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Progression Risk in People with HIV and COVID-19: Predictive Performance of Current Risk Scores
Pilar Vizcarra1, Alfonso Cabello2, Ana Moreno1
1Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Madrid, Spain.
Insights
COVID-19 risk scores performed poorly in people with HIV (PWH), failing to accurately predict critical illness. Adjusting scores for low CD4 counts improved prediction, highlighting the need for HIV-specific risk models.
Area of Science:
- Infectious Diseases
- Immunology
- Public Health
Background:
- People with HIV (PWH) may face increased risks for severe COVID-19 outcomes.
- Existing COVID-19 risk prediction scores are frequently applied to PWH.
- The accuracy of these scores in PWH populations requires thorough evaluation.
Purpose of the Study:
- To evaluate the performance of two common risk prediction scores (CALL and COVID-GRAM) in predicting critical COVID-19 outcomes among PWH.
- To assess the calibration and discrimination of these scores in a cohort of HIV-infected individuals.
- To determine if adjustments for HIV-specific factors, like nadir CD4 count, improve score accuracy.
Main Methods:
- A multicenter cohort study included 63 HIV-infected individuals with confirmed SARS-CoV-2 infection.
- CALL and COVID-GRAM scores were calculated, and participants were stratified into risk categories.
- Performance was assessed using receiver operating characteristic curves and calibration metrics (O:E ratios, Hosmer-Lemeshow test).
- Scores were adjusted by increasing risk category for individuals with nadir CD4 counts below 200/μL.
Main Results:
- Ten individuals (15.9%) progressed to critical disease, and four (6.3%) died.
- Both scores demonstrated acceptable discrimination (AUC 0.701-0.771) but showed calibration issues.
- Scores overestimated risk in low/high categories and underestimated it in the intermediate category.
- Without adjustment, 50% of critically ill individuals were not identified as high risk.
- Adjusting for low nadir CD4 counts reduced the proportion of unidentified high-risk individuals to 20%.
Conclusions:
- Standard COVID-19 risk scores have limited accuracy in PWH, failing to reliably identify those at high risk for critical illness.
- Adjustment for nadir CD4 count partially enhances the predictive performance of these scores.
- There is a critical need for developing and validating novel risk prediction equations that incorporate HIV-specific parameters for PWH.
Abstract:
People with HIV (PWH) might have a higher risk of adverse coronavirus disease 2019 (COVID-19) outcomes. Several scores were developed to predict COVID-19 progression to critical disease and are often used among PWH. We assessed the performance of two commonly used risk equations among PWH and COVID-19. Participants were identified from a multicenter cohort of 6,361 PWH on regular follow-up at 2 university hospitals. Of 99 HIV-infected individuals with confirmed SARS-CoV-2 infection, 63 had complete data and were included in this analysis. CALL and COVID-GRAM scores were calculated and participants were stratified into low-, intermediate-, and high-risk groups for each. Discrimination was assessed using receiver operating characteristic curves. Calibration was evaluated using observed versus expected (O:E) ratios and the Hosmer-Lemeshow χ2 goodness-of-fit statistic. Scores were adjusted by increasing one category level in individuals with nadir CD4 lymphocyte count <200/μL. Participants had a median nadir and current CD4 counts of 207 [interquartile range (IQR) 119-345] and 440 (IQR 280-719) cells/μL. Ten (15.9%) individuals progressed to critical disease and 4 (6.3%) died. Assessed scores showed acceptable discrimination (area under the curve 0.701-0.771) and were overall calibrated (O:E ratio 1.01). However, both overestimated the risk of progression among individuals in the low- and high-risk categories, whereas they underestimated the risk in the intermediate category (O:E 1.20-1.21). Thus, 50% of critically ill individuals were not identified as high risk. Assigning PWH with low nadir CD4 counts a higher risk of progression reduced the proportion of individuals not identified to 20%. COVID-19 risk scores had lower performance in PWH compared with that described in the general population and failed to adequately identify individuals who progressed to critical disease. Adjustment for nadir CD4 partially improved their accuracy. Risk equations incorporating HIV-related factors are needed.
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