Clinical composition of HIV/AIDS-related deaths during the COVID-19 pandemic: a nationwide natural experiment (2017–2024)

Objective: To assess whether the coronavirus disease 2019 (COVID-19) pandemic altered the clinical composition of HIV/AIDS–related deaths in Peru, distinguishing HIV/AIDS-only deaths from HIV/AIDS-COVID deaths and examining indicators of advanced HIV disease and opportunistic infections (OIs). Design: Nationwide retrospective observational study using the onset of COVID-19 as an exogenous shock within a natural–experiment framework. Triangulation was performed across interrupted time series, ecological, and individual-level analyses. Methods: Individual-level mortality records from Peru's National Death Registry (January 2017–December 2024) were analyzed. HIV/AIDS-related deaths were identified using ICD-10 codes and text terms and classified as HIV/AIDS-only or HIV/AIDS-COVID. Segmented interrupted time series models estimated changes in monthly proportions of clinical indicators among HIV/AIDS-only deaths. Ecological models examined relationships between the monthly share of HIV/AIDS-COVID deaths and patterns in HIV/AIDS-only deaths. Multivariable regressions compared individual-level clinical characteristics during 2020–2024. Results: The onset of COVID-19 coincided with abrupt declines in documentation of severe immunosuppression and OI among HIV/AIDS-only deaths. Months with a higher share of HIV/AIDS-COVID deaths were associated with lower prevalence of advanced HIV indicators among HIV/AIDS-only deaths. Individually, HIV/AIDS-COVID deaths showed slightly higher prevalence of advanced HIV disease but lower prevalence of OIs, whereas HIV/AIDS-only deaths more often reflected complex HIV-related pathology. Conclusions: The COVID-19 pandemic reconfigured the clinical composition of HIV/AIDS-related mortality in Peru, concentrating HIV/AIDS-only deaths among individuals with more advanced disease while generating a distinct profile of HIV/AIDS-COVID co-infection. Strengthening diagnostic capacity, continuity of HIV care, and integrated surveillance is essential to protect people living with HIV during future health-system shocks.