QUESTIONS AND ANSWERS ABOUT COVID-19, HIV AND ANTIRETROVIRAL DRUGS*
Are persons with HIV under greater risk of being infected with virus causing COVID-19?
Persons who suffer from HIV, are in the advanced stage of disease, have low CD4 cells and high viral risk and do not receive antiretroviral treatment (ART) are generally under increased risk of infection and are likely to be affected more. It is not known whether immunosuppressant feature of HIV puts a person in serious jeopardy for COVID-19. Therefore, further measures must be taken for all persons with HIV infection at advanced stage or are not under control until further information is obtained on this matter [1], [2].
For now, there is no evidence that COVID-19 infection risk or effects are different in persons with HIV who receive ART and whose clinical and immune system are kept at normal levels when compared to general population. Some persons with HIV may have some risk factors known for COVID-19 such as diabetes, hypertension and other non-communicable diseases, so there may be increased risks of COVID-19 which are not associated with HIV. We know that there are persons with HIV who are mildly ill with SARS and MERS.
Until now, there was a case report notifying a person with HIV had and got over COVID-19 [3] and a mini study was conducted in China on risk factors of persons with HIV who were diagnosed with COVID-19 and antiretrovirals used. This study reports similar rates of similar COVID-19 disease when compared to the whole population and the risk increasing with old ages (except low CD4 coefficient, high viral load level or antiretroviral regime) [4]. Current clinical data gives rise to thoughts that main risk factors of death are associated with old ages and other additional diseases such as cardiovascular diseases, diabetes, chronic respiratory disease and hypertension. It is known that some healthy persons go through a serious disease period associated with coronavirus disease [5]. It is recommended that HIV-positive persons take same measures as the general population [6], [7]:
It must be ensured that HIV-positive persons who use antiretroviral drugs supply drugs to be sufficient for 30 days to 6 months and if necessary, they are vaccinated again (flu and pneumococcal vaccines). It is also required to supply sufficient drugs to treat partner infections, coexisting diseases and addiction.
Can antiretroviral drugs be used to treat COVID-19?
A few studies showed that HIV-positive persons who are infected with the virus causing COVID-19 disease and relevant coronavirus infections (SARS-CoV and MERS-CoV) had good clinical progress and almost all cases made a full recovery. In some cases, patients were given antiretroviral drug: ritonavir/ lopinavir combination (LPV/r). These studies are usually conducted on HIV-negative persons. These studies using LPR/r have significant limitations. Studies are small-scaled; timing, time and dosage of treatment vary and many patients receive additional interventions / treatments that may have affected the reported result. While use of antiretrovirals has low benefit evidence to treat coronavirus infections, there are serious side effects. Among persons with HIV, routine use of LPV/r for treatment of HIV is associated with various side effects in moderate severity. However, it can be expected that side effects are lower than those reported in routine use since duration of treatment is generally limited to several weeks in patients with coronavirus infection.
Can antiretroviral drugs be used to prevent COVID-19?
Both studies reported use of LPV/r as prophylaxis after exposure for SARS-CoV and MERS-CoV. One of these studies reports that it is less likely for healthcare professionals who receive LPV/r develop MERS-CoV infection than those who do not receive the drug; the other study shows that there is no case of SARS-CoV infection among 19 HIV-positive persons with 11 persons receiving ART who stay in the same dormitory with SARS patients. Evidence is less precise due to small sample, variability in drugs used and uncertainty in intensity of exposure.
What kind of studies are planned for prevention and treatment of COVID-19 with antiretrovirals?
A few studies were planned to evaluate reliability and effectiveness of use of antiretroviral drugs - especially LPV/r - to treat COVID-19 with other drugs. Results are expected from in the middle of 2020.
What is the thought of the World Health Organization (WHO) on use of antiretroviral drugs for treatment of COVID-19?
Now, there is no adequate data to evaluate effectiveness of LPV/r or other antiviral agents in treatment of COVID-19. Most countries evaluate use of LPV/r and other antiviral agents.
Once again, WHO R&D Plan has been activated to accelerate diagnosis, vaccination and therapeutics for this new type of coronavirus as a part of the response of WHO to the pandemic. WHO also designed an array of procedures to evaluate performance, quality and safety of medical technologies in case of emergency.
What is the thought of the World WHO on use of corticosteroids for treatment of COVID-19?
