Covid-19 and HIV: Not Always an Unfavorable Combination

Covid-19 and HIV: Not Always an Unfavorable Combination | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case report Covid-19 and HIV: Not Always an Unfavorable Combination Pedro Vieira Bertozzi, Amanda de Oliveira Vicente, Amanda Siqueira Pereira, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-91431/v2 This work is licensed under a CC BY 4.0 License Archived Versions: Posted Version 2 posted You are reading this latest preprint version Version 1 posted Abstract Background A 73-years-old-man patient who had a history of Human Immunodefiency Virus (HIV) infection for over 20 years was diagnosed with SARS-CoV-2 infection. Case presentation The patient was admitted to the Intensive Care Unit (ICU), where he remained for 25 days, due to a severe condition. Intubation, hemodialysis and tracheostomy were necessary to maintain homeostasis. In addition to regular treatment with etravirine, dolutegravir, darunavir and ritonavir for highly active antiretroviral therapy, the patient received To-cilizumab, which showed a great recovery in the patient's condition. Conclusion  The patient had several risk factors, such as: male gender, age> 70 years and hypertension. The use of To-cilizumab was of great importance in the patient's recovery, since the drug increased his immune response, which is deficient, due to HIV infection. Cardiothoracic Surgery COVID-19 HIV Coinfection Figures Figure 1 Figure 2 Background A 73-year-old patient with a history of Human Immunodeficiency Virus (HIV) infection for more than 20 years was diagnosed with SARS-CoV-2 infection. The patient was admitted to the ICU, where he remained for 25 days. In addition to regular treatment, the patient received To-cilizumab, showing excellent recovery from severe symptoms. Thus, we aim to show how important the implementation of the immunosuppressant was to help in the immune response against COVID-19, together with the non-interruption of the highly active antiretroviral therapy. Introduction Since December 2019, an outbreak of COVID-19 appeared in Wuhan, China. The etiological agent was identified as a novel coronavirus closely related to the former epidemic SARS-CoV, therefore named SARS-CoV-2, a medium-sized enveloped RNA virus. The disease, COVID-19, was recognized as a pandemic by World Health Organization (WHO) on March, 2020. As the date publication of this report, more than 1,000,000 deaths due COVID-19 were confirmed (1). COVID-19 presents as a risk for people living with HIV (PLHIV), particularly in those with low TCD4+ cell count, high viral load and other comorbidities. The infection rates in PLHIV carriers are still uncertain, once there are few published literatures relating COVID-19 co-infection in PLHIV (2). In the present report, we describe a case of a 73-year-old-man HIV-positive that progressed to Severe Acute Respiratory Syndrome (SARS) with a successful outcome. Case Report On March 21, a 73-year-old man, entered the emergency room complaining of fever and dyspnea progressing over 10 days. Physical examination showed axillary temperature = 38.6ºC, blood pressure BP = 103/73 mmHg, heart rate = 88 bpm, respiratory rate = 39 bpm and pulse oximetry = 89% (O 2 nasal cannula with 3 L/min). He was put under non-rebreather mask with 10 L/min and was admitted to the ICU. He had history of HIV infection for over 20 years, regularly treating with etravirine, dolutegravir, darunavir and ritonavir for highly active antiretroviral therapy (HAART). The last TCD4+ cell count was above 500/µL and the viral load was undetectable for more than 5 years. He also had previous diagnosis of systemic arterial hypertension (SAH) and no history of diabetes mellitus or smoking. On the day of admission, a nasopharyngeal swab was collected, and the RT-PCR for SARS-CoV-2 resulted positive. The virus panel for others agents was negative. A chest computed tomography (CT) scan on admision ( Figure 1-A ) showed multiple ground-glass opacities, affecting all pulmonary lobes with predominantly peripheral distribution, associated with consolidation on lower lobes, with accented pulmonary involvement (> 50%). Empirical broad-spectrum antimicrobial therapy with ceftriaxone and azithromycin was started, the HAART was maintained and enoxaparin was prescribed (40mg/day). The laboratorial exams revealed high percentage of white blood cell, a normal neutrophil count 6,410/mm 3 (normal range: 1,700-7,000/mm 3 ), a normal percentage lymphocyte count 1,050/mm 3 (normal range: 900-2,900/mm 3 ). There were elevated blood levels of C-reactive protein (PCR) 34,17 mg/dL (normal range: 0-5 mg/dL), D-dimer 8,469 ng/mL (normal range: < 0.5 