Similar humoral immune responses against the SARS-CoV-2 spike protein in HIV and non-HIV individuals after COVID-19
Authors: María Martín-Vicente, Juan Berenguer, María José Muñoz-Gómez, Cristina Díez, Rafael Micán, María Jesús Pérez-Elías, Lucio Jesús García-Fraile, Joaquin Peraire, Inés Suárez-García, María Ángeles Jiménez-Sousa, Amanda Fernández-Rodríguez, Mónica Vázquez, Pablo Ryan, Juan González-García, Inmaculada Jarrín, Vicente Mas, Isidoro Martínez, Salvador Resino
Journal: Journal of Infection (2021)

We have read with interest the article of Venturas et al., who found persons living with HIV (PWH) are not at higher risk of moderate or severe COVID-19 than the general population1Venturas J. Zamparini J. Shaddock E. Stacey S. Murray L. Richards G.A. et al.Comparison of outcomes in HIV-positive and HIV-negative patients with COVID-19.J Infect. 2021; 83 (AugPubMed PMID: 34051225. Pubmed Central PMCID: PMC8152212. Epub 2021/05/30): 217-227Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar. The immune response against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in PWH is a matter of controversy and intense research, as HIV infection may impair the immune response to SARS-CoV-22Ambrosioni J. Blanco J.L. Reyes-Uruena J.M. Davies M.A. Sued O. Marcos M.A. et al.Overview of SARS-CoV-2 infection in adults living with HIV.Lancet HIV. 2021; 8 (MayPubMed PMID: 33915101. Pubmed Central PMCID: PMC8075775 consulting honoraria or research grants, or both, from Gilead Sciences, Janssen Pharmaceuticals, and ViiV Healthcare, outside the submitted work. EM reports grants and personal fees from Merck Sharp & Dohme and ViiV Healthcare, and personal fees from Gilead Sciences and Janssen Pharmaceuticals, outside the submitted work. JMM reports grants and personal fees from AbbVie, Angelini, ContraFect, Cubist, Genentech, Gilead Sciences, Jansen Pharmaceuticals, Lysovant, Medtronic, Merck Sharp & Dohme, Novartis, Pfizer, and ViiV Healthcare, outside the submitted work. All other authors declare no competing interests. The views and opinions expressed in this Review are those of the authors and do not necessarily reflect the official policy or position of the WHO. Epub 2021/04/30): e294-e305Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar. High levels of neutralizing antibodies against SARS-CoV-2 spike (S) protein are associated with less severe disease and a good prognosis in COVID-193Khoury D.S. Cromer D. Reynaldi A. Schlub T.E. Wheatley A.K. Juno J.A. et al.Neutralizing antibody levels are highly predictive of immune protection from symptomatic SARS-CoV-2 infection.Nat Med. 2021; 27 (2021/07//PubMed PMID: 34002089. eng): 1205-1211Crossref PubMed Scopus (2467) Google Scholar. These antibodies against the SARS-CoV-2 S protein block the virus union to its cellular receptor, the angiotensin-converting enzyme 2 (ACE2) receptor2Ambrosioni J. Blanco J.L. Reyes-Uruena J.M. Davies M.A. Sued O. Marcos M.A. et al.Overview of SARS-CoV-2 infection in adults living with HIV.Lancet HIV. 2021; 8 (MayPubMed PMID: 33915101. Pubmed Central PMCID: PMC8075775 consulting honoraria or research grants, or both, from Gilead Sciences, Janssen Pharmaceuticals, and ViiV Healthcare, outside the submitted work. EM reports grants and personal fees from Merck Sharp & Dohme and ViiV Healthcare, and personal fees from Gilead Sciences and Janssen Pharmaceuticals, outside the submitted work. JMM reports grants and personal fees from AbbVie, Angelini, ContraFect, Cubist, Genentech, Gilead Sciences, Jansen Pharmaceuticals, Lysovant, Medtronic, Merck Sharp & Dohme, Novartis, Pfizer, and ViiV Healthcare, outside the submitted work. All other authors declare no competing interests. The views and opinions expressed in this Review are those of the authors and do not necessarily reflect the official policy or position of the WHO. Epub 2021/04/30): e294-e305Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar. Thus, it is critical to determine whether the anti-SARS-CoV-2 neutralizing antibody response is impaired in PWH2Ambrosioni J. Blanco J.L. Reyes-Uruena J.M. Davies M.A. Sued O. Marcos M.A. et al.Overview of SARS-CoV-2 infection in adults living with HIV.Lancet HIV. 2021; 8 (MayPubMed PMID: 33915101. Pubmed Central PMCID: PMC8075775 consulting honoraria or research grants, or both, from Gilead Sciences, Janssen Pharmaceuticals, and ViiV Healthcare, outside the submitted work. EM reports grants and personal fees from