Prevalence of undiagnosed HIV in Venezuelan patients with suspected COVID-19 during the first wave: A complex syndemic

Dear Editor:

The impact of the COVID-19 pandemic is likely to be deeper in resource-limited settings, including Venezuela, where its effects are compounded by the country’s complex humanitarian crisis, inadequately resourced health systems, and concurrent HIV epidemics [1]. There is growing concern that COVID-19 will lead to the disruptions for HIV testing and treatment services, which could result in excess HIV-related deaths and onward transmission, jeopardizing the fulfillment of the first UNAIDS global 90-90-90 target that 90% of all people living with HIV will know their status [2]. Here we determined the prevalence of undiagnosed HIV in suspected COVID-19 patients during the first wave, as well as their clinical-epidemiological characteristics, at the main sentinel hospital in Caracas, Venezuela.

We cross-sectionally analyzed 118 consecutive suspected COVID-19 cases (according to WHO guidelines) [3] in the respiratory triage tent of the “Hospital Universitario de Caracas”, Venezuela, between May and August 2020. Ethics committee approval was obtained from the “Centro Nacional de Bioética”, Venezuela (CIBI-CENABI-11/2020). After signing the informed consent, clinical-epidemiological information was obtained from all patients. HIV testing was performed using the ABON™ HIV 1/2/O Tri-Line HIV rapid test device (ABON Biopharm Hangzhou Co., Ltd.). 4th-gen-ELISA confirmed positive and discordant results, initiating ART immediately in positive patients. Categorical variables were presented as frequencies and were compared using Fisher’s exact or Yates’s chi-squared tests. Continuous variables were presented as mean (SD) or median [IQR] and were compared using Student’s t-test or median test. All statistical analyses were performed using SPSS 25, with a 0.05 significance level.

Out of 118 COVID-19 patients, 5 (prevalence rate = 4.24 × 100 patients) were HIV positive. Patients’ mean age was 41 (SD 14), mostly female (57.1%), from Capital District (80.5%) and employed (43.2%). Compared to HIV-negative, a higher proportion of HIV-positive patients were homosexual (p < 0.001), had sexual intercourse under the influence of alcohol/drugs in the last six months (p = 0.044), and had syphilis history (p < 0.001) (Table 1 ). Fever (67.8%), dry cough (65.3%), headache (63.6%), dyspnea (54.2%) and asthenia (52.5%) were the most common symptoms in all patients; the less common symptoms included weight loss (14.4%), dysphagia (14.4%), abdominal pain (13.6), lymphadenopathies (7,6%) and skin lesions (6.8%). A higher proportion of skin lesions and lymphadenopathies were found in HIV-positive patients compared to HIV-negative ones (80% vs. 3.5%, p < 0.001; 60% vs. 5.1%, p < 0.001; respectively).

Table 1.

Epidemiological characteristics and personal history of 118 patients with suspected COVID-19 according to coinfection status.

	Total (n = 118; 100%)	HIV-negative patients (n = 113; 95.8%)	HIV-positive patients (n = 5; 4.2%)	p-value
Epidemiological characteristics
Age, mean (SD), years	41 (14)	41 (14)	38 (14)	0.622a
Sex, female/male (%)	61/57 (57.1/48.3)	59/54 (52.2/47.8)	2/3 (40/60)	0.468b
Provenance, n (%)				0.129b
Distrito Capital	95 (80.5)	92 (81.4)	3 (60)
Miranda	18 (15.3)	17 (15)	1 (20)
Other	5 (4.2)	4 (3.5)	1 (20)
Occupation, n (%)				0.508b
Employed	51 (43.2)	49 (43.4)	2 (40)
Self-employed	23 (19.5)	23 (20.4)	–
Healthcare worker	23 (19.5)	22 (19.5)	1 (20)
Unemployed/Retired	21 (17.8)	19 (16.8)	2 (40)
Personal history
Sexual orientation, n (%)
Heterosexual	110 (93.2)	108 (95.6)	2 (40)	<0.001c
Homosexual	6 (5.1)	3 (2.7)	3 (60)	<0.001c
Bisexual	2 (1.7)	2 (1.8)	0 (0)	1c
Age at first sexual intercourse, median [IQR], years	17 [3]	17 [3]	16 [2]	0.517d
Number of sexual partners in the last six months, median [IQR], partners	1 [0]	1 [0]	1 [1]	0.236d
Sexual intercourse under the influence of alcohol/drugs in the last six months, yes (%)	20 (16.9)	17 (15)	3 (60)	0.044d
Sexual assault victim, yes (%)	10 (8.5)	8 (7.1)	2 (40)	0.057c
STD history, yes (%)
HPV	4 (3.4)	3 (2.7)	1 (20)	0.404b
Gonorrhea	4 (3.4)	3 (2.7)	1 (20)	0.404b
Syphilis	5 (4.2)	2 (1.8)	3 (60)	<0.001b
Other	4 (3.4)	3 (2.7)	1 (20)	0.404b

^aIndependent samples t-test.

^bFisher’s Exact test.

^cYates’s chi-squared test.

^dMedian test; COVID-19: coronavirus disease 2019; HIV: human immunodeficiency virus; SD: standard deviation; STD: sexually transmitted disease; HPV: human papillomavirus.

Quarantine, social distancing, and community containment have reduced access to routine HIV testing and, thus, access to know their HIV status, which challenges completion of UNAIDS’ first 90-90-90 target globally [4]. Furthermore, the healthcare focus on COVID-19 has neglected other pathologies such as HIV, contributing to a lower rate of people diagnosed early [4,5]. Expanding HIV screening and linking it to COVID-19 care are important public health initiatives that should continue to be employed in the Venezuelan health system [6]. We recommend that the government, Venezuelan nongovernmental organizations, and international partners work together to maintain the continuity of HIV care during and after the COVID-19 pandemic, making a special effort to ensure the availability of routine HIV services and avoid their interruption and potential consequences [7].

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

The authors declare no conflicts of interest.