Chronic obstructive pulmonary disease: an emerging comorbidity in HIV-infected patients in the HAART era?

Novel approach to exploring protease activity and targets in HIV-associated obstructive lung disease using combined proteomic-peptidomic analysis

BACKGROUND

Obstructive lung disease (OLD) is increasingly prevalent among persons living with HIV (PLWH). However, the role of proteases in HIV-associated OLD remains unclear.

METHODS

We combined proteomics and peptidomics to comprehensively characterize protease activities. We combined mass spectrometry (MS) analysis on bronchoalveolar lavage fluid (BALF) peptides and proteins from PLWH with OLD (n = 25) and without OLD (n = 26) with a targeted Somascan aptamer-based proteomic approach to quantify individual proteases and assess their correlation with lung function. Endogenous peptidomics mapped peptides to native proteins to identify substrates of protease activity. Using the MEROPS database, we identified candidate proteases linked to peptide generation based on binding site affinities which were assessed via z-scores. We used t-tests to compare average forced expiratory volume in 1 s per predicted value (FEV1pp) between samples with and without detection of each cleaved protein and adjusted for multiple comparisons by controlling the false discovery rate (FDR).

FINDINGS

We identified 101 proteases, of which 95 had functional network associations and 22 correlated with FEV1pp. These included cathepsins, metalloproteinases (MMP), caspases and neutrophil elastase. We discovered 31 proteins subject to proteolytic cleavage that associate with FEV1pp, with the top pathways involved in small ubiquitin-like modifier mediated modification (SUMOylation). Proteases linked to protein cleavage included neutrophil elastase, granzyme, and cathepsin D.

INTERPRETATIONS

In HIV-associated OLD, a significant number of proteases are up-regulated, many of which are involved in protein degradation. These proteases degrade proteins involved in cell cycle and protein stability, thereby disrupting critical biological functions.

ROS Chronicles in HIV Infection: Genesis of Oxidative Stress, Associated Pathologies, and Therapeutic Strategies

Reactive oxygen species (ROS) are widely regarded as signaling molecules and play essential roles in various cellular processes, but when present in excess, they can lead to oxidative stress (OS). Growing evidence suggests that the OS plays a critical role in the pathogenesis of HIV infection and is associated with several comorbidities in HIV-infected individuals. ROS, generated both naturally during mitochondrial oxidative metabolism and as a response to various cellular processes, can trigger host antiviral responses but can also promote viral replication. While the multifaceted roles of ROS in HIV pathophysiology clearly need more investigation, this review paper unravels the mechanisms of OS generation in the context of HIV infections, offering insights into HIV viral protein-mediated and antiretroviral therapy-generated OS. Though the viral protein Tat is significantly attributed to the endogenous cellular increase in ROS post HIV infection, this paper sums up the contribution of other viral proteins in HIV-mediated elicitation of ROS. Given the investigations recognizing the significant role of ROS in the onset and progression of diverse pathologies, the paper also explores the critical function of ROS in the mediation of an of array of pathologies associated with HIV infection and retroviral therapy. HIV patients are observed with disruption to the antioxidant defense system, the antioxidant therapy is gaining focus as a potential therapeutic intervention and is well discussed. While ROS play a significant role in the HIV scenario, further exploratory studies are imperative to identifying alternative therapeutic strategies that could mitigate the toxicities and pathologies associated with ART-induced OS.

Novel Approach to Exploring Protease Activity and Targets in HIV-associated Obstructive Lung Disease using Combined Proteomic-Peptidomic Analysis

Background

Obstructive lung disease (OLD) is increasingly prevalent among persons living with HIV (PLWH). However, the role of proteases in HIV-associated OLD remains unclear.

Methods

We combined proteomics and peptidomics to comprehensively characterize protease activities. We combined mass spectrometry (MS) analysis on bronchoalveolar lavage fluid (BALF) peptides and proteins from PLWH with OLD (n=25) and without OLD (n=26) with a targeted Somascan aptamer-based proteomic approach to quantify individual proteases and assess their correlation with lung function. Endogenous peptidomics mapped peptides to native proteins to identify substrates of protease activity. Using the MEROPS database, we identified candidate proteases linked to peptide generation based on binding site affinities which were assessed via z-scores. We used t-tests to compare average forced expiratory volume in 1 second per predicted value (FEV1pp) between samples with and without detection of each cleaved protein and adjusted for multiple comparisons by controlling the false discovery rate (FDR).

Findings

We identified 101 proteases, of which 95 had functional network associations and 22 correlated with FEV1pp. These included cathepsins, metalloproteinases (MMP), caspases and neutrophil elastase. We discovered 31 proteins subject to proteolytic cleavage that associate with FEV1pp, with the top pathways involved in small ubiquitin-like modifier mediated modification (SUMOylation). Proteases linked to protein cleavage included neutrophil elastase, granzyme, and cathepsin D.

Interpretations

In HIV-associated OLD, a significant number of proteases are up-regulated, many of which are involved in protein degradation. These proteases degrade proteins involved in cell cycle and protein stability, thereby disrupting critical biological functions.

Pulmonary Function in People Living With Human Immunodeficiency Virus: A Meta-Analysis

BACKGROUND

HIV can infect bronchial epithelial cells rendering individuals susceptible to lung damage. Our objective was to determine the effects of human immunodeficiency virus (HIV) infection on pulmonary function tests.

METHODS

We performed a meta-analysis after conducting a literature search in PubMed, Embase, Cochrane Library and Virtual Health Library databases from inception to December 31st, 2022. We employed the inverse variance method with a random effects model to calculate the effect estimate as the mean difference (MD) and 95% confidence interval (CI). We calculated the heterogeneity with the I2 statistic and performed a meta-regression analysis by age, sex, smoking, CD4 T-cells count and antiretroviral therapy. We also conducted a sensitivity analysis according to the studies' publication date, and excluding the study with the greatest weight in the effect. The PROSPERO registry number was CRD42023401105.

RESULTS

The meta-analysis included 20 studies, with 7621 living with HIV and 7410 control participants. The pooled MD (95%CI) for the predicted percentage of FEV1, FVC and DLCO were -3.12 (-5.17, -1.06); p=0.003, -1.51 (-3.04, 0.02); p=0.05, and -5.26 (-6.64, -3.87); p<0.001, respectively. The pooled MD for FEV1/FVC was -0.01 (-0.02, -0.01); p=0.002. In all cases, there was a considerable heterogeneity. The meta-regression analysis showed that among studies heterogeneity was not explained by patient age, smoking, CD4 T-cells count or antiretroviral therapy.

CONCLUSION

Pulmonary function tests are impaired in people living with HIV, independently of age, smoking, CD4 T-cells count, and geographical region.

Integrated chronic care models for people with comorbid of HIV and non-communicable diseases in Sub-Saharan Africa: A scoping review

BACKGROUND

Integrated health care is an approach characterized by a high degree of collaboration and communication among health professionals. Integration of HIV/NCD is recommended to enhance the quality of healthcare services being provided. Duplication of limited resources is minimized, and a holistic care approach is promoted by shifting from acute and reactive care to care that embraces patient-centredness that includes promotive health and disease surveillance. The high burden of HIV disease in sub-Saharan Africa (SSA) combined with the increasing prevalence of chronic non-communicable diseases (NCDs) necessitates a review of how health systems has been doing to deliver quality integrated care for people living with HIV (PLWH) and comorbid chronic NCDs.

METHODS

A scoping review was conducted to identify and describe all publications on integrated chronic care management models at the primary care level in the SSA context, particularly those that addressed the care of PLHIV with co-morbid chronic NCDs. The inclusion and exclusion criteria were applied, and duplicates were removed.

RESULTS

A total of twenty-one articles were included in the final review. Integrated healthcare systems were reported in only eight SSA countries-(South Africa, Uganda, Kenya, the United Republic of Tanzania, Zambia, Malawi, Zimbabwe and Swaziland). Integrated care systems adopted one of three health models. These included added-on NCD services to previously dedicated HIV care facilities, expansion of primary care facilities to include HIV care and establishment of integrated care services. Short-term benefits included staff capacitation, improved retention of patients and improved screening and detection of NCDs. However, the expansion of existing services resulted in an increased workload with no additional staff. A significant positive change noted by communities was that there was less or no stigmatisation of people living with HIV when attending dedicated HIV clinics.

