ArticleMedicine2026
High risk of COVID-19 mortality in people living with advanced HIV disease in South Africa: A retrospective cohort study.
Article in Medicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Conflicting information exists in the literature regarding the relationship between HIV viral load suppression and immune suppression among people living with HIV (PLHIV) with coronavirus disease (COVID-19) comorbidity. We evaluated risk of in-hospital mortality among PLHIV with varying levels of immunosuppression and viral load in South Africa. We analyzed retrospectively collected individual-level cohort data from South Africa shared in the World Health Organization Global Clinic Platform comprising 3,10,522 hospitalized individuals, including 8191 PLHIV on antiretroviral therapy. Advanced disease was defined as CD4 counts of <200 cells/µL. The primary outcome was in-hospital mortality, defined as death within 28 days of hospital admission. Royston-Parmar survival models were used to assess the association of viral load and CD4 counts with in-hospital mortality among PLHIV on antiretroviral therapy. Models were adjusted for demographic factors, COVID-19 severity, severe acute respiratory syndrome coronavirus-2 variants, and comorbidities. Among the 8191 PLHIV with available CD4 and viral load data, 77.2% had viral suppression, and 35.9% had CD4 counts < 200 cells/μL. Compared to HIV-negative individuals, PLHIV with CD4 < 200 cells/μL and viral load ≥1000 copies/mL had a significantly higher risk of mortality (adjusted hazard ratio [aHR] 2.73, 95% CI: 2.45-3.04). Elevated mortality risk was also observed in PLHIV with CD4 < 200 cells/μL and viral load < 1000 copies/mL (aHR 2.01, 95% CI: 1.84-2.20), and those with CD4 ≥ 200 cells/μL and viral load ≥ 1000 copies/mL (aHR 1.47, 95% CI: 1.20-1.81). PLHIV with CD4 ≥ 200 cells/μL and viral suppression had the lowest, but still significant, increased in-hospital mortality risk (aHR 1.27, 95% CI: 1.18-1.36). A substantial increased risk of in-hospital mortality occurs among PLHIV with advanced HIV disease and unsuppressed viremia hospitalized with COVID-19. These findings highlight the importance of prioritizing COVID-19 vaccination and COVID-19 therapeutics for PLHIV during the post-pandemic phase. Further research is however needed to understand the high risk of mortality in virally suppressed PLHIV with CD4 ≥ 200 cells/μL.
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