Incidence and severity of COVID‐19 in adults with and without HIV diagnosis

Previous reports have indicated that HIV infection is associated with worse COVID-19 related outcomes [1–3] and that certain subpopulations among persons living with HIV (PLH) might be at a higher risk of severe COVID-19 [4]. In this registerand population-based cohort study, we analyzed the incidence and severity of COVID-19 from 1 March 2020 to 31 August 2021 in individuals >18 years living with and without HIV in Stockholm, Sweden. Furthermore, we compared demographics, comorbidities, and characteristics of HIV infection in PLH not hospitalized and hospitalized with COVID-19. Cohort definitions, data sources, study variables, and statistical analyses are presented in the supplement.


Incidence and severity of COVID-19 in adults with and without HIV diagnosis
Dear Editor, Previous reports have indicated that HIV infection is associated with worse COVID-19 related outcomes [1][2][3] and that certain subpopulations among persons living with HIV (PLH) might be at a higher risk of severe COVID-19 [4]. In this registerand population-based cohort study, we analyzed the incidence and severity of COVID-19 from 1 March 2020 to 31 August 2021 in individuals >18 years living with and without HIV in Stockholm, Sweden. Furthermore, we compared demographics, comorbidities, and characteristics of HIV infection in PLH not hospitalized and hospitalized with COVID-19. Cohort definitions, data sources, study variables, and statistical analyses are presented in the supplement.
Out of 1,728,069 individuals ≥18 years in Region Stockholm, 3209 were PLH. Demographics and comorbidities of the general population and PLH are presented in Table S2. Among individuals living with and without HIV, the median age was 51 (interquartile range [IQR] 43-59) and 47 (IQR 33-63) years, and 51% and 42% had any risk factor for severe COVID-19, respectively. The cumulative incidence of COVID-19 by 31 August 2021 was 12% for both individuals living with and without HIV (Fig. S1).
In this study, the cumulative incidence of COVID-19 was similar in PLH and the general population. This observation is in line with previous studies from high-income settings, but substantial differences between populations with different demographic and socioeconomic distributions might occur [5]. HIV infection was not associated with COVID-19 hospitalization, and a relevant association between HIV infection and ICU admission or 30-day all-cause mortality could not  Table S1 for a description of each condition.
be demonstrated nor excluded. Previous reports on the risk of severe outcomes in COVID-19 in PLH are conflicting, with different study designs and comparison groups precluding direct comparisons [6].
Earlier studies have reported that older and frailer PLH with lower CD4+ counts and higher levels of HIV-viremia have a higher risk of severe COVID-19 [1,7]. Herein, among PLH with COVID-19, hospitalized patients were older, had more comorbidities, lower CD4+ counts, and more often were on protease inhibitors. The overrepresentation of protease inhibitor treatment in our hospitalized individuals may be a reflection of the use of these drugs being more common in older PLH.
Limitations of the study include limited sample size, and lack of body mass index and COVID-19 vaccination data. A major strength of our study is the access to population-based data on comorbidities, drug prescriptions, and SARS-CoV-2 positive tests, facilitating the matching of PLH with controls.
In summary, our study indicates that in a cohort of well-treated PLH, HIV infection is not a risk factor for severe outcomes in COVID-19.

Funding information
The work was supported by EuCARE and Region Stockholm. P. H. was supported by Karolinska Institutet (combined clinical studies and PhD training program). The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Ethics approval and consent to participate
The need for consent was waived by the Swedish Ethical Review Authority (Dnr 2018/1030-31, COVID-19 research amendment Dnr 2020-01385) since analyses are based on retrospectively collected data from the administrative health registry.

Conflict of interests
None of the authors reports competing interests.

Authors contributions
Pontus Naucler had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. All authors have read and approved the manuscript.
Study concept and design: All authors Acquisition, analysis, or interpretation of data: PH, JV, PNo, Pna Drafting of the manuscript: PH, JV, CM, PNo, Pna Critical revision of the manuscript for important intellectual content: All authors Statistical analysis: PH.

Data availability statement
No data are available. Data from deidentified the administrative health registry are not freely available due to the protection of the personal integrity of the participants.