WHO does not recommend use of corticosteroids unless there is any other reason in the current interim guidance on clinical management of severe acute respiratory tract infection that may be caused by COVID-19 infection. [8] This recommendation is based on miscellaneous systematic analyses which show that routine treatment of viral pneumonia or acute respiratory distress syndrome (ARDS) with corticosteroids is less effective and may cause some damages. [9]
Do persons with HIV have trouble in supplying their drugs if countries use antiretroviral drugs for treatment of COVID-19?
ART is an effective and highly tenable treatment for persons with HIV. As an antiretroviral, LPV / r is researched as a possible treatment for COVID-19 now.
If these drugs will be used for treatment of COVID-19, a plan must be made to make sure all persons with HIV who use or will start to use LPV / r have a sufficient number of drugs to meet their needs. However, relatively a small part of persons with HIV receives this treatment since regimes containing LPV / r are used as the second-degree regime according to HIV treatment guidelines of WHO. Each country allowing to use HIV drugs for treatment of COVID-19 must ensure a sufficient and sustainable number of drugs is supplied.
How to guarantee human rights and reduce stigmatization and discrimination?
While the world increases measures on public health for COVID-19 pandemic, countries are asked to take firm steps to control the pandemic. WHO invites all countries to balance between protection of health, prevention of economic and social relapse and respect for human rights.
As a response to COVID-19, WHO works with partners such as UNAIDS Joint Programme and the Global Network of People living with HIV/AIDS to prevent damages to human rights and to ensure persons with HIV or persons affected by HIV are given the same access and services on HIV are provided uninterruptedly.
It is highly important to take much wider public health measures in prisons and migration detention places in order to reduce potential prison epidemic that may be caused by COVID-19 and reduce disease and death rates in persons kept in prisons and other locked environments. This requires a close collaboration between ministry of health and ministry of justice. Protocols are required to restrict mobility including health control at entrance, personal protective measures, social distance, environmental cleaning and disinfection, access for non-obligatory personnel and visitors, etc. In the current context, it is critical countries struggle to develop strategies beyond detention to prevent over-crowding in closed areas. This will be facilitated if health in prisons is controlled by the ministry of health rather than ministry of justice or other [11].
How can continuous access to services for HIV be ensured?
It is important to ensure access to basic services for prevention of HIV, test and treatment in places where restrictions are applied within public health measures continuously for COVID-19 pandemic. In addition to continuity of access to basic services, adapted and evidence-based measures must be considered and applied to reduced potential infections. These are [12]:
In general, members of the key population, vulnerable groups including the homeless and / or displaced persons might be under the risk of infection due to the fact that there are other comorbidities affecting their immune system, they are less likely to follow rules for isolation and social distance and they have limited access to health services. It is important services reaching these populations such as community-based services and social aid services can continue providing preventive services that may be life-saving (distribution of condom and injection), test and treatment while ensuring safety of personnel and patients. Services can be adapted to conditions above where applicable.
Where are long-term prescriptions and prescription of antiretrovirals and other drugs to be sufficient for a long time in the process?
Clinically stable adults, children, adolescents, pregnant and breastfeeding women and key population members (persons injected with narcotic drugs, sex workers, men having sex with men, transsexual persons, persons who have to live in prisons and locked places) can benefit from ART application models enabling multi-month prescriptions and drug use (3-6 months) which ensure sustainability of treatment to reduce frequency of visits to clinic. Clinically stable persons who receive methadone and buprenorphine maintenance treatment can be given their drugs similarly to relieve the burden on the healthcare sector.
Might women with HIV infect their babies with COVID-19 during pregnancy or post-partum period?
There are very few data on clinical progress of COVID-19 in specific groups such as children and pregnant women [13]; however, findings from a mini study reports there is no evidence for women who are infected with COVID-19 pneumonia in the late-period pregnancy spread virus to their babies and cause intrauterine infection [14]. Even if no vertical spread is documented, infection through contact with contagious respiratory secretions in the post-partum period is the source of concern. Infants born from mothers who are diagnosed with suspected or affirmed COVID-19 must be fed according to standard infant feeding while necessary measures are applied to prevent and control infection [15]. As in all affirmed or suspected cases of COVID-19, symptomatic mothers who adopt breast-feeding, skin-skin contact or kangaroo care must be careful by following hygiene rules for respiration even during breast-feeding (use of medical mask while the mother is with her baby), washing her hands before and after contact with the baby and cleaning and disinfecting all surfaces she touches regularly if she is symptomatic [16].
