In December 2019, a novel coronavirus, SARS-CoV-2, started a global pandemic of respiratory
illness, termed COVID-19 [1]. The spectrum of COVID-19 has ranged from a mild, self-limiting
respiratory tract illness to severe progressive pneumonia, multi-organ failure, and
death [2]. Older patients and those with a weaker immune system appear to have a greater
risk of death [3]. Thus far, the vast majority of deaths from COVID-19 have occurred
in Italy, China, Iran, and Spain—all Northern hemisphere countries with good health
care resources and a low HIV prevalence. After the SARS-CoV-2 pandemic reached sub-Saharan
Africa, COVID-19 cases may expand more quickly in high HIV prevalence communities
with poor health resources.
The first reported cases of COVID-19 in South Africa occurred in early March from
travelers who returned from Italy. South Africa has since reported over 400 cases
(as of this writing), and the number continues to grow each day. Given the rapid spread
of SARS-CoV-2 in South Africa, it now seems likely that COVID-19 cases will occur
in all sub-Saharan African countries (Fig. 1
). Perhaps what may be less certain is how SARS-CoV-2 will spread in HIV-endemic settings,
and whether COVID-19 will have a higher morbidity and mortality rate among people
living with HIV (PLHIV). In South Africa, where only 54% of the estimated 7.7 million
PLHIV are virally suppressed and tuberculosis remains the leading cause of HIV-related
mortality, these questions will need to be addressed.
Fig. 1
Reported cases of COVID-19, as of March 24, 2020. (Source: World Health Organization
[10]).
Fig. 1
So far, little is known about the pathogenesis and clinical outcomes of COVID-19 in
PLHIV. In this EClinicalMedicine issue, Dr. Zhao and colleagues describe a 50-year-old
Chinese male living with HIV who had evidence of viral shedding for 39 days after
symptom onset, but recovered after receiving human immunoglobulin, methylprednisolone,
and inhaled interferon alpha-2b [4]. Another case report described a 61‐year‐old Chinese
male with a history of diabetes, who presented with acute respiratory symptoms, and
was newly diagnosed with both HIV and COVID-19 pneumonia [5]. The patient recovered
after receiving steroid therapy, respiratory support, and starting antiretroviral
therapy (ART). This author (PKD), however, had a 66-year-old American male with suppressed
HIV recently succumb to COVID-19 pneumonia, despite ventilatory support and hydroxychloroquine.
Currently, the US Centers for Disease Control and Prevention and the International
AIDS Society consider PLHIV with low CD4+ T-cell count or not on ART as potentially
vulnerable to more severe COVID-19 disease [6]. This concern is based on data from
other respiratory diseases, including pneumococcal pneumonia and pulmonary tuberculosis,
where PLHIV with compromised immunity have significantly worse health outcomes [7,8].
However, the experience from prior coronavirus outbreaks, including SARS CoV-1 and
MERS, were limited among PLHIV, suggesting that PLHIV may not have a significantly
higher risk of infection or mortality from SARS-CoV-2.
For several years, the World Health Organization (WHO) has recommended a “Test and
Treat” strategy to identify all PLHIV and initiate ART. The current treatment options
for COVID-19 are limited and may not be effective—a randomized trial of lopinavir/ritonavir,
a common HIV medication, had no clinical benefit, while clinical trials of hydroxychloroquine,
Remdesivir, and Tocilizumab are ongoing [9]. With no proven therapeutic options for
COVID-19, the WHO recommends a “Test, Test, Test” strategy in response to the SARS
CoV-2 pandemic. Since the response to the HIV/AIDS epidemic was developed and refined
over decades, some lessons may be applicable for the response to SARS CoV-2.
First, establishing access to rapid, point-of-care COVID-19 testing in both community-based
and clinical settings will be essential. The WHO has identified the development and
evaluation of “rapid point-of-care diagnostics for use at the community level” as
a top research priority [10]. Second, the mortality rate of HIV-associated TB has
declined in part by initiating more PLHIV on ART. Starting ART may improve the immune
response to COVID-19 for PLHIV, and may help prevent onset of Cytokine Release Syndrome
or progression to severe respiratory failure. Third, the HIV epidemic led to crowded
and overburdened health care facilities and hospitals. There is now a similar concern
that COVID-19 will severely divert limited health care resources, which could reverse
observed reductions in HIV and TB mortality in recent years. The public health response
may need to incorporate additional COVID-specific resources, while still maintaining
the supply chain of care and ART for PLHIV. With millions of PLHIV receiving ART throughout
sub-Saharan Africa, perhaps the best way to protect this population from COVID-19
may be to ensure an uninterrupted supply of ART.
As the COVID-19 response gathers momentum across sub-Saharan Africa, additional research
will be needed to fully understand the susceptibility, transmission dynamics, pathogenesis
and clinical outcomes of COVID-19 among PLHIV compared to the general population.
Those most vulnerable to COVID-19 may be PLHIV who are either unaware of their diagnosis
or not yet receiving ART. An important part of the response therefore will be not
suspending the HIV 90-90-90 efforts during the SARS CoV-2 pandemic, but to expand
ART in order to protect PLHIV from severe COVID-19 disease. Since the response will
require adequate health care infrastructure, integrating COVID-19 testing services
within the HIV treatment infrastructure may be essential for controlling the spread
of SARS-CoV-2 in sub-Saharan Africa.
Declaration of Competing Interest
Dr. Paul K Drain reports receiving consulting or speaking fees from Gilead Science
and Cepheid, and research support from the NIH, CDC, Gilead Sciences, and the Bill
and Melinda Gates Foundation. He declares that he has no competing interests.