CONCLUSION

Evidence of integrated healthcare services for PLWH and co-morbid of NCDs in SSA is scanty. Data on some short-term benefits of integrated care was available, but evidence was absent on the long-term outcomes. Randomized clinical trials with clearly defined comparator groups and standardized measures of HIV and NCD outcomes are needed to demonstrate non-inferiority of integrated against non-integrated care.

COPD in People with HIV: Epidemiology, Pathogenesis, Management, and Prevention Strategies

Chronic obstructive pulmonary disease (COPD) is a progressive respiratory disorder characterized by airflow limitation and persistent respiratory symptoms. People with HIV (PWH) are particularly vulnerable to COPD development; PWH have demonstrated both higher rates of COPD and an earlier and more rapid decline in lung function than their seronegative counterparts, even after accounting for differences in cigarette smoking. Factors contributing to this HIV-associated difference include chronic immune activation and inflammation, accelerated aging, a predilection for pulmonary infections, alterations in the lung microbiome, and the interplay between HIV and inhalational toxins. In this review, we discuss what is known about the epidemiology and pathobiology of COPD among PWH and outline screening, diagnostic, prevention, and treatment strategies.

HIV-associated lung disease

Lung disease encompasses acute, infectious processes and chronic, non-infectious processes such as chronic obstructive pulmonary disease, asthma and lung cancer. People living with HIV are at increased risk of both acute and chronic lung diseases. Although the use of effective antiretroviral therapy has diminished the burden of infectious lung disease, people living with HIV experience growing morbidity and mortality from chronic lung diseases. A key risk factor for HIV-associated lung disease is cigarette smoking, which is more prevalent in people living with HIV than in uninfected people. Other risk factors include older age, history of bacterial pneumonia, Pneumocystis pneumonia, pulmonary tuberculosis and immunosuppression. Mechanistic investigations support roles for aberrant innate and adaptive immunity, local and systemic inflammation, oxidative stress, altered lung and gut microbiota, and environmental exposures such as biomass fuel burning in the development of HIV-associated lung disease. Assessment, prevention and treatment strategies are largely extrapolated from data from HIV-uninfected people. Smoking cessation is essential. Data on the long-term consequences of HIV-associated lung disease are limited. Efforts to continue quantifying the effects of HIV infection on the lung, especially in low-income and middle-income countries, are essential to advance our knowledge and optimize respiratory care in people living with HIV.

Living with HIV and Getting Vaccinated: A Narrative Review

After 40 years of its appearance, human immunodeficiency virus (HIV) infection remains a leading public health challenge worldwide. Since the introduction of antiretroviral treatment (ART), HIV infection has become a chronic condition, and people living with HIV could have life expectancies close to those of the general population. People with HIV often have an increased risk of infection or experience more severe morbidity following exposure to vaccine-preventable diseases. Nowadays, several vaccines are available against bacteria and viruses. However, national and international vaccination guidelines for people with HIV are heterogeneous, and not every vaccine is included. For these reasons, we aimed to perform a narrative review about the vaccinations available for adults living with HIV, reporting the most updated studies performed for each vaccine among this population. We performed a comprehensive literature search through electronic databases (Pubmed-MEDLINE and Embase) and search engines (Google Scholar). We included English peer-reviewed publications (articles and reviews) on HIV and vaccination. Despite widespread use and guideline recommendations, few vaccine trials have been conducted in people with HIV. In addition, not all vaccines are recommended for people with HIV, especially for those with low CD4 cells count. Clinicians should carefully collect the history of vaccinations and patients' acceptance and preferences and regularly check the presence of antibodies for vaccine-preventable pathogens.

Lung proteome and metabolome endotype in HIV-associated obstructive lung disease

Purpose

Obstructive lung disease is increasingly common among persons with HIV, both smokers and nonsmokers. We used aptamer proteomics to identify proteins and associated pathways in HIV-associated obstructive lung disease.

Methods

Bronchoalveolar lavage fluid (BALF) samples from 26 persons living with HIV with obstructive lung disease were matched to persons living with HIV without obstructive lung disease based on age, smoking status and antiretroviral treatment. 6414 proteins were measured using SomaScan® aptamer-based assay. We used sparse distance-weighted discrimination (sDWD) to test for a difference in protein expression and permutation tests to identify univariate associations between proteins and forced expiratory volume in 1 s % predicted (FEV₁ % pred). Significant proteins were entered into a pathway over-representation analysis. We also constructed protein-driven endotypes using K-means clustering and performed over-representation analysis on the proteins that were significantly different between clusters. We compared protein-associated clusters to those obtained from BALF and plasma metabolomics data on the same patient cohort.

Results

After filtering, we retained 3872 proteins for further analysis. Based on sDWD, protein expression was able to separate cases and controls. We found 575 proteins that were significantly correlated with FEV₁ % pred after multiple comparisons adjustment. We identified two protein-driven endotypes, one of which was associated with poor lung function, and found that insulin and apoptosis pathways were differentially represented. We found similar clusters driven by metabolomics in BALF but not plasma.

Conclusion

Protein expression differs in persons living with HIV with and without obstructive lung disease. We were not able to identify specific pathways differentially expressed among patients based on FEV₁ % pred; however, we identified a unique protein endotype associated with insulin and apoptotic pathways.

HIV and chronic lung disease

PURPOSE OF REVIEW

As people living with human immunodeficiency virus (HIV, PLWH) age, aging-related comorbidities have come into focus as major challenges to their overall health. In this review, an in-depth overview of the two most commonly encountered chronic lung diseases in PLWH, chronic obstructive pulmonary disease (COPD) and lung cancer, is provided.

RECENT FINDINGS

The risk for both COPD and lung cancer remains significantly higher in PLWH compared to the HIV-uninfected population, although fortunately rates of lung cancer appear to be declining over the last two decades. Outcomes for PLWH with these conditions, though, continue to be poor with worse survival rates in comparison to the general population. PLWH still face major barriers in accessing care for these conditions, including a higher likelihood of being underdiagnosed with COPD and a lower likelihood of being referred for lung cancer screening or treatment. A lack of evidence for optimal treatment strategies for both COPD and lung cancer still hampers the care of PLWH with these conditions.

SUMMARY

COPD and lung cancer represent substantial burdens of disease in PLWH. Improved access to standard-of-care screening and treatment and greater investigation into therapeutic responses specifically in this population are recommended.

X-Linked Agammaglobulinemia Leading to Chronic Obstructive Lung Disease

X-linked agammaglobulinemia (XLA) is a rare primary immunodeficiency disorder. It occurs in around one in 200,000 live births and is caused by mutations in the Bruton Tyrosine Kinase (BTK) gene leading to B lymphocyte deficiency and increased susceptibility to infection. Infection is the most common initial clinical presentation, followed by family history and neutropenia. Even in patients with a positive family history, only 34% of patients were diagnosed before clinical symptoms arose. Over half of patients are diagnosed by two years of age. Treatment is aimed at replacing immunoglobulin using intravenous immunoglobulin (IVIG) or subcutaneous immunoglobulin (SCIG) and prophylactic antibiotics to prevent infections. Despite these therapies, patients still suffer from repetitive infections. Another significant source of morbidity in patients with XLA is a chronic lung disease. By the time of diagnosis, 62% of patients had at least one case of pneumonia. We describe the case of a patient who has developed an accelerated course of chronic obstructive pulmonary disease (COPD) secondary to pre-existing X-linked agammaglobulinemia and recurrent respiratory infections.

Lung and Plasma Metabolome in HIV-Associated Obstructive Lung Disease

BACKGROUND

HIV is a risk factor for obstructive lung disease (OLD), independent of smoking. We used mass spectrometry (MS) approaches to identify metabolomic biomarkers that inform mechanistic pathogenesis of OLD in persons with HIV (PWH).

METHODS

We obtained bronchoalveolar lavage fluid (BALF) samples from 52 PWH, in case:control (+OLD/-OLD) pairs matched on age, smoking status, and antiretroviral treatment. Four hundred nine metabolites from 8 families were measured on BALF and plasma samples using a MS-based Biocrates platform. After filtering metabolites with a high proportion of missing values and values below the level of detection, we performed univariate testing using paired t tests followed by false discovery rate corrections. We used distance-weighted discrimination (DWD) to test for an overall difference in the metabolite profile between cases and controls.

