COVID-19 & HIV

Health authorities strongly recommend that everyone living with HIV, regardless of CD4 count, receive a COVID-19 vaccine to protect themselves against SARS-CoV-2, the virus that causes COVID-19. People living with HIV should be prioritized in countries’ vaccination policies.  

There is evidence that the COVID-19 vaccine is less effective for immunocompromised people than people with a fully functioning immune response. The vaccine is also less effective for people living with HIV with a CD4 count of <200 cells/mm³, who are not on HIV treatment or with a detectable viral load and advanced disease; that is, they are more susceptible to the virus after vaccination. 

The World Health Organization (WHO) recommends that all immunocompromised people receive additional doses of a COVID-19 vaccine to boost their immunity to the virus.  

Resources:  

Interim recommendations for an extended primary series with an additional vaccine dose for COVID-19 vaccination in immunocompromised persons. WHO, 26 October 2021 https://www.who.int/publications/i/item/WHO-2019-nCoV-vaccines-SAGE_recommendation-immunocompromised-persons 

Coronavirus disease (COVID-19): COVID-19 vaccines and people living with HIV. Q&A. WHO, 14 July 2021  https://www.who.int/news-room/questions-and-answers/item/coronavirus-disease-(covid-19)-covid-19-vaccines-and-people-living-with-hiv 

Vaccines cause the body to trigger a response against harmful pathogens, such as viruses and bacteria. Many vaccines contain weakened or inactive parts of the pathogen, called antigens. Newer vaccines help the body produce these antigens, rather than introduce the antigen into the body directly. 

The weakened version of the pathogen will not cause disease in the person receiving the vaccine. Instead, it prompts their immune system to respond as if it was naturally exposed to the pathogen. Multiple vaccine doses can help the immune system learn to recognize and defeat the pathogen; this can result in stronger immunity that may last longer. 

All vaccines are tested in a laboratory (pre-clinical) before being tested in humans. Human (clinical) testing then has three stages to make sure that the vaccine is safe and effective: 

• Phase 1 is a safety study. The vaccine is given to a small group of healthy people (around 100) to make sure that there is no harm and to see if it triggers an immune response. 

• Phase 2 is a larger study with hundreds of people to learn more about safety in different populations and the best dosage. 

• Phase 3 is a final study with thousands of people. The vaccine is compared to a placebo to see how effective it is at preventing disease, preventing infection or transmission of the virus. These studies can detect rarer side-effects. 

Resources:  

Vaccines explained series. WHO https://www.who.int/emergencies/diseases/novel-coronavirus-2019/covid-19-vaccines/explainers   

Since the introduction of COVID-19 vaccines, billions of people have been vaccinated.  

Although they were developed quickly, the clinical studies of COVID-19 vaccines were carried out to the same standards as other vaccine studies.  

All COVID-19 vaccines authorized for use have completed the Phase 3 study stage and are safe and effective. This means that the majority of vaccinated people did not become ill with COVID-19.  

People living with HIV have taken part in studies of many COVID-19 vaccines, including those developed by AstraZeneca/Oxford, Johnson & Johnson, Moderna, Pfizer/BioNTech, Sinopharm and Sinovac. Studies that have not included people living with HIV use similar vaccines to ones that have been tested in people living with HIV already. They are therefore assumed to be safe for people living with HIV. 

There is no evidence that COVID-19 vaccines have more side-effects in people living with HIV on antiretroviral (ARV) therapy than in people with no underlying health conditions.  

Many countries have guidelines for health conditions that can cause vaccination side-effects. If you have any other health-related conditions, such as allergies, it is important to let the healthcare staff giving the vaccine know. For example, people who have had previous allergies – particularly severe allergies or allergies following other vaccinations – may need to be monitored in the facility after vaccination.  

Resources:  

Coronavirus disease (COVID-19): HIV and antiretrovirals. Q&A. WHO, 30 November 2020 https://www.who.int/news-room/questions-and-answers/item/coronavirus-disease-covid-19-hiv-and-antiretrovirals  

The clinical trials of COVID-19 vaccines were set up to measure their effect on preventing disease (not infection). Effectiveness at preventing disease varies between the vaccines as they are tested in different populations, at different times and with different types of vaccines. Current evidence shows that when COVID-19 vaccines are given, fewer infections are diagnosed. This level of effectiveness does appear to be lower for some people and different variants of the virus.  