Merck Sharp & Dohme and ViiV Healthcare, and personal fees from Gilead Sciences and Janssen Pharmaceuticals, outside the submitted work. JMM reports grants and personal fees from AbbVie, Angelini, ContraFect, Cubist, Genentech, Gilead Sciences, Jansen Pharmaceuticals, Lysovant, Medtronic, Merck Sharp & Dohme, Novartis, Pfizer, and ViiV Healthcare, outside the submitted work. All other authors declare no competing interests. The views and opinions expressed in this Review are those of the authors and do not necessarily reflect the official policy or position of the WHO. Epub 2021/04/30): e294-e305Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar. This study aimed to characterize plasma antibodies against SARS-CoV-2 S protein in PWH and CTRLs recovered from COVID-19. We performed a cross-sectional study in 91 PWH from the Cohort of the Spanish HIV Research Network (CoRIS) seropositive for SARS-CoV-2 and with plasma specimens collected from April 1, 2020, to September 30, 20204Berenguer J. Diez C. Martin-Vicente M. Mican R. Perez-Elias M.J. Garcia-Fraile L.J. et al.Prevalence and factors associated with SARS-CoV-2 seropositivity in the Spanish HIV research network cohort.Clin Microbiol Infect. 2021; 27 (Jun 26PubMed PMID: 34186209. Pubmed Central PMCID: PMC8267776. Epub 2021/06/30): 1678-1684Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar. We also included HIV-uninfected CTRLs seropositive for SARS-CoV-2 with plasma specimens stored in the National center for Microbiology Instituto de Salud Carlos III. Both groups were matched for age and time since initiation of symptoms and were not vaccinated against SARS-CoV-2. The Ethics Committee of Hospital General Universitario Gregorio Marañón approved the study (Ref# 162/20). Blood samples were collected by venipuncture in EDTA tubes and were sent the same day to the Spanish HIV BioBank, where plasma samples were obtained and stored at −80 °C. These samples were sent to the Instituto de Salud Carlos III for its analysis. We used immunoassays to evaluate the antibody titer against the SARS-CoV-2 S protein, which gives us the area under the curve (AUC) of IgG, IgM, and IgA titration curves. Besides, we assayed the capacity of the antibodies to inhibit the binding of the soluble ACE2 receptor to S protein (see Supplemental file 1). The differences between groups were calculated by the Mann-Whitney U test for continuous variables and the Chi-square test or Fisher's exact test for categorical variables. Generalized Linear Models (GLM) with a gamma distribution (log-link) adjusted by age, gender, and COVID-19 disease severity were used to evaluate the differences in plasma anti-SARS-CoV-2 S protein antibody levels (IgG, IgM, and IgA) between groups. The inhibition of ACE2 binding to the S protein (inhibition percentage, y-axis) and the titers of plasma anti-SARS-CoV-2 S protein antibodies (sum of AUCs of IgG, IgM, and IgA titration curves, x-axis) were plotted according to a semilog line, and Pearson's correlation coefficient (r) was calculated. Then, GLM tests were used to assess if regression slopes in PWH and CTRLs were differents by analyzing the interaction between the groups (PWH vs. CTRLs) with the sum of AUCs and inhibition percentages. Statistical analysis was performed with GraphPad Prism 9.0 (GraphPad Software, Inc., San Diego, CA, USA) and IBM SPSS Statistics 25.0 (SPSS INC, Armonk, NY, USA). The level of significance was two-tailed and defined as p < 0.05 (two-tailed). The study population included 91 PWH – fully described elsewhere4Berenguer J. Diez C. Martin-Vicente M. Mican R. Perez-Elias M.J. Garcia-Fraile L.J. et al.Prevalence and factors associated with SARS-CoV-2 seropositivity in the Spanish HIV research network cohort.Clin Microbiol Infect. 2021; 27 (Jun 26PubMed PMID: 34186209. Pubmed Central PMCID: PMC8267776. Epub 2021/06/30): 1678-1684Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar – and 21 CTRLs, whose characteristics are shown in Table 1. Concerning COVID-19, 92.3% PWH had asymptomatic or mild COVID-19 disease, 7.7% were hospitalized, and the median time from symptoms to plasma collection was 11 weeks. CTRLs had similar characteristics to PWH, except for gender.Table 1Epidemiological and clinical characteristics of SARS-CoV-2 infected patients.VariableControl groupHIV groupp-valueNo.2191Demographic dataMale sex at birth – No./with data (%)13 (61.9%)85 (93.4%)< 0.001Age - Median (Q1; Q3) – yr.42.3 (38.9; 48.8)44.2 (36.8; 51.6)0.902COVID-19 dataSeverity status (asymptomatic or mild) – No./with data (%)18 (85.7%)84 (92.3%)0.277Hospital admission – No./with data (%)3 (14.3%)7 (7.7%)0.340Time from symptoms - Median (Q1; Q3) – wk.12.3 (11.1; 19.7)11 (8.1; 15.4)0.106Oxygen-therapy – No./with data (%)3 (14.3%)6 (6.6%)0.340HIV infection dataMechanism of HIV acquisition – No./with data (%)Men having sex with men-68 (74.7%)-Heterosexual-20 (22%)-Injection drug use-1 (1.1%)-Other-2 (2.2%)-Age of HIV diagnosis - Median (Q1; Q3) – yr.