RESULTS

After filtering, there were 252 BALF metabolites for analysis from 8 metabolite families. DWD testing found that collectively, BALF metabolites differentiated cases from controls, whereas plasma metabolites did not. In BALF samples, we identified 3 metabolites that correlated with OLD at the false discovery rate of 10%; all were in the phosphatidylcholine family. We identified additional BALF metabolites when analyzing lung function as a continuous variable, and these included acylcarnitines, triglycerides, and a cholesterol ester.

CONCLUSIONS

Collectively, BALF metabolites differentiate PWH with and without OLD. These included several BALF lipid metabolites. These findings were limited to BALF and were not found in plasma from the same individuals. Phosphatidylcholine, the most common lipid component of surfactant, was the predominant lipid metabolite differentially expressed.

Prevalence of Physical Health, Mental Health, and Disability Comorbidities among Women Living with HIV in Canada

Life expectancy for people living with HIV has increased, but management of HIV is now more complex due to comorbidities. This study aimed to measure the prevalence of comorbidities among women living with HIV in Canada. We conducted a cross-sectional analysis using data from the 18-months survey (2014−2016) of the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS). Self-report of diagnosed conditions was used to measure lifetime prevalence of chronic physical conditions, current mental health conditions, and disabilities. We examined frequency of overlapping conditions and prevalence stratified by gender identity, ethnicity, and age. Among 1039 participants, 70.1% reported a physical health diagnosis, 57.4% reported a current mental health diagnosis, 19.9% reported a disability, and 47.1% reported both physical and mental health comorbidities. The most prevalent comorbidities were depression (32.3%), anxiety (29.5%), obesity (26.7%, defined as body mass index >30 kg/m2), asthma/chronic obstructive pulmonary disease (23.3%), sleep disorder (22.0%), drug addiction (21.9%), and arthritis/osteoarthritis (20.9%). These results highlight the complexity of HIV care and the important prevalence of comorbidities. Personalized health care that integrates care and prevention of all comorbidities with HIV, with attention to social determinants of health, is necessary to optimize health and well-being of women living with HIV.

Airway Aging and Methylation Disruptions in HIV-associated Chronic Obstructive Pulmonary Disease

Rationale: Age-related diseases like chronic obstructive pulmonary disease (COPD) occur at higher rates in people living with human immunodeficiency virus (PLWH) than in uninfected populations. Objectives: To identify whether accelerated aging can be observed in the airways of PLWH with COPD, manifest by a unique DNA methylation signature. Methods: Bronchial epithelial brushings from PLWH with and without COPD and HIV-uninfected adults with and without COPD (N = 76) were profiled for DNA methylation and gene expression. We evaluated global Alu and LINE-1 methylation and calculated the epigenetic age using the Horvath clock and the methylation telomere length estimator. To identify genome-wide differential DNA methylation and gene expression associated with HIV and COPD, robust linear models were used followed by an expression quantitative trait methylation (eQTM) analysis. Measurements and Main Results: Epigenetic age acceleration and shorter methylation estimates of telomere length were found in PLWH with COPD compared with PLWH without COPD and uninfected patients with and without COPD. Global hypomethylation was identified in PLWH. We identified 7,970 cytosine bases located next to a guanine base (CpG sites), 293 genes, and 9 expression quantitative trait methylation-gene pairs associated with the interaction between HIV and COPD. Actin binding LIM protein family member 3 (ABLIM3) was one of the novel candidate genes for HIV-associated COPD highlighted by our analysis. Conclusions: Methylation age acceleration is observed in the airway epithelium of PLWH with COPD, a process that may be responsible for the heightened risk of COPD in this population. Their distinct methylation profile, differing from that observed in patients with COPD alone, suggests a unique pathogenesis to HIV-associated COPD. The associations warrant further investigation to establish causality.

Chronic obstructive pulmonary disease in HIV

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.

Assessing the health status and mortality of older people over 65 with HIV

Background

Nearly half of people with HIV in the United States are 50 years or older, and this proportion is growing. Between 2012 and 2016, the largest percent increase in the prevalence rate of HIV was among people aged 65 and older, the eligibility age for Medicare coverage for individuals without a disability or other qualifying condition. Previous work suggests that older people with HIV may have higher rates of chronic conditions and develop them more rapidly than older people who do not have HIV. This study compared the health status of older people with HIV with the older US population not living with HIV by comparing: (1) mortality; (2) prevalence of certain conditions, and (3) incidence of these conditions with increasing age.

Methods and findings

We used a sample of Medicare beneficiaries aged 65 and older from the Medicare Master Beneficiary Summary File for the years 2011 to 2016, including 100% of individuals with HIV (N = 43,708), as well as a random 1% sample of individuals without diagnosed HIV (N = 1,029,518). We conducted a survival analysis using a Cox proportional hazards model to assess mortality and to determine the need to adjust for differential mortality in our analyses of the incidence of certain chronic conditions. These results showed that Medicare beneficiaries living with HIV have a significantly higher hazard of mortality compared to older people without diagnosed HIV (3.6 times the hazard). We examined the prevalence of these conditions using logistic regression analysis and found that people with HIV have a statistically significant higher odds of depression, chronic kidney disease, chronic obstructive pulmonary disease (COPD), osteoporosis, hypertension, ischemic heart disease, diabetes, chronic hepatitis, end-stage liver disease, lung cancer, and colorectal cancer. To look at the rate at which older people are diagnosed with conditions as they age, we used a Fine-Gray competing risk model and showed that for individuals without diagnosis of a given condition at age 65, the future incidence of that condition over the remaining study period was higher for people with HIV even after adjusting for differential hazard of mortality and for other demographic characteristics. Many of these results also varied by personal characteristics including Medicaid dual enrollment, sex, and race and ethnicity, as well as by condition.

Conclusions

Increasing access to care and improving health outcomes for people with HIV is a critical goal of the National HIV/AIDS Strategy 2020. It is important for clinicians and policymakers to be aware that despite significant advances in the treatment and care of people with HIV, older people with HIV have a higher odds of having multiple chronic conditions at any point in time, a higher incidence of new diagnoses of these conditions over time, and a higher hazard of mortality than Medicare beneficiaries without HIV.

Is It Feasible to Impact on Smoking Habits in HIV-Infected Patients? Mission Impossible From the STOPSHIV Project Cohort

OBJECTIVE

Assessment of the feasibility and effectiveness of a brief intervention for smoking cessation in people living with HIV (PLWH).

SETTING

Multicenter cohort prospective study involving PLWH from 10 Italian infectious disease centers.

METHODS

During routine HIV care, clinicians delivered the 5As brief intervention (Ask, Advise, Assess, Assist, Arrange) to each patient who enrolled in the study, following the European AIDS Clinical Society guidelines. At study end, participating clinicians evaluated their own adherence to intervention: "standard" if counseling was delivered in at least half of the follow-up visits, "soft" if less. The main outcome measure was smoking abstinence ≥6 months. Abstinence predictors were evaluated using a Cox-proportional hazard regression model.

RESULTS

One thousand eighty-seven PLWH-patients (age 47.9 ± 10.8, male 73.5%) were followed for a median of 23 months (interquartile range 21-25). At baseline, current smokers were 561 (51.6%). Standard intervention was performed in 4 of 10 centers and included 343 smokers; soft intervention was performed in 6 centers (218 smokers). At last visit, 35 patients in standard (10.8%) and 6 in soft intervention (2.8%) achieved self-reported tobacco abstinence ≥6 months (P = 0.0009). Overall, the 5As intervention led to 7.3% 6-month interruptions. In the multivariable analysis, significant predictors for 6-month smoking cessation were: lower Fagerström score, stage of change (preparation/contemplation vs. precontemplation), and standard intervention.

CONCLUSION

Adherence to the 5As brief intervention emerged as a critical factor for success. In fact, compared with soft intervention, the standard intervention significantly increased abstinence, highlighting that clinicians need more time and supporting tools to encourage PLWH to quit smoking.

Missed opportunities for NCD multimorbidity prevention in adolescents and youth living with HIV in urban South Africa

BACKGROUND

Epidemiological transition in high HIV-burden settings is resulting in a rise in HIV/NCD multimorbidity. The majority of NCD risk behaviours start during adolescence, making this an important target group for NCD prevention and multimorbidity prevention in adolescents with a chronic condition such as HIV. However, there is data paucity on NCD risk and prevention in adolescents with HIV in high HIV-burden settings. The aim of this study was to investigate the extent to which NCD comorbidity (prevention, diagnosis, and management) is incorporated within existing adolescent HIV primary healthcare services in Cape Town, South Africa.

