How has our knowledge of COVID-19 and how it affects people with HIV evolved? IDSA board member Max Brito, MD, FIDSA of the University of Illinois at Chicago and HIVMA board member Rachel Bender Ignacio, MD, FIDSA of the University of Washington discuss the latest COVID-19 clinical considerations for people with HIV and the broader impacts of the COVID-19 pandemic on the HIV community and efforts to end the HIV epidemic.
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The Infectious Diseases Society of America (IDSA) is a community of over 12,000 physicians, scientists and public health experts who specialize in infectious diseases and strive for excellence in patient care, education, research, public health and prevention.
Amanda Jezek: [00:00:00] Hello, I'm Amanda Jezek, IDSA's senior vice President for Public Policy and Government relations. Welcome to IDSA's COVID-19 podcast series that aims to keep IDSA members, medical professionals and the public informed during this pandemic by talking with experts in the field of infectious diseases. In this episode, we'll be discussing the impact of COVID-19 on the HIV community, with IDSA board member Dr. Max Brito of the University of Illinois at Chicago and HIVMA board member Dr. Rachel Bender Ignacio of the University of Washington. Thank you both so much for joining us today. Dr. Bender Ignacio, how has our knowledge of COVID-19, and particularly how it affects people with HIV evolved over the last two plus years? And have any factors been identified that put people with HIV at greater risk, either for acquiring COVID or getting seriously ill from COVID-19?
Rachel Bender Ignacio, MD: [00:00:54] I think we have a little bit more specificity about the specific immunologic risks, as well as other risks that could put people with HIV at higher risk of both acquiring COVID and getting sick from COVID 19. So first off, to talk about who gets COVID. Well, I think we've learned not just from populations with HIV, but from general populations in the United States and across the world, that socially marginalized populations are at some of the highest risk of being exposed and therefore acquiring COVID-19. So one of the things that we worry about specifically among people with HIV is social marginalization, living in places where people can't necessarily isolate or protect themselves or having work or other obligations that might put them at risk. We saw this through the cohort work that I helped conduct, the integrated network of clinical systems. And what we really saw was that where somebody lived, which city they lived in and some factors of their identity, including racial or ethnic identity, was really influential in whether or not they acquired COVID. We actually didn't find that HIV specific factors were very influential in predicting who was diagnosed with COVID. However, when we look at who gets sick from COVID-19, we found some other predictors, including HIV specific risk factors. So persons with a CD4 count below 350 were at the highest risk in terms of immunologic factors, as well as people whose lowest recorded CD4 count or CD4 nadir was below 200, or people who currently had a low CD4 CD8 ratio.
[00:02:30] So what we take from this is it's not just current CD4 count, but also how exhausted or how tired somebody's immune system may be from responding to HIV or other chronic infections that may influence how well that they can protect themselves from becoming more sick with COVID. And also, this is probably not specific to HIV, but haven't seen this looked at in any other populations. We were able to show that the ASCVD risk score and the FIB-4 calculator score were able to predict who got sicker with COVID. And these are really commonly used tools that clinicians, primary care physicians can use to help have a conversation with their own patients about looking at somebody's risk. And these take into account liver inflammation and cardiovascular risk factors. So we know that these are common risk factors among the general population. And again, in addition to the CD4 counts thresholds that I mentioned, we also know that metabolic and cardiovascular comorbidities, chronic renal disease and diabetes put people at risk of COVID. And we can also use these simple calculators to help have that conversation and share decision making with our patients.
Jezek: [00:03:40] Dr. Brito, are the COVID-19 vaccines as safe and effective in people with HIV? And how are COVID-19 vaccination rates doing among people with HIV?
Max Brito, MD: [00:03:51] COVID vaccines are very safe in patients with HIV. We haven't detected any problems or any severe side effects or side effects outside of the norm, for that matter, in people with HIV. Effectiveness is also has proven to be very good as well as with all vaccines. The degree of immunosuppression in patients with HIV would be important when we're looking at the effectiveness of the vaccine. For example, folks who have a CD4 count below 200 who are severely immunosuppressed, then they will respond poorly to any vaccines. And I think that that could be the case in the COVID vaccine with the mRNA technology. However, that is not an excuse for not vaccinating patients. Perhaps it would be something to consider for a more close follow up of these patients and perhaps giving boosters at an earlier time in patients who have a CD4 less than 200 because the vaccines are safe and effective and prevent severe disease and. All HIV patients, regardless of CD4, should get it. Now, as to the question of what are the vaccination rates amongst HIV people living with HIV. A recent study published or discussed at Croydon in 2022. In February 2022, shed some light on this issue, and it seems like the vaccination rates mirror the vaccination rates of the population at large, so the wider population. They found that the same disparities and facilitators to vaccination are similar between the general population and folks with HIV.
