When COVID-19 crosses paths with HIV

When Larry Pike came down with a cough and a mild fever in early March, the 76-year-old was concerned. COVID-19 was in the news.

“I am up in that age range where they say you really have to be careful,” said Pike, a retired Seattle Chamber of Commerce manager.

He called his doctor, who knows him well. Because for 22 years, Pike has also been living with HIV.

Human Immunodeficiency Virus. The danger is right there in the virus’ name.

“I’ve been immune compromised,” Pike said. “How do I fit in here?

On March 10, his illness took a turn for the worse. He woke up to a severe headache and a higher fever. His doctor gave him a nasal swab test, and five days later Pike learned he was positive.

“When I was diagnosed in 1998, I was scared as hell,” he recalled. “I knew that the new drugs were kind of turning things around, but in those days if you met a group of people, one year they were fine, the next year they were sick, the next year, gone.”

This time, he feels lucky. “My doctor had one test kit left,” he said. A month later, he is feeling better.

Looking for clues to HIV’s role in COVID-19 risk

Fred Hutchinson Cancer Research Center associate Dr. Rachel A. Bender Ignacio treats people with HIV at the University of Washington Medical Center and Harborview Medical Center. Accustomed to seeing HIV patients vulnerable to infections, she shares the worries of those who may have to fight off a new pandemic virus, which seems to target patients who are older and have underlying health conditions.

Yet surprisingly, there is little evidence to date that HIV puts people at higher risk of COVID-19.

For those who are living with HIV but under treatment with antiviral drugs, it may be other background conditions such as diabetes, hypertension, obesity and a history of smoking that leave them vulnerable.

“People living with HIV have a higher frequency of those traditional risk factors,” said Bender Ignacio. “I tell my patients, if there ever was a time to quit smoking, it’s now.”

To get a better handle on the level of risk for people living with HIV, researchers are looking for clues in the medical records of those who have also been recently infected with COVID-19. She, together with Drs. Adrienne Shapiro, Heidi Crane, and Mari Kitahata of the University of Washington/Fred Hutch Center for AIDS Research, is working with colleagues at the University of California San Diego on a new epidemiological study of COVID-19 among more than 35,000 people living with HIV across the country.

The study will comb through medical records of those patients to search for patterns in the risk factors of those who also test positive for the new coronavirus. It will analyze records of those who were admitted to hospitals for COVID-19, those who required ventilators and those who died. The researchers will track levels of infection-fighting white blood cells (known as CD4 count) in these patients, as well as their histories of underlying health conditions.

A similar study at Kaiser Permanente Southern California, which has more than 4.7 million members, is examining if those living with HIV are at higher risk of severe COVID-19 outcomes compared to those without HIV.

Caesar Briones was a young Kaiser Permanente member in San Francisco when he was diagnosed with HIV in 1988. Thirty-two years later, he found himself in a Kaiser clinic in Seattle’s Capitol Hill neighborhood, confronting another pandemic, another positive test.

“I don’t want to go to a doctor unless it is necessary,” he said. “But for me, the lesson was I waited too long. I learned that COVID-19 can deteriorate your lungs.”

Despite long-term medical problems with high liver enzymes and a cyst on his kidney, he weathered his new illness without hospitalization. “If you are not feeling good for more than a few days, seek medical help,” he advised.

Doctors simply don’t have answers yet to explain how and why COVID-19 behaves so differently within its human hosts. The disease is so new that doctors are exploring whether immune suppression itself might be a biological advantage against the virus.

“It may be that people with HIV are more likely to acquire COVID-19, but we do not know whether HIV puts someone at lower or higher risk of severe disease,” Bender Ignacio said.

In this new pandemic, patients who seem to fare the worst are those whose own immune system revs up so powerfully that their lungs flood with inflammatory hormones and cellular debris. It is called a cytokine storm, and is similar to an unwanted side effect of cancer therapies that reawaken the immune system to fight the cancer, but can also turn it against the patient.

Yet it is too simple to describe people with HIV as having weakened immunity. There is nothing simple about the human immune system.

“People living with HIV often have a more aggressive immune response, because it is constantly being activated by the virus. But then they can experience immune exhaustion. It’s like running a marathon,” Bender Ignacio said.

“It all means that HIV is still a wild card in terms of COVID-19 risk. Until we gather data, we just won’t know,” she said.

Health inequality drives two epidemics

Meanwhile, evidence is mounting that COVID-19, like HIV, exploits socioeconomic disparities. Many people with HIV today are homeless, incarcerated, or struggling with substance abuse, mental health conditions or chronic diseases such as hepatitis.

Poverty and lack of access to medical care remain an issue for the 1.2 million Americans estimated to be living with HIV, and 25 years after the development of effective antiviral therapies, one-third of them have not received HIV care. Increasingly, new HIV infections are concentrated in communities in the South. Four out of ten of the estimated 38,000 new HIV infections in the U.S. each year are among African Americans, who are disproportionately affected by poverty and lack of access to medical care.

While antiviral treatments have transformed HIV from a death sentence in the 1980s to a manageable chronic disease today, people who have survived that pandemic have nearly double the risk of cardiovascular disease and higher risk of cancer. And by virtue of surviving HIV, they may now find themselves once again at mortal risk from a virus simply because they have become senior citizens.

At about the same time Pike was battling fever and fatigue at his home, he knew that a friend and neighbor living with HIV, Charles Perry, was gravely ill with COVID-19, kept alive by a ventilator.

“He had a great sense of humor, and was kind of the glue for our group of friends,” said Pike. “He knew by heart all those classic Bette Davis movies. He was always coming up with lines.”

Perry had lived with HIV for more than 30 years, but he was also diabetic. Just 19 days after coming down with COVID-19, he died. He was 66.