METHODS

We reviewed medical records of 491 adolescents and youth living with HIV (AYLHIV) aged 10-24 years across nine primary care facilities in Cape Town from November 2018-March 2019. Folders were systematically sampled from a master list of all AYLHIV per facility and information on HIV management and care, NCDs, NCD risk and NCD-related health promotion extracted.

RESULTS

The median age was 20 years (IQR: 14-23); median age at ART initiation 18 years (IQR: 6-21) and median duration on ART 3 years (IQR: 1.1-8.9). Fifty five percent of participants had a documented comorbidity, of which 11% had an NCD diagnosis with chronic respiratory diseases (60%) and mental disorders (37%) most common. Of those with documented anthropometrics (62%), 48% were overweight or obese. Fifty nine percent of participants had a documented blood pressure, of which 27% were abnormal. Twenty-six percent had a documented health promoting intervention, 42% of which were NCD-related; ranging from alcohol or substance abuse (13%); smoking (9%); healthy weight or diet (9%) and mental health counselling (10%).

CONCLUSIONS

Our study demonstrates limited NCD screening and health promotion in AYLHIV accessing healthcare services. Where documented, our data demonstrates existing NCD comorbidity and NCD risk factors highlighting a missed opportunity for multimorbidity prevention through NCD screening and health promotion. Addressing this missed opportunity requires an integrated health system and intersectoral action on upstream NCD determinants to turn the tide on the rising NCD and multimorbidity epidemic.

Chronic lung disease in adult recurrent tuberculosis survivors in Zimbabwe: a cohort study

OBJECTIVE

To examine the prevalence and magnitude of chronic lung disease (CLD) and its association with empiric anti-tuberculosis treatment (due to lack of bacteriologic confirmation) among recurrent tuberculosis (TB) survivors in a human immunodeficiency virus (HIV) prevalent setting.

METHODS

Prospective cohort study of retreatment TB survivors in Harare, Zimbabwe. At median follow-up of 2 years post-treatment initiation, we characterized mortality, respiratory impairment, and mental health.

RESULTS

Among 175 retreatment TB survivors, 65% of whom were HIV-positive and 21% had been empirically treated, multiparameter CLD was noted at follow-up among 14% of patients (95%CI 9.0-19.7), with a six-fold increase in age-adjusted death in the first year following treatment completion. Empirically treated TB (relative risk [RR] 3.4, 95%CI 1.4-8.3) was associated with CLD, as was the number of previous anti-tuberculosis treatment courses in dose-dependent fashion (three vs. one, RR 6.2, 95%CI 1.7-22.1). Among retreatment TB survivors, 33% (95%CI 26.0-40.1) had persistent respiratory symptoms (Chronic Obstructive Pulmonary Disease Assessment Test score 10); 26% (95%CI 19.8-33.0) significant deficits in exercise capacity (median incremental shuttle walk test distance, 550 m; Q₁-Q₃ 440-730 m); 83% (95%CI 75.7-89.7) residual radiographic abnormalities on chest X-ray; 12% (95%CI 6.6-16.1%) moderate-to-severe obstruction on spirometry; and 13% (95%CI 7.6-17.5%) major depression.

CONCLUSIONS

Despite successful treatment, retreatment TB survivors retain a substantial risk of morbidity and mortality.

Incidence of chronic obstructive pulmonary disease in people with HIV in Ontario, 1996-2015: a retrospective population-based cohort study

BACKGROUND

Because of high smoking rates and HIV-related factors, people with HIV may be at high risk for chronic obstructive pulmonary disease (COPD); however, population-based estimates of the incidence of COPD among people with HIV are lacking, particularly for women. We compared the incidence of COPD among Ontario adults aged 35 years or more with and without HIV between Jan. 1, 1996, and Dec. 31, 2015.

METHODS

We conducted a population-based study using Ontario's health administrative databases. We compared the incidence of COPD between people with and without HIV using standardized incidence ratios and generalized estimating equations with a log link function.

RESULTS

We identified 1849 people with HIV and 1 168 727 HIV-negative people who were newly diagnosed with COPD between 1996 and 2015. People with HIV were younger than HIV-negative people (mean age 49.7 [standard deviation 10.4] yr v. 62.2 [standard deviation 14.8] yr; standardized difference 0.98). Rates of COPD were higher among people with HIV than among HIV-negative people (10.4 v. 9.0 cases per 1000 person-years; standardized incidence ratio 1.16, 95% confidence interval [CI] 1.10 to 1.21; adjusted rate ratio 1.34, 95% CI 1.27 to 1.41). In sex-stratified analyses, rates of COPD were higher among men with HIV (adjusted rate ratio 1.32, 95% CI 1.24 to 1.40) and women with HIV (adjusted rate ratio 1.54, 95% CI 1.37 to 1.72) than among men and women without HIV. In a sensitivity analysis, smoking explained observed differences in COPD incidence.

INTERPRETATION

People with HIV had higher rates of incident COPD than HIV-negative people. This may reflect the disproportionately higher prevalence of smoking among the former.

A pilot study to examine the acceptability and health effects of electronic cigarettes in HIV-positive smokers

INTRODUCTION

Some HIV-positive smokers report ambivalence about quitting. Switching to electronic cigarettes (ECs) may be a viable option to reduce the negative health effects for smokers who are unable or unwilling to quit smoking combustible cigarettes (CCs). This study examined the acceptability and health-related effects of ECs in HIV-positive smokers who were not seeking smoking cessation treatment.

METHODS

HIV-positive smokers (N = 19) were enrolled and followed for 12 weeks. Cartridge-based ECs were provided at baseline, and E-liquid was provided weekly for 8 weeks. At baseline, weeks 1-8, and week 12, EC and CC use, cardiopulmonary function, respiratory symptoms, and carbon monoxide (CO) levels were measured.

RESULTS

At week 8, cigarettes per day (CPD) were reduced by more than 80%, with reduction maintained at week 12 (p's < .001). Cigarette dependence scores were 40% lower at week 8 than at baseline (p <  .001). Seven (36.8%) participants reported transitioning completely from CCs to ECs. Mean CO decreased significantly from BL to week 8 (p < .05) and remained significantly lower at week 12 (p <  .001). Intention to quit increased significantly over time.

CONCLUSIONS

Switching from CCs to ECs in HIV-positive smokers who are not ready to quit smoking in the next 30 days appears to be feasible. Beneficial effects were seen, such as reduced CPD, reduced CO and CC dependence, and increased motivation to quit. ECs may be promising as a harm reduction approach among HIV-positive smokers who are unable or unwilling to quit smoking.

Predictors of smoking cessation among people living with HIV receiving routine clinical care

People living with HIV (PLWH) have a higher prevalence of smoking and are less likely to quit smoking than the general population. Few studies involving a large sample of PLWH receiving routine care have evaluated factors associated with smoking cessation. This retrospective longitudinal cohort study evaluated factors associated with smoking cessation among PLWH from 2007 to 2018. Of 1,714 PLWH smokers included in the study, 27.6% reported quitting smoking. Suppressed plasma HIV-1 RNA (<200 copies/ml) was significantly associated with an increased likelihood of smoking cessation (HR_adjusted = 1.27, 95% CI [1.03, 1.58]); whereas age/10 year increments (HR_adjusted = 0.12, 95% CI [0.04, 0.38]), greater length of care at the HIV clinic (HR_adjusted = 0.97, 95% CI [0.94, 0.99]), lack of insurance (HR_adjusted = 0.77, 95% CI [0.61, 0.99]) or having public insurance (HR_adjusted = 0.74, 95% CI [0.55, 0.97)]), current substance use (HR_adjusted = 0.66, 95% CI [0.43, 0.97]) and risk of developing alcohol use disorder (HR_adjusted = 0.60, 95% CI [0.43, 0.84]) were associated with a reduced likelihood of quitting smoking. These findings underscore the importance of early smoking cessation intervention among PLWH. In addition, targeted smoking cessation intervention strategies are needed for groups at risk for being less likely to quit, including older patients, and those with alcohol and substance use disorders.