ng/mL), and Lactic Dehydrogenase (LDH) 592 U/L (normal range: 240-480 U/L). The viral load was undetectable, and the CD4 cell count was 876 cell/mm 3 (normal range: 404-1,612 cell/mm 3 ), CD8 cell count was 876 cell/mm 3 (normal range: 229-1,129 cell/mm³). On March 22, endotracheal intubation was performed and the patient underwent mechanical ventilation with FIO2 60%, PEEP 8 mmHg and pressure support 20 mmHg. Blood gas analysis revealed pH 7.32 (normal range: 7.35-7.45), pO2 116 mmHg (normal range: 30-50 mmHg), pCO2 38 mmHg (normal range: 35-45 mmHg) and SatO2 98% (normal range: 94-100%). Hydroxychloroquine (HCQ), Azithromycin and Ceftriaxone were prescribed besides previous use of Etravirine, Dolutegravir, Darunavir and Ritonavir for HIV as maintenance treatment. On March 27, the use of Azithromycin and HCQ was interrupted and a Sulfamethoxazole-Trimetroprim in a prophylactic dose (800/160 mg/day) was initiated, due to TCD4+ cells count = 92 µ/L. On March 29, cultures identified Staphylococcus epidermidis (central venous catheter blood) , S taphylococcus hominis (central venous catheter blood) and Candida dubliniensis in the tracheal secretion and Meropenem, Linezolid and Micafungin were incorporated to the treatment. HIV viral load remained undetectable during this period. On March 29th, the creatinine level was 2.4 mg/dL (normal range: 0.7-1.3 mg/dL) and he presented low diuresis (700 mL/24 hours), revealing a worsening in kidney function, and continuos veno-venous hemodialysis (CVVHD) was initiated. On early April, the interleukin-6 (IL6) measurement was 79.3 pg/mL (reference value: 1.5 – 7 pg/mL). On April 3rd, the patient received to-cilizumab 8 mg/kg (600 mg) intravenously. One day after, was patient’s first day without fever since admission, and started to improve progressively. On April 7th, tracheostomy was performed, and five days later, he presented an improvement on respiratory condition - CT done on April 15th showed a significant improvement on pulmonary involvement ( Figure 1-B ) and mechanical ventilation was no longer needed. On April 15th, the patient was discharged from the ICU and seven days later the tracheostomy was removed. On May 1 st the patient was discharged from the hospital, and no prescription was needed unless the use of his regular medications. Clinical chronologic outcome is showed on Figure 2 . Discussion Worldwide, there are approximately 37.9 million PLHIV and under a higher risk of being exposed to SARS-CoV-2 (2). In Brazil, 966,058 people have been infected since 1980, being 51.2% in the Southeastern area, where the city of São Paulo is located (3). According to Centers for Disease Control and Prevention (CDC), people with HIV are in the COVID-19´s risk group, needing extra precautions. It also affirms that people with low CD4 cell count and those who are not on HIV treatment (HAART) are under an even higher probability of getting sick ( 4 ). HIV physiopathology consists of destroy the immune cells system and specific antibody responses, which in cases of COVID-19 association may cause a longer course of the disease (5). A recent study has shown that acute respiratory infections increased mortality in HIV-positive people in Africa (1). Nevertheless, studies from other countries presented a different outcome, showing that COVID-19 and PLHIV association didn’t impact the survival. (6) The fact that the patient was already taking antiretroviral medication is a hypothesis that would explain this scenario (6). Another factor that seems to have a positive impact on the outcome of the patients is the undetectable viral load, as recent studies suggests it results in a better general prognosis (2). Generalized immune activation and systemic CD4 lymphocyte depletion occurs in the chronic phase of untreated HIV, also, the remaining T cells may initiate abnormal responses to antigens. The lymphocyte B dysfunction results in abnormal polyclonal activation and lack of specific antibody responses. COVID-19 causes a significantly reduce in the total number of lymphocyte B, lymphocyte T and natural killer (NK) cells. The pathophysiology of the severe cases is not yet fully understood, but it appears not only to be related to virulence factors of the pathogen, but also to the dysfunctional and self-aggressive immune response triggered by the infection. This phenomenon has been called “cytokine storm” and usually occurs in the second week of infection for COVID-19, which was observed in the patient in this brief report, admitted on the tenth day of symptoms 8 . A recent study suggests that SARS-CoV-2 may damage lymphocytes, especially T lymphocytes, and the immune system was harm during the period of disease (5). In addition to these findings, a characteristic of COVID-19 patients is an increased laboratorial level of PCR, D-dimer and LDH, as our patient presented on the admission exams, the lung is the main organ affected by this virus, which will cause microvascular lesions, due to a systemic inflammatory response (SIR). The intestines and kidneys also have receptors that are affected by SIR, but the main concern are the kidneys, which by this process can generate low diuresis, proteinuria and changes in the amounts of albumin in the urine, requiring hemodialysis. (6,7) HIV infections can be classified in five stages (0,1,2,3, or unknown), depending on negative/indeterminate result (stage 0) or test results of CD4+ T-lymphocyte associated or not with opportunistic illness. Our patient presented CD4+ lymphocyte count 876 Cells / µL, being classified as stage 2 (750–1,499 Cells / µL) according to CDC classification (8). The undetectable viral load was probably a crucial factor for the patient’s positive disclosure, besides previous use of Darunavir (HAART). Our patient is over 60-years-old-man, presenting immunodeficiency, characterized by decreased in immunological system functions. These alterations trigger a rise in the incidence and severity in infectious diseases, explaining the risk of COVID-19 in this group (9). Besides being elderly, the patient has a history of SAH. When this chronic disease is treated with ACE inhibitors, present upregulation of ACE2 receptor and the raise expression of ACE2, could facilitate the viral entry (10). Beyond that, heart and lung present a high expression of ACE2 receptors (11). Regarding treatment, the use of tocilizumab, HAART and broad-spectrum antibiotics is in accordance with the most recent literature for the treatment of COVID-19 in patients with impaired immune system functions. The only medication that has not been administered is dexamethasone, which has an important reducing factor in lung injuries and has been shown to reduce mortality in patients hospitalized with SARS-CoV-2. (12) Conclusion The reported patient presents the following variables as risk factors: male sex, age > 70 years and hypertension. Despite HIV infection, the patient had good adherence to HAART, TCD4 cells > 500 / µL and long-standing undetectable viral load. We choosed to maintain HAART throughout the hospitalization and this decision may have contributed to the good outcome. It is possible that all the severity of the case was due to infection by SARS-CoV-2 and dysfunctional immune response. Abbreviations Human Immunodefiency Virus – HIV Intensive Care Unit – ICU People living with HIV – PLHIV Severe Acute Respiratory Syndrome – SARS Highly active antiretroviral therapy – HAART Systemic arterial hypertension – SAH Computed tomography – CT C-reactive protein – PCR Lactic Dehydrogenase – LDH Hydroxychloroquine – HCQ Continuos veno-venous hemodialysis – CVVHD Centers for Disease Control and Prevention – CDC Natural killer – NK Systemic inflammatory response – SIR Declarations Ethics approval : We declare that this case report was approved by the ethics committee of Hospital Alemão Oswaldo Cruz. Consent for publication : Not applicable. Availability of data and materials: All data generated or analysed during this study are included in this published article [and its supplementary information files]. Competing interests: The authors declare that they have no competing interests. Funding: This study has no source of funding. Authors' contributions: BPV, VAO, PAS, SJPE, MRBC, JLS and SRAS contributed to the writing of this manuscript. JLS and SRAS are the correctors, reviewers and advisers of this manuscript. All authors read and approved the final manuscript. Acknowledgements: Not applicable. References Vicente Soriano and Pablo Barreiro. Impact of New Coronavirus Epidemics on HIV-Infected Patients. UNIR Health Sciences School and Medical Center. Madrid, Spain. AIDS Rev. 2020; 22:57-58. Altuntas Aydin, O., Kumbasar Karaosmanoglu, H. and Kart Yasar, K. HIV/SARS‐CoV‐2 co‐infected patients in Istanbul, Turkey. Hoboken, United States. Journal of Medical Virology, April 29, 2020. Indicators and Basic Data on HIV/AIDS in Brazilian Municipalities. Ministry of Health of Brazil, Health Surveillance Secretary, Department of Chronic Conditions and Sexually Transmitted Infections. Brasilia, Brazil, 2019. What to Know About HIV and COVID-19. Coronavirus Disease 2019 (COVID-19), People Who Need Extra Precautions, People Who Are At Higher Risk, People With HIV. Center of Disease Control and Prevention. Georgy, United States, March 18, 2020. Maomao Wang, Limin Luo, Haiji Bud and Hu Xia. One case of coronavirus disease 2019 (COVID-19) in a patient co-infected by HIV with a low CD4 + T-cell count. International Journal of Infectious Diseases, April 23,2020; Vol. 96, P148-150. Guangchang Pei, Zhiguo Zhang, Jing Peng, Liu Liu, Chunxiu Zhang, Chong Yu, Zufu Ma, Yi Huang, Wei Liu, Ying Yao, Rui Zeng and Gang Xu. Renal Involvement and Early Prognosis in Patients with COVID-19 Pneumonia. Journal of the American Society of Nephrology. 