Pathogenesis and management of emphysema in people with HIV

ABSTRACT

Introduction

Since early in the HIV epidemic, emphysema has been identified among people with HIV (PWH) and has been associated with increased mortality. Smoking cessation is key to risk reduction. Health maintenance for PWH and emphysema should ensure appropriate vaccination and lung cancer screening. Treatment should adhere to inhaler guidelines for the general population, but inhaled corticosteroid (ICS) should be used with caution. Frontiers in treatment include targeted therapeutics. Major knowledge gaps exist in the epidemiology of and optimal care for PWH and emphysema, particularly in low and middle-income countries (LMIC).

Areas covered

Topics addressed include risk factors, pathogenesis, current treatment and prevention strategies, and frontiers in research.

Expert opinion

There are limited data on the epidemiology of emphysema in LMIC, where more than 90% of deaths from COPD occur and where the morbidity of HIV is most heavily concentrated. The population of PWH is aging, and age-related co-morbidities such as emphysema will only increase in salience. Over the next 5 years, the authors anticipate novel trials of targeted therapy for emphysema specific to PWH, and we anticipate a growing body of evidence to inform optimal clinical care for lung health among PWH in LMIC.

KEYWORDS:

• Emphysema
• HIV
• chronic obstructive pulmonary disease
• COPD
• human immunodeficiency virus

Article highlights

• Emphysema is frequently identified in PWH and has serious implications for quality of life and long-term health.

• Smoking cessation is the key intervention for emphysema among PWH.

• Vaccinations and regular screening for lung cancer improve outcomes for PWH and emphysema.

• Inhalers are the mainstay of therapy; ICS use should be approached with caution in PWH.

• Targeted therapies directed at mechanisms of pathogenesis are a frontier in treatment research.

• Major knowledge gaps exist in the epidemiology of and optimal care for PWH and emphysema, particularly for PWH in low- and middle-income countries.

Declaration of interest

MJ Glesby has received research support to their institution from Gilead Sciences and Regeneron; royalties from UpToDate; consulting fees from ReAlta Life Sciences. RJ Kaner is a consultant for Boehringer Ingelheim and United Therapeutics; an investigator in clinical trials for Bellerophon, Boehringer Ingelheim, National Institutes of Health, Respivant, Toray, and CSL Behring; received grant funding from Boehringer Ingelheim and National Institutes of Health; performed endpoint adjudication for Galapagos; participated in the data safety monitoring board for Pliant and PureTech. 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

Additional information

Funding

This work was supported in part by the National Institutes of Health, grants UH3 HL154944 and T32 AI007613.