The results of this study show that the incidence of COVID-19 among PLWH in Southern Spain during the first wave of the pandemic was low and not different of that found in Spanish patients without HIV infection 9 and in other cohorts of PLWH 15. Remarkably, no asymptomatic cases were discovered by antibody testing, and all patients who developed COVID-19 had showed symptoms which led to a diagnosis of suspected, or PCR-confirmed COVID-19.
The incidence of COVID-19 among the general population aged from 20- to 79-year-old during the first wave of the pandemic in Spain was 0,417% 9. This figure falls into the 95% CI for COVID-19 incidence found in this study. Among PLWH, the reported incidence of COVID-19 has ranged from 0.2% to 2.8% 15, again not different to that found herein. In ENE-COVID study, a cross-sectional seroepidemiological survey conducted across all Spanish regions from May 18th to June 1st, 2020 16,17, the prevalence of positive plasma SARS-CoV-2 antibodies by a chemiluminescent assay in a random sample of 1805 Seville province inhabitants was 1.3%. In 1697 members of this population, the seroprevalence observed from June 8th to June 22nd, 2020, was 2.7% (95% CI 1,8%-3,9%) using a point-of-care test 17. Assuming that the four seroconverters identified in our study were seropositive in the above-stated weeks, the figure observed by us would be not significantly different of those found in this nationwide study.
The estimated proportion of asymptomatic SARS-CoV-2 infections reported so far has been very variable, ranging from 18% to 81% 10,18. Specifically, in the seroepidemiological nationwide Spanish ENE-COVID study 16,17, around one third of patients harboring plasma SARS-CoV-2 antibodies did not report any symptom suggesting COVID-19. Therefore, it is noteworthy that no asymptomatic case has been observed in our study. We cannot rule out that some patient who had developed asymptomatic infection at the beginning of the pandemic tested negative for SARS-CoV-2 serology in June, because of plasma antibody vanishing. In fact, plasma antibodies against SARS-CoV-2 have been reported to disappear shortly in a part of asymptomatic patients 19. However, these results have not been confirmed in other study from Iceland, including a larger number of patients, which showed that antibodies do not decline within 4 months after diagnosis 20. In any case, data presented herein are in line with the greater clinical severity of this disease among HIV-infected patients suggested by studies conducted in South Africa 8 or in Italy 21.
Four (1.25%) patients tested positive for serum SARS-CoV-2 antibodies in the sample collected in the pre-pandemic period by the ECLIA technique used as a first step in this study. Two of them also yielded a positive result by EIA for IgG anti-SARS-CoV-2. A thorough analysis of these samples showed that they were false positive results, due to unspecific reactions against the EIA plaque or because the patient harbored IgG antibodies against N3 antigen, a coronavirus protein not specific for SARS-CoV-2. The proportion of false positive results observed in this study is consistent with that reported by the procedure’s manufactures 13,14. However, we should be aware of the possibility of these reactions when interpreting a positive SARS-CoV-2 antibody test, particularly in patients without symptoms and in low incidence settings.
Surprisingly, a trend to a statically significant association between tobacco smoking and lower incidence of COVID-19 was found in this study. Smoking has been reported to be associated with and increased risk of COVID-19 severity 22. Tobacco smoke exposure results in inflammatory processes in the lung, increased mucosal inflammation, expression of inflammatory cytokines and tumor necrosis factor α, increased permeability in epithelial cells, mucus overproduction, and impaired mucociliary clearance 23. Moreover, nicotine induces ACE-2 overexpression in human bronchial epithelial cells 24. All these factors may contribute to a greater severity of COVID-19 among smokers. Conversely, there is no data to quantify the risk of smokers for acquiring the infection with SARS-CoV-2 22. Smoking is characterized by inhalation and by repetitive hand-to-mouth movements, which may increase the chances of viral contamination. Because of this we do not have a convincing explanation for an association between tobacco smoking and lower risk of COVID-19 among PLWH. In our opinion, this result needs replication in other studies, in order to rule out a spurious statistical association because the low number of COVID-19 cases observed. If so, the mechanism by which tobacco smoking might protect against SARS-CoV-2 infection should be investigated.
In this study, no clear association between antiretroviral drugs or combinations and the risk for COVID-19 was found. Previous studies have shown that tenofovir has potent antiviral effect against SARS-CoV-2, because it tightly binds the viral RNA-dependent RNA polymerase 25. Because of this, clinical trials aimed to assess the efficacy of TDF, a tenofovir salt which reaches higher plasma concentration than TAF, both in the prevention and treatment of COVID-19 were undertaken 26. Furthermore, in a retrospective study an association between TDF plus FTC treatment and less severity of COVID-19 was found 9. In our study, only two patients were on TDF plus FTC, because most individuals in this cohort have been switched from TDF to TAF in the last few years. Consequently, we were unable to accurately analyze the effect of TDF on the risk of SARS-CoV-2 infection. In patients on TDF or TAF plus FTC, the incidence of COVID-19 tended to be lower than in those with ABC plus 3TC, which would be in line with a protector effect of tenofovir. However, the incidence among subjects on nucleos(t)ide-free regimen or 3TC based-dual therapy was zero, which would argue against the former hypothesis.
As stated above, the main limitation of this study is the low number of COVID-19 episodes observed among PLWH. This fact prevents us from drawing firm conclusions on factors associated with COVID-19 emergence in this setting, as well as on the precise impact of HIV infection on the outcome of COVID-19, which would require larger sample sizes. However, this study has been conducted in a well-followed cohort, in which clinical data are homogenously collected and serum samples are routinely cryopreserved. Also, COVID-19 diagnosis has been based on PCR and serology, which was carried out in all patients. These are important strengths of this study, which allows a more precise estimation of total and severe COVID-19 incidence among PLWH than that provided by studies based on case reports.
In summary, the incidence of COVID-19 among PLWH in Seville during the first wave of the pandemic was low and similar to that observed in the general population, although the proportion of asymptomatic cases might be lower than in patients without HIV infection. That parameter should be periodically monitored, in order to analyze how it evolves with time and to detect further COVID-19 cases. Future studies with higher number of patients will allow us to more accurately define the role of antiretroviral therapy and tobacco smoking on the incidence and outcome of SARS-CoV-2 infection among PLWH.