What do people living with HIV need to know most about COVID-19?
One of our greatest challenges in this pandemic is uncertainty. There is a lot we still do not understand about COVID-19 and when we don’t have information many of us tend to fear the worst. Right now, what holds for people living without HIV holds for people living with HIV. This includes keeping far enough away from others so they cannot infect you. In the HIV community we know a lot about prevention and some of those same principles apply to keeping from getting COVID-19.
There is no evidence that people living with HIV are at heightened risk of infection with this coronavirus or are more likely to have complications if infected. People with weaker immune systems may be at higher risk for both but many living with HIV have strong immune systems and high CD4 cell counts. It also seems like the severe respiratory failure that can occur during COVID-19 may be driven, at least in part, by an aggressive immune response. So, it is hard to say if people living with HIV are different from anyone else when it comes to these risks.
The clear danger to people living with HIV during this outbreak is the serious disruptions in health care that can impact getting HIV meds and accessing routine services like clinic visits and labs. People living with HIV will have to be strong advocates for themselves and make sure they have enough medications on hand and not wait until the last pill to start calling for a refill. Despite being more isolated, they will have to continue to take care of themselves—take their meds, exercise as best as they can, and avoid slipping into despair. Sew masks, call elderly neighbors, make art, blog about Cary Grant movies. Do something constructive.
What do providers need to know when it comes to treating PLWHIV with COVID-19?
Clinicians are understandably distracted, many clinics are closed, and patients are hunkered down at home. But, we still need to be able to provide HIV care whether by phone or video and make sure people have what they need until this all passes. Clinicians need to establish some clear pathway for their patients to contact them such as for a medication refill, or non-COVID-19 illness.
Just because we are in the middle of a pandemic does not mean people won’t get kidney stones or shingles. I am finding that direct messaging from my patients is the most effective way for me to know what they need and then respond. This communicating can be done by text, email, or the electronic medical record. We clinicians also have to not wear COVID-19 blinders—thinking that every cough or shortness of breath is COVID-19 when it could be something much more routine. We have to fight hard not to let the outbreak become an impenetrable barrier to care.
What is the research being done that you find most promising or interesting?
It should be stated clearly: there is no proven treatment for COVID-19 right now (April 2020). Small studies suggest that hydroxychloroquine and lopinavir/ritonavir may work for some people with COVID-19, but these studies all have serious limitations and the researchers leading these investigations all say that much more definitive research is needed given the question of benefit and the known risks. Such studies are underway.
The research community has responded rapidly to COVID-19. It took many, many months before meaningful therapeutics and vaccine research was able to be launched during the huge West Africa Ebola outbreak—a sad missed opportunity. Many of us learned then that streamlined procedures are essential to get research from design to implementation during an outbreak.
With COVID-19 we are seeing a swift research response and important studies have already started or will very shortly to examine rigorously potential treatments as well as vaccines. One important aspect of this is understanding that what works early in the infection, when the virus is replicating in the upper airway, may not be effective in treating more advanced COVID-19, where inflammation in the lungs can shut down the passage of oxygen into the blood. We need to figure out what is most effective at the right point in the disease.
Has your work in Ebola helped to inform your work in COVID-19? What are the parallels, and what's different?
Working in Liberia during and after the Ebola outbreak there, I was struck by the social distancing that people there were able to do—not for weeks, but for over a year. Seeing this again, but now at home really blurs for me the “here” versus “there” mindset that I had as a researcher working domestically and abroad. My experience learning about infection control in West Africa has certainly served me, assisting my incredible colleagues as we created drive-through COVID-19 testing centers and prepared our hospital for admitting patients with suspected and confirmed COVID-19.
After Ebola, members of our team created “Liberians are Survivors” bumper stickers to celebrate the strength that people showed in doing the hard things that made the end of the outbreak possible. I still see them there. We will do the same and survive through strength.
What is the most important thing people can do to help in the effort?
Don’t freak out. It is hard to be separated and to not worry, to not miss the things we enjoyed but can’t do now, and not feel sad for ourselves, our communities, and our world. No one knows when this outbreak will pass, but it will. And, when we can get back to a more normal existence we will appreciate it so much more. We will rejoice in what was once the mundane and, I hope, feel closer to one another. Until then, stay home.
David Alain Wohl, MD, is a professor of medicine at the University of North Carolina at Chapel Hill. There he leads the HIV Prevention and Treatment Clinical Research Site and sees patients in the university’s Infectious Diseases Clinic.