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Incidence and Severity of COVID-19 in HIV-Positive Persons Receiving Antiretroviral Therapy: A Cohort Study

Our take —

In this large, multi-site cohort study of 60 HIV clinics throughout Spain, age- and sex-adjusted risk estimates of COVID-19 diagnosis, hospitalization, ICU admission, and death were similar for persons with and without HIV. Of most interest, HIV-positive patients receiving TDF/FTC had a lower risk for COVID-19 and hospitalization than all other regimens. However, generalizability may be limited due to high rates of viral suppression in the population, and, additionally, residual confounding due to co-morbid conditions or selection bias due to differential testing patterns cannot be ruled out.

Study design

Retrospective Cohort

Study population and setting

The objective of this study was to describe the incidence, severity, and mortality of PCR-confirmed SARS-CoV-2 infection among 77,590 persons living with HIV (PLWH) receiving antiretroviral therapy (ART) at 60 Spanish hospitals. Patients were followed from February 1 to April 15, 2020. Age, sex, and ART regimen distributions were compared between the population of HIV clinics and those reported in the 2019 National HIV Hospital Survey. The Spanish National COVID-19 Health Information System and National Statistics Institute were also used to compare age and sex-standardized risks of COVID-19 between PLWH and the general population.

Summary of Main Findings

During the study period, 236 PLWH receiving ART in Spain were diagnosed with COVID-19 (86% male, 42% were 50-59). Standardized to the age and sex of the general population of Spain, the risk for COVID-19 diagnosis, hospitalization, ICU admission, and death among PLWH were 30 per 10,000, 17.8 per 10,000, 2.5 per 10,000, and 3.7 per 10,000, respectively. Over the same time period, the risks for COVID-19 diagnosis and death in the general population were 41.7 per 10,000 and 2.1 per 10,000. Similar to those not living with HIV, older age (>70) and male sex were associated with higher risk for COVID-19 diagnosis, severe disease and death among PLWH. Interestingly, PLWH receiving TDF/FTC (16% of all PLWH receiving ART but only 9% of COVID-19 diagnosis) had the lowest risks for COVID-19 diagnosis and hospital admission, relative to those taking other therapies, and none were admitted to the ICU or died.

Study Strengths

This was a large multi-site study, leveraging numerous rich data sources to characterize the age- and sex-standardized risks of COVID-19 diagnosis, hospitalization, ICU admission, and death, among PLWH in Spain and compared to the general population in Spain.


ART use is high in Spain (>90%), and 95% of this study population (65% of all people receiving ART in Spain) has achieved viral suppression, so the results may be of limited generalizability to populations where ART use and viral suppression are less common. Reporting delays, lack of adjustment for factors other than age and sex, frequency of health care seeking behavior, and differences in behavioral precautions in the timeframe of COVID-19 justify cautious interpretation of the comparisons between PLWH and the general population. The findings that PLWH on TDF/FTC are at lower risk for COVID-19 are novel, and more attention to the underlying mechanisms driving the observation is warranted. It is possible that patients who receive TDF/FTC are in some ways (other than age and sex) different from the overall population of PLWH receiving ART, perhaps by removal of the most susceptible persons, but the authors think this unlikely.

Value added

This was a well-designed, multi-site, cohort study including the largest population of people living with HIV (PLWH) to date.

This review was posted on: 18 July 2020