Coronavirus

Jane Yee, MD, on HIV Care During the COVID-19 Pandemic

The global medical community is in the midst of unprecedented times brought forth by the coronavirus disease 2019 (COVID-19) pandemic.

Although everyone is at risk of contracting the novel coronavirus (severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]), preliminary data indicate that populations with the greatest risk of complications and mortality include the elderly, patients with underlying conditions, and those who are immunocompromised, including patients with HIV.1 Now more than ever, it is important to ensure that patients with HIV are able to access the information, medications, and care they need.

Infectious Diseases Consultant spoke with Jane Yee, MD, currently a global health fellow and  masters candidate in public health, and physician with the division of emergency medicine at the University of Utah, about what practitioners should know about caring for patients with HIV during the COVID-19 pandemic.

ID CON: What risks are patients with HIV facing amid the COVID-19 pandemic?

Dr Yee: The information we have about COVID-19 is still evolving. Despite that it has affected many people in many countries, we do not yet have specific guidance for patients with HIV/AIDS, because we currently do not have enough data. What is currently recommended for this patient population is based on what we currently know about HIV, SARS-CoV-2, and related respiratory illnesses, as well as how COVID-19 is affecting the general population.

The epidemiological data that first emerged from China indicated that factors for mortality from COVID-19 infection include older age and comorbidities–specifically, cardiovascular disease (CVD), diabetes, chronic respiratory diseases, and hypertension.2,3

Although none of these comorbidities are specific to HIV, these comorbidities are known to affect patients with HIV differently and more frequently than the general population. Studies have indicated that patients with HIV may have a 2-fold risk of developing CVD compared with the general population,4 and some infectious disease experts consider HIV to be an independent risk factor for cardiac disease. In addition, HIV is known to cause dyslipidemia, and antiretroviral therapy (ART) medications can be contributing factors.5

Metabolic syndrome, lipodystrophy, altered glucose metabolism, and adverse effects from medications are associated with a higher rate of diabetes among patients with HIV.6 A 2017 meta-analysis indicated that 35% of all HIV-infected adults on ART around the world have hypertension compared with 30% of the general population.7

It is also known that rates of pulmonary complications and infections are higher in the HIV population than in the general population, and it remains the highest cause of morbidity, mortality, and hospital admission among patients with HIV.8 In addition, it is important to remember that previous respiratory insults that patients may have had could have lasting scarring and impairment in their lung function that could increase their vulnerability to COVID-19.

While none of the available studies of COVID-19 specifically mention immunocompromised patients, it is important to remember that people who are immunocompromised are at risk for any infection, including COVID-19. For patients with HIV, poor control of HIV or any of the previously mentioned risk factors are causes for concern.

ID CON: What are some social factors that are important to take into consideration when treating patients with HIV during the COVID-19 pandemic?

Dr Yee: The COVID-19 pandemic has definitely highlighted the failures and disparities in our healthcare system. Among patients with HIV, these disparities are associated with a variety of social factors. We must consider the psychosocial and structural determinants of health that could affect outcomes among our patients with HIV. These factors may include, but are not limited to, low income, unemployment, lack of healthcare, low literacy or education, homelessness, addiction, violence, and any untreated mental health conditions.

A low-income job and inability to work from home increases a patient’s risk of exposure to COVID-19. Unemployment due to COVID-19 could translate to a lack of insurance or inability to afford medication and housing. Homelessness is not conducive to self-quarantining or frequent hand hygiene, and shelters are currently not an ideal situation due to community spread. It is important to consider patients with HIV who have an increased risk of intimate partner violence, especially during this period of self-quarantining.

We must also consider whether patients are able to access accurate medical information. Patients without internet access are less likely to have access to quick, reliable information and may also have difficulty engaging in a telemedicine visit, potentially making an in-person visit unavoidable.

ID CON: What steps are important for infectious disease specialists and related health care practitioners to take when caring for this patient population during the COVID-19 pandemic?

Dr Yee: It is important to encourage all patients, including patients with HIV, to practice universal, tried-and-true measures that effectively reduce the spread of infection including good hand hygiene, respiratory etiquette, and social distancing. Prevention is better than contracting the infection, because we currently do not have a vaccine or any medication for the virus.

If your patients have not already been treated with ART, it is important to ensure that these patients have access to ART, as well as prophylactic and other medications. It has been suggested that patients with HIV should have a 3-month supply and enough refills so that they do not have to break social distancing or visit the office, especially since COVID-19 is no longer travel-related but also has community spread. If this is not possible, practitioners should ensure that safety measures are in place so these patients can access their medication, such as having a family member who can pick up medication for them. For patients who need to come in for a visit, it is important to stay up-to-date on pneumococcal vaccines and influenza vaccines.

The HIV medication lopinavir/ritonavir (Kaletra) has been combined in the past with ribavirin, which has been shown to be helpful with SARS and MERS in retrospective studies.9 The World Health Organization is currently conducting the SOLIDARITY Trial, a global mega-trial designed to determine the safety and efficacy remdesivir, hydroxychloroquine, and standard-of-care in patients with COVID-19. It is important for practitioners to keep an eye on whether the results of ongoing trials show benefit in terms of treatment or prophylaxis for our patients with HIV.