There is evidence that immunocompromised people respond less to the COVID-19 vaccine than people with a fully functioning immune response. The vaccine is less effective for people living with HIV with a CD4 count of <200 cells/mm³, who are not on HIV treatment or with a detectable viral load and advanced disease; that is, they are more susceptible to the virus after vaccination. WHO recommends that all immunocompromised people receive additional doses of a COVID-19 vaccine to boost their immunity to the virus.  

Most of the COVID-19 vaccines fall into one of three types of vaccines:  

Vaccines based on mRNA 

mRNA vaccines contain a blueprint – a synthetic portion of the genetic material from SARS-CoV-2, encased in fat bubbles so that it can enter human cells. When the vaccine is injected, the cells of the body produce viral proteins from the blueprint (in this case, a specific protein called the spike protein) using the normal process of making proteins from mRNA. The viral spike protein then stimulates an immune response. The mRNA degrades quickly and does not change human genes.  

Vaccines based on a genetically modified adenovirus 

Adenovirus-based vaccines contain genetically modified adenovirus, like the virus that causes the common cold, but which has been weakened. This technology has been used for other vaccines. A copy of some genetic material from SARS-CoV-2 has been inserted into the adenovirus genetic code. This means that when the vaccine is injected, the body produces the spike protein using the same natural process of making proteins and then goes on to mount an immune response against the viral protein. 

Vaccines based on inactivated viruses 

Inactivated virus vaccines mean that the vaccines have been treated with chemicals to inactivate them so they do not contain live viruses. People living with HIV with CD4 counts of below 200 cells/mm³ and immunocompromised people are not usually offered vaccines made from live bacteria or viruses. This is because they contain a weak form of the pathogen that may cause a mild case of the disease. 

Resources:  

Vaccines explained. Series. WHO https://www.who.int/emergencies/diseases/novel-coronavirus-2019/covid-19-vaccines/explainers 

People living with HIV should be prioritized in countries’ vaccination policies. Depending on the public health approaches implemented in different countries, some people living with HIV may be offered a COVID-19 vaccine earlier than other people of the same age. 

For example, in some countries, this might apply to people living with HIV with CD4 cell counts of below 50 cells/mm³ or to people living with HIV with CD4 counts of 50-200 cells/mm³ who have other health conditions that may increase the risk of becoming very ill with COVID-19. 

Based on current evidence from clinical trials, some researchers have raised concern that people given vaccines based on a type of adenovirus called Ad5 may have increased susceptibility to HIV-1. This increased susceptibility was seen in people who were given experimental HIV-1 vaccines in areas of high HIV incidence. The use of COVID-19 vaccines with Ad5 in more than 58 million people has not shown any concern over HIV acquisition, but research is ongoing. Countries where there is high HIV prevalence might consider using non-Ad5 COVID-19 vaccines if possible.  

SARS-CoV-2 – like influenza (which causes flu), HIV and other viruses – can and does mutate. These genetic variations may change the virus, for example, making it more transmissible, causing different symptoms or causing more severe illness. 

The emergence of new variants highlights the importance of vaccinating people around the world as rapidly as possible to reduce the opportunity for the virus to create more mutations. Viruses do not respect borders and, in an interconnected world, vaccine roll out must scale up everywhere. Due to the lack of access to vaccines in many countries, global population immunity may not be achieved.  

Research is ongoing to understand the nature of the new variants of SARS-CoV-2 and to identify and manage their impact. If other variants that escape the vaccine’s effects do emerge, we need to be able to rapidly develop, approve and use new vaccines. Every year, new vaccines against the circulating strains of the influenza virus are rolled out based on surveillance to understand how to design the vaccine. New vaccines and annual doses may be used in future for SARS-CoV-2. 

Resources:

The effects of the virus variants on COVID-19 vaccines. WHO, 1 March 2021 https://www.who.int/news-room/feature-stories/detail/the-effects-of-virus-variants-on-covid-19-vaccines 

COVID-19 is the name given to the disease caused by the novel coronavirus, SARS-CoV-2. The large family of coronaviruses may cause illness in animals or humans. Not everyone who acquires SARS-CoV-2 will end up getting sick with COVID-19, and people can have anything from no symptoms at all to being mildly or severely ill. SARS-CoV-2 and COVID-19 were unknown before the outbreak began in Wuhan, China, in December 2019. On 11 March 2020, the World Health Organization (WHO) declared the COVID-19 outbreak a pandemic.  

