COVID-19 Is Not Over; It Has Simply Evolved:
Why Vigilance Still Matters for People with Comorbidities
Dr. José M. Zuniga, President/CEO, Fast-Track Health
There is a growing narrative – subtle but pervasive – that COVID-19 is no longer something to worry about. Case counts are lower than in previous years, emergency declarations have ended, and daily life has largely resumed. But this narrative is not only incomplete; it is dangerous. COVID-19 has not disappeared but instead has evolved and settled into endemic circulation. Although it gets less coverage, it continues to exact a measurable toll, particularly among people with comorbidities and those living in urban environments where both infectious and non-communicable diseases intersect.
First, the data are unequivocal: SARS-CoV-2 continues to cause substantial morbidity and mortality worldwide. While global reported case counts may appear modest with roughly 38,000 cases reported across 80 countries in a recent 28-day period, these figures mask significant underreporting due to significantly reduced testing and surveillance. Indeed, experts have long cautioned that official COVID-19 death counts underestimate the true burden because of limited testing, inconsistent reporting, and misclassification of deaths.
More importantly, COVID-19 is no longer a uniform threat; it is a stratified risk, disproportionately affecting those with underlying health conditions. Individuals with cardiovascular disease, diabetes, chronic respiratory illness, cancer, and immunocompromising conditions – including people living with HIV – continue to face elevated risks of severe outcomes, hospitalization, and death. The interplay between SARS-CoV-2 infection and these comorbidities is not incidental; it is synergistic. COVID-19 exacerbates existing conditions while those same conditions impair the body’s ability to respond effectively to infection.
This is particularly concerning in urban settings. Cities are epicenters not only of economic and social activity but also of disease concentration. HIV prevalence, alongside non-communicable diseases such as hypertension, obesity, and diabetes, is often higher in urban populations due to a combination of structural inequities, environmental exposures, and access disparities. These same populations, already navigating layered health vulnerabilities, are at heightened risk when COVID-19 circulates and thus priority candidates for vaccination.
And circulate it does. One of the clearest indicators comes from wastewater surveillance. The U.S. Centers for Disease Control and Prevention (CDC) continues to track SARS-CoV-2 levels in wastewater across the country, updating data weekly as part of its National Wastewater Surveillance System. Wastewater analysis provides a community-level signal of viral activity independent of individual testing behaviors. Importantly, studies consistently show a strong correlation between wastewater viral levels and subsequent hospitalizations, often with a lead time of one to two weeks.
In other words, the virus is still spreading even when we are not testing for it.
This brings us to a critical and underappreciated issue: testing and treatment uptake have declined sharply. With the normalization of COVID-19, fewer people are seeking testing when symptomatic, and fewer are accessing antiviral treatments such as nirmatrelvir/ritonavir (Paxlovid), which can significantly reduce the risk of severe illness if administered early. This decline is not benign; it represents a missed opportunity to interrupt disease progression, particularly among high-risk individuals.
Compounding this challenge is the ongoing evolution of the virus itself. New variants, such as the recently identified BA.3.2 lineage, demonstrate mutations that may enhance immune escape and reduce the effectiveness of prior immunity from infection or vaccination. While current vaccines continue to provide protection against severe disease and should be strongly encouraged for individuals at increased risk of serious illness and death, the virus’s capacity to adapt underscores the need for continued vigilance, surveillance, and periodic vaccine updates.
Importantly, this ongoing evolution means that individuals living with comorbidities may remain at elevated risk for severe outcomes, reinforcing the importance of sustained risk awareness, early testing, and timely access to effective treatment. For people living with HIV and other immunocompromising conditions, this is not an abstract concern. Even with well-managed HIV, immune dysregulation can persist, potentially influencing COVID-19 outcomes. When layered with other comorbidities, the risk profile becomes more complex and more concerning.
So, what should we be doing?
First, we must reject complacency. COVID-19 is no longer an emergency, but it remains a persistent public health threat. Second, we must re-emphasize targeted testing, particularly for individuals with symptoms or known exposures, and especially for those with comorbidities. Third, we must normalize early treatment, ensuring that vulnerable individuals have timely access to antivirals that can prevent severe outcomes. Fourth, we must sustain and expand wastewater surveillance and genomic monitoring, which provide critical early warning signals in a landscape of declining clinical testing.
Last but certainly not least, we must recognize that COVID-19 does not exist in isolation. COVID-19 intersects with the broader realities of urban health – HIV, NCDs, mental health, and social determinants of health. A whole-person, whole-system approach is not optional; it is essential. Efforts to increase vaccination, testing, and treatment uptake will be most effective when integrated into broader strategies that address chronic disease management, healthcare access, housing stability, food security, and other factors that shape health outcomes.
The pandemic phase may have passed, but the virus remains. The question is not whether COVID-19 is still here; it is whether we are willing to see it clearly and respond accordingly. For millions of people living with HIV, chronic diseases, and other conditions that increase their risk of severe illness, the consequences of complacency can be profound. The tools to reduce suffering and save lives vaccines, testing, treatments, and trusted public health communication remain available; our challenge is to ensure they reach those who need them most.