HIV and risk of COVID-19 death: a population cohort study from the Western Cape Province, South Africa

ABSTRACT

BACKGROUND: The effect of HIV co-infection on COVID-19 outcomes in sub-Saharan Africa is unknown. METHODS: We conducted a population cohort study using linked data from adults attending public sector health facilities in the Western Cape, South Africa. We used Cox-proportional hazards models adjusted for age, sex, location and comorbidities to examine the association between HIV and COVID-19 death among (i) public sector 'active patients' (at least 1 health visit in the 3 years before March 2020), (ii) laboratory-diagnosed COVID-19 cases and (iii) hospitalized COVID-19 cases. COVID-19 was diagnosed with SARS-CoV-2 PCR tests. We calculated the standardized mortality ratio (SMR) for COVID-19 comparing HIV positive vs. negative adults using modelled population estimates. RESULTS: Among 3,460,932 public sector patients (16% HIV positive), 22,308 were diagnosed with COVID-19, of whom 625 died. In adjusted analysis, HIV increased risk of COVID-19 mortality (adjusted hazard ratio [aHR]2.14;95% confidence interval [CI]1.70;2.70), with similar risks across strata of viral load and immunosuppression. increased HIV-associated risk of COVID-19 death remained when restricting to COVID-19 cases (aHR1.70;95%CI132;2.18) or hospitalized cases (aHR1.45;95%CI1.14;1.84). Current and previous tuberculosis also increased COVID-19 mortality risk (aHR [95%CI]2.70 [1.81;4.04] and 1.51 [1.18;1.93] respectively). The SMR for COVID-19 death associated with HIV was 2.39 (95% CI1.96;2.86);population attributable fraction 8.5% (95%CI6.1;11.1). CONCLUSION: HIV was associated with a doubling of COVID-19 mortality risk. While our findings may over-estimate the HIV-associated risk COVID-19 death due to residual confounding, people with HIV should be considered a high-risk group for COVID-19 management.