As the country is in the process of lifting restrictions, there is an increasing vulnerability to outbreaks. We can’t live in lockdown forever – we need an economy – so we must live with increased risk until there is a vaccine. This vulnerability means, I think, that people living with HIV (PLHIV) need to stick to the prevention guidelines more than ever (not less).

My fear is that lifting restrictions will lead to less compliance with physical distancing for many in the broader community – something that has already been observed.

An artistic depiction of SARS- CoV-2

Vulnerability for PLHIV?

Heading into winter may also make PLHIV more vulnerable. It is estimated that winter causes a 20 to 30% increase in the chance of coming into contact with COVID-19, just as it does with flu. When we have reduced the chances of transmission through prevention measures, that 20 to 30% may make a significant difference in infection rates, particularly in states like Victoria and Tasmania where winter weather is cold and closed windows and recycled air conditioning are more necessary. I think this sets up the ideal conditions for COVID-19 spreader events if there are a lot of people inside in spaces like this. (1)

“I am an avid reader of science and participate in a few online COVID-19 information sharing sites. There are a number of repeating questions: about the impact of HIV infection on COVID-19 progression; about prevention such as whether masks work; and about the likely timelines for vaccines and effective treatments.”

There are two recent groups that have looked at the impact of having HIV infection on COVID-19 disease progression – in Germany and in New York. There were people with HIV in these studies and they concluded that having HIV did not lead to a statistically increased chance of disease progression. The New York study did warn about bacterial pneumonia in people with HIV, though – so if you haven’t had the pneumovax, then it might be a good idea to get it (though it has been in short supply here, presumably due to increased demand). (2)

Prevention and wearing masks?

In terms of prevention, the initial standard guidelines from the Federal Government of regular 20-second hand washing, use of hand sanitiser, and physical distancing are still incredibly important – especially as restrictions are lifted by the States.

In Australia, the advice about masks has been widely debated. There is certainly consensus that someone who has COVID-19 (but does not know it) is far less likely to transmit COVID-19 if they are wearing a mask. There is less agreement about how much protection they provide from getting COVID-19. What convinced me was reading about super-spreader events where one person transmitted the virus to many, many people. Most of these events happened inside, behind closed windows and in recycled air. One event happened on a bus in China in winter. People all over the bus – regardless of distance – got infected from one person sitting near the back. There were several people on the bus wearing face masks and none of them got infected.

There are a few documented transmissions in restaurants. The chance of infection seems to relate to where people sit in relation to the airflow and how long they sit there. These observations have led to a difference in some guidelines, such as more people being allowed to sit outside than inside restaurants, and time limits for how long people can stay inside places like restaurants. (3)

“For me, it means I now choose to wear a face mask whenever I’m inside or where there is a large group of people (e.g. supermarkets, public transport) and try to get in and out as fast as possible (i.e. a few smaller shopping trips instead of one big weekly shop).”

Mask usage on public transport

Treatments and vaccines?

A common question is ‘when can I get my life back?’ Can you make an educated guess about COVID-19 treatments and vaccines? When compared to HIV in the 1980s, it is staggering how fast scientific discovery now moves.

We knew the SARS-CoV-2 virus and its genetic pattern in weeks – this took years in HIV. We know most of the targets for drug therapy and vaccines – which again took years in HIV.

There has been an explosion of information and scientific reports – but just like early HIV science – there is a lot of speculation and some not very good science included. (4)

There are already treatments which show some small benefit against a few different targets – something that took a long time in HIV. It is possible that these treatments will show more benefit if they are given early – just like in HIV. But that would mean a lot of early testing in a disease which progresses rapidly.

“With COVID-19 it is much easier to demonstrate benefit quickly – the course of the illness is much faster than HIV. But at the moment, trials are mostly using drugs that have already been tested in humans – which speeds the process. It will take longer to develop drugs that have been specifically developed for COVID-19.”

Even if existing drugs show enough benefit for a mass rollout – depending on the drug – scaling up manufacturing to the huge capacity needed may take up to 12 months. And if production companies think a vaccine could happen soon, then they might be reluctant to fund such capacity.

