Home Tuberculosis How The Covid-19 Pandemic Has Impacted People With HIV In Sub-Saharan Africa

How The Covid-19 Pandemic Has Impacted People With HIV In Sub-Saharan Africa


Infectious disease expert Dr. Dave Wessner explores how the Covid-19 pandemic has impacted HIV patients in parts of Africa.

When the world first became aware of Covid-19, public health experts worried about its impact on the African continent. Home to 1.2 billion people, this region has the lowest GDP per capita of any continent, the health care systems of many African countries rank among the poorest in the world, and, particularly in sub-Saharan Africa, the citizens remain burdened by HIV and tuberculosis. Could the novel coronavirus overwhelm the governments, institutions, and people of this region?

Although many African countries now are experiencing a second wave of infections and deaths, the coronavirus pandemic apparently has not raced through the population. Indeed, according to data provided by Johns Hopkins University, only about 3.3% of novel coronavirus infections reported worldwide have occurred in African countries, even though the continent is home to about 17% of the world’s population. Limited testing in some countries may result in an under-representation of the number of cases. But the proportion of Covid-19 deaths reported by African countries is similarly low. Researchers have posited several explanations for the apparently limited impact of Covid-19 on African countries, including the young age of population and the possible protective effects of previous coronavirus infections.

Even though the prevalence of Covid-19 in most African countries seems limited, the impact of this disease on people living with HIV remains a great concern. Several early studies provided evidence that HIV infection does not lead to an increased risk of SARS-CoV-2 infection or an increased severity of Covid-19 disease. These studies, however, were fairly small. In contrast, the results of a large study just published in The Lancet HIV suggest that HIV does lead to an increased risk of Covid-19 death. In this study, the researchers used electronic medical record data available for residents of the United Kingdom to determine the rate of Covid-19 death in people with and without HIV. The results? HIV infection was associated with a modest increase in Covid-19 mortality.

The story may be different in sub-Saharan Africa.

All of these studies focused on Western populations. Within this region, the number of people co-infected with SARS-CoV-2 and HIV remains small. Additionally, most of the HIV-positive individuals are receiving antiretroviral therapy (ART) and, for the most part, are relatively healthy.

The prevalence of HIV is significantly higher in sub-Saharan Africa and the availability of ART is lower. Because of these differences, the effects of Covid-19 on people living with HIV could be greater. To address this question, researchers looked at Covid-19-associated mortality in HIV-positive and HIV-negative individuals in South Africa. Like the researchers in the UK, they used electronic health records to compare Covid-19 death rates in HIV-negative and HIV-positive individuals. Their results, published in Clinical Infectious Diseases, shows a roughly 2-fold greater risk of Covid-19 mortality in people living with HIV. A current or previous tuberculosis infection also was associated with an increased risk of Covid-19 death.

But the data needs to be examined a bit more closely. Yes, an existing HIV infection does correlate with an increased risk of Covid-19-associated death. It’s difficult, however, to determine if this increased risk results from HIV infection per se, or the immunosuppression associated with advanced HIV disease. The authors of the South African study tried to examine this point. For a large number of people in their study, though, accurate information about HIV viral load or CD4 cell count, two typical measurements of HIV disease, was not available. Additionally, the researchers acknowledged that other, undocumented comorbidities may contribute to the increased risk of Covid-19 death in people living with HIV.

So, what can we conclude? The data remains unclear. For people living with HIV who are receiving antiretroviral therapy, their HIV infection alone probably does not greatly increase their risk of Covid-19 death. Unmanaged HIV disease and comorbidities often associated with HIV infection, however, may negatively impact Covid-19 outcomes. For researchers, clinicians, and public health workers, the intersection of these two infections demands continued surveillance.

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