Should HIV-positive pregnant and post-partum women and new-born babies diagnosed with COVID-19 be approached differently?
For now, there is no difference between pregnant, non-pregnant women and women in reproductive age group regarding clinical symptoms and severity of COVID-19. Pregnant women and women recently conceived with suspected or affirmed COVID-19 must be treated in view of immunological and physiological adaptations that might coincide with symptoms of COVID-19 during and after pregnancy. Data are limited, but pregnant women infected with COVID-19 and accompanied by other medical diseases must be specifically treated until we have clearer knowledge. No death was reported until these information were published [17], but symptomatic pregnant women might be required to attach priority to COVID-19 test for special treatment. All pregnant women who are COVID-19 positive or have recently got over COVID-19 must be given information and counseling about appropriate measures to feed infants safely and prevent spread of COVID-19 [18].
Management of suspected or affirmed cases is like that of non-pregnant women who are included in appropriate isolation methods. Birth centers must be prepared by being informed that it is required to see every baby born from a mother diagnosed with COVID-19 as “person to be researched” and isolate it according to guideline for prevention and control of infection. Now, it is not known whether new-born babies with COVID-19 are under increased risk of serious complications.
Sources:
[1] DHHS, Interim Guidance for COVID-19 and Persons with HIV, https://aidsinfo.nih.gov/guidelines/html/8/covid-19-and-persons-with-hiv--interim-guidance-/554/interim-guidance-for-covid-19-and-persons-with-hiv (March 20, 2020)
2] US CDC, COVID-19: People who are at higher risk for severe illnesshttps://www.cdc.gov/coronavirus/2019-ncov/specific-groups/people-at-higher-risk.html (March 22, 2020)
[3] Zhu F, Cao Y, Xu S, Zhou M. Co‐infection of SARS‐CoV‐2 and HIV in a patient in Wuhan city, China, J of Medical Virology 11 March 2020. https://onlinelibrary.wiley.com/doi/full/10.1002/jmv.25732
[4]Guo W, Ming F, Dong Y et al. A Survey for COVID-19 among HIV/AIDS Patients in Two Districts of Wuhan, China. Preprint research paper, The Lancet, 2020.
[5] Clinical management of severe acute respiratory infection when novel coronavirus infection is suspected, www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected
[6] WHO Guidance con the COVID-19 outbreak can be found here: https://www.who.int/emergencies/diseases/novel-coronavirus-2019.
[7] WHO country and technical guidance can be found here: https://www.who.int/emergencies/diseases/novel-coronavirus-2019
[8] Clinical management of severe acute respiratory infection when novel coronavirus infection is suspected, www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected
[9] Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury, www.thelancet.com/pb-assets/Lancet/pdfs/coronavirus/S0140673620303172.pdf
[10] Effectiveness of interventions to address HIV in prisons. Geneva, World Health Organization, 2007(Evidence for Action Technical Papers) http://whqlibdoc.who.int/publications/2007/9789241596190_eng.pdf?ua=1
[11] Kinner S. Jesse T. Snow K. Southalan L. et al. Prisons and custodial settings are part of a comprehensive response to COVID-19. The Lancet Public Health. Published: March 17,2020; DOI:https://doi.org/10.1016/S2468-2667(20)30058-X
[12] Taken and adapted from: Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected. Interim guidance. 25 January 2020; WHO Geneva. accessed at: file:///C:/Users/luhmannn/Downloads/9789240000919-eng.pdf
[13] World Health Organization. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected Interim guidance, 13 March 2020
[14] Huijun Chen*, Juanjuan Guo* et al, Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Published Online February 12, 2020 https://doi.org/10.1016/S0140-6736(20)30360-3
[15] Global strategy for infant and young child feeding (https://apps.who.int/iris/bitstream/handle/10665/42590/9241562218.pdf)
[16] Centres for Disease Control. Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings
[17] Royal College of Obstetricians and Gynaecologists. Corona virus (COVID - 19) infection in Pregnancy. Information for healthcare professionals Version 2: Published Friday 13 March 2020
[18] Caring for pregnant women with COVID-19 Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: Interim guidance
*The text published at the website of the World Health Organization on March 24, 2020 was taken and translated to Turkish.
https://www.who.int/news-room/q-a-detail/q-a-on-covid-19-hiv-and-antiretrovirals