-36.4 (28.1; 43.6)-Time with HIV infection - Median (Q1; Q3) – yr.-6.2 (3.3; 11.5)-Prior AIDS-defining conditions – No./with data (%)-11 (12.1%)-Age - Median (Q1; Q3) – yr.-45 (36.9; 46.9)-Last CD4+ countMedian (Q1; Q3) - cells/mm3-696.5 (491.5; 939)-Distribution – No./with data (%)< 350-9/84 (10.7%)-350–499-13/84 (15.5%)-≥ 500-62/84 (73.8%)-Last HIV-RNA load ≤ 50 copies/mm3 – No./with data (%)-80 (94.1%)-Antiretroviral therapy – No./with data (%)-88 (96.7%)-Antiretroviral therapy (N[t]RTI backbone) – No./with data (%)TAF/FTC-40 (44%)-ABC/3TC-25 (27.5%)-TDF/FTC-5 (5.5%)-Antiretroviral therapy (third drug)NNRTI-48 (52.7%)-Protease inhibitor-4 (4.4%)-Integrase inhibitor-51 (56%)-Abbreviations: PWH. People with HIV; Q1. 1st quartile; Q3. 3rd quartile; N(t)RTI. nucleoside/nucleotide reverse transcriptase inhibitors; TAF. tenofovir alafenamide; FTC. emtricitabine; ABC. abacavir; 3TC. lamivudine; TDF; tenofovir disoproxil fumarate; NNRTI. non-nucleoside reverse transcriptase inhibitors. Open table in a new tab Abbreviations: PWH. People with HIV; Q1. 1st quartile; Q3. 3rd quartile; N(t)RTI. nucleoside/nucleotide reverse transcriptase inhibitors; TAF. tenofovir alafenamide; FTC. emtricitabine; ABC. abacavir; 3TC. lamivudine; TDF; tenofovir disoproxil fumarate; NNRTI. non-nucleoside reverse transcriptase inhibitors. No significant differences were found between groups in plasma levels of different classes of immunoglobulins against SARS-CoV-2 S protein [IgG (p = 0.414; Fig. 1A), IgM (p = 0.862; Fig. 1B), and IgA (p = 0.134; Fig. 1C)], and percentages of inhibition of ACE2 binding to the S protein (p = 0.237; Fig. 1D). Adjusted regression analysis also found no significant differences (Supplemental Table 1). Furthermore, we found solid and similar correlations between total plasma antibody titers against SARS-CoV-2 S protein and the percentage of inhibition of ACE2 binding to the S protein in CTRLs (r = 0.580; p = 0.005; Fig. 1E) and PWH (r = 0.548; p < 0.001; Fig. 1F). No differences were found between the regression slopes of the two study groups (p = 0.849). Several studies have reported that PWH usually shows poor antibody response to other viruses or viral vaccines5Overton E.T. Sungkanuparph S. Powderly W.G. Seyfried W. Groger R.K. Aberg J.A. Undetectable plasma HIV RNA load predicts success after hepatitis B vaccination in HIV-infected persons.Clin Infect Dis. 2005; 41 (Oct 1PubMed PMID: 16142673. Epub 2005/09/06): 1045-1048Crossref PubMed Scopus (141) Google Scholar, 6George V.K. Pallikkuth S. Parmigiani A. Alcaide M. Fischl M. Arheart K.L. et al.HIV infection worsens age-associated defects in antibody responses to influenza vaccine.J Infect Dis. 2015; 211 (Jun 15PubMed PMID: 25556252. Pubmed Central PMCID: PMC4836723. Epub 2015/01/04): 1959-1968Crossref PubMed Scopus (56) Google Scholar–7Kerneis S. Launay O. Turbelin C. Batteux F. Hanslik T. Boelle P.Y. Long-term immune responses to vaccination in HIV-infected patients: a systematic review and meta-analysis.Clin Infect Dis. 2014; 58 (AprPubMed PMID: 24415637. Pubmed Central PMCID: PMC4761378. Epub 2014/01/15): 1130-1139Crossref PubMed Scopus (119) Google Scholar, raising concerns about whether they can mount an adequate humoral response against SARS-CoV-2. This issue is relevant since high antibody titers against the SARS-CoV-2 S protein correlate with virus neutralization and protection3Khoury D.S. Cromer D. Reynaldi A. Schlub T.E. Wheatley A.K. Juno J.A. et al.Neutralizing antibody levels are highly predictive of immune protection from symptomatic SARS-CoV-2 infection.Nat Med. 2021; 27 (2021/07//PubMed PMID: 34002089. eng): 1205-1211Crossref PubMed Scopus (2467) Google Scholar. Our study shows that PWH and CTRLs who recovered from COVID-19 display a similar antibody response against the S protein. To detect neutralizing antibodies, we used a stabilized trimeric S protein in its native pre-fusion conformation. The suitability