Transcript Related Guidelines

Managing HIV Patients in the Era of COVID-19

Richard A. Elion, MD · George Washington University


August 18, 2022

Key Takeaways:

  • It is now clear from the experience during the COVID-19 pandemic that it is possible to care for people living with HIV (PLWH) through remote approaches, such as telemedicine.

  • While most PLWH are now able to return to physician offices, it is important to recognize that the threat of COVID-19 infection persists, requiring such strategies as masks and social distancing to reduce risk.

  • Vaccines are not as effective in PLWH than in the general population, but they are recommended and they do reduce the risk of serious disease.

  • In PLWH who do develop COVID-19, monoclonal antibody therapies are not recommended, but antiviral medications, particularly nirmatrelvir, do appear to be effective and safe for shortening the course of COVID-19.

  • Overall, the COVID-19 pandemic has not imposed a major increase in risk of morbidity and mortality among PLWH, particularly those with optimally suppressed HIV and who are fully vaccinated against COVID-19.

This transcript has been edited for clarity.

So the current era of COVID has certainly been an evolution from when we started close to 2½ years ago. We've seen enormous advances with the success of the vaccines preventing life-threatening illness, which is all a huge improvement. At the same time, COVID hasn't gone away. And so, what have really been the biggest changes since I spoke to you all close to 2 years ago, and what have been the biggest improvements and the biggest challenges? 

Well, the biggest improvements I think is that people don't have to stay indoors as much. People can go out. They're going out. They can decide to wear masks in indoor settings or not. But people can go to the doctors again. During the first year of COVID, we saw visits to their physicians declined markedly, less lab tests, less treatment for sexual health, all of which were deleterious for the HIV community. So now, we see that the uptick in visits and the uptick in engagement with providers has improved. 

We've also seen changes because of COVID that have been the development of virtual visits, telephone visits, video visits, in addition to in-person visits. This combination I think has made it easier for HIV patients to have access to health care providers and has been a good thing. Number two, the ability to go out to the pharmacy and protect yourself while you go pick up your medications has improved as well. And all of those things have been significant improvements in terms of patient care and engagement. Those are the pluses of COVID. 

The second plus is that we know that the vaccines for the most part have worked almost—but not quite—as good [as they do] for people who are HIV negative. They work way better than not being vaccinated. But we hoped in the beginning they would work just as well for everybody, and they don't work quite as well. They work better when your viral load is completely suppressed, but they still require careful vigilance about just symptom management and other things in case you're worried you're exposed to COVID. 

In terms of how a person who's HIV-positive should carry themselves in public settings, I think there's no clear answer on whether you need to wear a mask or not. I believe that it's best to wear a mask when you're indoors to protect yourself against others because even vaccinated people can pass along COVID. 

But the good news is that if a person catches COVID, and we do know that people who've been vaccinated can catch COVID again because of the variants, we know that the impact on a person's health is much, much less serious. 

Rates of hospitalization are markedly down, and arguably only elevated for those over 65. So that the consequences of a COVID infection are smaller. That is the reason why some people are deciding when to wear masks and when not to wear masks. 

Finally, there is medication these days if you've had a COVID exposure. There's a couple of different medications. There are monoclonal antibodies to prevent exposure to COVID. They're harder to get and harder to come by and not recommended for HIV-positive people. Vaccination I think is critical, including updates of vaccination for those of you on the third vaccination, and for some people even the fourth. That's relevant for you when you've been 6 to 9 months past your last vaccination. 

There are two different medications if you're positive with COVID. One is molnupiravir, which I wouldn't recommend as much as I would nirmatrelvir, otherwise known as Paxlovid. That's the one that's most commonly used, nirmatrelvir. It has a protease inhibitor as part of its constituents, which can make a difference for some of the medications that people who are on HIV meds need to be careful of.

So, all in all, for HIV-positive people in this new day of COVID, HIV-positive people continue to fare well. They're able to go out and see their doctors. They're able to go out and see their friends. They're able to have social interactions, all of which is very positive. We know that suppressing HIV continues to result in better improvements in health and also better responses if a person becomes COVID-positive and also protects against COVID infection. 

I think, all in all, we've seen that the HIV-positive community has been able to continue to flourish in the midst of COVID. There are certainly issues of differences in access to some of these medications, both HIV meds as well as the medicines for COVID for certain parts of the HIV community. This continues to be a national issue in how we can have better equity among different groups of economic and racial groups to make sure that everybody has access to these medications. 


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