Extensive research shows that COVID-19 vaccines are safe, regardless of HIV status. Yet researchers are still assessing whether there is any difference in effectiveness for people living with HIV. Two important questions are: Are fully vaccinated people living with HIV more likely to contract a breakthrough infection? How much does a lack of HIV viral suppression affect the COVID-19 vaccine’s protectiveness?
The CDC currently recommends that people with untreated or advanced HIV, including AIDS, should receive an additional primary COVID-19 vaccine dose 28 days after their initial two doses, because they are more immunocompromised. This is meant to improve immune response as part of the initial vaccine series, which is different from a booster shot taken later to “boost” or remind the immune system to respond to the COVID-19 virus. Like the initial COVID-19 vaccine series, boosters are safe and recommended, regardless of HIV status. (Currently, 85.4% of the U.S. population over age 5 has received at least one dose of COVID-19 vaccine and 73.2% have received both primary doses, according to Centers for Disease Control data.)
Two important studies from Johns Hopkins University found that people living with HIV–even if moderately to fully virally suppressed and vaccinated against COVID-19–were at a somewhat higher risk of breakthrough COVID-19 infection. However, the researchers found that COVID-19 vaccination protects against severe illness across the board, regardless of HIV status. More information about these studies is below:
A major U.S. study published in June by researchers at the Johns Hopkins Bloomberg School of Public Health analyzed the anonymized health records of 113,994 fully vaccinated people from June 30, 2021 through Dec. 31, 2021 and found a 28% higher incidence of breakthrough COVID-19 infection for those living with HIV. However, the breakthrough infection rate was relatively low overall: 4.4% among people living with HIV, compared with 3.8% for those who were HIV-negative. The researchers assessed the breakthrough infection rate at nine months after full vaccination with either the Pfizer, Moderna or Johnson & Johnson vaccines.
The risk of breakthrough COVID-19 infection was higher for people with moderate HIV viral suppression (with CD4 T-cell counts of 200 to 350 cells/mm3) than for people with full HIV viral suppression. That led researchers to suggest that an additional primary COVID-19 dose should be recommended more broadly for people living with HIV, beyond those with untreated or advanced HIV.
The Johns Hopkins study analyzed health records for mostly older men, drawing on data from the Department of Veterans Affairs and other health systems. Overall, 92.1% of the records were for men and 70% were age 55 or older. As far as race, 41% were Black and 38% were white.
While the Johns Hopkins study found that people living with HIV who aren’t fully virally suppressed are more susceptible to COVID-19 infection, even if fully vaccinated, researchers are still assessing whether a breakthrough infection is likely to be more severe for them, with higher rates of hospitalization and death. The risk and severity of a breakthrough COVID-19 infection also depends on the COVID-19 virus subvariant, other co-occurring health conditions, and social factors, such as age.
Interestingly, the study found that those living with HIV who contracted breakthrough infections were more likely to be under age 45, had previously been infected with COVID-19, and did not receive an additional vaccination dose. The study’s authors suggested that more widespread masking and social distancing among older people may have reduced their breakthrough infection rate. That underscores how important it is to continue taking precautions that keep people at higher risk safe.
The research also highlights how important it is for people living with HIV to stay up to date with their COVID-19 vaccinations, including the new bivalent booster. A separate Johns Hopkins study of breakthrough COVID-19 infections for fully vaccinated people living with HIV found that even those with full HIV viral suppression were more likely to experience them than the general population. The good news was that fully vaccinated people, regardless of HIV status, had less severe COVID-19 illness.
It’s important to continue to push for including people living with HIV in COVID-19 vaccine trials, so fuller information about how the vaccines affect them is available from the beginning.