Resources:  

Coronavirus (COVID-19). Q&A. WHO, 13 May 2021 https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/coronavirus-disease-covid-19 

Since the start of the COVID-19 outbreak, data has been collected on how it affects people living with HIV. People living with HIV who are immunocompromised are at an increased risk of severe COVID-19. These are people living with HIV who are not taking antiretroviral treatment (ART) or have co-morbidities, low CD4 cell counts and/or advanced HIV disease.  

Many studies have shown that outcomes, including the risk of hospitalization and death, are similar for people living with HIV who are not immunocompromised and the general population. This data continues to be updated as in some settings, all people living with HIV have been shown to have a higher risk of severe disease, regardless of their immune status. People living with HIV also have higher rates of certain underlying conditions that can make them more likely to have severe COVID-19.  

All people living with HIV are advised to take the same precautions as everyone else to reduce their risk of exposure to SARS-CoV-2. These precautions include wearing a face mask, washing hands, keeping a physical distance and avoiding crowded spaces. Health authorities strongly recommend that everyone living with HIV, regardless of CD4 count, receive a COVID-19 vaccine to protect themselves against SARS-CoV-2.  

Resources:  

Coronavirus (COVID-19): HIV and antiretrovirals. Q&A. WHO, 30 November 2021 https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/coronavirus-disease-covid-19-hiv-and-antiretrovirals  

Regardless of HIV status, it remains important for everyone to continue to adhere to specific government recommendations to protect themselves and others from COVID-19. Countries continue to update their guidance to protect individuals and communities from COVID-19.  

Things you can do to protect yourself and others from COVID-19 include: 

• Wash your hands regularly and thoroughly with soap and water or an alcohol-based hand rub.  

• Wear a face mask in settings where there is a high risk of transmission.  

• Cover your mouth and nose with a tissue, your sleeve or your elbow (not your hands) when you cough or sneeze. Wash your hands and dispose of the tissue immediately afterwards. 

• Avoid touching eyes, nose or mouth with unwashed hands. 

• Follow national guidance about physical distancing between yourself and other people. 

• If you become sick, even with mild symptoms, stay home and away from work, school, public spaces and other people until you have taken a test for COVID-19.  

• If you test positive for COVID-19, follow national guidelines for self-isolation.  

• Continue to take your HIV treatment regularly, as prescribed, to keep your immune system as strong as possible. 

• If you need to access health services, it is recommended that you follow national guidance and, where possible, call your healthcare provider before arriving at a health facility.  

• Health authorities strongly recommend that everyone living with HIV, regardless of CD4 count, receive a COVID-19 vaccine.  

If you take an HIV test and the results are positive, you should access treatment services to ensure that your viral load remains undetectable and your CD4 count high to protect yourself as far as possible from the effects of both HIV and COVID-19. Everyone should know their HIV status. 

Resources:  

What people living with HIV need to know about HIV and COVID-19. Infographic. UNAIDS, 18 March 2020 https://www.unaids.org/en/resources/infographics/hiv-and-covid-19  

Handwashing with soap – our best defence against coronavirus. WashEm https://washem-guides.s3.eu-west-2.amazonaws.com/washem_quicktip_coronavirus.pdf 

Use and Care of Masks. Centers for Disease Control and Prevention, 25 Feb 2022 https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fprevent-getting-sick%2Fcloth-face-cover-guidance.html 

People living with HIV who know their status and are not yet on antiretroviral treatment (ART) should start treatment without delay. 

People living with HIV who are on ART should ensure that they have at least 30 days of antiretrovirals (ARVs) with them and, where possible, a three- to six-month supply of ARVs. The World Health Organization recommends that clinically stable adults, children, adolescents and pregnant and breastfeeding women, as well as members of key populations (men who have sex with men, people who inject drugs, sex workers and trans people), could benefit from multi-month prescriptions and refills. 

Multi-month refills mean that three to six months of HIV medication are dispensed to reduce the frequency of visits to clinical settings. With longer prescriptions, people living with HIV can access longer ART refills and/or receive ART refills from community-based services. This limits unnecessary visits to healthcare facilities and reduces the risk of SARS-CoV-2 exposure and treatment interruption that can be caused by disruptions to clinic schedules during the COVID-19 pandemic. 

