The emergence of the current pandemic is far reaching, with devastating effects on individuals with chronic health conditions such as HIV who also face multiple morbidities, being at heightened risk of experiencing severe complications from the Novel coronavirus. Such comorbidities need to be considered alongside other socially produced burdens to identify the roots of health disparities. Furthermore, the impacts of the virus also amplify the effects of mental health and other pre-existing health concerns, especially for marginalized communities. Using the context of a syndemic perspective to understand the impact of COVID-19 on people living with HIV, this paper’s purpose is to list: (a) similarities and differences between the viruses, (b) note the current status future outlook for PLWH regarding psychosocial factors and overall health implications, and (c) suggest a call to action for the community to respond to the impact of COVID-19 on HIV treatment and prevention.
As the Coronavirus has impacted millions of lives around the globe, it has only scratched the surface for the average person. According to the CDC, those at increased risk for the virus include those with HIV/AIDS, or people living with HIV (PLWH) (4). This leads to a large disproportion of people infected with COVID-19 if they have an underlying medical condition. However, the HIV and AIDS epidemic remains heavily burdened by the new virus due to its limited treatments and underlying socioeconomic issues across the globe that perpetuate the cycle for infections.
A syndemic, as defined by Shiau, is where two or more epidemics synergistically work together to produce an increased burden of one or both diseases in the population (21). With perspective, a severe infection of COVID-19 results in a heavier burden for PLWH biologically and socially. Biologically, a weaker immune system due to Coronavirus, already weakened by HIV, would see much quicker deterioration in health and therefore much more likely to catch other infections as well, such as a flu virus, staphylococcus, UTIs, and STDs. In addition, older PLWH are particularly susceptible to contracting chronic non-communicable diseases, such as diabetes, hypertension, cardiovascular disease, and chronic lung disease (21).
To date, most analyses have noted the importance of the syndemic framework that the coronavirus and HIV presents. Their similar modes of transmission and current orders that restrict physical human interactions work together to significantly increase infection rates. In the midst of HIV, PLWH may also face many other challenges, such as mental health burden, substance abuse, financial struggles, and/or psychosocial drivers that only progress HIV to AIDS faster. Here, we observe and discuss how HIV and medical comorbidities synergistically function with the Coronavirus in increasing infection and morbidity rates.
An observation study conducted by Vizcarra and colleagues noted the current estimates of the prevalence of HIV and COVID-19 co-infections in Madrid, Spain and reported it to be 3.8% of the cohort of 1339 PLWH who contracted COVID-19 (24). In another study, Richardson et al. calculated a 0.8% prevalence of HIV among 5700 patients admitted with COVID-19 across twelve different hospitals in New York (20). Several studies have noted that PLWH with COVID-19 have a decade lower average age compared to those without HIV, despite similar prevalence and comorbidities (7). This raises the possibility that the age threshold for determining high risk among the HIV positives differs from that in the general population and thus could lead to much more serious implications. On the contrary, ethnic disparities in COVID-19 incidence have also been noted among the PLWH population. A study conducted in the UK revealed that Black individuals in a cohort of HIV-positive population had significantly higher chances of being hospitalized with COVID-19 compared to non-Black individuals (2). In another Veterans Aging Cohort Study (VACS) consisting of 30,891 PLWH , 70 % were Black and Latino veterans independent of HIV status who were 40% more likely than Caucasians to contract COVID-19 (16). Factors such as a higher prevalence of comorbidities, increased occupational exposure as well as other socioeconomic factors play a role in explaining the reasons behind this.
The COVID-19 mortality rate among the PLWH population does not differ from the general population. A case-control study conducted by Sigel et al. compared 88 PLWH with COVID-19 in New York City who were then matched to individuals without HIV-1 infection on age, sex, race/ethnicity and week of infection (22). The study found no difference in ventilation treatment, in hospitalization, ICU admission, intubation, or death. Similarly, another study by Lee et al. found no mortality difference by HIV status but noted that individuals with HIV were more likely to show clinical improvements and be discharged within 28 days of admission (14).
The study conducted by Vizcarra et al. noted a much higher prevalence of comorbidities among PLWH with COVID-19 than individuals without HIV, which was 63% and 38% respectively (24). The older PLWH population are reported to have a higher risk of non-communicable comorbidities, including diabetes, hypertension, cardiovascular disease, and chronic lung disease than uninfected individuals of similar age (5). Such comorbidities have presumptive mechanisms of chronic inflammation caused by HIV or its treatments; this is further supported by epidemiologic evidence which suggests that both older age and a number of comorbidities are risk factors for severe COVID-19 implications (8). Although there is very limited data published on COVID-19, HIV-coinfection and on the potential protective effects of HIV antivirals, the evidence nonetheless allows for a better understanding through a syndemic framework.
A study conducted by Fang and colleagues identified the expression of ACE2 (the angiotensin-converting enzyme 2 as a crucial factor that facilitates SARS-CoV-2 virus to bind and enter host cells, to be substantially increased in patients with diabetes and hypertension (9). In their case series, Vizcarra et al. found individuals who became critically ill tended to have low levels of CD4 T cell counts (<200 cells/μL) (24). Another study performed by Ho et al. analyzed 72 individuals with HIV-1 and COVID-19 in New York City found that individuals who did not survive had lower levels of lymphocyte counts and higher levels of inflammatory markers (C-reactive protein, IL-6, and IL-8) compared to those who survived (11). In parallel, the trial conducted by Patel et al. noted a higher rate of death and intubation among HIV positive patients who were virally suppressed and also had higher CD4 T cell counts (17). Since HIV acts primarily by depleting the immune system cells, namely macrophages and CD4+ cells, these findings suggest that the higher CD4 T cell count leaves one vulnerable to opportunistic infections.
