Racial and ethnic disparities in coronavirus disease 2019 disease incidence independent of comorbidities, among people with HIV in the United States
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Abstract
To define the incidence of clinically detected coronavirus disease 2019 (COVID-19) in people with HIV (PWH) in the United States and evaluate how racial and ethnic disparities, comorbidities, and HIV-related factors contribute to risk of COVID-19.
Design:
Observational study within the CFAR Network of Integrated Clinical Systems cohort in seven cities during 2020.
Methods:
We calculated cumulative incidence rates of COVID-19 diagnosis among PWH in routine care by key characteristics including race/ethnicity, current and lowest CD4 + cell count, and geographic area. We evaluated risk factors for COVID-19 among PWH using relative risk regression models adjusted with disease risk scores.
Results:
Among 16 056 PWH in care, of whom 44.5% were black, 12.5% were Hispanic, with a median age of 52 years (IQR 40–59), 18% had a current CD4 + cell count less than 350 cells/μl, including 7% less than 200; 95.5% were on antiretroviral therapy (ART), and 85.6% were virologically suppressed. Overall in 2020, 649 PWH were diagnosed with COVID-19 for a rate of 4.94 cases per 100 person-years. The cumulative incidence of COVID-19 was 2.4-fold and 1.7-fold higher in Hispanic and black PWH respectively, than non-Hispanic white PWH. In adjusted analyses, factors associated with COVID-19 included female sex, Hispanic or black identity, lowest historical CD4 + cell count less than 350 cells/μl (proxy for CD4 + nadir), current low CD4 + : CD8 + ratio, diabetes, and obesity.
Conclusion:
Our results suggest that the presence of structural racial inequities above and beyond medical comorbidities increased the risk of COVID-19 among PWH. PWH with immune exhaustion as evidenced by lowest historical CD4 + cell count or current low CD4 + : CD8 + ratio had greater risk of COVID-19.
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SciScore for 10.1101/2021.12.07.21267296: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Ethics IRB: CNICS research has been approved by the institutional review boards at each site. Sex as a biological variable not detected. Randomization not detected. Blinding not detected. Power Analysis not detected. Table 2: Resources
Antibodies Sentences Resources Covariates: We examined demographic covariates (age, sex at birth, self-reported race and Hispanic ethnicity, CNICS site) and the following chronic comorbid conditions: diabetes defined using a previously validated approach as hemoglobin A1c (HbA1c) ≥6.5%, a prescription of a diabetes-specific medication, or a diagnosis of diabetes with diabetes-related prescription[25]; treated hypertension as a diagnosis of hypertension with prescription of an … SciScore for 10.1101/2021.12.07.21267296: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Ethics IRB: CNICS research has been approved by the institutional review boards at each site. Sex as a biological variable not detected. Randomization not detected. Blinding not detected. Power Analysis not detected. Table 2: Resources
Antibodies Sentences Resources Covariates: We examined demographic covariates (age, sex at birth, self-reported race and Hispanic ethnicity, CNICS site) and the following chronic comorbid conditions: diabetes defined using a previously validated approach as hemoglobin A1c (HbA1c) ≥6.5%, a prescription of a diabetes-specific medication, or a diagnosis of diabetes with diabetes-related prescription[25]; treated hypertension as a diagnosis of hypertension with prescription of an anti-hypertensive medication; obesity as body mass index (BMI) ≥30 kg/m2; hepatitis C virus (HCV) coinfection by the presence of positive HCV antibody or detectable RNA or genotype; and chronic obstructive pulmonary disease (COPD) using a previously validated approach[26] as a diagnosis of COPD and ≥90-day continuous supply of long-acting controller medications. BMIsuggested: NoneSoftware and Algorithms Sentences Resources All analyses were conducted in Stata version 17 (StataCorp, College Station, TX). StataCorpsuggested: (Stata, RRID:SCR_012763)Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:Limitations of our study include lack of systematic surveillance testing, wherein case identification is limited by access to testing and availability of results, and ascertainment limited to PWH engaged in care. PWH with asymptomatic or minimally symptomatic COVID-19 were likely undertested and under-reported in medical records, a limitation also present in both cohort studies and public health data. Strengths of our study include comprehensive data on more than 16,000 PWH in care across the US with well-characterized comorbidities and HIV-specific clinical data. The latter allowed greater measurement precision to distinguish between the contribution of comorbidities, race/ethnic identity, and HIV factors to risk of COVID-19 diagnosis than studies using public health data. During the earliest months of the pandemic, people with mild symptoms or lacking risk factors for severe disease were discouraged from accessing clinical care, which may have introduced some bias in who was tested during those months[45]. Facility-based testing was often performed in emergency departments and hospitals, thus, people with advanced age or comorbidities may have been overrepresented amongst reported cases, although we do not expect that there was differential testing by CD4 count, ART status, sex, or race/ethnicity among people who presented to care. Conversely, persons with a history of AIDS or other comorbidities, who perceived themselves at greater risk of poor outcomes, may have been more...
Results from TrialIdentifier: No clinical trial numbers were referenced.
Results from Barzooka: We did not find any issues relating to the usage of bar graphs.
Results from JetFighter: We did not find any issues relating to colormaps.
Results from rtransparent:- Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
- Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
- No protocol registration statement was detected.
Results from scite Reference Check: We found no unreliable references.
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