HIV testing during the COVID-19 pandemic

Editor – We support the recommendations made in the recent report by Kelly et al for increased awareness of importance of HIV testing during the COVID-19 pandemic.¹

During the UK's first wave, our hospital trust in north west London experienced a high burden of COVID-19 patients, with clinical staff quickly becoming familiar with the clinical and radiological features of COVID-19. Studies that have compared pooled nasopharyngeal aspirate results with cross-sectional imaging indicate that the sensitivity of reverse transcriptase polymerase chain reaction (RT-PCR) for SARS-CoV-2 may be very poor.² As a result, a significant proportion of COVID-19 patients are diagnosed on the basis of typical clinical and radiological features, despite negative tests.³

Between March and June 2020, three patients were admitted with signs and symptoms consistent with COVID-19 (respiratory failure and bilateral infiltrates on chest imaging) but were COVID-19 RT-PCR negative. These patients were subsequently diagnosed with advanced HIV (mean CD4 count 62 × 10⁶/L (range 12–108 × 10⁶/L)) and Pneumocystis jirovecii pneumonia (PCP). Due to the initial presumed clinical diagnosis of COVID-19 there was a delay in testing for HIV and diagnosing and treating PCP.

PCP and COVID-19 are difficult to distinguish on clinical grounds, with shared symptoms including fever, dyspnoea, dry cough and fatigue; although, in COVID-19 the onset is more acute.^4,5 The similar radiological findings include bilateral infiltrates with COVID-19 typically involving the lung peripheries whereas PCP is often peripherally sparing.⁵

Our experience highlights the importance of maintaining diagnostic vigilance when pursuing a diagnosis of COVID-19.¹ We strongly advocate HIV testing all individuals presenting with acute respiratory illness, including those with ‘typical’ features of COVID-19 as per UK national guidelines.⁶