2020. 31 : (6) 1157-1165. Jeffrey Laurence. Why Aren’t People Living with HIV at Higher Risk for Developing Severe Coronavirus Disease 2019 (COVID-19)?. AIDS PATIENT CARE and STDs. Mary Ann Liebert, Inc., May 14, 2020; Vol. 34, Number 6. Richard M. Selik, Eve D. Mokotoff, Bernard Branson, S. Michele Owen, Suzanne Whitmore and H. Irene Hall. Revised Surveillance Case Definition for HIV Infection United States, 2014. Center of Disease Control and Prevention. Morbidity and Mortality Weekly Report, April 11, 2014; Vol. 63, Number 3. Flores, T.G. and Lampert, M.A. POR QUE IDOSOS SÃO MAIS PROPENSOS A EVENTOS ADVERSOS COM A INFECÇÃO POR COVID-19?. Federal University of Santa Maria. Santa Maria, RS, Brazil, 2020.(https://raggfunati.com.br/docs/covid/Flores%20e%20Lampert.pdf). Lei Fang, George Karakiulakis and Michael Roth. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection?. The Lancet Respiratory Medicine. March 11, 2020; Vol. 8, ISSUE 4, E21, 2020. Ying-Ying Zheng ,Yi-Tong Ma ,Jin-Ying Zhang and Xiang Xie. COVID-19 and the cardiovascular system. Nature Reviews Cardiology. March 05, 2020; Vol. 17, 259–260. Tomazini BM, Maia IS, Cavalcanti AB, et al. Effect of Dexamethasone on Days Alive and Ventilator-Free in Patients With Moderate or Severe Acute Respiratory Distress Syndrome and COVID-19: The CoDEX Randomized Clinical Trial. JAMA. 2020. DOI: 10.1001 / jama.2020.17021 Cite Share Download PDF Archived Versions: Posted Version 2 posted You are reading this latest preprint version Version 1 posted Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-91431","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[{"code":2,"date":"2020-11-02 17:53:44","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"aids-research-and-therapy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arty","sideBox":"Learn more about [AIDS Research and Therapy](http://aidsrestherapy.biomedcentral.com/)","snPcode":"12981","submissionUrl":"https://submission.nature.com/new-submission/12981/3","title":"AIDS Research and 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The patient was admitted to the ICU, where he remained for 25 days. In addition to regular treatment, the patient received To-cilizumab, showing excellent recovery from severe symptoms.\u003c/p\u003e\n\u003cp\u003eThus, we aim to show how important the implementation of the immunosuppressant was to help in the immune response against COVID-19, together with the non-interruption of the highly active antiretroviral therapy.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eSince December 2019, an outbreak of COVID-19 appeared in Wuhan, China. The etiological agent was identified as a novel coronavirus closely related to the former epidemic SARS-CoV, therefore named SARS-CoV-2, a medium-sized enveloped RNA virus. The disease, COVID-19, was recognized as a pandemic by World Health Organization (WHO) on March, 2020. As the date publication of this report, more than 1,000,000 deaths due COVID-19 were confirmed (1).\u003c/p\u003e\n\u003cp\u003eCOVID-19 presents as a risk for people living with HIV (PLHIV), particularly in those with low TCD4+ cell count, high viral load and other comorbidities. The infection rates in PLHIV carriers are still uncertain, once there are few published literatures relating COVID-19 co-infection in PLHIV (2).\u003c/p\u003e\n\u003cp\u003eIn the present report, we describe a case of a 73-year-old-man HIV-positive that progressed to Severe Acute Respiratory Syndrome (SARS) with a successful outcome.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eOn March 21, a 73-year-old man, entered the emergency room complaining of fever and dyspnea progressing over 10 days. Physical examination showed axillary temperature = 38.6\u0026ordm;C, blood pressure BP = 103/73 mmHg, heart rate = 88 bpm, respiratory rate = 39 bpm and pulse oximetry = 89% (O\u003csub\u003e2\u003c/sub\u003e nasal cannula with 3 L/min). He was put under non-rebreather mask with 10 L/min and was admitted to the ICU.\u003c/p\u003e\n\u003cp\u003eHe had history of HIV infection for over 20 years, regularly treating with etravirine, dolutegravir, darunavir and ritonavir for highly active antiretroviral therapy (HAART). The last TCD4+ cell count was above 500/\u0026micro;L and the viral load was undetectable for more than 5 years. He also had previous diagnosis of systemic arterial hypertension (SAH) and no history of diabetes mellitus or smoking.