Use of Smoking Cessation Aids in a Convenience Sample of PLHIV in a Canadian Tertiary Care Clinic

Background:

Tobacco smoking is among the most significant predictors of cardiovascular disease and lung cancer in People Living with HIV (PLHIV). Smoking rates in this population are high, necessitating more effective smoking cessation strategies. We conducted a descriptive analysis of tobacco-related clinical and sociodemographic characteristics of smokers at a tertiary care HIV clinic in Montreal and an exploratory analysis of smoking cessation methods in order to identify potential areas of improvement in the clinic’s approach to smoking cessation.

Methods:

A convenience sample of patients completed a 10-minute questionnaire on tobacco-related behaviours and outcomes. Use of smoking cessation methods was compared using McNemar’s exact test with a Bonferroni correction for multiple testing (p<0.01 considered significant).

Results:

Seventy-two PLHIV participated. Two-thirds of our total participants were interested in quitting within six months, but the use of effective cessation strategies was low, particularly for counseling and oral therapy. Overall, oral therapy (e.g. varenicline) (16.7%) and counseling for cessation (5.6%) were used less than nicotine patches (50.0%) or ‘other’ methods (50.0%), which included abstinence and nicotine gum (p<0.001).

Conclusion:

Despite a small and potentially unrepresentative sample of HIV positive tobacco smokers at our clinic, this study could help guide further research aiming to determine and address barriers to smoking cessation and access to effective smoking cessation aids in PLHIV. Future studies might consider factors that affect motivation to quit, such as co-morbid mental health and substance use disorders, or the attitudes of HIV healthcare providers.

Prevalence and predictors of airflow obstruction in an HIV tertiary care clinic in Montreal, Canada: a cross-sectional study

Objectives

The reported prevalence of chronic obstructive pulmonary disease (COPD) in people living with HIV (PLWHIV) varies widely. Our objective was to estimate the prevalence of airflow obstruction and COPD in unselected PLWHIV and identify characteristics that increase the risk of nonreversible airflow obstruction in order to guide case finding strategies for COPD.

Methods

All adults attending the Chronic Viral Illness Service were invited to participate in the study, regardless of smoking status or history of known COPD/asthma. Individuals underwent spirometric testing both before and after use of a salbutamol bronchodilator. Airflow obstruction was defined as forced expiratory volume in 1 s (FEV₁)/forced vital capacity (FVC) < 0.7 post‐bronchodilation, whereas COPD was defined as FEV₁/FVC < 0.7 post‐bronchodilation and Medical Research Council (MRC) score > 2. Multivariate logistic regression was used to evaluate risk factors associated with airflow obstruction, reported as adjusted odds ratios (aORs).

Results

Five hundred and three participants successfully completed spirometry testing. The median (Q1; Q3) age was 52 (44; 58) years. The median (Q1; Q3) CD4 count was 598 (438; 784) cells/μL and the median (Q1; Q3) nadir CD4 count was 224 (121; 351) cells/μL. There were 119 (24%) current smokers and 145 (29%) former smokers. Among those screened, 54 (11%) had airflow obstruction whereas three (1%) of the participants had COPD. Factors that were associated with airflow obstruction included a history of smoking [aOR 2.2; 95% confidence interval (CI) 1.1; 4.7], older age (aOR 1.6; 95% CI 1.2; 2.2), and lower CD4 count (aOR 0.8; 95% CI 0.7; 1.0).

Conclusions

Airflow obstruction was relatively uncommon. Our findings suggest that PLWHIV who are ≥50 years old, smokers and those with nadir CD4 counts ≤ 200 cells/μL could be targeted to undergo spirometry to diagnose chronic airflow obstruction.

Tobacco Smoking, Substance Use, and Mental Health Symptoms in People with HIV in an Urban HIV Clinic

The prevalence of tobacco smoking among people with HIV (PWH) ranges from 40% to 70%. Additionally, tobacco smoking is higher among low-income individuals, yet few studies have examined tobacco smoking in low socioeconomic status PWH. Using data from a cohort of PWH receiving care in an urban HIV clinic, we characterized factors associated with current and former smoking and with initiation/re-initiation and cessation of tobacco use. Among a study sample of 1,607 PWH, the prevalence of current smoking was 46.6% among men and 46.0% among women. Current smoking in men and women was associated with Medicaid insurance status, substance use, and panic symptoms. In women, but not men, hazardous alcohol use decreased the likelihood of quitting smoking and increased the risk of initiation/re-initiation. Smoking interventions for low-income, urban PWH may need to be tailored to address mental health and substance use comorbidities.

Association Between Health-Related Quality of Life and Physical Functioning in Antiretroviral-Naive HIV-Infected Patients

Background:

Poor functional status can significantly affect Health-Related Quality of Life (HRQoL) of HIV patients. However, there is scarce information on the functional profile of such patients before starting antiretroviral therapy (ART).

Objective:

To estimate the association between health-related quality of life and physical functioning in Antiretroviral-Naive HIV-infected patients.

Methods:

We conducted a cross-sectional study with HIV-infected patients older than 18 years, and naïve to antiretroviral therapy. The patients were evaluated for functional profile by pulmonary function (forced vital capacity, forced expiratory volume at one second, and Tiffeneau index), handgrip strength, and six-minute walk test in a cross-sectional study. HRQoL was evaluated by the 36-Item Short-Form Health Survey and its Physical (PCS) and Mental (MCS) Component Summaries. Multiple linear regression analyses were used to evaluate the association of predictor variables with PCS and MCS scores.

Results:

We found lower HRQoL among females patients, with far below average impairment of mental health component. Both male and female patients presented lower 6MWD function test values. Patients with dynapenia were older than patients without it, presented lower PCS mean score, lower family income, poor 6 MWD function test, lower FVC, and lower FEV1 t. Multivariable logistic regression analyses showed that Grip Strength, age and family income were predictor variables for Physical component of HRQoL. Female gender and smoking habit were predictive for the mental component of HRQoL.

Conclusion:

HRQoL in HIV, drug-naïve patients is predicted by level of dynapenia, smoking, income and gender. Therefore, lifestyle changes and active exercising can help to improve HRQoL in such patients.

Pulmonary disease in HIV-infected adults in the era of antiretroviral therapy

: HIV in the antiretroviral therapy era is characterized by multimorbidity and the frequent occurrence of HIV-associated non-AIDS chronic health conditions. Respiratory symptoms and chronic pulmonary diseases, including chronic obstructive pulmonary disease, asthma, and cardiopulmonary dysfunction, are among the conditions that may present in persons living with HIV. Tobacco smoking, which is disproportionately high among persons living HIV, strongly contributes to the risk of pulmonary disease. Additionally, features associated with and at times unique to HIV, including persistent inflammation, immune cell activation, oxidative stress, and dysbiosis, may also contribute. This review summarizes the available literature regarding epidemiology of and risk factors for respiratory symptoms and chronic pulmonary disease in the current era.

HIV is associated with airway obstruction: a matched controlled study

OBJECTIVE

To explore whether airway obstruction is associated with HIV in a cohort of HIV-infected and uninfected smokers.

METHODS

People living with HIV (PLWHIV) participated in the ANRS EP48 HIV CHEST study, an early lung cancer diagnosis study with low-dose chest tomography. HIV-uninfected study participants were from the CONSTANCES cohort. Inclusion criteria were an age greater than 40 years, a smoking history of at least 20 pack-years, and for PLWHIV, a CD4 T-lymphocyte nadir less than 350/μl and last CD4 cell count more than 100 cells/μl. Two randomly selected HIV-uninfected study participants were matched by age and sex with one PLWHIV. Prebronchodilatator forced expiratory volume in 1 s (FEV1) to forced vital capacity (FVC) ratio was the primary outcome, and association of FEV1/FVC ratio less than 0.70 and FEV1 less than 80% of the theoretical value, as a proxy of chronic obstructive pulmonary disease, the secondary outcome.

RESULTS

In total, 351 PLWHIV and 702 HIV-uninfected study participants were included. Median age was 50 years, and 17% of study participants were women. Plasma HIV RNA was less than 50 copies/ml in 89% of PLWHIV, with a median CD4 cell count of 573 cells/μl. HIV (β -2.19), age (per 10 years increase; β -2.81), tobacco use (per 5 pack-years increase; β -0.34), and hepatitis C virus serology (β-2.50) were negatively associated with FEV1/FVC. HIV [odds ratio (OR: 1.72)], age (per 10 years increase; OR 1.77), and tobacco use (per 5 pack-years increase; OR 1.11) were significantly associated with the secondary outcome.

