The emergence of the COVID-19 pandemic, caused by the SARS-CoV-2 virus, prompted immediate questions for people living with HIV (PLWH). Given that HIV affects the immune system, concerns naturally arose about whether this would create a unique and more dangerous interaction with the new respiratory virus. Many wondered if having HIV would automatically lead to a higher chance of getting infected or experiencing a more severe form of COVID-19.
This article serves as a resource to explore the relationship between these two viruses. It will examine the risks, outcomes, and preventive measures based on scientific evidence gathered since the pandemic began.
Vulnerability to COVID-19 Infection
At the onset of the pandemic, a common assumption was that any condition compromising the immune system would increase a person’s susceptibility to contracting SARS-CoV-2. This created significant apprehension for people living with HIV.
However, extensive research has clarified this initial assumption. For the majority of people living with HIV who are on effective antiretroviral therapy (ART), the risk of becoming infected with SARS-CoV-2 is not significantly different from that of the HIV-negative population. Effective ART suppresses the amount of HIV in the body to undetectable levels, allowing the immune system to function properly.
This restored immune capability means the body is better equipped to defend against new pathogens, including the virus that causes COVID-19. The primary drivers of infection risk for this group are largely the same as those for everyone else. Factors such as older age, close contact with infected individuals, and not adhering to public health guidance are more significant predictors of who gets infected, and socioeconomic factors also have a substantial impact on a person’s likelihood of exposure.
COVID-19 Severity and Outcomes
The course of a COVID-19 infection in a person with HIV is strongly linked to the status of their HIV condition. For individuals with well-controlled HIV—meaning they are on stable antiretroviral therapy (ART), have a high CD4 cell count, and an undetectable viral load—the risk of developing severe COVID-19 is largely comparable to the general population.
In these cases, outcomes are predominantly influenced by other factors like advanced age and underlying health issues such as hypertension or diabetes, rather than their HIV status.
The situation is markedly different for individuals with uncontrolled or advanced HIV. This group includes those not on treatment, those with a high HIV viral load, or those with a significantly weakened immune system, often defined by a CD4 cell count below 200 cells/mm³. For these individuals, the risk of severe COVID-19 outcomes—including hospitalization, admission to an intensive care unit (ICU), and death—is substantially higher.
The reason for this increased risk lies in the compromised state of the immune system. With a low CD4 count, the body lacks the necessary cells to coordinate an effective defense against SARS-CoV-2. This diminished capacity can lead to a more severe and prolonged illness. Additionally, individuals with advanced HIV may experience prolonged viral shedding of SARS-CoV-2, meaning they remain infectious for a longer period.
The Role of HIV Treatment and COVID-19 Therapies
Early in the pandemic, researchers investigated whether certain antiretroviral therapy (ART) drugs could offer a direct protective benefit against SARS-CoV-2. The evidence has since shown that the primary benefit of ART in the context of COVID-19 is its ability to restore and maintain immune function. By suppressing HIV, ART allows the immune system to recover and strengthen, equipping a person to better combat a SARS-CoV-2 infection. Continuing ART without interruption is fundamental for people with HIV to maintain their health.
When it comes to treating an active COVID-19 infection, therapies like Paxlovid are available and recommended for people with HIV. However, managing potential drug-drug interactions is a necessity. Paxlovid contains a component called ritonavir, which is also used in some ART regimens as a boosting agent.
The use of ritonavir in both treatments can lead to complex interactions, potentially altering the concentrations of HIV medications in the body. It is necessary for individuals to consult with their healthcare provider before starting any COVID-19 therapy. A doctor can review the specific ART regimen and determine if any adjustments are needed to safely administer treatments for both conditions.
Vaccination and Prevention Strategies
COVID-19 vaccines are a recommended and safe prevention tool for people living with HIV. Major global and national health organizations have consistently advised that all individuals with HIV, regardless of their CD4 count or viral load, receive the vaccine. Clinical trials for COVID-19 vaccines included people with HIV, and subsequent real-world data have confirmed their safety and effectiveness in this population. There is no evidence that the vaccines interfere with the effectiveness of antiretroviral therapy.
The immune response generated by vaccines in people with well-controlled HIV is generally strong and protective, preventing severe illness, hospitalization, and death from COVID-19.
Public health agencies often provide specific guidance for immunocompromised populations, which can include people with advanced or untreated HIV. Individuals with a low CD4 count, for instance, may be advised to receive additional or booster doses of the COVID-19 vaccine. This strategy aims to help their immune systems build a more robust and durable level of protection against the virus.
Beyond vaccination, standard preventive measures remain an important part of reducing risk. These practices include good hand hygiene, improving ventilation in indoor spaces, and wearing masks in high-risk settings.