When the Centers for Disease Control and Prevention (CDC) first issued advisements about the risk of COVID-19 in high-risk populations, immunocompromised people were among the groups considered to be at an increased risk of severe illness and death from contracting the novel coronavirus.

To many, this includes groups whose immune systems are characteristically compromised due to disease and/or treatment interventions, such as organ transplant recipients on immunosuppressant drugs or people with cancer on chemotherapy.

But, to some, the first and most obvious group that came to mind are people living with HIV, whose disease is characterized by the progressive deterioration of the immune system when not treated with antiretroviral therapy.

While it might seem reasonable to assume that having HIV places a person at risk of not only getting COVID-19 but developing more severe illness, the determination of risk on an individual basis is not so straightforward.

What Is Coronavirus?

COVID-19—referred to scientifically as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)—is a type of virus that can be spread from person to person and cause respiratory illness, sometimes severe.

It is one of seven major types of coronaviruses, four of which cause the common cold and the other three of which can cause potentially severe respiratory illness.

According to the CDC, COVID-19 is most commonly spread by exposure to respiratory droplets when in close contact (within 6 feet) with someone with COVID-19. It can also potentially be spread by airborne transmission and less commonly by contact with contaminated surfaces.

Symptoms and Complications

When exposed to the virus, some people will experience no symptoms, others may have mild cold or flu symptoms, and others still will develop severe and potentially life-threatening illnesses.

If symptoms develop, they tend to do so within 2 to 14 days of exposure and may include fever, cough, shortness of breath, loss of taste or smell, muscle aches, fatigue, nausea, vomiting, and diarrhea.

In some people, the infection can worsen, leading not only to severe respiratory complications like pneumonia or acute respiratory distress syndrome, but also non-respiratory complications such as blood clots, endocarditis, and acute kidney injury.

Risks for People With HIV

To have HIV does not mean that a person is inherently immunocompromised. HIV is ultimately a disease characterized by the progressive depletion of immune cells. If left untreated, the loss of these cells can become severe enough that a person becomes immunocompromised.

Immunocompromised people are presumed to be at high risk of COVID-19 complications. This is evidenced in part by studies that have shown that immunocompromised people with cancer experience more severe disease (30% vs. 16%) and deaths (5.6% vs. 2.3%) from COVID-19 than the general population.

Without an intact immune system, the body is less able to fight opportunistic infections that it would otherwise be able to control. If the loss of the cells is profound, it can even cause an infection to spread (disseminate) from its original site, into the bloodstream, and to distant organs.

People with HIV are vulnerable to a variety of acute and chronic respiratory infections, the risk of which tends to increase with the decline of immune function.

Low CD4 Count

The definition of “immunocompromised” varies somewhat by disease. With cancer, for example, the healthcare provider will look for the depletion of different types of white blood cells central to the immune defense, including neutrophils and basophils.

While it remains unclear if having HIV can increase your risk of getting COVID-19, an increasing body of evidence suggests that it can complicate the coronavirus infection if the immune system is compromised.

With HIV, the one type of white blood cell healthcare providers will monitor is the CD4 T-cell lymphocyte. CD4 T-cells are “helper cells” that send signals to other immune cells, including “killer” CD8 T-cells, to destroy disease-causing organisms (pathogens).

What makes HIV insidious is that it preferentially attacks and destroys CD4 T-cells, while “hijacking” their genetic machinery to churn out new copies of itself.

Unless antiretroviral therapy is started, the loss of these cells will leave the immune system increasingly “blind” to an ever-widening range of pathogens and opportunistic infections.

Respiratory Infections by CD4 Count

Because the risk of certain infections increases with the loss of CD4 T-cells, a blood test called a CD4 count is considered a reliable marker of immune function. Typically, a CD4 count of 500 and above is considered “normal.” When the count drops below 200, a person is said to have AIDS and be immunocompromised.

Although studies are often conflicting, evidence increasingly suggests that declines in the CD4 count correspond to an increase in the risk of severe COVID-19 symptoms.

Within the context of COVID-19, a low CD4 count is especially concerning in that it may increase the risk of a disseminated infection in which other organs besides the lungs are affected.

A February 2021 study published in JAMA Open Network concluded that people with CD4 counts under 200 are up to 150% more likely to be hospitalized due to COVID-19 than those with CD4 counts between 200 and 500 and more than twice as those with CD4 counts over 500.