CONCLUSION

Our study found a significant association of airway obstruction with HIV status in smokers aged more than 40 years with previous immunodeficiency.

Airflow limitation in people living with HIV and matched uninfected controls

Introduction

Whether HIV influences pulmonary function remains controversial. We assessed dynamic pulmonary function in people living with HIV (PLWHIV) and uninfected controls.

Methods

A total of 1098 PLWHIV from the Copenhagen Co-morbidity in HIV infection study and 12 161 age-matched and sex-matched controls from the Copenhagen General Population Study were included. Lung function was assessed using FEV1 and FVC, while airflow limitation was defined by the lower limit of normal (LLN) of FEV1/FVC and by FEV1/FVC<0.7 with FEV1predicted <80% (fixed). Logistic and linear regression models were used to determine the association between HIV and pulmonary function adjusting for potential confounders (including smoking and socioeconomic status).

Results

In predominantly white men with mean (SD) age of 50.6 (11.1) the prevalence of airflow limitation (LLN) was 10.6% (95% CI 8.9% to 12.6%) in PLWHIV and 10.6% (95% CI 10.0 to 11.1) in uninfected controls. The multivariable adjusted OR for airflow limitation defined by LLN for HIV was 0.97 (0.77–1.21, P<0.78) and 1.71 (1.34–2.16, P<0.0001) when defined by the fixed criteria. We found no evidence of interaction between HIV and cumulative smoking in these models (P interaction: 0.25 and 0.17 for LLN and fixed criteria, respectively). HIV was independently associated with 197 mL (152–242, P<0.0001) lower FEV1 and 395 mL (344–447, P<0.0001) lower FVC, and 100 cells/mm3 lower CD4 nadir was associated with 30 mL (7–52, P<0.01) lower FEV1 and 51 mL (24–78, P<0.001) lower FVC.

Conclusion

HIV is a risk factor for concurrently decreased FEV1 and FVC. This excess risk is not explained by smoking or socioeconomic status and may be mediated by prior immunodeficiency.

Trial registration number

NCT02382822.

Prevalence of chronic obstructive pulmonary disease in the global population with HIV: a systematic review and meta-analysis

BACKGROUND

In recent years, the concept has been raised that people with HIV are at risk of developing chronic obstructive pulmonary disease (COPD) because of HIV infection. However, much remains to be understood about the relationship between COPD and HIV infection. We aimed to investigate this association by assessing studies that reported the prevalence of COPD in the global population with HIV.

METHODS

In this systematic review and meta-analysis, we assessed observational studies of COPD in people with HIV. We searched PubMed, Embase, Web of Science, and Global Index Medicus, with no language restriction, to identify articles published until June 21, 2017, and we searched the reference lists of the retrieved articles. Eligible studies reported the prevalence of COPD or had enough data to compute these estimates. We excluded studies in subgroups of participants selected on the basis of the presence of COPD; studies that were limited to other specific groups or populations, such as people with other chronic respiratory diseases; and case series, letters, reviews, commentaries, editorials, and studies without primary data or an explicit description of methods. The main outcome assessed was prevalence of COPD. Each study was independently reviewed for methodological quality. We used a random-effects model to pool individual studies and assessed heterogeneity (I²) using the χ² test on Cochrane's Q statistic. This study is registered with PROSPERO, number CRD42016052639.

FINDINGS

Of 4036 studies identified, we included 30 studies (151 686 participants) from all WHO regions in the meta-analysis of COPD prevalence. 23 studies (77%) had low risk of bias, six (20%) had moderate risk of bias, and one (3%) had high risk of bias in their methodological quality. The overall prevalence of COPD was 10·5% (95% CI 6·2-15·7; I²=97·2%; six studies) according to the lower limit of normal definition of COPD, and 10·6% (6·9-15·0; 94·7%; 16 studies) according to the fixed-ratio definition. COPD prevalence was higher in Europe and among current and ever smokers, and increased with level of income and proportion of participants with detectable HIV viral load. Prevalence of COPD was significantly higher in patients with HIV than in HIV-negative controls (pooled odds ratio 1·14, 95% CI 1·05-1·25, I²=63·5%; 11 studies), even after adjustment for tobacco consumption (2·58, 1·05-6·35, 74·9%; four studies).

INTERPRETATION

Our findings suggest a high prevalence of COPD in the global population with HIV, and an association with HIV. As such, COPD deserves more attention from HIV health-care providers, researchers, policy makers, and stakeholders for improved detection, overall proper management, and efficient control of COPD in people with HIV. Efforts to address this burden should focus on promoting the decrease of tobacco consumption and adherence to highly active antiretroviral therapy to reduce viral load.

FUNDING

None.

Factors associated with pulmonary impairment in HIV-infected South African adults

Background

HIV-infected individuals have increased risk of developing obstructive lung disease (OLD). Studies from developed countries report high viral load, low CD4 counts, and anti-retroviral therapy (ART) to be associated with OLD; but these findings may not be generalizable to populations in resource-limited settings.

Methods

We conducted a prospective cohort study of lung function in 730 HIV-infected black South African adults. Pre-bronchodilator spirometry was performed at enrollment and repeated annually for three years. Logistic regression models were used to identify factors associated with OLD, defined as FEV1/FVC<0.70, at enrollment. Excess annual declines in FEV1 and FVC were modelled as the product-term of follow-up time and exposures using random effects regression.

Results

Median (IQR) age at enrollment was 36 (32–41) years, 85% were female and 30% ever-smoked with a median (IQR) exposure of 3 (1–6) pack-years. Median (IQR) CD4 count and viral load at enrollment were 372 (261–518) cells/mm³ and 2655 (91–13,548) copies/mL respectively. Overall, 25% were receiving ART at enrollment, 16% of whom reported at least 6 months of ART receipt. OLD was found in 35 (5%) at enrollment. Increasing age (aOR = 2.08 per 10-years [95%CI 1.22–3.57], p = 0.007), current smoking (aOR = 3.55 [95%CI 1.20–10.53], p = 0.02), and CRP (aOR = 1.01 per unit-increase [95%CI 1.00–1.03], p = 0.04) were significantly associated with OLD at enrollment; while increasing CD4 count (aOR = 1.02 per-100 cells/mm³ [95%CI 0.85–1.22], p = 0.82), viral load (aOR = 0.67 per log-increase [95%CI 0.43–1.10], p = 0.12) and receipt of ART (aOR = 0.57 [95%CI 0.18–1.75], p = 0.32) were not. The median (IQR) follow-up time was 18 (12–24) months. Participants with a history of tuberculosis (TB) had a 35 mL (95%CI 2–68, p = 0.03) and 57 mL (95%CI 19–96, p = 0.003) per year excess loss of FEV1 and FVC respectively.

Conclusion

Prevalent OLD was associated with older age, current smoking and higher CRP levels, but not CD4 counts and ART, in HIV-infected South African adults. Better understanding of the long-term effects of TB, smoking and inflammation on lung function in HIV-infected populations is urgently needed.

Positive smoking cessation-related interactions with HIV care providers increase the likelihood of interest in cessation among HIV-positive cigarette smokers

Smoking cessation has proven to be a challenge for HIV-positive smokers. Patient and provider characteristics may provide barriers to smoking cessation. We aimed to identify characteristics associated with interest in cessation as well as characterize use of, current interest in, and provider recommendations for smoking cessation modalities. Data came from 275 HIV-positive smokers recruited online. Half (49.1%) of the sample was interested in quitting; daily smoking was associated with decreased likelihood of interest in cessation, whereas making a lifetime quit attempt, receiving encouragement to quit from an HIV care provider, and greater frequency of discussions regarding cessation with HIV care providers were associated with increased likelihood of interest in cessation. Nicotine replacement therapy was the most commonly used (42.9%), generated the most interest (59.1%), and was the most commonly clinician-recommended (70.7%) cessation modality. Findings emphasize the importance of the healthcare provider-patient relationship for smoking cessation promotion in HIV-positive smokers.

