ASHM COVID-19 Regional Advisory Group interim recommendations regarding COVID-19 and adults living with HIV1

 

Prepared by Dr Nicholas Medland (RAG Chair) and members of the RAG’s Clinical Care – HIV and SRH Sub-Groups. The guidance is adapted from the ASHM COVID-19 Taskforce interim recommendations regarding COVID-19 and adults living with HIV 

 

UPDATED ON: 7 May 2020.

 

Disclaimer: The recommendations provided are the opinions of the authors and are not intended to provide a standard of care, or practice. This document does not reflect a systematic review of the evidence, but will be revised to include relevant future systematic review findings. The recommendations are not intended to replace national guidance. 

 

I.    Streamline routine care for PLWHIV stable on ART

if on ART>1yr, no OI, CD4>200, no comorbidities, adherent, VL undetectable2 


•    deferred clinic visits and phone/tele visits
•    deferred blood tests
•    avoid patient travel to receive ART 
•    caution changing ART
•    check adherence

 

2.    Do no defer ART initiation in newly diagnosed or not on treatment

 

 3.    Check vaccinations:  Influenza and Pneumococcal

 

 4.    Protect ART supply

•    ensure hospital pharmacies review and maintain adequate buffer stock 
•    avoid patient travel to receive ART (deliver ART or prescription or dispense locally)  
•    liaise with pharmacies patients are attending
•    protect stocks by discouraging large personal supplies 
•    small personal 1-2 mo buffer stock if local supplies permit
•    refill prescriptions early
 

5.    Check adherence: 

•    refer for adherence support 
•    connect to community services
 

6.    Check Psychosocial status: connect patients to available services

•    Mental health
•    Drug and alcohol
•    Housing and security
•    Poverty
•    Food supply and security
 

7.    Connect with CBOs

•    CBOs and outreach workers can support clinicians to support patients

 

8.    Optimise health and comorbidities.

•    stop smoking
•    optimise hypertension and diabetes control
•    N.B. older age, obesity, cardiovascular disease, lung disease, cancer, and chronic liver disease1-5 are associated with increased risk of more severe COVID-19 illness
•    do not stop or change ACE inhibitors or angiotensin receptor blocker medications for high blood pressure6

HIV and COVID-19: Evidence is limited and emerging. Currently it appears that:


•    HIV does not affect COVID-19 outcomes  1,7-9
•    Severe COVID is not more common in people with HIV.
•    Patients with HIV are expected to recover as well as other patients 
•    Patients with HIV should get the same high level of care for COVID, including hospital admission, oxygen, intensive care, ventilator support [link to our document]

 

People living with HIV who may be at increased risk of severe COVID:
 
•    Not on ART 
•    Current OI/AIDS 
•    CD4 < 350
•    Comorbidities that are common in patients with HIV are associated with increased risk of severe COVID

 
Managing PLWHIV with COVID-19 symptoms:


•    advocate for the same level of care for PLWHIV requiring hospital treatment
•    caution in interpreting CD4 cell counts taken during acute illness which may be reduced.
•    exclude TB infection, use GeneXpert where atypical or smear negative TB is a possible alternative diagnosis (e.g. low CD4 cell count).
•    drug-drug interactions are common: consult a pharmacist

Adhere to measures that reduce COVID infection
Social/physical distancing: adhere to local guidelines


•    Patients with suspected COVID should wear a mask, where available
•    Regular hand washing
•    Refrain from touching the face 
•    Cough etiquette
•    Physical isolation of contacts & those with mild symptoms

1.    Wang D, Hu B, Hu C, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA 2020. http://www.ncbi.nlm.nih.gov/pubmed/32031570
2.    Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention. JAMA 2020. http://www.ncbi.nlm.nih.gov/pubmed/32091533
3.    Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395(10229): 1054-62. http://www.ncbi.nlm.nih.gov/pubmed/32171076
4.    Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) United States, February 12–March 16, 2020. MMWR Morb Mortal Wkly Rep. https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e2.htm
5.    Porcheddu R, Serra C, Kelvin D, Kelvin N, Rubino S. Similarity in Case Fatality Rates (CFR) of COVID-19/SARS-COV-2 in Italy and China. J Infect Dev Ctries 2020; 14(2): 125-8. http://www.ncbi.nlm.nih.gov/pubmed/32146445
6.    Vaduganathan M, Vardeny O, Michel T, McMurray JJV, Pfeffer MA, Solomon SD. Renin-Angiotensin-Aldosterone System Inhibitors in Patients with Covid-19. N Engl J Med 2020. http://www.ncbi.nlm.nih.gov/pubmed/32227760
7.    Zhu F, Cao Y, Xu S, Zhou M. Co-infection of SARS-CoV-2 and HIV in a patient in Wuhan city, China. J Med Virol 2020. http://www.ncbi.nlm.nih.gov/pubmed/32160316
8.    Blanco JL, Ambrosioni J, Garcia F, et al. COVID-19 in patients with HIV: clinical case series. The Lancet HIV 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7159872
9.    British HIV Association, European AIDS Clinical Society. EACS & BHIVA Statement on risk of COVID-19 for people living with HIV 2020. https://www.bhiva.org/EACS-BHIVA-Statement-on-risk-of-COVID-19-for-people-living-with-HIV