This is a phenomenon believed to occur in people with severe COVID-19 infections, some of whom develop sepsis, encephalitis, kidney failure, and other serious non-respiratory complications.

A similar pattern is seen in people with advanced HIV infection in which the risk of dissemination from respiratory infections like tuberculosis and histoplasmosis increases when the CD4 count drops below 200.

Treatment Status

A person’s treatment status—whether they are on antiretrovirals and/or taking them as prescribed—may also influence a person’s risk of COVID-19.

This is because a person who starts taking antiretroviral drugs will typically experience immune recovery. Many who start treatment early, before the immune system is compromised, will see their CD4 count return to the normal range.

This appears to translate to reduced morbidity (illness) and mortality (death). A number of recent studies, for example, have shown that people with HIV who are hospitalized with COVID-19 are at lesser risk of death if they are on therapy with a CD4 count over 200.

The challenge, of course, is that not everyone with HIV is on antiretroviral therapy and that around 15% of the 1.2 million Americans with HIV remain undiagnosed. Even among those who have been diagnosed, only 76% have accessed treatment, according to data from the Department of Health and Human Services.

An October 2020 review of studies in HIV Medicines similarly showed that when the disease is properly treated and controlled, a person with HIV has the same risk of COVID-19 complications as the general population.

Moreover, being on treatment doesn’t necessarily mean you will achieve full immune recovery. People who start therapy late when their CD4 count is low may never see their CD4 count return to normal. Some may even remain below the 200 CD4 count threshold.

Comorbidities and Other Factors

Co-occurring medical conditions, also known as comorbidities, are common in people with HIV. These are conditions that are not HIV related but may be influenced by HIV or exacerbated by the persistent chronic inflammation associated with HIV.

The most common comorbidities among people with HIV include:

  • Cardiovascular diseases: Including hypertension and heart failure
  • Diabetes: Most predominantly type 2 diabetes
  • Liver diseases: Including hepatitis B and hepatitis C
  • Respiratory diseases: Including chronic obstructive pulmonary disease (COPD)

Interestingly enough, all four comorbidities are considered independent risk factors for COVID-19. Because COVID-19 is understudied in people with HIV, however, it is often difficult to know if HIV is adversely affecting outcomes or if the comorbidities are to blame.

Older age—a risk factor for COVID-19—may also play a part given that advancing age typically leads to the loss of CD4 T-cells. With that said, older adults who start antiretroviral therapy generally experience the same level of immune recovery as younger people. The recovery may be slower but more or less the same as someone in their 20s.

Precautions

If you have HIV, the precautions you would take to avoid COVID-19 are the same as anyone else. However, if your CD4 count is low, you may want to be extra careful and pay strict attention to current CDC guidelines.

On the flip side, there is evidence that HIV may have a beneficial effect among some who get COVID-19. Because the immune response is often blunted, it is less likely to overact and lead to a potentially life-threatening complication known as a cytokine storm.

Avoid Infection

The CDC recommends the following precautionary measures to avoid getting or passing COVID-19 to others:

  • Face masks: Anyone age 2 and over should wear a face mask that fits snugly against the sides of the face whenever out in public.
  • Socially distancing: Remain 6 feet (around two arm’s length) from others and keep well away from anyone who appears sick. In addition to social distancing, crowds should be avoided as best as possible.
  • Hand washing: Wash your hands with soap and water for at least 20 seconds, especially after blowing your nose, coughing, sneezing, or being out in public.
  • Covering coughs and sneezes: Use a tissue or the inside of your elbow when sneezing or coughing, washing your hands immediately afterward.
  • Disinfecting surfaces: Regularly clean touched surfaces, using disinfectants approved by the Environmental Protection Agency (EPA) for COVID-19.

Prepare and Be Safe

As a person living with HIV, there are preparations you should make to maintain a healthy immune response during the pandemic:

If you have been in close contact with someone who has COVID-19, the current CDC guidelines include that you were a high-quality mask when indoors and around others for 10 days and get tested after 5 days. If you develop symptoms, you should isolate yourself immediately, get tested, and stay home.

