Q&A on COVID-19, HIV and antiretrovirals

April 2, 2020April 2, 2020 admin 0 Comments

Table of Contents

Are people living with HIV at increased risk of being infected with the virus that causes COVID-19?

                People living with HIV with advanced disease, those with low CD4 and high viral load and those who are not taking antiretroviral treatment have an increased risk of infections and related complications in general.  It is unknown if the immunosuppression of HIV will put a person at greater risk for COVID-19, thus, until more is known, additional precautions for all people with advanced HIV or poorly controlled HIV, should be employed[1],[2].

At present there is no evidence that the risk of infection or complications of COVID-19 is different among people living with HIV who are clinically and immunologically stable on antiretroviral treatment when compared with the general population. Some people living with HIV may have known risk factors for COVID-19 complications, such as diabetes, hypertension and other noncommunicable diseases and as such may have increased risk of COVID-19 unrelated to HIV. We know that during the SARS and MERS outbreaks there were only a few case reports of mild disease among people living with HIV.

To date, there is a case report of a person living with HIV who had COVID-19 and recovered[3] and a small study on risk factors and antiretrovirals used among people living with HIV with COVID-19 from China. This study reported similar rates of COVID-19 disease as compared to the entire population and increased risk with older age, but not with low CD4, high viral load level or antiretroviral regimen[4]. Current clinical data suggest the main mortality risk factors are linked to older age and other comorbidities including cardiovascular disease, diabetes, chronic respiratory disease, and hypertension. Some very healthy people have also developed severe disease from the coronavirus infection[5].

PLHIV are advised to take the same precautions as the general population[6],[7]:

wash hands often

cough etiquette

physical distancing

seek medical care if symptomatic

self-isolation if in contact with someone with COVID-19 and

other actions per the government response

People living with HIV who are taking antiretroviral drugs should ensure that they have at least 30 days and up to 6-month supply of medicines and ensure that their vaccinations are up to date (influenza and pneumococcal vaccines). Adequate supplies of medicines to treat co-infections and comorbidities and addiction should also be ensured.

Can antiretrovirals be used to treat COVID-19?

Several studies have suggested that patients infected with the virus causing COVID-19, and the related coronavirus infections (SARS-CoV and MERS-CoV) had good clinical outcomes, with almost all cases recovering fully. In some cases, patients were given an antiretroviral drug: lopinavir boosted with ritonavir (LPV/r). These studies were mostly carried out in HIV-negative individuals.

It is important to note that these studies using LPV/r had important limitations. The studies were small, timing, duration and dosing for treatment were varied and most patients received co-interventions/co-treatments which may have contributed to the reported outcomes.

While the evidence of benefit of using antiretrovirals to treat coronavirus infections is of very low certainty, serious side effects were rare. Among people living with HIV, the routine use of LPV/r as treatment for HIV is associated with several side effects of moderate severity. However, as the duration of treatment in patients with coronavirus infections was generally limited to a few weeks, these occurrences can be expected to be low or less than that reported from routine use.

Can antiretrovirals be used to prevent COVID-19 infection?

Two studies have reported the use of LPV/r as post-exposure prophylaxis for SARS-CoV and MERS-CoV. One of these studies suggested that the occurrence of MERS-CoV infection was lower among health workers receiving LPV/r compared to those who did not receive any drugs; the other study found no cases of SARS-CoV infection among 19 people living with HIV hospitalized in the same ward of SARS patients, of whom 11 were on antiretroviral therapy. Again, the certainty of the evidence is very low due to small sample size, variability in drugs provided, and uncertainty regarding intensity of exposure.

What studies on treatment and prevention of COVID-19 with antiretrovirals are being planned?

Several randomized trials are planned to assess the safety and efficacy of using antiretroviral drugs – mainly LPV/r – for treating COVID-19, in combination with other drugs. Results are expected from mid-2020 onwards.

What is WHO’s position on the use of antiretrovirals for the treatment of COVID-19?