\u003c/p\u003e\n\u003cp\u003eOn the day of admission, a nasopharyngeal swab was collected, and the RT-PCR for SARS-CoV-2 resulted positive. The virus panel for others agents was negative.\u003c/p\u003e\n\u003cp\u003eA chest \u003cem\u003ecomputed tomography\u003c/em\u003e (CT) scan on admision (\u003cstrong\u003eFigure 1-A\u003c/strong\u003e) showed multiple ground-glass opacities, affecting all pulmonary lobes with predominantly peripheral distribution, associated with consolidation on lower lobes, with accented pulmonary involvement (\u0026gt; 50%). Empirical broad-spectrum antimicrobial therapy with ceftriaxone and azithromycin was started, the HAART was maintained and enoxaparin was prescribed (40mg/day).\u003c/p\u003e\n\u003cp\u003eThe laboratorial exams revealed high percentage of white blood cell, a normal neutrophil count 6,410/mm\u003csup\u003e3\u003c/sup\u003e (normal range: 1,700-7,000/mm\u003csup\u003e3\u003c/sup\u003e), a normal percentage lymphocyte count 1,050/mm\u003csup\u003e3\u003c/sup\u003e (normal range: 900-2,900/mm\u003csup\u003e3\u003c/sup\u003e). There were elevated blood levels of C-reactive protein (PCR) 34,17 mg/dL (normal range: 0-5 mg/dL), D-dimer 8,469 ng/mL (normal range: \u0026lt; 0.5 ng/mL), and Lactic Dehydrogenase (LDH) 592 U/L (normal range: 240-480 U/L). The viral load was undetectable, and the CD4 cell count was 876 cell/mm\u003csup\u003e3 \u003c/sup\u003e(normal range: 404-1,612 cell/mm\u003csup\u003e3\u003c/sup\u003e), CD8 cell count was 876 cell/mm\u003csup\u003e3 \u003c/sup\u003e(normal range: 229-1,129 cell/mm\u0026sup3;).\u003c/p\u003e\n\u003cp\u003eOn March 22, endotracheal intubation was performed and the patient underwent mechanical ventilation with FIO2 60%, PEEP 8 mmHg and pressure support 20 mmHg. Blood gas analysis revealed pH 7.32 (normal range: 7.35-7.45), pO2 116 mmHg (normal range: 30-50 mmHg), pCO2 38 mmHg (normal range: 35-45 mmHg) and SatO2 98% (normal range: 94-100%). Hydroxychloroquine (HCQ), Azithromycin and Ceftriaxone were prescribed besides previous use of Etravirine, Dolutegravir, Darunavir and Ritonavir for HIV as maintenance treatment. On March 27, the use of Azithromycin and HCQ was interrupted and a Sulfamethoxazole-Trimetroprim in a prophylactic dose (800/160 mg/day) was initiated, due to TCD4+ cells count = 92 \u0026micro;/L.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;On March 29, cultures identified \u003cem\u003eStaphylococcus epidermidis \u003c/em\u003e(central venous catheter blood)\u003cem\u003e, S\u003c/em\u003e\u003cem\u003etaphylococcus\u003c/em\u003e\u003cem\u003e hominis \u003c/em\u003e(central venous catheter blood)\u003cem\u003e and Candida dubliniensis\u003c/em\u003e in the tracheal secretion and Meropenem, Linezolid and Micafungin were incorporated to the treatment. HIV viral load remained undetectable during this period.\u003c/p\u003e\n\u003cp\u003eOn March 29th, the creatinine level was 2.4 mg/dL (normal range: 0.7-1.3 mg/dL) and he presented low diuresis (700 mL/24 hours), revealing a worsening in kidney function, and continuos veno-venous hemodialysis (CVVHD) was initiated. On early April, the interleukin-6 (IL6) measurement was 79.3 pg/mL (reference value: 1.5 \u0026ndash; 7 pg/mL). On April 3rd, the patient received to-cilizumab 8 mg/kg (600 mg) intravenously. One day after, was patient\u0026rsquo;s first day without fever since admission, and started to improve progressively.\u003c/p\u003e\n\u003cp\u003eOn April 7th, tracheostomy was performed, and five days later, he presented an improvement on respiratory condition - CT done on April 15th showed a significant improvement on pulmonary involvement (\u003cstrong\u003eFigure 1-B\u003c/strong\u003e) and mechanical ventilation was no longer needed.\u003c/p\u003e\n\u003cp\u003eOn April 15th, the patient was discharged from the ICU and seven days later the tracheostomy was removed. On May 1\u003csup\u003est\u003c/sup\u003e the patient was discharged from the hospital, and no prescription was needed unless the use of his regular medications. Clinical chronologic outcome is showed on \u003cstrong\u003eFigure 2\u003c/strong\u003e.