Diana Espinosa, MPP
Health Resources & Services Administration
5600 Fishers Lane
Rockville, Maryland 20857
Dear Administrator Espinosa,
We write to urge the U.S. Health Resources and Services Administration to include positive HIV status in the criteria used to define persons considered immunocompromised for purposes of determining eligibility for Covid-19 vaccination. While many states and U.S. territories have taken steps, in line with U.S. Department of Health and Human Services (HHS) guidance, to prioritize people over 65 and those who are immunocompromised, there are still jurisdictions that have not done so or that have yet to define the conditions included in criteria for “immunocompromised” or “at increased risk.” We are concerned that some states and U.S. territories may not be aware of or recognize the significance of existing evidence demonstrating the increased health risks faced by people with HIV during the COVID-19 pandemic, in order to appropriately prioritize them in their vaccine distribution efforts.
Recent evidence published by the New York State Department of Health AIDS Institute and the New York City Department of Health and Mental Hygiene (DOHMH) shows that people with HIV (PWH) in New York have experienced significantly higher rates of COVID-related hospitalization and mortality than the general population, strongly supporting the inclusion of people with an HIV diagnosis as a category of immunocompromised people at enhanced risk of poor COVID-19 outcomes and increased mortality.
CDC materials currently classify people with HIV among those who may be at increased risk from COVID-19.1 However, at the time of that determination the CDC rated the available evidence on HIV infection and COVID-19 outcomes to be “limited,” citing only a handful of studies. The majority of those studies were small and limited to hospitalized populations of people with HIV, factors limiting their generalizability. Most importantly, the determination was made prior to release of the New York State and New York City studies, at a time when there were not yet any large-scale population-based studies from U.S. jurisdictions. These New York studies provide substantial confirmation that PWH are at increased risk due to COVID-19 and should be prioritized for vaccine access as an immunocompromised population.
The recently published, large-scale, population-based New York studies were undertaken to better understand the intersection of COVID-19 and HIV. The NYS DOH, together with colleagues at the University at Albany School of Public Health, matched NYS’s HIV surveillance registry against its COVID-19 diagnoses and hospitalization databases, examining SARS-CoV-2 infections diagnosed during the period of March 1 through June 7, 2020, providing the first population-level comparison of COVID-19 outcomes between the PWH and non-PWH populations within a U.S. jurisdiction.2 The data match revealed that the rate of COVID-19 hospitalization was significantly elevated among PWH (8.29 per 1,000) versus non-PWH (3.15 per 1,000), with PWH over two and one half times (2.61) more likely to experience severe COVID-19 disease requiring hospitalization. While PWH and non-PWH mortality once hospitalized did not differ significantly in analyses adjusted for age, underlying conditions and other factors, the much higher rate of hospitalization among PWH resulted in a significantly higher rate of mortality among PWH versus non-PWH. Overall, PWH had a COVID-19 diagnosis and died in the hospital at a rate 2.55 fold the rate in the non-PWH population.
Significantly, while rates of severe COVID-19 disease resulting in hospitalization were found to be higher among PWH not virally suppressed and those with lower CD4 counts, suggesting that less controlled HIV virus may increase COVID-19 severity, analyses found higher hospitalization rates compared to the non-PWH population persisted even among PWH who were virally suppressed with high CD4 counts. This suggests that additional factors may explain elevated hospitalization rates among PWH, including other comorbidities, systemic stress of chronic viral infection, and social determinants of COVID-19 severity. The study also found that hospitalized and fatal COVID-19 cases were younger among PWH than in the non-PWH population, which the authors noted may lend support to the notion that HIV infection can accelerate biological aging.
The NYC DOHMH has likewise recently published findings from a match of lab-confirmed COVID-19 case and death data reported to the NYC Health Department as of June 2, 2020, against the NYC HIV surveillance registry.3 Linked data revealed that compared with all NYC COVID-19 cases, higher proportions of PWH with COVID-19 experienced severe COVID-19 disease and death during this period: 42% of PWH with COVID-19 were hospitalized (vs. 26% of all cases); 5% of PWH admitted to ICU (vs. 3% of all cases); and 13% died (vs. 8% of all cases). While those PWH who had poor COVID-19-related outcomes, particularly those who were admitted to ICU or died, had lower CD4 counts, the vast majority of PWH with COVID-19 who were hospitalized, admitted to ICU and died were virally suppressed at last HIV viral load.
The researchers who conducted these New York analyses call for continued, rigorous exploration of COVID-19 outcomes among PWH compared with people without HIV to understand what factors may be contributing to worse clinical outcomes, and conclude that the data demonstrates increased COVID-19 morbidity and mortality for PWH, requiring a public health response.
We note similar findings of increased risk of severe illness, hospitalization and death from COVID-19 among PWH in other studies as well. A large population cohort study of health care facility attendees in Western Cape of South Africa showed that a positive HIV status was associated with a doubling of COVID-19 mortality risk.4 Likewise, a large population-based analysis of United Kingdom National Health Service data found PWH at increased risk of COVID-related mortality, calling for targeted policies and noting that “[p]eople living with HIV might also need priority consideration if and when a vaccine against SARS-CoV-2 becomes available.”5
While we are still learning more about the complex interplay between HIV and COVID-19, it has become exceedingly clear to us in the HIV community that the COVID-19 pandemic presents an outsized risk of severe illness, hospitalization and death in PWH, even among individuals with a suppressed viral load and normal CD4 counts. All of the evidence we are seeing points to an urgent need for the federal government to clarify the definition of “immunocompromised” to appropriately include PWH and to officially recommend that PWH be prioritized by states and U.S. territories in their COVID-19 vaccine rollout protocols. We hope that you will work with us to protect the health and lives of PWH, particularly those long term survivors for whom COVID is not their first deadly pandemic and whose age and related comorbidities place them at the highest risk.
The ACT NOW: END AIDS Coalition
2 Tesoriero, J.M., Swain, C.E., Pierce, J.L., Zamboni, L., Wu, M., Holtgrave, D.R., Gonzalez, C.J., Udo, T., Morne, J.E., Hart-Malloy, R., Rajulu MSa, D.T., Leung, S.J., Rosenberg, E.S. Elevated COVID-19 outcomes among persons living with diagnosed HIV infection in New York State: Results from a population-level match of HIV, COVID-19, and hospitalization databases. medRxiv. doi: https://doi.org/10.1101/2020.11.04.20226118, posted November 6, 2020.
3 Braunstein, S.L., Lazar, R., Wahnich, A., Daskalakis, D.C., Blackstock, O.J. COVID-19 infection among people with HIV in New York City: A population-level analysis of linked surveillance data, Clinical Infectious Diseases, 2020; ciaa1793, https://doi.org/10.1093/cid/ciaa1793
4 Davies, M.A. HIV and risk of COVID-19 death: a population cohort study from the Western Cape Province, South Africa. medRxiv. 2020. doi: 10.1101/2020.07.02.20145185.
5 Bhaskaran,K., Rentsch, T.C., MacKenna, H. HIV infection and COVID-19 death: a population-based cohort analysis of UK primary care data and linked national death registrations within the OpenSAFELY platform. Lancet HIV 2021; 8: e24–32.
Disclaimer: The content of this statement may not express the views of all members of the Act Now: End AIDS coalition or our government partners.