Currently, there is insufficient data to assess the effectiveness of LPV/r or other antivirals for treating COVID-19. Several countries are evaluating the use of LPV/r and other antivirals and we welcome the results of these investigations.

Again, as part of WHO’s response to the outbreak, the WHO R&D Blueprint has been activated to accelerate evaluation of diagnostics, vaccines and therapeutics for this novel coronavirus. WHO has also designed a set of procedures to assess the performance, quality and safety of medical technologies during emergency situations.

What is WHO’s position on use of corticosteroids for the treatment of COVID-19?

The current interim guidance from WHO on clinical management of severe acute respiratory infection when COVID-19 infection is suspected advises against the use of corticosteroids unless indicated for another reason.[8]

This guidance is based on several systematic reviews that cite lack of effectiveness and possible harm from routine treatment with corticosteroids for viral pneumonia or acute respiratory distress syndrome.[9]

If countries use antiretrovirals for COVID-19, are there concerns about treatment shortages for people living with HIV?

Antiretrovirals are an efficacious and highly tolerable treatment for people living with HIV. The antiretroviral LPV/r is currently being investigated as a possible treatment for COVID-19.

If they are to be used for the treatment of COVID-19, a plan should be in place to ensure there is adequate and continuous supply to cover the needs of all people living with HIV already using LPV/r and those who will need to begin treatment. However, a relatively small proportion of people are on regimens which include LPV/r, since it is used as a second-line regimen according to WHO’s HIV treatment guidelines. Any country that allows the use of HIV medicines for the treatment of COVID-19 must ensure that an adequate and sustainable supply is in place.

How do we ensure human rights and reduce stigma and discrimination?

As the world scales up public health responses to the COVID19 pandemic, countries are being urged to take decisive action to control the epidemic. WHO has urged all countries to ensure an appropriate balance between protecting health, preventing economic and social disruption, and respecting human rights.

WHO is working with partners including the UNAIDS Joint Programme and the Global Network of People Living with HIV to ensure that human rights are not eroded in the response to COVID-19 and to ensure that people living with or affected by HIV are offered the same access to services as others and to ensure HIV-related services continue without disruption.

To mitigate potential prison outbreaks of COVID19 and reduce morbidity and mortality among people in prisons and other closed settings, it is crucial that prisons and immigration detention centres are embedded within the broader public health response. This requires close collaboration between health and justice ministries and includes protocols for entry screening, personal protection measures, physical distancing, environmental cleaning and disinfection, and restriction of movement, including limitation of transfers and access for non-essential staff and visitors. In the current context it is of critical importance that countries work toward developing non-custodial strategies to prevent overcrowding in closed settings[10]. Governance of prison health by a ministry of health, rather than a ministry of justice or similar, is likely to facilitate this[11].

How can programmes assure continued access to HIV services?

It is important to assure continuous access to essential HIV prevention, testing and treatment services also where measurements of confinement are implemented within the public health response to the COVID-19 pandemic. While access to essential services should be maintained, adapted and evidence-based measures to reduce possible transmission should be considered and implemented. These include[12]:

Applying standard precautions for all patients (including ensuring that all patients cover their nose and mouth with a tissue or elbow when coughing or sneezing, offering a medical mask to patients with suspected COVID-19 infection while they are in waiting in the service, perform hand hygiene etc.)
Health care and outreach workers, as well as peer educators and clients should apply adapted hand hygiene measures
Ensuring triage, early recognition, and source control (isolating patients with suspected COVID-19 infection)
Ensure there is adequate ventilation in all areas in the healthcare facility
Spatial separation of at least 1 metre should ideally be maintained between all patients within all types of services
Cleaning and disinfection procedures should be followed consistently and correctly
Dispensing medicines (for treatment of HIV, TB and other chronic conditions such as opioid dependence) for longer periods allowing reduced frequency of patient visits
Consider reduction of services to the most critical ones (provision of essential treatment and prevention services; services such as counselling sessions may be reduced or adapted)

Generally, vulnerable populations, including members of key populations, as well as homeless and/or displaced people may be at increased risk of infection – because of additional comorbidities impacting on their immune system, reduced ability to apply measures of confinement and social distancing, as well as generally limited access to health services. It is critical that services that reach these populations such as community-based services, drop-in centres and outreach services can continue providing life-saving prevention (distribution of condoms, needles and syringes), testing and treatment while securing safety of staff and clients. Services can be adapted according to above considerations where applicable.

