Analysis of Severe Illness After Postvaccination COVID-19 Breakthrough Among Adults With and Without HIV in the US

• Type of Material: Article
• Authors: Raynell Lang, Johns Hopkins Bloomberg School of Public Health; Elizabeth Humes, Johns Hopkins Bloomberg School of Public Health; Sally B Coburn, Johns Hopkins Bloomberg School of Public Health; Michaek A Horberg, Mid-Atlantic Permanente Research Institute, Rockville; Lily F Fathi, Mid-Atlantic Permanente Research Institute, Rockville; Eric Watson, Mid-Atlantic Permanente Research Institute, Rockville; Caleena R Jefferson, Mid-Atlantic Permanente Research Institute, Rockville; Lesley S Park, Stanford Center for Population Health Sciences; Kirsha S Gordon, VA Connecticut Healthcare System; Kathleen M Akgun, VA Connecticut Healthcare System; Amy C Justice, VA Connecticut Healthcare System; Sonia Napravnik, University of North Carolina; Jessie K Edwards, University of North Carolina; Lindsay E Browne, University of North Carolina; Deana M Agil, University of North Carolina; Michael J Silverberg, Kaiser Permanente Northern California; Jacek Skarbinski, Kaiser Permanente Northern California; Wendy A Leyden, Kaiser Permanente Northern California; Cameron Stewart, Johns Hopkins Bloomberg School of Public Health; Brenna C Hogan, Johns Hopkins Bloomberg School of Public Health; KA Gebo, Johns Hopkins Bloomberg School of Public Health; Vincent Marconi, Emory University; Carolyn F Williams, National Institute of Allergy and Infectious Diseases, National Institute of Health, Rockville; Keri N Althoff, Johns Hopkins Bloomberg School of Public Health
• Language: English
• Date: 2022-10-13
• Publisher: AMER MEDICAL ASSOC
• Publication Version: Final Published Version
• Copyright Statement: 2022 Lang R et al. JAMA Network Open.
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1001/jamanetworkopen.2022.36397
• Title of Journal or Parent Work: JAMA NETWORK OPEN
• Volume: 5
• Issue: 10
• Start Page: E2236397
• End Page: E2236397
• Grant/Funding Information: This project was made possible with supplemental funds to the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD, U01AI069918) from the National Institute of Allergy and Infectious Diseases (NIAID). The NA-ACCORD is supported by NIH grants U01AI069918, F31AI124794, F31DA037788, G12MD007583, K01AI093197, K01AI131895, K23EY013707, K24AI065298, K24AI118591, K24DA000432, KL2TR000421, N01CP01004, N02CP055504, N02CP91027, P30AI027757, P30AI027763, P30AI027767, P30AI036219, P30AI050409, P30AI050410, P30AI094189, P30AI110527, P30MH62246, R01AA016893, R01DA011602, R01DA012568, R01AG053100, R24AI067039, R34DA045592, U01AA013566, U01AA020790, U01AI038855, U01AI038858, U01AI068634, U01AI068636, U01AI069432, U01AI069434, U01DA036297, U01DA036935, U10EY008057, U10EY008052, U10EY008067, U01HL146192, U01HL146193, U01HL146194, U01HL146201, U01HL146202, U01HL146203, U01HL146204, U01HL146205, U01HL146208, U01HL146240, U01HL146241, U01HL146242, U01HL146245, U01HL146333, U24AA020794, U54GM133807, UL1RR024131, UL1TR000004, UL1TR000083, UL1TR002378, UL1TR002489, Z01CP010214 and Z01CP010176; contracts CDC-200-2006-18797 and CDC-200-2015-63931 from the Centers for Disease Control and Prevention (CDC); contract 90047713 from the Agency for Healthcare Research and Quality; contract 90051652 from the Health Resources and Services Administration; the Grady Health System; grants CBR-86906, CBR-94036, HCP-97105, and TGF-96118 from the CIHR; Ontario Ministry of Health and Long Term Care; and the Government of Alberta, Canada. Additional support was provided by the NIAID, National Cancer Institute, National Heart, Lung, and Blood Institute, Eunice Kennedy Shriver National Institute of Child Health & Human Development, National Human Genome Research Institute, National Institute for Mental Health, National Institute on Drug Abuse, National Institute on Aging, National Institute of Dental & Craniofacial Research, National Institute of Neurological Disorders and Stroke, National Institute of Nursing Research, National Institute on Alcohol Abuse and Alcoholism, National Institute on Deafness and Other Communication Disorders, and National Institute of Diabetes and Digestive and Kidney Diseases.
• Keywords: Medicine, General & Internal; OUTCOMES; General & Internal Medicine; Science & Technology; Life Sciences & Biomedicine; INFECTION

Abstract

Importance: Understanding the severity of postvaccination SARS-CoV-2 (ie, COVID-19) breakthrough illness among people with HIV (PWH) can inform vaccine guidelines and risk-reduction recommendations. Objective: To estimate the rate and risk of severe breakthrough illness among vaccinated PWH and people without HIV (PWoH) who experience a breakthrough infection. Design, Setting, and Participants: In this cohort study, the Corona-Infectious-Virus Epidemiology Team (CIVET-II) collaboration included adults (aged ≥18 years) with HIV who were receiving care and were fully vaccinated by June 30, 2021, along with PWoH matched according to date fully vaccinated, age group, race, ethnicity, and sex from 4 US integrated health systems and academic centers. Those with postvaccination COVID-19 breakthrough before December 31, 2021, were eligible. Exposures: HIV infection. Main Outcomes and Measures: The main outcome was severe COVID-19 breakthrough illness, defined as hospitalization within 28 days after a breakthrough SARS-CoV-2 infection with a primary or secondary COVID-19 discharge diagnosis. Discrete time proportional hazards models estimated adjusted hazard ratios (aHRs) and 95% CIs of severe breakthrough illness within 28 days of breakthrough COVID-19 by HIV status adjusting for demographic variables, COVID-19 vaccine type, and clinical factors. The proportion of patients who received mechanical ventilation or died was compared by HIV status. Results: Among 3649 patients with breakthrough COVID-19 (1241 PWH and 2408 PWoH), most were aged 55 years or older (2182 patients [59.8%]) and male (3244 patients [88.9%]). The cumulative incidence of severe illness in the first 28 days was low and comparable between PWoH and PWH (7.3% vs 6.7%; risk difference, -0.67%; 95% CI, -2.58% to 1.23%). The risk of severe breakthrough illness was 59% higher in PWH with CD4 cell counts less than 350 cells/μL compared with PWoH (aHR, 1.59; 95% CI, 0.99 to 2.46; P =.049). In multivariable analyses among PWH, being female, older, having a cancer diagnosis, and lower CD4 cell count were associated with increased risk of severe breakthrough illness, whereas previous COVID-19 was associated with reduced risk. Among 249 hospitalized patients, 24 (9.6%) were mechanically ventilated and 20 (8.0%) died, with no difference by HIV status. Conclusions and Relevance: In this cohort study, the risk of severe COVID-19 breakthrough illness within 28 days of a breakthrough infection was low among vaccinated PWH and PWoH. PWH with moderate or severe immune suppression had a higher risk of severe breakthrough infection and should be included in groups prioritized for additional vaccine doses and risk-reduction strategies..