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COVID-19 Risk and ART

CME

COVID-19 Risk in Patients With HIV: Implications for ART Management

Physicians: Maximum of 0.50 AMA PRA Category 1 Credit™

Released: April 10, 2020

Expiration: April 09, 2021

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For persons with HIV (PWH) and for the clinicians who provide their care, a critical question during the current pandemic is whether COVID-19, the disease caused by SARS-CoV-2, is more severe in PWH. Currently, we have no clear data to answer this question. However, based on the risk factors that have been identified for severe COVID-19 disease in the general population, we can speculate that many PWH may be at risk—likely not due to HIV itself, but due to age-related medical conditions and comorbidities that tend to occur more frequently among PWH. First, individuals who are older than 60 years of age have a higher incidence of severe disease. In the United States, approximately 50% of PWH are older than 50 years of age, so this group is at increased risk by virtue of their age. In addition, PWH tend to have higher rates of certain underlying comorbidities, such as hypertension and cardiopulmonary diseases, and are more likely to be smokers, additional risk factors that are associated with more severe COVID-19 disease.

To advise clinicians during this urgent and dynamic public health crisis, the DHHS has released interim guidance on COVID-19 for PWH. Here are my key takeaways from the guidance regarding protecting our patients from COVID-19 exposure and infection.

Advice for Patients with Stable HIV Disease
The guidance for individuals with stable HIV disease—that is, someone with stable HIV suppression and stable health—is similar to those who are HIV negative in terms of practicing CDC-recommended prevention measures such as social distancing and frequent handwashing. For stable patients who typically report to the clinic every 6 months, we can defer routine visits so that they are not entering a busy outpatient clinic or hospital and risking exposure. I find this guidance very practical; it is extremely unlikely that a stable patient will have an issue if they delay their next appointment to 9 or 10 months vs 6 months.

The DHHS also recommends that all PWH should maintain an adequate ART medication supply, ideally increasing from a typical 30-day supply to a 90-day supply. This will prevent potential interruptions in HIV treatment and help patients avoid unnecessary visits to pharmacies. Moreover, patients should try to arrange for medication delivery if possible. I have received several recent requests from patients to prescribe 90-day ART supplies, and I know that some third-party payers are reimbursing for an increased ART supply during these exceptional circumstances. Of note, patients receiving biweekly ibalizumab infusions warrant specific consideration, and arrangements should be made for continued administration of these infusions without interruption.

Advice for Patients With Severe Immunosuppression
For patients with severe HIV-related immunosuppression, again, we do not have clear evidence, but we would speculate that their risk for severe COVID-19 is probably higher because they are generally at increased risk for a variety of infections (the guidance specifically mentions influenza). This group would include individuals who are not receiving ART treatment, either because they have undiagnosed HIV or because they experience barriers to receiving and/or adhering to effective therapy. In particular, patients with CD4+ cell counts < 200 cells/mm3 are potentially at higher risk of severe disease.

By contrast, there is one hypothesis positing that immunocompromised individuals may be protected from some immune-mediated aspects of COVID-19 disease. However, that is strictly a hypothesis and most of us tend to think that immunocompromised individuals are likely at a higher risk.

Advice Regarding ART Switching
The interim guidance addresses switching ART in specific scenarios. First, we should consider delaying regimen changes in cases where a switch was planned. If possible, we should wait until a safer time for the close monitoring and frequent follow-up visits that are required during a regimen switch. For patients with low level viremia (HIV-1 RNA between 50-200 copies/mL), remember, there is no firm guidance on how to manage these patients aside from adherence counseling. I would strongly caution against switching ART in these patients at this time. The DHHS guidance recommends telemedicine to continue nonurgent care and adherence counseling. By contrast, patients with virologic failure (HIV-1 RNA ≥ 200 copies/mL) should probably be evaluated sooner vs later. In this case, I might arrange for a quick blood draw that includes resistance testing followed by a telemedicine visit to discuss the best management options.

Finally, the DHHS offered specific caution against switching patients to an ART regimen containing lopinavir (LPV)/ritonavir (RTV) in the hopes that it will be protective against SARS-CoV-2 infection. Although there has been speculation that LPV/RTV may have antiviral activity against SARS-CoV-2 and clinical trials are underway to assess its efficacy, an early report found no significant difference in COVID-19 outcomes between hospitalized patients who received LPV/RTV vs standard of care. In addition, there is currently no evidence that any other ARV agents are active against SARS-CoV-2, so there is no indication for ART switching for this purpose.

Your Thoughts
How are you counseling PWH in your practice regarding their risks and safety during the COVID-19 pandemic? Answer the polling question and please share your thoughts in the discussion section.

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