[00:05:37] For example, rates. This study was done as part of the REPRIEVE trial, which is a trial looking at statins to prevent cardiovascular disease in patients with HIV. So they looked at all the patients participating in this study, and then they found that there were disparities by region of the world and international randomized study. So folks in sub-Saharan Africa, the uptake of vaccine in sub-Saharan Africa is much lower than the uptake in more developed settings where the average uptake amongst patients with HIV is about 70%, whereas in sub-Saharan Africa is 48%. However, countries in Southeast Asia have the highest rates of uptake of vaccinations, with about 93% of taking Thailand, for example. So rates of vaccination vary by setting by country and also by socioeconomic status, which is mirroring what happens in the population at large. I should caution you, the listeners, that perhaps the lower vaccination rates in some of these settings has a lot to do with availability of vaccine and not just with the willingness of people to get vaccinated, because as you know, disparities in health exist. Vaccines are not immune to that. We got to be cautious when interpreting data that comes from countries that have different rates of accessibility to vaccines.
Jezek: [00:07:44] Dr. Bender Ignacio, what do you think providers need to know about prescribing COVID-19 antivirals for people with HIV? And do you recommend any of these drugs for your patients?
Bender Ignacio: [00:07:54] Yes, absolutely. I think one of the key messages right now is that oral antivirals, the two that are currently have emergency use authorization being nirmatrelvir-ritonavir and molnupiravir are both really being underutilized, I think, by primary care physicians, HIV providers and general medical providers. We think about people being at higher risk for severe outcomes from COVID. As mentioned previously, those who have a lower CD4 count and potentially people who don't have well-controlled viremia or people who are either not on antiretroviral therapy or not taking their therapy regularly. But we really need to think of when we decide who to treat with antivirals, to think about someone globally and as an entire person. And I have to say that among the population that I take care of most of people's risk factors for severity really have to do with other factors of their health and not specifically their HIV. And so I'm really encouraging HIV providers to think about people and not just their HIV risk factors, things to think about. Does this person have diabetes, cardiovascular disease, chronic renal disease? Are they pregnant? Are they older? We can look at the high-risk criteria when we make these decisions. The NIH also has a tiering system for prioritizing treatments. But we do know that at least in most parts of the United States right now, both of these medications are fairly available at commercial pharmacies. And from talking to both patients and other providers, it's really the know do gap between people having theoretical access to these medications and that they're sitting in a pharmacy and could be prescribed for them, but that providers, whether it's an urgent care or their primary care physician not thinking about some of these risk factors and offering to make that prescription for them, specifically for folks with HIV or being treated for hepatitis C, there are some considerations that people may worry about with drug-drug interactions.
Bender Ignacio: [00:09:59] An antiretroviral therapy, for example. But there is great guidance available on the HIV and websites that talk about how to use specifically nirmatrelvir-ritonavir with HIV protease inhibitors and with hepatitis C protease inhibitors. And the recommendation is for the five days, go ahead and just prescribe both without any alteration. It results in someone getting additional doses of their booster, whether that's cobicistat or ritonavir. But it's just five days and it could potentially result in a little bit of an increased incidence of diarrhea or stomach upset, for example. But it's considered to be very safe. And the alternatives of either not receiving therapy or interrupting HIV therapy could be very important for that patient. And so, again, the recommendation is that that drug, specifically nirmatrelvir-ritonavir, is very effective against COVID-19 and preventing folks from becoming sicker. So please prescribe these regardless of what somebody is antiretroviral therapy regimen is. And if that's not available or there's other drug-drug interactions that can't be avoided, consider molnupiravir. But again, the efficacy of molnupiravir has been shown to be nowhere near as strong as that for ritonavir. And so we would really consider that to be the first option and should be really considered for anyone, regardless of their antiretroviral therapy regimen.
Jezek: [00:11:24] Doctor Brito, will the work that has been done to develop and manufacture our safe and effective COVID-19 vaccines ultimately benefit the development of an HIV vaccine?
Brito: [00:11:35] I believe it will for several reasons. Number one, the distribution scale up and uptake of a vaccine. The process by which that happens has been improved significantly by the COVID pandemic because we produced a vaccine or generated the trials and all the early experience with the vaccine in record times. And that could be a roadmap for other vaccines. The HIV vaccines being being one of them. And the second one is that the mRNA technology is pretty versatile and so it can be used for other diseases, including HIV. And recently the NIH has launched through the HVTN system, the HVTN Network, the HVTN 302 trial, which is a phase one trial to test three vaccines with mRNA technology against HIV. And so trials are on the way. In time, we will know if these trials work for HIV and can proceed to larger trials with clinical trials and randomized that could produce some randomized clinical data. So, yes, absolutely. I mean, not only the technology, but the network and distribution systems that we have used or put in place for this vaccine will serve as well for HIV and other vaccines in the future.
