International Journal of Science and Healthcare Research Vol.5; Issue: 2; April-June 2020 Website: ijshr.com Review Article ISSN: 2455-7587

HIV and COVID-19 Comorbidity: Current Evidence

Adeniyi David Segun

Technical Officer - Directorate of Laboratory Services - APIN Public Health Initiatives, Jos, Nigeria.

ABSTRACT Key Words: COVID-19, SARS-CoV-2, HIV, Comorbidity, PLWH The spread of the COVID-19 has now crossed all known human borders with so much 1. INTRODUCTION virulence and defiance to the acclaimed When the first incidence cases of the international efforts aimed at mitigating its Coronavirus Diseases 2019 (COVID-19) impacts. The emergence of this disease in emerged at Wuhan China in early December December 2019 at Wuhan in China has left the 2019, the world was still in a state of world in tatters; with collapsed national economies, massive loss of jobs and sources of slumber; not knowing the marauding impact livelihoods, a redefining of social ethics and of what was coming. As tale bits of news concourse, and a restructuring of the ethos that begins to filter into main stream media and guide our national ways of life. The increased the internet about a novel strain of risk of severe disease with COVID-19 is closely Coronavirus rampaging China from late associated with advanced age (>50 years), male January 2020, the world became alert and gender, hypertension, diabetes, Chronic suddenly woke up into a nightmare of epic Obstructive Pulmonary Diseases, proportion. Social life and the ingrained Cardiovascular diseases, and Cerebrovascular idea of personal liberty and freedom has not diseases. People Living With HIV are most being the same ever since, and this is prone to increased morbidity, and the advent of coupled with the crumbling of the world the COVID-19 has now created an additional comorbid burden on the over 37.9 million economies, loss of jobs, and a monumental PLWH globally. There is no known cure or toll on the mental health of individuals. effective treatment for COVID-19 as at yet, but Medical Experts all over the world by there are promising therapeutic alternatives. merely observing the virulence nature and People Living With HIV stands a better chance the case fatality rate of this novel disease of a positive disease outcome when infected knew what was coming, however, the WHO with COVID-19 provided their viral load is held that this was not a pandemic until suppressed, if they are on an active HIV March 11, 2020. [1] The COVID-19 has Antiretroviral Therapy, if they have a high CD4 however being transmitted to at least 213 T-helper cells counts (>200 cells/µL), and countries ever since, leading to the complete provided they have no underlying chronic shutdown of cities, human social activities diseases conditions. Some studies have shown that a dysregulated immune response might be and entire nations. Bringing social and responsible for conferring some level of economic activities to a standstill while still protection against the SARS-CoV-2 virus marching on with the defiance of an all- infection in HIV patients. Thus, the disease conquering master. Nevertheless, the world outcome of People Living with HIV who are co- will overcome this common enemy with a infected with the SARS-CoV-2 virus is no common resolve, cooperation and mutual different from the prognostic outlook of any efforts.COVID-19 is a viral respiratory averagely healthy individual infected with the disease that causes severe Pneumonia. As at SARS-CoV-2 virus without any underlying June 12, 2020, over 7.5 million COVID-19 chronic health conditions.

