Chronic obstructive pulmonary disease in HIV

ABSTRACT

Introduction: Chronic obstructive pulmonary disease (COPD) is more prevalent in people with HIV (PWH) than in the general population and leads to an increased burden of morbidity and mortality in this population. The mechanisms behind COPD development and progression in PWH are not fully elucidated, and there are no PWH-specific guidelines for COPD management.

Areas covered: The goal of this broad narrative review is to review the epidemiology of COPD in PWH globally, highlight proposed pathways contributing to increased COPD prevalence and progression in PWH, discuss structural and functional changes in the lungs in this population, assesses the excess mortality and comorbidities in PWH with COPD, and address management practices for this unique population.

Expert opinion: Understanding how a chronic viral infection leads to COPD, independent of cigarette smoking, is of critical scientific importance. Further research should focus on the pathophysiology of the interaction between HIV and COPD, and determine the role of disease-modifying risk factors such as opportunistic pneumonia and air pollution, as well as generate data from randomized clinical trials on the safety and efficacy of specific therapies for this vulnerable patient population.

KEYWORDS:

• Air pollution
• COPD
• HIV
• inflammation
• lung function
• lung structure
• management
• smoking

Article highlights

• HIV is an independent risk factor for obstructive lung disease. People with HIV develop the comorbid chronic obstructive pulmonary disease at a younger age and at a higher rate than the general population, independent of cigarette smoking. The precise reason(s) for this are incompletely understood but are the subject of active scientific investigation.

• Infection with HIV and COPD shares common pathological pathways that result in chronic inflammation and progression of obstructive lung disease. Higher levels of systemic markers of inflammation are associated with the progression of HIV-related COPD, even among virally suppressed patients on antiretroviral treatment (ART).

• Decreased DLco is a consistent finding in PWH that may indicate mechanisms of lung impairment specific to chronic HIV infection. Low DLco is associated with higher mortality and represents an important phenotype of lung impairment in this population.

• Compared to general COPD patients, PWH with COPD has a higher symptom burden and risk of COPD exacerbations, more cardiopulmonary comorbidities, and higher mortality.

• Given the high prevalence of COPD in PWH, case-finding strategies are needed for early recognition of the disease. Strategies to implement COPD case-finding within HIV clinics are promising despite identified challenges.

• Medical management of COPD in PWH is similar to that in the general population, and smoking cessation is the cornerstone of COPD management and prevention.

• Inhaled corticosteroids should be used with caution in PWH with COPD, due to important drug interactions with ART and concerns about bacterial pneumonia risk in PWH.

Declaration of interest

KM Kunisaki reports personal fees from GlaxoSmithKline for consulting and from Nuvaira for independent Data Monitoring Committee services; contracted clinical research support from Sanofi; and government grants from NIH R01 HL140971, Department of Defense, and Department of Veterans Affairs. J Vasquez is supported by NIH K01 HL140804 and the Robert Wood Johnson Foundation Harold Amos Medical Faculty Development Program; P30 AI027763; U19 AI096109; and R01 AI141003. L Huang is partly supported by NIH R01 HL128156 and R01 HL143998. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

This material is also the result of work supported with resources and the use of facilities at the Minneapolis Veterans Affairs Medical Center, Minneapolis, MN, USA (KMK). The views expressed in this article are those of the authors and do not reflect the views of the United States Government, the National Institutes of Health, the Department of Veterans Affairs, the funders, the sponsors, or any of the authors’ affiliated academic institutions.