Jezek: [00:13:02] Dr. Bender Ignacio, what do you see as some of the short term and longer-term impacts of COVID-19 on efforts to end HIV as an epidemic in the United States? And are there any lessons learned during the COVID-19 pandemic that could help accelerate our progress toward ending HIV as an epidemic, both in the US and globally?
Bender Ignacio: [00:13:23] So in terms of short-term impact, it still really remains to be seen what the impact has been in the short term on, for example, HIV incidence. When we look at numbers in the United States over the last year or two, there is maybe a false reassurance that the incidence of HIV is going down. However, there's really a significant concern and data would show that there's less HIV testing happening. And so it seems as though we are detecting less HIV rather than there's actually a decrease in this. There's been modeling studies that were done early on in the pandemic that looked at varying changes in human behavior during times during lockdown, as well as interruption in services including and HIV screening services and treatment services, and found that if there is a significant decrease in human behavior, meaning less people were mixing with other people, less sex was happening, for example, that there might be a decrease in HIV acquisition. And if that was coupled with a decrease in services, then maybe we wouldn't see an increase in HIV incidence. However, really this sort of initial phase of the pandemic is over and people have resumed their lives for the most part. And so with humans being humans but still having some interruptions in services as well as ongoing concern about accessing services, I think the concern is that we're detecting less HIV rather than there are fewer cases being acquired. There's really a concern that just like we've seen with rates of substance abuse. An overdose, for example, during the pandemic that impact in services and social isolation and in some ways is at risk of increasing, at least in the short term, HIV incidence. I think we also need to think about the intersecting reasons why HIV and the COVID-19 pandemics are similar, and that's that we really see an impact on marginalized populations, whether that's by sexual identity or by gender and by race and ethnicity and socioeconomic status in the United States and by geography for that matter.
[00:15:34] And so very similar disparities we are seeing between who acquires HIV and who acquires COVID. And so we really need to think about closing the gap on those disparities and think that's a lesson that we can take from this, is that what we've really learned and has come to light not for the first time, but for the second or third time about who's impacted by HIV is also who's impacted by COVID 19. What we really need is obviously closing those disparities, better access to health care, better health care coverage in general, better access as well to treatment for substance use disorders and other factors that can accelerate the HIV epidemic as well as really, as I mentioned, the know do gap or implementation science on getting prep and other efforts to populations at risk for HIV. And in terms of accelerating the process of ending the epidemic in both the US and globally, I think we need to really focus on these barriers in care, building trust in communities and combating misinformation. And that really cuts across whether we're talking about local or global populations and also thinking about focusing, as Dr. Brito said, about not just uptake, but accessibility of these interventions. So getting prep and getting testing services to populations who are impacted both in places that that matters in the United States and globally, and closing that gap in who has access.
Brito: [00:17:05] If I may interject here, Amanda and Dr. Bender. Ignacio, one of the biggest impacts of this pandemic, as we all know, has been on people's mental health. And we've had just echoing what you were saying about all the social determinants of health that have contributed to the wide dissemination of this disease in populations. I can tell you that from my personal experience as an HIV provider, I've had a few patients of my own cohort being hospitalized with COVID, and some of them have died from COVID. But for every patient that I've had hospitalized for severe COVID that has died from COVID, I have five who have worse mental illness and depression than at the beginning of the pandemic. So the impact of mental health of this pandemic on the mental health of individuals with HIV as a whole and to the population as a whole, and the social determinants of health and the differences in the impact that socioeconomic factors and health disparities have had in mental health will be felt for a long time. And we're only beginning to understand how this pandemic has impacted the rates of all those different mental health disorders in our population and substance abuse, like Dr. Bender Ignacio mentioned.
Jezek: [00:18:33] And Dr. Brito, for the last question, I'd like to ask, what have been the impacts of the COVID-19 pandemic on the HIV workforce, and how have you personally managed the tension and stress of responding to COVID-19 while also ensuring that the needs of your patients with HIV are met and that your HIV focused research projects and studies do not fall behind?
