. The PLHA with comorbidities like diabetes mellitus, hypertension, etc, also needs to be comprehensively managed. Through a literature search in PubMed and World Health Organization's database on COVID‐19, we obtained five case reports, and five case series on PLHA infected with severe acute respiratory syndrome coronavirus 2 (SARS CoV‐2). The five case series were, one from Germany (32 patients), one from Spain (five cases), two from the United States (nine cases and four cases) and one from Turkey (four cases). , , , , India, the second‐most populous country in the world, reported its first COVID‐19 case on 30 January 2020, and presently crossed 548 318 cases. HIV prevalence in India is about 0.22%, with the total number of PLHA estimated at 21.40 lakhs, constituting third‐largest epidemic in the world. However, no study on HIV‐COVID‐19 coinfection could be found in India. Hence, we conducted a retrospective, record‐based case series on the PLHA who were infected with SARS CoV‐2, in the Indian state of Tamil Nadu. The data of the HIV‐COVID‐19 patients, treated and discharged, till 10th June 2020, were collected using a data extraction sheet from the records of the COVID‐19 designated hospitals across the state.

All data have been anonymized. Ethical permission for the study was obtained (Ref no. 961/AIDS/ART/C2/TANSACS/2018) from the Research Review Committee of Tamil Nadu AIDS Control Society (TANSACS).

Six PLHA coinfected with SARS CoV‐2 were identified during the study period: three males, two females, and one transgender patient. The median age of the patients was 38 years (22‐55 years). One of the patients was not under clinical HIV control, with an opportunistic infection. Five (83.3%) of our patients had a mild illness with symptoms, while one of the patients was asymptomatic. Fever (5), followed by cough (2), and sore throat (1), were the presenting symptoms in our patients. Five (83.3%) of our patients were symptomatic contacts of known COVID‐19 positive cases, and one (16.7%) had a travel history from Mumbai. Five patients were on highly active antiretroviral therapy (HAART), one patient was antiretroviral therapy (ART) naïve. All patients had stable vitals at room conditions, did not have any complications during their entire stay in a health care facility for COVID‐19, treated and discharged according to the Government of India guidelines. Other characteristics of the patients are tabulated in Table 1.

Table 1

Demography, clinical characteristics, and outcomes of the HIV‐SARS CoV‐2 coinfected patients

Variables	Patient 1	Patient 2	Patient 3	Patient 4	Patient 5	Patient 6
Age (in years)	45	36	22	40	23	55
Sex	Female	Female	Male	Male	Male	Transgender
Rural/urban	Rural	Rural	Rural	Rural	Urban	Rural
BMI, Kg/m2	21.2	17.9	20.9	23.7	17.9	20.8
Years since HIV diagnosis	10	3	10	14	15	Records not available
Years since ART initiation	10	3	8	Pre ART	10	Records not available
ART regimen taken (drugs name)	Zidovudine, Lamivudine, Nevirapine (ZLN)	Tenofovir, Lamivudine, Efavirenz (TLE)	Zidovudine, Lamivudine, Nevirapine (ZLN)	Tenofovir, Lamivudine, Efavirenz (TLE)a	Tenofovir, Lamivudine	Tenofovir, Lamivudine, Efavirenz (TLE)
					Atazanavir/Ritonavir (TL ATV/r)
COVID‐19 case type	Primary contact	Primary contact	Primary contact	Primary contact	Primary contact	Travel history
Symptoms during admission	fever 5 d	fever and cough 4 d	fever 5 d	fever and cough 5 d	fever, sore throat for 5 d	Asymptomatic
CD4 count (cells/mm3)	1047	129	457	565	543	530
Total WBC count (cells/mm3)	4800	6100	4500	4900	5900	6600
Hb (gram %)	12.1	11.1	13.3	13	15.3	12.6
Platelets (lakhs cells/mm3)	2.7	2.7	2.9	2.7	2.1	2.9
Comorbidities	Hypertension	Nil	Nil	Nil	Patient had oro‐oesophageal candidiasis during admission	Hypertension
Radiological findings	CXR and CT—normal	CXR and CT—normal	CXR normal	CXR normal	CXR and CT—normal	CXR normal
Treatment given:	ART drugs (ZLN), paracetamol, vitamin supplements, antihypertensives	ART Drugs (TLE), paracetamol, antitussives, iron‐folic acid, and vitamin supplements	ART drugs (ZLN), paracetamol, and vitamin supplements	ART Drugs (TLE), paracetamol, antitussives, and vitamin supplements	ART drugs(TL ATV/r), paracetamol, vitamin supplements, Fluconazole, Cotrimaxazole	ART drugs (TLE) vitamin supplements, antihypertensives
Days of hospital stay	8	4	11	11	6	24
Outcome	Recovered and discharged	Recovered and discharged	Recovered and discharged	Recovered and discharged	Recovered and discharged	Recovered and discharged