If you’ve lived in communities affected by HIV and followed vaccine development, you know it is a fraught process. There is no HIV vaccine because HIV has a trick. When it buds from a cell to go off and infect other cells, it coats itself with a common human cellular protein making the immune system ignore it.

SARS-CoV-2 (the virus that causes COVID-19) does not have this trick. Already over 50 antibodies have been identified in immune responses to COVID-19 – and many of these are neutralising.

About 70% of people who get COVID-19 develop a T-cell mediated immune response (5). All of these provide hope for an effective vaccine, and already there are over 120 vaccines in development and at least 10 in human trials. This is happening at a staggering pace.

If you listen to the experts, one will say: “this year” and another will say: “maybe never”. Both are guesses, but I am hopeful for early next year. then there is scale-up and the politics of equitable distribution. The costs involved in global delivery are huge. Scale-up and delivery will take over a year.

For the medium term, COVID-19 being in our communities is something we need to live with. And when a vaccine happens, our communities need to be arguing for equitable distribution.

 

Footnotes:

1. Air conditioning

a. “The Risks – Know them – Avoid them”
Blog post by Erin Bromage:
https://www.erinbromage.com/post/the-risks-know-them-avoid-them
The above article is relevant for understanding issues to do with airflow and air conditioning with COVID-19 and the difference between risks outside and inside.

b. Qantas outlines the new flying rules
https://www.airlineratings.com/news/qantas-outlines-new-flying-rules/
The relevant paragraph is:-
In addition, the air conditioning systems of all Qantas and Jetstar aircraft are already fitted with hospital-grade HEPA filters, which remove 99.9% of all particles including viruses. The air inside the cabin is refreshed on average every five minutes during flight.
The above is a reference to the air standards in respiratory Intensive Care Units where the air must be refreshed 10 times per hour.

2. Covid-19 in people with HIV – Aidsmap article

The article states that there is no increased risk of severe COVID-19 in people living with HIV, but that vigilance over bacterial pneumonia required.

The German and New York studies are referenced here.
https://www.aidsmap.com/news/may-2020/no-increased-risk-severe-covid-19-people-living-hiv-vigilance-over-bacterial?fbclid=IwAR3gvy9EKkN1VO3mTRUvgoyx_LXgW8i1QNuG20vOT92Euu3VdURMzto66mA

3. Wearing masks

The evidence on wearing masks with COVID-19 is controversial and debated. I am stating my personal view here.

This is a big academic article, but it is still in preprint:
https://www.preprints.org/manuscript/202004.0203/v1 – pre-print review

This is a more discursive article on masks:
https://www.weforum.org/agenda/2020/04/should-we-be-promoting-the-widespread-use-of-masks/

This is the newspaper article that convinced me to wear masks when inside in a crowd:
https://www.scmp.com/news/china/science/article/3074351/coronavirus-can-travel-twice-far-official-safe-distance-and-stay

4. The virus and the disease: the difference

Just like with HIV, HIV is the virus and AIDS is the disease.
For this epidemic, SARS-CoV-2 is the virus and COVID-19 is the disease

The naming of the virus is as follows:
SARS-CoV-2:
SARS = severe acute respiratory syndrome
CoV = coronavirus
2 = 2nd virus causing this

5. T-cell mediated response definition

With a T-cell mediated response, the immune system develops a permanent memory. This provides long lasting immunity so if a vaccine helps with that you don’t need to have a booster shot every year.

A few basics about treatment side effects

There is a basic set of knowledge about HIV drugs and side effects that is useful to have. That does not mean you need to know the name of every drug and their common side effects, but it is useful to know the types of side effects and how to get more information.

U=U and dating in 2020

Even though the scientific evidence is clear, has U=U made a difference for people living with HIV to freely enjoy all the sexual pleasures that go with dating whether it is finding love or a fleeting dalliance? Heather Ellis investigates the impact of U=U on Dating in 2020.