International Journal of Science and Healthcare Research (www.ijshr.com) 349 Vol.5; Issue: 2; April-June 2020 Adeniyi David Segun et.al. HIV and COVID-19 comorbidity: current evidence cases have been reported globally with over disease outcome and increased case fatality 422 thousand deaths and over 3.5 million rate among COVID-19 patients with recoveries. [2] Due to the rapid spread of this underlying chronic disease conditions like disease and the very high mortality rate Hypertension, Diabetes, Cardiovascular associated with it, it is imperative that the diseases, Cerebrovascular diseases, and comorbidities and the associated risk factors Chronic Obstructive Pulmonary Diseases that may predicate the clinical outcome of (COPDs). [3, 7-8, 10, 16] In the pooled analysis this disease be clearly established as this of 1558 COVID-19 patients from 6 studies, may help guide the clinical and palliative Wang, et al. [3] finds no correlation management of this disease. Studies have associated with comorbidity risk among shown that comorbidities in COVID-19 COVID-19 patients with malignancies, liver patients may lead to poor prognosis. [3-4] diseases or renal diseases; instead, they find Due to the novel nature of COVID- major risk factors associated with 19, many facts about the nature of this hypertension, diabetes, cardiovascular disease are still emerging. Several studies to diseases, and COPDs. Diabetes Mellitus establishing its risk factors, comorbidities, (DM) have been distinctively associated possible choice of chemotherapy, and the with more severe COVID-19 case fatality development of an appropriate vaccine and increased mortality rate. [17] In addition, against the COVID-19 strain is still as older adults (>50 years) have been ongoing. Due to the case fatality rate of this increasingly associated with poor prognosis disease, it has been associated with several of COVID-19, DM can be presumed more comorbidities that forms a cluster of chronic likely to be prevalent among the older health conditions. [3, 5-10] HIV is a chronic population than among the younger disease condition associated with population; this may partly explain the immunosuppression, thus the emergence of underlying cause of the increased case COVID-19 now create an additional burden fatality among the adult population. [17] of disease for the over 37.9 million People Other studies have also shown a high Living with HIV (PLWH) globally. [11] Case prevalence of Cardiovascular Diseases series of COVID-19 infection in HIV among COVID-19 patients. [5-6, 8] Yang, et patients have been reported from China, al. (2020) has also reported that the most Europe, and the United States, [12-15] but thus common COVID-19 comorbidity associated far, the disease progression and outcome in with increased mortality among COVID-19 this group of patients have not been non-surviving patients is cerebrovascular different from those of HIV Negative diseases and Diabetes. [8] individuals. [12-15] This review seeks to 3. HIV and COVID-19 Comorbidity: establish the low risk associated with the Current Evidence comorbidity of HIV and COVID-19 in light Due to the compromised immunity of available evidence. of PLWH, such patients are most prone to 2. COVID-19 and Chronic Health morbidities. Thus with the advent of the Conditions COVID-19 pandemic, the morbidity burden The advent of the COVID-19 has let on PLWH has increased. Our current loose a plethora of underlying chronic knowledge indicates that older adults (>50 health conditions in affected individuals. years), male gender, those with underlying The comorbidity of this underlying chronic chronic diseases conditions and with health conditions and COVID-19 has compromised immunity stands a greater significantly increased the Odd Ratio (OR) chance of more severe COVID-19 infection of affected patients having a poor COVID- prognostic outcome with increased fatality 19infection outcome. [9] Several meta- and mortality rates. Available data from analytical studies on COVID-19 different studies have however excluded comorbidities have revealed the poor PLWH without any other underlying

International Journal of Science and Healthcare Research (www.ijshr.com) 350 Vol.5; Issue: 2; April-June 2020 Adeniyi David Segun et.al. HIV and COVID-19 comorbidity: current evidence chronic health conditions from this high-risk efficacy at treating COVID-19. Such drugs population, provided they are on ART with include the famed Hydroxychloroquine with a reasonably high CD4 T-helper cells count or without Azithromycin, and Chloroquine, (>200 cells/µL). [12] Studies have shown that which has not been well proven as at yet to in PLWH, a dysregulated immune response be effective against the COVID-19 infection to the SARS-CoV-2 infection leads to a in the face of other complicated adverse delayed plasma antibody production against effects. [22] Other drugs undergoing trials the COVID-19 virus and a lack of include the HIV drug Lopinavir/Ritonavir, inflammatory changes with no clinical which has also been proven not to be symptoms elicited after infection with the effective in the treatment of COVID-19. virus. [18-19] According to a report by Joob Other promising drugs currently being and Wiwanitkit (2020), PLWH who are not tested include the failed Ebola drug, on HIV Antiretroviral Therapy (ART) are at Remdesivir and Famotidine which has so far increased risk of developing a more severe shown possible signs of efficacy based on form of the COVID-19. [13] However, the COVID-19 survival rate of clients on PLWH who are currently on the standard these drugs as compared to those clients on ART regimen and whose CD4 T-helper Placebo. [12,21] Several other efforts are cells are >200 cells/µl without any being made at developing an active vaccine underlying chronic diseases conditions will against the SARS-CoV-2 virus. Efforts are have better prognostic outcome as also under way at identifying the specific comparable to other averagely healthy antibodies produced against the SARS- SARS-CoV-2 infected individuals without CoV-2 virus from the plasma of any underlying chronic diseases conditions. convalescing or recovered COVID-19 [13] Some researchers have presumed the patients. It should also be noted that PreP possibility of the standard anti-HIV drugs treatments have not shown any effectiveness being able to proffer a protective against COVID-19 recovery. [12] mechanism against the SARS-CoV-2 5. HIV Services during the COVID-19 infection in PLWH. [13, 18] However, a large Pandemic countrywide survey in China has shown that Due to the global shutdowns, such standard anti-HIV drugs like lockdowns, social distancing, and the total Lopinavir/Ritonavir though largely restriction of movements occasioned by the publicized, as a possible wonder drug COVID-19 Pandemic, many of the gains against the COVID-19, may not really be of made at mitigating the impacts of earlier much benefit to COVID-19 patients. [20] pandemic diseases like HIV and Thus at a time like this, it is imperative that Tuberculosis are now being eroded. [23] The we encourage PLWH to religiously adhere emergence of the COVID-19 pandemic now to their ART regimens, ensuring their viral threatens the achievement of the UNAIDS Load is suppressed, while also dispensing to 90:90:90 targets on HIV. The restrictions on them prophylactics against Opportunistic movement have now hampered many Infections (OIs). [12] HIV/AIDS clients from assessing ART and 4. COVID-19 Treatment clinic visits. [24] Many PLWH are now As the race to finding a cure for the unable to get their needed Antiretroviral COVID-19 intensifies, the WHO is leading (ARV) drugs refill as at when due as a result the charge in a global effort aimed at of the restrictions on movement which is harnessing a solid treatment data that could limited to only personnel on essential duties. help proffer the way forward in the midst of In some countries with the rumored efficacy this current global conundrum. [21] Several of Lopinavir/Ritonavir against the COVID- possible drugs are currently undergoing 19 infection, there has been the steady randomized control trials at different parts shortage of this HIV drug because of of the world in a bid to assessing their hoarding by uninformed individuals. The