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWorldwide, there are approximately 37.9 million PLHIV and under a higher risk of being exposed to SARS-CoV-2 (2). In Brazil, 966,058 people have been infected since 1980, being 51.2% in the Southeastern area, where the city of S\u0026atilde;o Paulo is located (3). According to Centers for Disease Control and Prevention (CDC), people with HIV are in the COVID-19\u0026acute;s risk group, needing extra precautions. It also affirms that people with low CD4 cell count and those who are not on HIV treatment (HAART) are under an even higher probability of getting sick (\u003cu\u003e4\u003c/u\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHIV physiopathology consists of destroy the immune cells system and specific antibody responses, which in cases of COVID-19 association may cause a longer course of the disease (5). A recent study has shown that acute respiratory infections increased mortality in HIV-positive people in Africa (1). Nevertheless, studies from other countries presented a different outcome, showing that COVID-19 and PLHIV association didn\u0026rsquo;t impact the survival. (6)\u003c/p\u003e\n\u003cp\u003eThe fact that the patient was already taking antiretroviral medication is a hypothesis that would explain this scenario (6). Another factor that seems to have a positive impact on the outcome of the patients is the undetectable viral load, as recent studies suggests it results in a better general prognosis (2).\u003c/p\u003e\n\u003cp\u003eGeneralized immune activation and systemic CD4 lymphocyte depletion occurs in the chronic phase of untreated HIV, also, the remaining T cells may initiate abnormal responses to antigens. The lymphocyte B dysfunction results in abnormal polyclonal activation and lack of specific antibody responses. COVID-19 causes a significantly reduce in the total number of lymphocyte B, lymphocyte T and natural killer (NK) cells. The pathophysiology of the severe cases is not yet fully understood, but it appears not only to be related to virulence factors of the pathogen, but also to the dysfunctional and self-aggressive immune response triggered by the infection. This phenomenon has been called \u0026ldquo;cytokine storm\u0026rdquo; and usually occurs in the second week of infection for COVID-19, which was observed in the patient in this brief report, admitted on the tenth day of symptoms\u003csup\u003e8\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eA recent study suggests that SARS-CoV-2 may damage lymphocytes, especially T lymphocytes, and the immune system was harm during the period of disease (5). In addition to these findings, a characteristic of COVID-19 patients is an increased laboratorial level of PCR, D-dimer and LDH, as our patient presented on the admission exams, the lung is the main organ affected by this virus, which will cause microvascular lesions, due to a systemic inflammatory response (SIR). The intestines and kidneys also have receptors that are affected by SIR, but the main concern are the kidneys, which by this process can generate low diuresis, proteinuria and changes in the amounts of albumin in the urine, requiring hemodialysis. (6,7)\u003c/p\u003e\n\u003cp\u003eHIV infections can be classified in five stages (0,1,2,3, or unknown), depending on negative/indeterminate result (stage 0) or test results of CD4+ T-lymphocyte associated or not with opportunistic illness. Our patient presented CD4+ lymphocyte count 876 Cells / \u0026micro;L, being classified as stage 2 (750\u0026ndash;1,499 Cells / \u0026micro;L) according to CDC classification (8). The undetectable viral load was probably a crucial factor for the patient\u0026rsquo;s positive disclosure, besides previous use of Darunavir (HAART).\u003c/p\u003e\n\u003cp\u003eOur patient is over 60-years-old-man, presenting immunodeficiency, characterized by decreased in immunological system functions. These alterations trigger a rise in the incidence and severity in infectious diseases, explaining the risk of COVID-19 in this group (9). Besides being elderly, the patient has a history of SAH. When this chronic disease is treated with ACE inhibitors, present upregulation of ACE2 receptor and the raise expression of ACE2, could facilitate the viral entry (10). Beyond that, heart and lung present a high expression of ACE2 receptors (11).\u003c/p\u003e\n\u003cp\u003eRegarding treatment, the use of tocilizumab, HAART and broad-spectrum antibiotics is in accordance with the most recent literature for the treatment of COVID-19 in patients with impaired immune system functions. The only medication that has not been administered is dexamethasone, which has an important reducing factor in lung injuries and has been shown to reduce mortality in patients hospitalized with SARS-CoV-2. (12)\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe reported patient presents the following variables as risk factors: male sex, age \u0026gt; 70 years and hypertension. Despite HIV infection, the patient had good adherence to HAART, TCD4 cells \u0026gt; 500 / \u0026micro;L and long-standing undetectable viral load. We choosed to maintain HAART throughout the hospitalization and this decision may have contributed to the good outcome. It is possible that all the severity of the case was due to infection by SARS-CoV-2 and dysfunctional immune response.