Brito: [00:18:54] Luckily, we're getting to some degree of normalcy now. This is beginning to feel more like in our HIV practices 2019, more than 2020 to 2022. The impact that this pandemic has had on the HIV workforce is the same impact that has had for the health care workforce. I mean, nurses, technicians, physicians and everybody who is involved in health care has been impacted significantly. We all had to drop whatever we were doing early 2020 and then devote all our efforts to COVID-19, either by doing administrative stuff to try to get our institutions ready for what was about to come or to take care of patients. We're inundated with patients with COVID-19 in our ERs in those early months of 2020, and that had an impact in our mental health. And when I say our mental health, I, you know, I include. Everyone in the workforce and the health care workforce around the US and around the world. So we've all had to cope with a lot of burnout and there have been people who have left their health care professions to dedicate themselves to something else because the stress was very significant on the workforce in those early days. We had to adapt. We had to see our patients via telehealth. We weren't seeing anybody in person. We managed patients over the phone, especially those who were very well controlled, and there was more of a primary care issue than it was an infectious disease, which is my case problem. You know, we had to adapt. We had to take deliver pills to patients when they couldn't come to the to our office or to our clinics.
[00:20:50] We had to provide more mental health services to our patients who were in need. We have people in our clinics who were experiencing homelessness and lots of isolation. So we had to contend with that and we had to adapt to that. So very, very stressful to try to manage a very complex set of social determinants of health around HIV and COVID added an added layer to what our patients experience every day because of virtue of their socioeconomic status of the health equities in some of these communities. And the way it impacted our research here at UIC, we turned our clinical research unit, which is led by Dr. Richard Novak, into a COVID vaccine unit. So we were we promptly devoted all our efforts and our personnel to scale up two of the vaccines in the market to try to help in getting the data to scale up these vaccines and to prove that they were safe and effective. So it put on the back burner some of the studies that we were starting. And then we are resuming those now. But the infrastructure helped the cause and that is important. HIV providers and researchers from Dr. Fauci to all of us, you know, we devoted all of our resources and networks to try to speed up these treatments and these vaccines. So when the story the history of COVID 19 is written, I think HIV providers, infectious disease on primary care providers who do HIV will have a prominent role in getting these treatments to people. And kudos to the society for all the efforts to try to get information out to clinicians in a timely manner.
Bender Ignacio: [00:22:47] You know, it is remarkable how many HIV focused clinicians and researchers have pivoted to responding to COVID-19. The infrastructure from the HVTN really built the foundation for the COVID prevention network. The ACTG, among other networks, really pivoted to working on COVID therapeutics and and really have leaned into standing up resources for clinicians and helping work on not only bringing, you know, the research on COVID prevention and COVID treatment, but also bringing these things into the clinic, working on distribution, working on vaccine campaigns. And so I can't thank many of our colleagues enough and many members of the society for all of the incredible work that they've done during this time. And it is really amazing to see what people have accomplished. The one last point, and I'd never want our community to be left out, is that there's also been an incredible effort by people living with HIV, especially long term survivors who lived through a prior pandemic in really informing us on ways to not leave out the community, on ways to be advocates, both at the federal level and locally, on ways to engage with the community around trust in new interventions. And I think that many very vocal members of the community, people who've been living with HIV for a long time in some ways really advised on how to conduct this research, including having community advisory boards, which is something that not all research does. And in helping disseminate information about effective preventions and treatments, people who've been living with HIV for a long time in some ways have been very instrumental in helping us understand how to avoid pitfalls in responding to this pandemic.
Brito: [00:24:32] We're most proud of people living with HIV who stand up to try to push us and lawmakers to do the right thing and think this is, as we're observing at the moment with monkeypox. It's a source of pride and it is a unique feature of the HIV epidemic. And for all of us who work in HIV that we know how to advocate on behalf of the marginalized groups. And we show up and we stand up and think that from the efforts of IDSA to change policy to the efforts of our patient to make sure that those policies represent them and help further their cause, we must be very proud.
Jezek: [00:25:16] At this time. I'd like to thank doctors Brito and Bender Ignacio for their time, participation and expertise for the latest information and resources on the COVID-19 pandemic, visit IDSA's website, IDsociety.org. And don't forget to follow us on social media. Tune in next time as another diverse panel of medical experts discusses the latest on COVID-19. I'm Amanda Jezek.
Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.
If applicable, all relevant financial relationships have been mitigated.
Financial Support Disclosure Statement: This podcast episode was funded by a cooperative agreement with the Centers for Disease Control and Prevention (grant number NU50CK000574). The Centers for Disease Control and Prevention is an agency within the Department of Health and Human Services (HHS). The contents of this podcast do not necessarily represent the policy of CDC or HHS, and should not be considered an endorsement by the Federal Government.
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