The changing epidemiology of HIV in the criminal justice system

Although the rate of HIV infection among US prison inmates is considerably higher than that of the general population, little is known about age-related changes in HIV-infected inmates over the last decade. This study of the nation's largest state prison system examined (1) whether the mean age of the HIV-infected inmate increased over the last decade, and (2) whether the prevalence of HIV and associated comorbidities varied according to age. The study population included all 230,103 inmates incarcerated in the Texas prison system for any duration during 2014. A separate analysis was conducted on all HIV-infected inmates incarcerated between 2004 and 2014. Information on medical conditions and demographic factors was obtained from an institution-wide electronic medical record system. From 2004 to 2014, the mean age of HIV-infected inmates in the prison system increased from 39.3 to 42.5 years, compared to an increase of 36.1-37.9 for all Texas prison inmates. Multivariable logistic regression was used to assess the independent contributions of multiple demographic and clinical covariates in predicting the binary outcome, HIV infection. The model showed that, in 2014, HIV infection was elevated in inmates who were aged 40-49 years (OR = 3.1; 95% CI 2.7-3.3), aged 50-59 years (OR = 2.4; 95% CI 2.1-2.7), African American (OR = 3.0; 95% CI 2.8-3.3), and in those with several chronic diseases, including chronic obstructive pulmonary disease (OR = 1.7; 95% CI 1.5-1.9), hepatitis C (OR = 2.7; 95% CI 2.5-3.1), major depressive disorder (OR = 1.7; 95% CI 1.5-2.1), bipolar disorder (OR = 2.3; 95% CI 1.8-2.8), and schizophrenia (OR = 1.5; 95% CI 1.3-1.8). Among HIV-infected inmates (n = 2960), the percentage with comorbid disease increased in a linear fashion according to age (p < .01). Correctional health systems must adapt to address the evolving epidemiology of HIV among inmate populations.

Plasma sphingolipids in HIV-associated chronic obstructive pulmonary disease

Introduction

Chronic obstructive pulmonary disease (COPD) is a significant cause of morbidity in persons living with HIV (PLWH) and HIV appears to uniquely cause COPD, independent of smoking. The mechanisms by which HIV leads to COPD are not clear. The objective of this study was to identify metabolomic biomarkers and potential mechanistic pathways of HIV-associated COPD (HIV-COPD).

Methods

We performed case–control metabolite profiling via mass spectrometry in plasma from 38 individuals with HIV-COPD (cases), comparing to matched controls with/without HIV and with/without COPD. Untargeted metabolites of interest were identified with liquid chromatography with mass spectrometry (LC-MS/mass spectrometry (MS)), and targeted metabolomics for tryptophan (Trp) and kynurenine (Kyn) were measured by selective reaction monitoring (SRM) with LC-MS/MS. We used mixed-effects models to compare metabolite concentrations in cases compared with controls while controlling for relevant biological variables.

Results

We identified 1689 analytes associated with HIV-COPD at a false discovery rate (FDR) of 10%. In PLWH, we identified 263 analytes (10% FDR) between those with and without COPD. LC MS/MS identified Trp and 17 lipids, including sphingolipids and diacylglycerol. After adjusting for relevant covariates, the Kyn/Trp ratio measured by SRM was significantly higher in PLWH (p=0.022), but was not associated with COPD status (p=0.95).

Conclusions

There is a unique metabolite profile in HIV-COPD that includes sphingolipids. Trp metabolism is increased in HIV, but does not appear to independently contribute to HIV-COPD.

Trial registration numbers

NCT01810289, NCT01797367, NCT00608764.

Respiratory health status is impaired in UK HIV-positive adults with virologically suppressed HIV infection

OBJECTIVES

We sought to evaluate whether people living with HIV (PLWH) using effective antiretroviral therapy (ART) have worse respiratory health status than similar HIV-negative individuals.

METHODS

We recruited 197 HIV-positive and 93 HIV-negative adults from HIV and sexual health clinics. They completed a questionnaire regarding risk factors for respiratory illness. Respiratory health status was assessed using the St George's Respiratory Questionnaire (SGRQ) and the Medical Research Council (MRC) breathlessness scale. Subjects underwent spirometry without bronchodilation.

RESULTS

PLWH had worse respiratory health status: the median SGRQ Total score was 12 [interquartile range (IQR) 6-25] in HIV-positive subjects vs. 6 (IQR 2-14) in HIV-negative subjects (P < 0.001); breathlessness was common in the HIV-positive group, where 47% compared with 24% had an MRC breathlessness score ≥ 2 (P = 0.001). Eighteen (11%) HIV-positive and seven (9%) HIV-negative participants had airflow obstruction. In multivariable analyses (adjusted for age, gender, smoking, body mass index and depression), HIV infection remained associated with higher SGRQ and MRC scores, with an adjusted fold-change in SGRQ Total score of 1.54 [95% confidence interval (CI) 1.14-2.09; P = 0.005] and adjusted odds ratio of having an MRC score of ≥ 2 of 2.45 (95% CI 1.15-5.20; P = 0.02). Similar findings were obtained when analyses were repeated including only HIV-positive participants with a viral load < 40 HIV-1 RNA copies/mL.

CONCLUSIONS

Despite effective ART, impaired respiratory health appears more common in HIV-positive adults, and has a significant impact on health-related quality of life.

Non-infectious pulmonary disorders in HIV

INTRODUCTION

Since the advent of antiretroviral therapy (ART), non-infectious pulmonary disorders have become common comorbidities in the human immunodeficiency virus (HIV) positive population. Clinicians caring for those with HIV disease should be aware of the prevalence of non-infectious pulmonary disorders. A comprehensive understanding is required to diagnosis and manage these syndromes appropriately. Areas covered: This review focuses on the epidemiology, risk factors, pathogenesis, clinical feature and diagnosis, and treatment of HIV-related chronic obstructive pulmonary disease (COPD), lung cancer, pulmonary hypertension. Expert Commentary: The prevalence of COPD in the HIV population is frequent and requires appropriate diagnosis and treatment. HIV-positive individuals with lung cancer carry a poorer prognosis and require early diagnosis and treatment. A complex condition exists with pulmonary hypertension in the HIV population and requires a high degree of clinical suspicion for early diagnosis.

COPD in HIV-Infected Patients: CD4 Cell Count Highly Correlated

BACKGROUND

COPD is a frequent and significant cause of respiratory morbidity in HIV-infected patients despite the control of HIV. We aimed to analyze the factors correlated with COPD in this population to evaluate the existence of specific indicators of vulnerability in this population.

METHODS AND FINDINGS

623 HIV-infected outpatients were enrolled during one year. This population was characterised by a dedicated questionnaire and electronic patient records. COPD screening was performed according to recommended spirometric criteria. The prevalence of COPD was 9.0%. Age and smoking were independently correlated with COPD (OR, 1.61 per 10 years increase, P = 0.007; OR, 1.28 per 10 pack-year increase, P = 0.003, respectively). Body mass index (BMI) and CD4 cell-count were independently and negatively correlated with COPD (OR, 0.78, P < 0.001; 0R, 0.77 per 100 cell/mm3 increase, P < 0.001, respectively). Among COPD patients, 77% did not know their diagnosis. Five COPD-patients never smoked and 44.2% did not have any respiratory symptoms and so were not eligible to perform a spirometry according to the guidelines.

CONCLUSIONS

In addition to known risk factors, immune defect through CD4 cell count was independently and strongly correlated with COPD. COPD is largely underdiagnosed and thus unmanaged. However, early management and urgent smoking cessation are essential to improve prognosis. Clinicians' awareness on the particular vulnerability for COPD in HIV-infected patients is crucial. Moreover, indications to perform conventional spirometry to diagnose COPD may include more parameters than tobacco-smoking and respiratory complaints with a particular concern toward patients with a profound CD4 cell count defect.

Trends in Epidemiology of COPD in HIV-Infected Patients in Spain (1997-2012)

Purpose

The aim of this study was to estimate trends of incidence of hospital admissions and in-hospital mortality (IHM) in HIV-infected patients with COPD in the combination antiretroviral therapy (cART) era in Spain (1997–2012).

Methods

A retrospective study with data from nationwide population-based COPD diagnoses in the Spanish Minimum Basic Data Set (MBDS) was performed. We established groups according to their HIV and HCV infections: 1) HIV-uninfected patients; 2) HIV-infected patients (with or without HCV coinfection).