What is the role multi-month prescriptions and dispensing for antiretrovirals and other medicines?

                Clinically stable adults, children, adolescents and pregnant and breastfeeding women as well as members of key populations (people who inject drugs, sex workers, men who have sex with men, transgender people and people living in prisons and closed settings) can benefit from simplified antiretroviral therapy delivery models which include multi-month prescriptions and dispensing (3-6 month supply) which will reduce the frequency of visits to clinical settings and ensures continuity of treatment during possible disruption of movements during the coronavirus outbreak.  Similar consideration should be given to providing people who are clinically stable on methadone or buprenorphine substitution therapy with an increased possibility for take-home medications to reduce additional burden on the health sector.
                <h3 id="elementor-tab-title-20411" data-tab="11" role="tab" aria-controls="elementor-tab-content-20411">
                                            <a href="">Can pregnant or postpartum women living with HIV transmit the COVID-19 virus to their unborn child or infant?</a>
                </h3>
                There are few data on the clinical presentation of COVID-19 in specific populations, such as children and pregnant women[13] but findings from a small published study suggest that there is currently no evidence for intrauterine infection caused by vertical transmission in women who develop COVID-19 pneumonia in late pregnancy[14].<strong>  </strong>Although no vertical transmission has been documented, transmission after birth via contact with infectious respiratory secretions is a concern. Infants born to mothers with suspected, probable, or confirmed COVID-19 should be fed according to standard infant feeding guidelines[15], while applying necessary precautions for infection prevention and control (IPC).  As with all confirmed or suspected COVID-19 cases, symptomatic mothers who are breastfeeding or practicing skin-to-skin contact or kangaroo mother care should practice respiratory hygiene, including during feeding (for example, use of a medical mask when near a child if the mother has respiratory symptoms), perform hand hygiene before and after contact with the child, and routinely clean and disinfect surfaces with which the symptomatic mother has been in contact[16].   
                <h3 id="elementor-tab-title-20412" data-tab="12" role="tab" aria-controls="elementor-tab-content-20412">
                                            <a href="">Should pregnant and breastfeeding women living with HIV with COVID-19 and their newborns be managed differently?</a>
                </h3>
                There is currently no known difference between the clinical manifestations of COVID-19 or risk of severe illness or foetal compromise for pregnant and non-pregnant women or adults of reproductive age.  Pregnant and recently pregnant women with suspected or confirmed COVID-19 should be treated with supportive and management therapies, considering the immunologic and physiologic adaptations during and after pregnancy which may overlap with COVID-19 symptoms.  Data are limited but, until the evidence base provides clearer information, special consideration should be given to pregnant women with concomitant medical illnesses who could be infected with COVID-19. There are no reported deaths in pregnant women at time of publishing this information[17] however, COVID-19 testing of symptomatic pregnant women may need to be prioritized to enable access to specialized care.  All recently pregnant women with COVID-19 or who have recovered from COVID-19 should be provided with information and counselling on safe infant feeding and appropriate IPC measures to prevent COVID-19 virus transmission[18].

With confirmed disease or under investigation, management is similar to non-pregnant women, with appropriate isolation of confirmed or under investigation. Obstetric facilities must be notified and prepared, noting that each infant born to any mother with confirmed COVID-19 should be considered a ‘person under investigation’ and should be isolated according to the IPC guidance. Currently, it is unknown whether newborns with COVID-19 are at increased risk for severe complications.