Resources:  

Coronavirus disease (COVID-19): HIV and antiretrovirals. Q&A. WHO, 30 November 2020 https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/coronavirus-disease-covid-19-hiv-and-antiretrovirals 

COVID-19 DSD resources: recommended service delivery adaptations https://differentiatedservicedelivery.org/Resources/Resource-Library/COVID-19-DSD-Resources-Service-delivery-adaptations 

Early in the COVID-19 pandemic, some antivirals used in HIV treatment, especially lopinavir/ritonavir, were studied in people who are HIV negative to see if they could improve outcomes for people hospitalized with COVID-19. There is no evidence that lopinavir/ritonavir or other ART used for HIV is effective for treating COVID-19.    

There is no evidence that pre-exposure prophylaxis (PrEP) prevents you from getting COVID-19 or that PrEP will help you recover quicker from COVID-19. 

Most people with COVID-19 have mild to moderate symptoms and do not require admission to hospital. WHO continues to monitor developments and trials of treatments for COVID-19 as more evidence becomes available. Several treatments, including classes of antivirals, are recommended for use, particularly for clients most likely to develop severe COVID-19.  

Resources:  

Coronavirus disease (COVID-19): HIV and antiretrovirals. Q&A. WHO, 30 November 2020  https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/coronavirus-disease-covid-19-hiv-and-antiretrovirals 

Therapeutics and COVID-19: living guideline https://app.magicapp.org/#/guideline/nBkO1E/rec/LwrMyv 

Older people and people with other co-morbidities, including cancer, cardiovascular disease, diabetes, obesity, chronic respiratory disease and hypertension, are at an increased risk of developing severe COVID-19 illness compared with people without underlying health conditions.  

If you are living with HIV and are older and/or have other health conditions, such as those listed in the previous paragraph, then it is particularly important that you keep taking any prescribed chronic medication in addition to your antiretroviral treatment.

COVID-19 and tuberculosis (TB) both affect the lungs. People living with HIV who are also living with TB or who are TB survivors often have lung damage and are likely to be more susceptible to COVID-19 and serious illness. People with TB should take precautions recommended by health authorities to protect themselves from COVID-19 and continue to take TB treatment. They should pay particular attention to the guidance on infection control practices, such as physical distancing and mask wearing.  

Countries with a high burden of TB need to protect people with TB and TB survivors from SARS-CoV-2 exposure. This includes ensuring that measures are in place to limit transmission in healthcare settings, providing access to testing for TB and COVID-19 and maintaining treatment and care services.   

Resources: 

Webinar: Addressing the TB screening, prevention and treatment needs of people living with HIV in the era of COVID-19. IAS, 13 April 2021 https://iasociety.org/webinars-and-recordings 

Coronavirus disease (COVID-19): Tuberculosis. WHO, 11 May 2020 https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/coronavirus-disease-covid-19-tuberculosis 

Maintenance of HIV testing, prevention and continuity of HIV treatment are essential during the COVID-19 pandemic as it continues to impact communities. The COVID-19 pandemic has significantly disrupted health systems and services since 2020. In some cases, this disruption has accelerated the implementation of HIV service delivery methods, notably community-led services and differentiated service delivery, self-testing, multi-month prescriptions and the use of telehealth.  

Lockdowns, restrictions and diversion of health resources and services during the COVID-19 pandemic have likely resulted in:    

• Higher risk of contracting HIV for children and adolescents, especially girls, due to school closures  

• Higher exposure to domestic violence for women during lockdowns  

• Reduced access to prevention, testing and treatment services for key populations  

• Disrupted HIV prevention services, including male circumcisions and the roll out of PrEP  

• A reduction in HIV testing and referrals to care  

• Lower testing uptake for HIV at antenatal clinic visits  

• Slowing of treatment initiation. About 26 million people were on ART in mid-June 2020, reflecting only a 2.4% increase from the end of 2019, compared with a 4.8% treatment coverage increase seen in 2019.  

Lessons and opportunities from the COVID-19 pandemic must be continually reviewed and addressed to ensure that the impact on the HIV response is minimized.     

Resources:  

2021 UNAIDS Global AIDS Update – Confronting inequalities – Lessons from pandemic responses from 40 years of AIDS. 14 July 2021 https://www.unaids.org/en/resources/documents/2021/2021-global-aids-update  

Impact of the COVID-19 Pandemic on the UNAIDS Six 95% HIV Control Targets. Tiande Jiang et al, Frontiers in Medicine https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8896494/