It is understandable that our patients may be concerned and have a lot of questions during this time. We must make sure we are accessible to our patients, whether this means having telemedicine abilities for our clinics or being available for a telephone consultation. It is important to take advantage of every opportunity to prevent any unnecessary visits to the emergency department.

As providers caring for patients with HIV, we often work with care management, social workers, patient navigators, and hospital systems to ensure our patients have access to their safety nets. I would recommend speaking with patients to see what their contingency plans are if there is wide community spread in their area. I would ask questions like “how are you getting your groceries?” and “is there someone in your household that can help you with errands?” There are various mutual aid networks across the nation that have emerged during the COVID-19 crisis, which could be an important resource.

It could also be beneficial to reach out to your hospital system or affiliation to learn what kinds of safety nets are available for different patient demographics. For example, at the University of Utah, where I work, our emergency department has worked with clinics in our area to create options for homeless patients in need of self-quarantining and isolation.

ID CON: How can health care practitioners reassure patients with HIV during this time?

Dr Yee: It is very important for practitioners to address our patients’ questions and concerns, and to be able to refer them to accurate information. There is a lot of information circulating online, both true and false.

It is also crucial to ensure that our patients are not attempting to self-medicate with any unproven treatments for COVID-19 prophylaxis, such as hydroxychloroquine and chloroquine. These drugs have not performed well in trials yet, but people are still trying to get their hands on the medication because of unclear information that has been disseminated about the role of these drugs in COVID-19, which has caused a shortage of these drugs for people who need them. In some cases, patients have tried to take these drugs and have either overdosed and died or had to be hospitalized as a result.

There is also a lot of information circulating online about the effects of vitamin supplements on COVID-19. Some of my own patients have asked me about the effects of vitamins on preventing COVID-19 because of claims they saw online or heard elsewhere. Although it does not necessarily hurt to take vitamins, it is important to communicate to patients that vitamins are not a suitable substitute for prevention, nor is it necessary for patients to unsafely hoard vitamins.

ID CON: What key clinical takeaways do you hope to leave with infectious disease specialists and related health care practitioners on caring for patients with HIV during the COVID-19 pandemic?

Dr Yee: Available data thus far have indicated that patients with HIV are at high risk of the mortality risk factors associated with COVID-19.1 With this in mind, I would recommend greater diligence and caution when caring for these patients, especially with respect to viral suppression. However, it is also important to avoid exposing patients to unnecessary visits. Prevention will always foster better outcomes among patients in the long run, and patients with HIV are certainly no exception.

What we know about COVID-19 is constantly evolving, and new data are emerging every day. While we have learned a lot from our colleagues abroad, some outcomes observed abroad may not apply to our local populations. It is important to monitor the emergence of new information so that we can make responsible recommendations to our patients and give them the best care, especially regarding emerging treatment options and your local testing capabilities.

—Christina Vogt

References:

  1. Centers for Disease Control and Prevention. People who are at higher risk for severe illness. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher-risk.html. Page last reviewed March 31, 2020. Accessed April 1, 2020.
  2. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-1062. doi:10.1016/S0140-6736(20)30566-3
  3. Guan W, Liang W, Zhao Y, et al. Comorbidity and its impact on 1590 patients with Covid-19 in China: a nationwide analysis. Eur Respir J. 2020;55(3). doi:10.1183/13993003.00547-2020
  4. Shah ASV, Stelze D, Lee KK, et al. Global burden of atherosclerotic cardiovascular disease in people living with HIV: systematic review and meta-analysis. Circulation. 2018;138:1100-1112. doi:10.1161/CIRCULATIONAHA.117.033369
  5. Malvestutto CD, Aberg JA. Management of dyslipidemia in HIV-infected patients. Clin Lipidol. 2011 Aug; 6(4): 447-462. doi:10.2217/CLP.11.25
  6. Kalra S, Kalra B, Agrawal N, Unnikrishnan AG. Understanding diabetes in patients with HIV/AIDS. Diabetol Metabol Syndrome. 2011;3(2). doi:10.1186/1758-5996-3-2
  7. Xu Y, Chen X, Wang K. Global prevalence of hypertension among people living with HIV: a systematic review and meta-analysis. 2017;11(8):530-540. doi:10.1016/j.jash.2017.06.004
  8. Benito N, Moreno A, Miro JM, Torres A. Pulmonary infections in HIV-infected patients: an update in the 21st century. Eur Respir J. 2012;39:730-745. DOI:10.1183/09031936.00200210
  9. Yao TT, Qian JD, Zhu WY, Wang Y, Wang GQ. A systematic review of lopinavir therapy for SARS coronavirus and MERS coronavirus—A possible reference for coronavirus disease‐19 treatment option [Published online February 27, 2020]. J Med Virol. doi:10.1002/jmv.25729