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eHuman Immunodefiency Virus \u0026ndash; HIV\u003c/p\u003e\n\u003cp\u003eIntensive Care Unit \u0026ndash; ICU\u003c/p\u003e\n\u003cp\u003ePeople living with HIV \u0026ndash; PLHIV\u003c/p\u003e\n\u003cp\u003eSevere Acute Respiratory Syndrome \u0026ndash; SARS\u003c/p\u003e\n\u003cp\u003eHighly active antiretroviral therapy \u0026ndash; HAART\u003c/p\u003e\n\u003cp\u003eSystemic arterial hypertension \u0026ndash; SAH\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eComputed tomography \u0026ndash; CT\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eC-reactive protein \u0026ndash; PCR\u003c/p\u003e\n\u003cp\u003eLactic Dehydrogenase \u0026ndash; \u003cem\u003eLDH\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHydroxychloroquine \u0026ndash; HCQ\u003c/p\u003e\n\u003cp\u003eContinuos veno-venous hemodialysis \u0026ndash; CVVHD\u003c/p\u003e\n\u003cp\u003eCenters for Disease Control and Prevention \u0026ndash; CDC\u003c/p\u003e\n\u003cp\u003eNatural killer \u0026ndash; NK\u003c/p\u003e\n\u003cp\u003eSystemic inflammatory response \u0026ndash; SIR\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval\u0026nbsp;: We declare that this case report was approved by the ethics committee of Hospital Alem\u0026atilde;o Oswaldo Cruz.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u0026nbsp;: Not applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: All data generated or analysed during this study are included in this published article [and its supplementary information files].\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding: This study has no source of funding.\u003c/p\u003e\n\u003cp\u003eAuthors' contributions: BPV, VAO, PAS, SJPE, MRBC, JLS and SRAS contributed to the writing of this manuscript. JLS and SRAS are the correctors, reviewers and advisers of this manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eVicente Soriano and Pablo Barreiro. Impact of New Coronavirus Epidemics on HIV-Infected Patients. UNIR Health Sciences School and Medical Center. Madrid, Spain. AIDS Rev. 2020; 22:57-58.\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"2\"\u003e\n\u003cli\u003eAltuntas Aydin, O., Kumbasar Karaosmanoglu, H. and Kart Yasar, K. HIV/SARS‐CoV‐2 co‐infected patients in Istanbul, Turkey. Hoboken, United States. Journal of Medical Virology, April 29, 2020.\u003c/li\u003e\n\u003cli\u003eIndicators and Basic Data on HIV/AIDS in Brazilian Municipalities. Ministry of Health of Brazil, Health Surveillance Secretary, Department of Chronic Conditions and Sexually Transmitted Infections. Brasilia, Brazil, 2019.\u003c/li\u003e\n\u003cli\u003eWhat to Know About HIV and COVID-19. Coronavirus Disease 2019 (COVID-19), People Who Need Extra Precautions, People Who Are At Higher Risk, People With HIV. Center of Disease Control and Prevention. Georgy, United States, March 18, 2020.\u003c/li\u003e\n\u003cli\u003eMaomao Wang, Limin Luo, Haiji Bud and Hu Xia. One case of coronavirus disease 2019 (COVID-19) in a patient co-infected by HIV with a low CD4 + T-cell count. International Journal of Infectious Diseases, April 23,2020; Vol. 96, P148-150.\u003c/li\u003e\n\u003cli\u003eGuangchang Pei, Zhiguo Zhang, Jing Peng, Liu Liu, Chunxiu Zhang, Chong Yu, Zufu Ma, Yi Huang, Wei Liu, Ying Yao, Rui Zeng and Gang Xu. Renal Involvement and Early Prognosis in Patients with COVID-19 Pneumonia. Journal of the American Society of Nephrology. 2020.\u0026nbsp;31\u0026nbsp;: (6) 1157-1165.\u003c/li\u003e\n\u003cli\u003eJeffrey Laurence. Why Aren\u0026rsquo;t People Living with HIV at Higher Risk for Developing Severe Coronavirus Disease 2019 (COVID-19)?. AIDS PATIENT CARE and STDs. Mary Ann Liebert, Inc., May 14, 2020; Vol. 34, Number 6.\u003c/li\u003e\n\u003cli\u003eRichard M. Selik, Eve D. Mokotoff, Bernard Branson, S. Michele Owen, Suzanne Whitmore and H. Irene Hall. Revised Surveillance Case Definition for HIV Infection United States, 2014. Center of Disease Control and Prevention. Morbidity and Mortality Weekly Report, April 11, 2014; Vol. 63, Number 3.\u003c/li\u003e\n\u003cli\u003eFlores, T.G. and Lampert, M.A. POR QUE IDOSOS S\u0026Atilde;O MAIS PROPENSOS A EVENTOS ADVERSOS COM A INFEC\u0026Ccedil;\u0026Atilde;O POR COVID-19?. Federal University of Santa Maria. Santa Maria, RS, Brazil, 2020.(https://raggfunati.com.br/docs/covid/Flores%20e%20Lampert.pdf).\u003c/li\u003e\n\u003cli\u003eLei Fang, George Karakiulakis and Michael Roth. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection?. The Lancet Respiratory Medicine. March 11, 2020; Vol. 8, ISSUE 4, E21, 2020.\u003c/li\u003e\n\u003cli\u003eYing-Ying Zheng ,Yi-Tong Ma ,Jin-Ying Zhang and Xiang Xie. COVID-19 and the cardiovascular system. Nature Reviews Cardiology. March 05, 2020; Vol. 17, 259\u0026ndash;260.\u003c/li\u003e\n\u003cli\u003eTomazini BM, Maia IS, Cavalcanti AB, et al. Effect of Dexamethasone on Days Alive and Ventilator-Free in Patients With Moderate or Severe Acute Respiratory Distress Syndrome and COVID-19:\u0026nbsp;The CoDEX Randomized Clinical Trial. JAMA. 2020. DOI: 10.1001 / jama.2020.17021\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"aids-research-and-therapy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arty","sideBox":"Learn more about [AIDS Research and Therapy](http://aidsrestherapy.biomedcentral.com/)","snPcode":"12981","submissionUrl":"https://submission.nature.com/new-submission/12981/3","title":"AIDS Research and Therapy","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"COVID-19, HIV, Coinfection","lastPublishedDoi":"10.21203/rs.3.rs-91431/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-91431/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\u003cp\u003eA 73-years-old-man patient who had a history of Human Immunodefiency Virus (HIV) infection for over 20 years was diagnosed with SARS-CoV-2 infection.\u003c/p\u003e\u003cp\u003eCase presentation\u003c/p\u003e\u003cp\u003eThe patient was admitted to the Intensive Care Unit (ICU), where he remained for 25 days, due to a severe condition. Intubation, hemodialysis and tracheostomy were necessary to maintain homeostasis. In addition to regular treatment with etravirine, dolutegravir, darunavir and ritonavir for highly active antiretroviral therapy, the patient received To-cilizumab, which showed a great recovery in the patient's condition.\u003c/p\u003e\u003cp\u003eConclusion\u003c/p\u003e\u003cp\u003e\u003cspan class=\"ql-cursor\"\u003e\u003c/span\u003eThe patient had several risk factors, such as: male gender, age\u0026gt; 70 years and hypertension. The use of To-cilizumab was of great importance in the patient's recovery, since the drug increased his immune response, which is deficient, due to HIV infection.\u003c/p\u003e","manuscriptTitle":"Covid-19 and HIV: Not Always an Unfavorable Combination","msid":"","msnumber":"","nonDraftVersions":[{"code":"","date":"2021-06-30 00:00:00","doi":"","editorialEvents":[{"type":"decision","content":"Minor revision","date":"2021-06-30T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-04-08T00:00:00+00:00","index":2,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"reviewerAgreed","content":"","date":"2021-04-05T00:00:00+00:00","index":2,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-04-03T00:00:00+00:00","index":1,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-04-03T00:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"reviewersInvited","content":"","date":"2021-04-02T00:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-03-29T00:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-03-28T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-03-28T23:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"AIDS Research and Therapy","date":"2021-03-28T17:19:38+00:00","index":"","fulltext":""},{"type":"notPreprinted","content":""}],"status":"timeline","journal":{"display":true,"email":"[email protected]","identity":"aids-research-and-therapy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arty","sideBox":"Learn more about [AIDS Research and Therapy](http://aidsrestherapy.biomedcentral.com/)","snPcode":"12981","submissionUrl":"https://submission.nature.com/new-submission/12981/3","title":"AIDS Research and Therapy","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f0a88c61-2ccb-4a5a-bf71-746c362d3dfa","owner":[],"postedDate":"November 2nd, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":8042369,"name":"Cardiothoracic Surgery"}],"tags":[],"updatedAt":"2021-10-22T14:54:00+00:00","versionOfRecord":{"articleIdentity":"rs-91431","link":"https://doi.org/10.1186/s12981-021-00404-5","journal":{"identity":"aids-research-and-therapy","isVorOnly":false,"title":"AIDS Research and Therapy"},"publishedOn":"2021-10-16 00:00:00","publishedOnDateReadable":"October 16th, 2021"},"versionCreatedAt":"2020-11-02 17:53:44","video":"","vorDoi":"10.1186/s12981-021-00404-5","vorDoiUrl":"https://doi.org/10.1186/s12981-021-00404-5","workflowStages":[]},"version":"v2","identity":"rs-91431","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-91431","identity":"rs-91431","version":["v2"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}