of our assay was confirmed by the strong correlation between the antibody titers and their capacity to inhibit the interaction S protein-ACE2 receptor. Our data agree with recently published results showing comparable anti-SARS-CoV-2 neutralizing antibody levels between PWH under effective antiretroviral therapy (ART) and HIV-uninfected individuals8Alrubayyi A, Gea-Mallorqui E, Touizer E, Hameiri-Bowen D, Kopycinski J, Charlton B, et al. Characterization of humoral and SARS-CoV-2 specific T cell responses in people living with HIV. Res Sq. 2021 Mar 17. PubMed PMID: 33758833. Pubmed Central PMCID: PMC7987102. Epub 2021/03/25.Google Scholar,9Snyman J. Hwa S.H. Krause R. Muema D. Reddy T. Ganga Y. et al.Similar antibody responses against SARS-CoV-2 in HIV uninfected and infected individuals on antiretroviral therapy during the first South African infection wave.Clin Infect Dis. 2021; (Sep 2PubMed PMID: 34472583. Epub 2021/09/03)Crossref PubMed Scopus (22) Google Scholar. Succesful HIV suppression seems to be crucial for developing an adequate humoral immune response. In our study, almost all HIV patients analyzed were on ART, with good clinical, virological, and immunological control, which may have contributed to similar anti-SARS-CoV-2 antibody titers between PWH and CTRLs. We analyzed the antibody titers against the SARS-CoV-2 S protein and percentages of inhibition of ACE2 binding to the S protein according to CD4+ strata (< 350, 350–500, > 500 cells/mm3), and we did not find significant differences (data not shown). In contrast, lower neutralizing antibody titers against SARS-CoV-2 were found in PWH than in HIV-uninfected individuals recovering from COVID-19 by Spinelli et al.10Spinelli M.A. Lynch K.L. Yun C. Glidden D.V. Peluso M.J. Henrich T.J. et al.SARS-CoV-2 seroprevalence, and IgG concentration and pseudovirus neutralising antibody titres after infection, compared by HIV status: a matched case-control observational study.Lancet HIV. 2021; 8 (JunPubMed PMID: 33933189. Pubmed Central PMCID: PMC8084354 National Institutes of Health during conduct of the study. DVG reports personal fees from Gilead Sciences outside the submitted work. All other authors declare no competing interests. Epub 2021/05/03): e334-ee41Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar, although its sample size was three times lower than in our study. Differences in the characteristics of the study cohorts (sample size, ethnicity, age, sex, COVID-19 severity, percentage of people with unsuppressed viral loads, among others), study design, or assays for antibody characterization may explain these conflicting results. In conclusion, no differences in quantitative and qualitative SARS-CoV-2-specific immune humoral response were found between well-controlled PWH and CRTLs after recovery from COVID-19. This finding suggests that PWH are not an at-risk population for this infection and are potentially good vaccination responders. •Study conception and design: Salvador Resino, Juan Berenguer, and Isidoro Martínez.•Acquisition of data: all authors.•Laboratory procedures: María Martín-Vicente, and María José Muñoz-Gómez.•Analyses and interpretation of data: Salvador Resino and Isidoro Martínez.•Drafting the article: Salvador Resino and Isidoro Martínez.•Critical revision of the article: Juan Berenguer.•Funding acquisition: Salvador Resino and Juan Berenguer.•All authors have read and approved the final manuscript. The authors declare that they have no competing interests. We are indebted to all the patients who participated in this research. We want to acknowledge the patients in this study for their participation and the Spanish HIV HGM BioBank integrated into the Spanish AIDS Research Network (RIS) and collaborating Centers for the generous gifts of clinical samples used in this work. This study would not have been possible without the collaboration of all medical and nursing staff and data managers who have taken part in the project. This study was supported by grants from Instituto de Salud Carlos III (ISCII; grant numbers COV20/00108 and COV20/1144). The study was also funded by the Spanish AIDS Research Network (RD16/0025/0017, RD16/0025/0018 and RD16CIII/0002/0002) and Centro de Investigación Biomédica en Red (CIBER) en Enfermedades Infecciosas (CB21/13/00044). AFR and MAJS are Miguel Servet researchers supported and funded by ISCIII (grant numbers: CP14CIII/00010 to AFR and CP17CIII/00007 to MAJS).