Due to their immunosuppression, people with HIV are undoubtedly among the vulnerable groups in the COVID-19 pandemic. But does this apply across the board to all HIV patients? And which vaccine against SARS-CoV-2 is suitable for protecting people with HIV?
One year of the Corona pandemic has passed and the first data on HIV-infected people and their course of disease with COVID-19 co-infection are slowly coming out. Among other things, a retrospective cohort analysis was presented at this year's virtual DÖAK 2021 (Deutsch-Österreichischer AIDS-Kongress, German-Austrian AIDS Congress).
The participants of the study were predominantly male (84%) and in 99% of the cases were on antiretroviral therapy. The symptoms of people with HIV who were simultaneously infected with SARS-CoV-2 did not differ significantly from those of the general population. Accordingly, 11% of the study participants had an asymptomatic and 79% a mild course. The most frequently observed symptoms included:
About 10% of the study participants experienced a severe course of the disease, and 3.2% died. But what ultimately determined which of the HIV-infected people became seriously ill and how?
It turned out that those who currently had low CD4+ cell counts (< 200 cells/µl) or a low nadir (< 200 cells/µl) were most prone to severe COVID-19 courses. In practice, this means that especially those HIV patients with more severe immunosuppression can develop severe SARS-CoV-2.
In addition, immunodeficiency also increased the risk of hospitalisation, as did age > 60 years in combination with HIV/SARS-CoV-2 co-infection. Participants with one or more comorbidities were also at risk.
The current EACS (European AIDS Clinical Society) guidelines 10.1 recommend that people infected with HIV should be vaccinated against various vaccine-preventable infectious diseases after immune reconstitution (CD4+ > 200 cells/µl). It should be noted that live-attenuated vaccines should not be administered to people with HIV who are currently immunocompromised (CD4+ < 200 cells/µl). Similarly, polysaccharide vaccines are contraindicated in people with HIV. As a success control of a vaccination, it is recommended to determine the vaccination titer. The following vaccinations are currently recommended for people with HIV infection:
But what about COVID-19 vaccines? These do not appear in the current recommendations either, or HIV patients are not explicitly addressed as a vulnerable vaccination group. Not without reason, as was explained at the DÖAK on the basis of the currently available COVID-19 vaccines.
As of early March 2021, there were 60 phase II/III trials of COVID-10 vaccines, involving more than 680,000 subjects. There are also currently four major vaccine classes being researched: Adenovirus vector-based vaccines, inactivated vaccines, recombinant spike protein vaccines and, for the first time in vaccine history, mRNA vaccines.
However, a look at the exclusion criteria of the studies quickly makes it clear why, given the abundance of options, there are still no reliable statements on vaccine tolerability and efficacy in people with HIV. This was not forgotten in the approval studies, but simply rejected from the outset as an exclusion criterion by the majority of the studies as immunodeficient.
For example, three of the five studies on the BioNTech vaccine completely excluded HIV patients. The two other studies, however, only allowed patients whose CD4 cell count was > 200 cells/µl. Immunocompromised patients, who have a higher risk of severe COVID-19 progression, were thus not studied. Moderna and CureVac excluded people with HIV from the study overall. AstraZeneca and Johnson & Johnson have no data for patients below 300 CD4+ cells/µl.
Thus, people with HIV are currently effectively excluded from the COVID-19 vaccination. A recommendation for or against one of the vaccines already approved in Germany is currently impossible due to the lack of data for these cases.