Examining the Interplay of COVID-19 and HIV: Impacts on HIV Care, Disparities, and Long-Term Outcomes

Abstract COVID-19 may have negatively impacted efforts aimed at EHE and exacerbated disparities in HIV outcomes. For EHE to be successful, it is important to understand any lasting impacts that adversely complicate HIV control and impact care of people with HIV (PWH), and to address structural issues at the root of disparities during and after an overlapping pandemic. The impact of post COVID conditions (PCC) PCC on HIV outcomes has not been studied. While PCC has been documented to increase incident comorbidities and complications, data on the epidemiology of PCC are lacking for PWH. It is critical to understand epidemiological risk and any long-term increases in comorbidities among PWH due to SARS-CoV-2 to inform care and support. The goal of the proposed study is to understand the clinical and social factors that impact HIV and COVID-19 outcomes among PWH and to characterize how the COVID-19 pandemic, including PCC, may influence HIV care outcomes. This research will leverage established cohorts: 1) clinical cohorts of PWH and PWoH from the Johns Hopkins Healthcare System and Kaiser Permanente Mid-Atlantic States and 2) the CHASING COVID Cohort, an online community-based cohort of US adults. The proposed research poses unique methodological challenges due to the varying definitions of PCC, the quantity of exposure data and the longitudinal design, all of which may increase measurement error. This K01 will provide experience, knowledge and training in methods (advanced biostatistics methods related to improving inferences in settings with complex exposure pathways and measurement error) and content (comorbidity development among PWH, including PCC, and social determinants of health). The study aims to: (1) compare clinical risk factors for PCC-related comorbidities by HIV status using target trial approaches with marginal structural models for time-varying confounding and outcome censoring; (2) characterize the role of social determinants of PCC-related comorbidities by HIV status using multi-level models; and (3) assess the role of COVID-era factors on disparities in HIV outcomes, using a novel mediation approach in combination with modern approaches for minimizing bias (e.g., potential-mediator weighted models). Focusing the research, in part, on PCC will provide an opportunity to address a complicated and multi- faceted problem lacking robust epidemiological data for PWH. Findings from the proposed study are critical to understanding the longer-term impact of COVID-19 on HIV outcomes, disparities in HIV and COVID outcomes, the epidemiology and natural history of PCC within an immunocompromised population, and pandemic preparedness for PWH and EHE. Other innovations include: 1) triangulating electronic health record data with reported data from one of the few national-community-based cohorts and 2) improving inference by incorporating advanced design and methods with clinical insight. Furthermore, the focus on clinical and social pathways is critical for identifying the next generation of HIV interventions for EHE.