International Journal of Science and Healthcare Research (www.ijshr.com) 351 Vol.5; Issue: 2; April-June 2020 Adeniyi David Segun et.al. HIV and COVID-19 comorbidity: current evidence unavailability of the right ARV regimen and now take HTS to the people at their the inability to assessing ARV at the right localities especially on “Lockdown-free time could both contribute to a rapid Days” when the people can have a bit of increase in the HIV plasma viremia of movement. Because of the economic PLWH. This could also lead to the hardships now created by the COVID-19 development of HIV drug resistance by the Pandemic, people now consider it a priority HIV RNA because of inadequate, to looking after themselves and their family intermittent, or suboptimal drug exposure. sustenance first before considering any In addition, the inability to assessing HIV other thing. We must now endeavor to Testing Services (HTS) at the right time taking HTS to people at their business and could spell a phase for the rapid spread of work places, offering and rendering them HIV. The COVID-19 Pandemic has grossly our services once they are obliged. We need hampered logistics for the shipment and to now prioritize high-risk groups, and map movements of Public Health Commodities. out strategies to reaching them in clusters. [25] HIV services and logistics has been This continued effort will enable us to generally slowed down with many keeping the pace with the first UNAIDS 90 deleterious effects already hovering if we do target. not redouble our efforts at reprogramming 6.2 Access to ART and strategizing our approaches. Efforts should now be intensified at 6. Reprogramming HIV Services during differentiating PLWH into different Models the COVID-19 Pandemic of Care. Dispensing of ARVs at Community Public Health efforts in HIV services Pharmacy Stores should be intensified. In needs to be re-doubled, and a re-strategizing addition, the Multi-months Dispensing in HIV Programming is now needed in (MMD) of ARVs should be rapidly order to maintaining the gains already made encouraged. All newly diagnosed HIV in HIV care and services. As different Positive clients should be encouraged to countries begins to ease the COVID-19 commence treatment immediately. Efforts Pandemic lockdowns, one obvious facts is should be made at ensuring the ready that things may not go back to the way they availability of ARVs, as shortages or were until a lasting cure or treatment is unavailability may lead to undue rationing found for the SARS-CoV-2 infection. With which may not be convenient for the the active spread of COVID-19 and the patients. Regular Health Talks during Clinic major collapse of world economies, we visits should emphasise the importance of must not lose our grip on the major gains taking ARV regimens as prescribed and made in the fight against the HIV Pandemic. without fail. The danger associated with Our strategies must be built around the poor adherence should also be emphasized. UNAIDS 90:90:90 targets; hence, in our bid Ensuring a free flow of access to ARVs by to maintaining the speed and momentum we PLWH and strict adherence to ARV have gained in HIV Programming, we must regimens will help in keeping pace with the urgently intensify our efforts on the second UNAIDS 90 target. following: 6.3 Community Phlebotomy 6.1 Community HTS Outreaches Provisions should now be made at In light of the restrictions on bleeding PLWH who are eligible for viral movement occasioned by the COVID-19 load testing at the community level. Clusters Pandemic, more Community Outreaches in of PLWH living in proximate communities smaller units now needs to be organized on can be tracked and mapped into groups for a regular basis. Large-scale outreaches collective ARV refills and HIV viral load should be avoided in order to maintaining Phlebotomy. The use of Dried Blood Spot Social Distancing. Since the people can no (DBS) for HIV viral load can greatly help longer move freely and at will, we must simplify this effort. This effort will help