Abbreviations: ART, antiretroviral therapy; BMI, body mass index; COVID‐19, coronavirus disease 2019; CT, computed tomography; CXR, chest X‐ray; Hb, hemoglobin; HIV, human immunodeficiency virus; SARS CoV‐2, severe acute respiratory syndrome coronavirus 2; WBC, white blood cell.

Initiated during COVID‐19 admission.

The latest median CD4 count among our patients was 535 cells/mm3 (129‐1047). There was no difference in course of illness and the outcome of the patients with varying CD4 counts in our study, thus indicating CD4 may have no role in COVID‐19 prognosis. This is in contrast to the studies which observed that lower CD4 counts could actually protect against the severe form of COVID‐19. , It is based on the hypothesis that immune system activation may actually increase the injury caused by COVID‐19. However, Suwanwongse et al observed that low CD4+ count in the HIV infected patients may adversely affect the COVID‐19 outcomes. One of our patients presented with oro‐oesophageal candidiasis. It might be an HIV opportunistic infection due to poor ART adherence or treatment failure, which must be probed further. It might also be a secondary infection to SARS CoV‐2. Though reports on fungal infection in SARS CoV‐2 are inadequate, candida infection has been reported among SARS patients in 2003. Blanco et al reported a concurrent Penumocytis jiroveci infection in one of their cases.

Two of our patients had hypertension as comorbidity. Comorbidities of hypertension, diabetes mellitus 2, chronic obstructive pulmonary disease, hyperlipidemia were reported among the HIV‐COVID‐19 coinfected as well as exclusively COVID‐19 infected patients, across the globe. , , , , The mainstay of treatment given for our patients consisted of multivitamins, ART drugs, paracetamol, and antitussives. Vitamins, especially A and D, have shown to improve the immune system and may have potential benefits against viral infections. Antiretroviral (ARV) drugs such as Darunavir, Lopinavir/ritonavir, and Remdesivir by virtue of their antiviral properties may have a prophylactic and protective role in keeping the COVID‐19 infection as mild in PLHAs. But clinical evidence against the Lopinavir/ritonavir and other HIV protease inhibitors efficacy in COVID‐19 management is emerging. Molecular dynamics simulation studies have identified Zidovudine as the next potential candidate among the ARVs for clinical trials in COVID‐19 treatment. Among our patients, one was on low dose Ritonavir boosted HAART, and two were on Zidovudine containing regimen. But the ART naïve patient too had mild infection similar to the ones on HAART, thus giving an inconclusive picture on the effect of HAART on the COVID‐19 disease course in our study. The recovery rate was 100% among our patients, same as that of Benkovic et al In contrast, Suwanwongse et al and Harter et al reported a higher case fatality rate of 78% and 9%, respectively. However, Harter et al included only symptomatic COVID‐19 PLHA and observed that they might have overestimated the morbidity and mortality than the general population.

Our study reports that the clinical features of COVID‐19 coinfection among PLHA in South India are mild, and the clinical outcomes are favorable. Comorbidities were present in our patients but did not impact the outcome. However, the number of cases included was low and all cases were from a single state. Further studies including a greater number of patients should be done, to better understand the epidemiology, clinical outcomes, and appropriate treatment modalities in the HIV‐COVID‐19 coinfection.

CONFLICT OF INTERESTS

The authors declare that there are no conflict of interests.

KEYWORDS

epidemiology, human immunodeficiency virus, pandemics, SARS coronavirus, virus classification