Evaluation and Diagnosis of HIV-associated Lung Disease

Stephanie Maximous, MD; Laurence Huang, MD; Alison Morris, MD, MS


Semin Respir Crit Care Med. 2016;37(2):199-213. 

In This Article

Shifting Demographics of Pulmonary Complications in HIV

Over the past 20 years, the approach to HIV and the acquired immunodeficiency syndrome (AIDS) has changed dramatically. HIV is more commonly considered a manageable chronic condition rather than an imminently terminal illness and is now complicated more often by noninfectious pulmonary complications such as chronic obstructive pulmonary disease (COPD) than opportunistic infections (OIs) and AIDS-associated malignancies such as Pneumocystis pneumonia (PCP) and Kaposi sarcoma (KS). This change has occurred in large part because of the efficacy of combination antiretroviral therapy (ART) and appropriate infectious prophylaxis, but the aging of the HIV-infected population has also contributed. Compared with the pre-ART era when the most commonly diagnosed pulmonary complications of HIV were PCP and bacterial pneumonia, COPD and bacterial pneumonia are now recognized to be the most common respiratory conditions among HIV-infected patients.[2]

Despite these changes, pulmonary diseases remain a leading cause of HIV-associated morbidity and mortality.[3,4] It is estimated that 70% of HIV-infected individuals will experience a pulmonary complication during their lifetime, and pulmonary disease is frequently the first presentation of HIV.[5] HIV-infected individuals more commonly experience respiratory illness than those who are HIV uninfected. An analysis of more than 33,000 HIV-infected veterans revealed that COPD, lung cancer, pulmonary hypertension (PH), pulmonary fibrosis, and pulmonary infections were significantly more likely in HIV-infected compared with -uninfected veterans.[2]

One barrier to accurate diagnosis of pulmonary disease is failure to recognize an initial presentation of HIV infection. Despite the changing epidemiology of both HIV disease and pulmonary illness in HIV-infected patients, it is still of utmost importance to maintain a high degree of suspicion for underlying HIV even in otherwise low-risk communities or geographic regions. Not infrequently, patients present with respiratory symptoms caused by OIs or malignancies as their first signs of HIV infection. Correct diagnosis may be missed despite several interactions with the health care system if HIV status is not evaluated. In fact, around 20% of HIV-infected individuals are unaware of their diagnosis.[6] Delayed diagnosis of HIV infection may contribute to worse outcomes from pulmonary illnesses in cases that might have been otherwise treatable.

While HIV incidence was highest within the population of men who have sex with men (MSM) in the 1980s and 1990s in the United States, the demographics appear to be shifting with the increasing prescription opioid dependence epidemic. For example, there has been a spike in injection of potent opioids and heroin use by individuals in more suburban and rural areas historically at low risk for HIV, as occurred in rural Indiana in 2015.[7] Other populations that continue to be disproportionately affected include young women in sub-Saharan Africa; MSM in Africa, Asia, and America; and minorities in the United States.[8]

For those already diagnosed with HIV, the epidemiology of HIV-associated illnesses may also be evolving with the recent change in treatment guidelines. The START trial randomized HIV-infected participants with a CD4 cell count greater than 500 cells/μL to starting ART immediately or waiting until the CD4 cell count fell below 350 cells/μL.[9] Study participants who were immediately started on ART experienced a 72% relative reduction in serious AIDS-related events, particularly from reduced rates of tuberculosis (TB), KS, and lymphoma. The study provides strong evidence that all HIV-infected individuals should initiate ART regardless of CD4 cell count, a departure from prior recommendations for starting ART at a CD4 cell count of less than 350 cells/μL.[9] It remains to be seen if more chronic lung diseases such as COPD are also mitigated by the early initiation of ART.