With the introduction of antiretroviral therapy (ART), the HIV epidemic has undergone a tremendous shift in life expectancy and age distribution. ART has substantially improved survival with HIV1 and, by 2015, 50% of people living with HIV in the USA will be aged 50 years and older.2 Additionally, the age standardised death rate attributable to HIV/AIDS has reduced by 68% in the past 20 years.3 Since the introduction of ART, deaths attributable to classic AIDS-defining opportunistic infections have decreased whereas causes related to lifestyle and ageing have increased.4 Subsequent to the rise in life expectancy, the risk of age-associated chronic diseases (eg, cardiovascular, metabolic, renal, neurological) and non-AIDS defining malignancies is increasing in HIV-infected individuals.2, 4, 5, 6, 7 The prevalence of multiple morbidities in HIV-infected individuals is 65%,8 with lower nadir CD4 cell count and higher viral load associated with greater multimorbidity.9
Data suggest an increased prevalence of obstructive lung diseases in HIV-infected individuals, including both asthma and chronic obstructive pulmonary disease (COPD).10, 11, 12, 13 The mechanisms underlying this association are unclear. This Review summarises the present epidemiological data for associations between COPD, asthma, and HIV infection. To help to inform the clinician caring for HIV-infected patients who are at-risk of obstructive lung diseases, we present data for pulmonary function testing and lung cancer screening in HIV-infected individuals, and specific pharmacotherapy considerations for patients on ART. We conclude with a discussion of the current gaps in information about the management of HIV-associated obstructive lung diseases.
Key messages Asthma and COPD are more prevalent in HIV-infected populations Up to 21% of HIV-infected individuals have obstructive ventilatory defects Reduction in diffusing capacity is seen in more than 50% of HIV-infected populations Inhaled corticosteroids should be used with caution in HIV-infected patients on regimens containing ritonavir Screening spirometry and diffusing capacity testing might be needed in HIV-infected people with a history of smoking or respiratory symptoms
Before the introduction of effective ART regimens in the mid-1990s, the predominant pulmonary complications of HIV related to infectious causes, with scarce attention focused on chronic, non-infectious, lung diseases. However, several case reports and case-control studies described accelerated radiographic emphysema, air trapping, and diffusing capacity impairments in patients with HIV infection.12, 14, 15, 16 Early in the HIV epidemic, a reduction in diffusing capacity of the lung for carbon
In the general population, asthma and COPD are associated with tremendous morbidity and mortality. Asthma prevalence has been increasing since 2001,18 and HIV infection is associated with an increase of all-cause mortality in adults with asthma of more than three times (odds ratio [OR] 3·64, 95% CI 1·34–9·87).19 Results from prevalence studies before the ART era show variable associations between HIV infection and asthma, which range from 20% to 54%, depending on the criteria used.20, 21
Spirometric measurements, including FEV1 and FVC, are the definitive measurements to ascertain the presence of airflow obstruction such as that seen in asthma and COPD. The prevalence of obstructive ventilatory defects (defined as FEV1/FVC<0·70) in HIV-infected people ranges from 7% to 21% despite the widespread use of ART.11, 36, 41, 42, 43, 44 This increase in prevalence is seen in both children and adults with HIV infection.11, 36, 41, 42, 43, 44 Chronic HIV infection in vertically infected
Substantial data lend support to an association between HIV infection and lung cancer risk, independent of smoking.7 In HIV-uninfected smokers, low-dose CT screening reduced lung cancer mortality.56 In view of the high smoking prevalence30, 31 and lung cancer risk in HIV-infected patients, this population is expected to have an increased need for screening CT in the near future. Whether HIV infection should be regarded as an additional lung cancer risk factor and prompt screening at younger
Prevalence of asthma and COPD is increasing in the HIV-infected population, and therefore pulmonologists, infectious disease specialists, and general practitioners need to more frequently consider the potential interactions of treatments for these comorbid diseases. The mainstays of inhaled therapy for obstructive lung diseases include inhaled corticosteroids, short-acting and long-acting β-agonists, and long-acting muscarinic antagonists. Inhaled corticosteroid use in the HIV-infected
Increasing attention is being paid to complications of obstructive lung disease that arise in people with chronic HIV infection, so that clinicians will recognise and improve concurrent management of these comorbidities. Despite the substantial increase in the number of studies contributing data for the prevalence, risk, and sequelae of obstructive lung diseases in the HIV-infected population, many areas of uncertainty still remain. Should the diagnosis of obstructive lung disease in HIV
References for this Review were identified through searches of PubMed, Embase, Cochrane, and Scopus for English-language articles published from Jan 1, 2011, to Jan 24, 2014, containing terms such as: “HIV and lung function”, “HIV” and “HIV treatments and respiratory medicines”, and “HIV and respiratory diseases”. Full details of the search strategy and results can be requested from the authors. MeSH terms and related keywords were included in search strategies to ensure thoroughness. 5199
Antiretroviral therapy (ART) with multidrug can suppress the HIV viral load, prevent disease progression to AIDS, and reduce HIV- and AIDS-related mortality [5–8]. Despite the successful results of ART, long-term survivors with HIV infection often suffer from chronic respiratory conditions, such as HIV-related lung function disorders, asthma, and chronic obstructive pulmonary disease (COPD) [6,7,9–16]. Non-specific airway hyperresponsiveness (AHR) results in recurrent wheeze and respiratory symptoms in patients with HIV infection [6,7,9].
Additionally, at time of lung cancer diagnosis, PLWH may present at a mean age 20 years younger than the general population.15,21 Most PLWH are symptomatic at the time of diagnosis with locally advanced or metastatic disease in 70% to 96% of cases.13,22,23 Though several studies suggest that patients with HIV-associated NSCLC have elevated mortality compared with the general NSCLC population,18,19,24-27 some studies have reported similar outcomes between both groups.28,29
Studies have demonstrated an increased incidence of emphysema in HIV infected adults even after adjusting for age and smoking [57,58]. There is a known independent association between chronic COAD in adults and HIV [50,59,60] and even more so in those with uncontrolled HIV disease [36]. The effects of cART on the development of COAD have also been investigated.