International Journal of Science and Healthcare Research (www.ijshr.com) 352 Vol.5; Issue: 2; April-June 2020 Adeniyi David Segun et.al. HIV and COVID-19 comorbidity: current evidence reduce the challenge of transportation and 7. CONCLUSION restrictions placed on movement by The emergence of the COVID-19 pandemic governments because of the COVID-19 in early December 2019 at Wuhan, China, Pandemic. Moreover, for some PLWH who has so far changed some fundamental tenets are afraid of visiting the hospitals because of the global order, as we know it. Massive of the possible comorbidity risk associated global economic down turns, loss of jobs with HIV and COVID-19, and the and sources of livelihoods, changes in social possibility of having hospital contact with structures and a redefining of norms and COVID-19 patients, having their viral load social exchanges. [27,28] Several chronic samples taken at the community will come diseases conditions increase the risk, case as a great relief. This effort when properly fatality, and mortality rate of the COVID-19 harnessed could help in maintaining the infection. In the midst of the hardships and gains made at meeting the UNAIDS third 90 mental stress caused by this pandemic, target. chronic diseases such as hypertension, 6.4 Enhance Adherence Counselling diabetes, COPDs, Cardiovascular diseases, (EAC) and Cerebrovascular diseases all increases The essence of carrying out HIV the chances of a case fatality with SARS- viral load testing for PLWH is to assessing CoV-2 infection. [3,5,8] Studies have however the efficacy of a given ARV regimen and to shown that with a normal CD4 T-helper monitoring HIV viral load suppression. The cells count (>200 cells/µl), and with active WHO has defined HIV viral load ARV regimen with no underlying chronic suppression as an HIV patient having a health conditions, PLWH have similar circulating HIV RNA of <1000 copies/ml; survival outcome with averagely healthy and an unsuppressed HIV viral load as individuals who are infected with the having a circulating HIV RNA of >1000 SARS-CoV-2.Thus, HIV infection copies/ml. [26] PLWH with unsuppressed comorbidity with COVID-19 does not HIV viral load are to be immediately predispose PLWH to additional risk, tracked and enrolled into the EAC program. provided the HIV viral load is suppressed A mandatory HIV viral load re-testing is to (<1000 copies/ml) with a normal CD4 T- be carried out at the end of the EAC helper cells count (>200 cell/µl). [12] Several program in order to assessing the un- drugs are undergoing trials as treatment suppression to know whether it is because options against the COVID-19, however, of non-adherence or because of ARVs Hydroxychloroquine with or without failure. The outcome of the EAC should Azithromycin, Chloroquine, and determine the next course of action for such Lopinavir/Ritonavir have all been proven a client. not to be effective against the SARS-CoV-2 6.5 Community Support Group infection. [12, 20, 22] Some of these drugs have Member also shown a deleterious adverse effect on The HIV Community Support Group patients in randomized control trials. Two Members (CSGMs) plays a pivotal role in drugs, Remdesivir and Famotidine are helping to mobilize PLWH in the currently been tested for their promising communities for HIV care and services. efficacy at increasing the survival chances This experienced and specialized PLWH of COVID-19 patients. [12,22] In addition, a should be involved in Community Tracking, dysregulated immune response to COVID- ARV mobilization for PLWH in the 19 infection seen in PLWH might possibly communities, and mobilization for viral load be conferring some level of protection sampling. As informed members of PLWH against the SARS-CoV-2 infection in in the communities, the CSGMs should PLWH. [18-19] serve as the voice and eye of the HIV A lot has changed in the HIV care programs at the community level. services because of the COVID-19

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International Journal of Science and Healthcare Research (www.ijshr.com) 355 Vol.5; Issue: 2; April-June 2020