  • Prescription refills: Make sure that you have at least a 30-day supply of your medicines on hand. You can ask your pharmacist to schedule reminders so that you are advised when a prescription is about to run out.
  • Medication adherence: Missing antiretroviral doses increases the risk of treatment failure. If you are unable to take your drugs as prescribed, speak with your healthcare provider. If appropriate, your treatment may be changed to one that is more tolerable or has a simpler dosing schedule.
  • Routine bloodwork: If indicated, have your CD4 count, viral load, and other routine blood tests performed as scheduled, usually every 4 to 6 months. Some insurers will not approve prescription refills until these tests are done.
  • Healthy lifestyle: Eating right, managing stress, and getting 8 hours of sleep every night can support immune function in people with HIV, as it can with everyone else.

Treatments

Clearly, the first and best treatment to reduce your risk of COVID-19 is antiretroviral therapy. Typically taken daily and often as in a single combination tablet, the pills work by interrupting a stage in the virus’s replication cycle. By blocking replication, the virus can be suppressed to undetectable levels, providing the immune system a chance to recover.

Unlike in the past, antiretroviral therapy is started at the time of diagnosis without exception. For optimal suppression, greater than 95% adherence may be needed.

In the early days of the COVID-19 pandemic, it was thought that antiretrovirals—most especially lopinavir and ritonavir found in the combination drug Kaletra—might aid in the treatment of COVID-19. Today, the current body of evidence indicates that antiretrovirals have no benefit in preventing or treating coronavirus infection.

Never switch or stop your HIV medications under the presumption that doing so can prevent or treat COVID-19.

If your CD4 count falls beneath a certain threshold, your healthcare provider may put you on prophylactic drugs to prevent certain opportunistic infections. While these do nothing to protect against COVID-19, they are a sign that you need to take extra steps to avoid infection in all forms.

HIV and COVID-19 Vaccines

The emergency approval of COVID-19 vaccines has led some people with HIV to question whether they are safe. Although the long-term effects of the vaccines have yet to be established, there is nothing to suggest that they are any less safe for people with HIV than anyone else.

Generally speaking, the only vaccines that may pose risks to people with HIV are live vaccines, and none of the current lot falls into that category.

The four COVID-19 vaccines available in the United States are:

  • Pfizer-BioNTech: available to people 6 months and older
  • Moderna; available to people 6 months and older
  • Janssen/Johnson & Johnson (J&J): available to people 18 years and older
  • Novavax: available to people 12 years and older

Due to possible side effects from the J&J COVID-19 vaccine, the Centers for Disease Control and Prevention (CDC) recommends that people seek one of the mRNA vaccines (Moderna or Pfizer) or the Novavax vaccine over the J&J vaccine. The CDC recommends that anyone living with HIV receive a primary series of a COVID-19 vaccine, regardless of CD4 or viral load. Additionally, the CDC recommends updated bivalent booster shots by Pfizer or Moderna for everyone 5 years and older, two months after the second dose or last booster.

In limited situations, a monovalent Novavax booster dose may be used in people ages 18 and older who are unable to receive an mRNA vaccine.

Vaccine Efficacy

It is unknown whether the immunologic response from the vaccines will be as robust or durable in people who are immunocompromised as those with intact immune systems. This is because immunosuppressed people were excluded from vaccine trials.

As such, it may take time before scientists know whether immunocompromised people will do fine with the current vaccination protocols, need additional vaccinations, or require alternative approaches.

If in doubt, speak with your healthcare provider to get better clarity based on your current immune status and individual health concerns.

Concerns about efficacy should in no way sway people with HIV from getting vaccinated. By and large, the benefits of COVID-19 vaccination are seen to outweigh the risks.

A Word From Verywell

Living with HIV can be challenging for some, and the added stress of COVID-19 can make you feel all the more vulnerable. This is both reasonable and understandable.

With that said, there is little indication that having HIV increases your risk of getting COVID-19. There is, however, evidence that antiretroviral therapy can reduce your risk of severe illness and hospitalization if you get infected.

If you have HIV but haven’t yet started treatment, speak with your healthcare provider; there may be no better time than now to do so. If, on the other hand, you are at risk of HIV but have never been tested, you should also consider taking action. In the United States, HIV testing is recommended for all Americans 15 to 65 as part of a routine healthcare provider’s visit.

Finally, it is important to understand that many of the early signs of HIV, including muscle aches and flu-like symptoms, overlap with those of COVID-19. If you develop these symptoms and had a recent risk of HIV exposure, don’t keep silent; let your healthcare provider know.

The information in this article is current as of the date listed. As new research becomes available, we’ll update this article. For the latest on COVID-19, visit our coronavirus news page.