Antiretroviral therapy (ART), that is the first line of HIV treatment, consists primarily of a combination of three drugs that suppress the progression of HIV virus. Soon after an individual is diagnosed with HIV, the treatment regimen begins. The therapy has shown to improve life expectancy of HIV positive individuals dramatically, especially when initiated earlier in the course of infection. However, many of these clinical trials have been halted to maintain social distancing and focus efforts solely on COVID-19 research. Instead, a global effort has been made to research how to combat HIV alongside COVID-19. Examples of ongoing clinical trials include studying patients who are using Pre-Exposure Prophylaxis (12) and/or HIV Protease Inhibitors in their treatments and the use of Nucleoside reverse transcriptase inhibitors (NRTIs) (13). Pre-Exposure Prophylaxis is an effective way to protect people from contracting HIV from people who do have the virus, while HIV protease inhibitors prevent viral DNA replication (18,19,25). NRTIs block viral RNA synthesis by acting on the RNA-dependent RNA polymerase and form the backbone of first-line ART (13).
Concerning the novel COVID-19 mRNA vaccines, there are some worried that PLWH are being excluded from large phase III studies assessing the vaccine efficacy (13). Considering that current ART regimens have no protective effect against the Coronavirus, we do not see a clinical justification for excluding people with a manageable HIV-1 when other types of patients with less severe medical conditions are prioritized to participate in these studies. The unconscious exclusion can further reduce access to PLWH, as seen with Zostavax several years ago. Some people living with HIV were not able to initially access Zostavax due to a lack of insurance or obtaining insurance, until a separate clinical trial was made available for others. This added stress and frustration can only increase the mental health burden many people living with HIV face (1).
Psychosocial implications are essential in understanding the causes of health disparities for people living with HIV or AIDS (21). Figure 1 (21) depicts the increased likelihood that PLWH have for an increased mental health burden, substance and illicit drug abuse, and malnutrition (23),which are amplified by these psychosocial burdens for marginalized communities due to their social identity, including race, ethnicity, sex, gender, and socioeconomic status. However, the impact of these factors are very fluid, as it is dependent upon an individual’s overall situation.
The likelihood a person living with HIV will seek treatment, both for HIV and the social issues or barriers they may be faced with, also depends on the ongoing pandemic. Social distancing coupled with an increased mental health burden are especially powerful factors in perpetuating the health disparities across the world. People living with HIV rely on regular hospital/clinic visits and treatment, so long-term health outcomes may be vulnerable due to COVID-19. Less social interactions with a lockdown also prevents a PLWH from seeing friends and family who serve as their support system, including those who are usually physically a part of their day-to-day life. In addition, older PLWH already experience heightened rates of loneliness and social isolation. With these added burdens, evidence in a study for people living with HIV aged 50 and over showed diminished neurocognitive functioning and heightened mental health burden, which may impede upon effective self-care (10). Food insecurity may also put one at high risk for the syndemic, due to the domino effect it may incur on a person’s situation. It has previously been known to increase HIV transmission risk, leading to poor clinic attendance, poor ART adherence, poor immunological and virologic responses, lower efficacy of ART, and high mortality rates (24).
The burden of being a less developed country may also infringe upon one’s ability to receive proper HIV and COVID-19 treatment. In China, reports show that people living with HIV are struggling to find access to antiretroviral therapy due to the COVID-19 pandemic, stigma, and discrimination (26). If PLWH do not have access to ART, viremia is likely to increase, which increases the risk for contracting opportunistic infections, thereby increasing the likelihood of transmission to others (6).
A current method to ensure not just PLWH have access to healthcare but also the general population is telemedicine. Providers can either have a phone or video call with their patients. So far, it has been especially helpful for mental healthcare providers in transitioning their practices to use resources from The American Psychological Association’s (APA) Joint Task Force for the Development of Telepsychology Guidelines for Psychologists (3). Some sub-populations of PLWH who have also benefited from this mode of healthcare access include women and smokers (15). In regards to research, scientists have also been encouraged to get creative with their HIV projects to include as much of the population as possible for their studies. For example, this could mean adding the impact of COVID-19 in addition to their project or expanding the population to which they are studying. Finally, researchers and healthcare providers are also encouraged to reduce health disparities. This may include expanding economic and social support, building trust, and actively denouncing stigmas (3).
This paper outlined the current impact of comorbidities and pathology regarding HIV and COVID-19, as well as their psychosocial implications and their syndemic relationship. Pandemics have the power to control the social climate as well as the manageability of illnesses and diseases. Current treatments were also discussed to shed light on how the scientific community can continue making strides for people living with HIV. It is important for not only the healthcare community but across the world to acknowledge and denounce the stigmas that still plague our HIV/AIDS community today to promote a positive, social outlook and progress in HIV/AIDS research. Essentially, it is imperative to note that pandemics biological, psychological, and social implications, in which healthcare providers and scientists across the globe play a crucial role in their responses.
Sarah Khair
B.A Anthropology ---- University of California, Santa Cruz
Camille Fang
B.S Human Biology ---- University of California, San Diego
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