Results

1,580,207 patients discharge with a COPD diagnosis were included in the study, 8902 of them were HIV-infected patients (5000 HIV-monoinfected patients and 3902 HIV/HCV-coinfected patients). The HIV-infected patients had higher incidence rates of hospital admissions for COPD than the HIV-uninfected patients during the study period. The HIV-monoinfected patients had higher rates of hospitalizations for COPD than the HIV/HCV-coinfected patients in the early-period cART (1997–1999), but these rates decreased in the first group and increased in the second, being even similar in both groups in the late-period cART (2004–2011). On the other hand, the HIV-infected patients with COPD had higher IHM than the HIV-uninfected patients with COPD. The mortality rates were higher in the HIV-monoinfected patients with COPD than in the HIV/HCV-coinfected patients with COPD in the early-period cART; however, in the late-period cART, the mortality rates trends seems higher in the HIV/HCV group. The likelihood of death in HIV/HCV-coinfected patients with COPD was similar to than in HIV-monoinfected patients with COPD.

Conclusions

Incidence of hospital admissions for COPD and IHM have decreased among HIV-monoinfected individuals but have increased steadily among HIV/HCV-coinfected individuals in the cART era.

Respiratory symptoms in people living with HIV and the effect of antiretroviral therapy: a systematic review and meta-analysis

Background

Antiretroviral therapy (ART) has significantly altered the pattern of acute and chronic HIV-related disease. However, it is not clear what this means in terms of respiratory symptoms. We sought to investigate the association between HIV status and respiratory symptoms and how these have changed with the availability of ART.

Methods

We searched Cochrane, Medline and Embase databases for studies published between 1946 and August 2015 comparing the prevalence of respiratory symptoms in populations with and without HIV infection. We undertook random effects meta-analysis of the main symptoms reported. We studied heterogeneity and completed sensitivity analyses and funnel plots.

Results

From 5788 unique references identified, 24 papers provided relevant data: 18 documented the prevalence of cough and 11 examined the prevalence of breathlessness among other symptoms reported. Compared with the HIV negative, people living with HIV (PLWH) were more likely to have respiratory symptoms with pooled ORs for the prevalence of cough of 3.05 (95% CI 2.24 to 4.16) in resource-limited populations without access to ART; 2.18 (1.56 to 3.18) in resource-rich populations without access to ART and 1.11 (0.99 to 1.24) in resource-rich populations with access to ART. In resource-rich settings, although the availability of ART was associated with a reduction in the difference between HIV-positive and HIV-negative individuals, PLWH were more likely to report breathlessness, OR 1.39 (95% CI 1.11 to 1.73).

Conclusions

Respiratory symptoms are more common in PLWH than controls. This association persists although at a reduced level in populations with access to ART.

Pulmonary effects of immediate versus deferred antiretroviral therapy in HIV-positive individuals: a nested substudy within the multicentre, international, randomised, controlled Strategic Timing of Antiretroviral Treatment (START) trial

BACKGROUND

Observational data have been conflicted regarding the potential role of HIV antiretroviral therapy (ART) as a causative factor for, or protective factor against, COPD. We therefore aimed to investigate the effect of immediate versus deferred ART on decline in lung function in HIV-positive individuals.

METHODS

We did a nested substudy within the randomised, controlled Strategic Timing of Antiretroviral Treatment (START) trial at 80 sites in multiple settings in 20 high-income and low-to-middle-income countries. Participants were HIV-1 infected individuals aged at least 25 years, naive to ART, with CD4 T-cell counts of more than 500 per μL, not receiving treatment for asthma, and without recent respiratory infections (baseline COPD was not an exclusion criterion). Participants were randomly assigned to receive ART (an approved drug combination derived from US Department of Health and Human Services guidelines) either immediately, or deferred until CD4 T-cell counts decreased to 350 per μL or AIDS developed. The randomisation was determined by participation in the parent START study, and was not specific to the substudy. Because of the nature of our study, site investigators and participants were not masked to the treatment group assignment; however, the assessors who reviewed the outcomes were masked to the treatment group. The primary outcome was the annual rate of decline in lung function, expressed as the FEV₁ slope in mL/year; spirometry was done annually during follow-up for up to 5 years. We analysed data on an intention-to-treat basis, and planned separate analyses in smokers and non-smokers because of the known effects of smoking on FEV₁ decline. The substudy was registered at ClinicalTrials.gov number NCT01797367.

FINDINGS

Between March 11, 2010, and Aug 23, 2013, we enrolled 1026 participants to our substudy, who were then randomly assigned to either immediate (n=518) or deferred (n=508) ART. Median baseline characteristics included age 36 years (IQR 30-44), CD4 T-cell count 648 per μL (583-767), and HIV plasma viral load 4·2 log₁₀ copies per mL (3·5-4·7). 29% were female and 28% were current smokers. Median follow-up time was 2·0 years (IQR 1·9-3·0). We noted no differences in FEV₁ slopes between the immediate and deferred ART groups either in smokers (difference of -3·3 mL/year, 95% CI -38·8 to 32·2; p=0·86) or in non-smokers (difference of -5·6 mL/year, -29·4 to 18·3; p=0·65) or in pooled analyses adjusted for smoking status at each study visit (difference of -5·2 mL/year, -25·1 to 14·6; p=0·61).

INTERPRETATION

The timing of ART initiation has no major short-term effect on rate of lung function decline in HIV-positive individuals who are naive to ART, with CD4 T-cell counts of more than 500 per μL. In light of updated WHO recommendations that all HIV-positive individuals should be treated with ART, regardless of their CD4 T-cell count, our results suggest an absence of significant pulmonary harm with such an approach.

FUNDING

US National Heart Lung and Blood Institute, US National Institute of Allergy and Infectious Diseases, Division of AIDS, Agence Nationale de Recherches sur le SIDA et les Hipatites Virales (France), Australian National Health and Medical Research Council, Danish National Research Foundation, European AIDS Treatment Network, German Ministry of Education and Research, UK Medical Research Council and National Institute for Health Research, and US Veterans Health Administration Office of Research and Development.

Maintaining lung health with longstanding HIV

PURPOSE OF REVIEW

Human immunodeficiency virus (HIV) is now managed as a chronic disease. Non-infectious pulmonary conditions have replaced infection as the biggest threat to lung health, particularly as HIV cohorts age, but there is no consensus on how best to maintain long-term lung health. We review the epidemiology and pathogenesis of chronic obstructive pulmonary disease (COPD), pulmonary arterial hypertension (PAH), and lung cancer in HIV-seropositive individuals.

RECENT FINDINGS

Diagnoses of COPD are now up to 50% more prevalent in HIV-seropositive individuals than HIV-uninfected controls, and prospective pulmonary function studies find significant impairment in 7% to more than 50% of HIV-seropositive individuals. The prevalence of HIV-PAH is 0.2-0.5%, and lung cancer is two to three times more prevalent in HIV-seropositive individuals. Although host factors such as age and smoking have a role, HIV is an independent contributor to the pathogenesis of COPD, PAH, and lung cancer. Chronic inflammation, immune senescence, oxidative stress, and direct effects of viral proteins are all potential pathogenetic mechanisms. Despite their prevalence, non-infectious lung diseases remain underrecognized and evidence for effective screening strategies in HIV-seropositive individuals is limited.

SUMMARY

COPD, PAH, and lung cancer are a growing threat to lung health in the highly active antiretroviral therapy era necessitating early recognition.

HIV Infection Is Associated with Shortened Telomere Length in Ugandans with Suspected Tuberculosis

Introduction

HIV infection is a risk factor for opportunistic pneumonias such as tuberculosis (TB) and for age-associated health complications. Short telomeres, markers of biological aging, are also associated with an increased risk of age-associated diseases and mortality. Our goals were to use a single cohort of HIV-infected and HIV-uninfected individuals hospitalized with pneumonia to assess whether shortened telomere length was associated with HIV infection, TB diagnosis, and 2-month mortality.

Methods

This was a sub-study of the IHOP Study, a prospective observational study. Participants consisted of 184 adults admitted to Mulago Hospital in Kampala, Uganda who underwent evaluation for suspected TB and were followed for 2 months. Standardized questionnaires were administered to collect demographic and clinical data. PBMCs were isolated and analyzed using quantitative PCR to determine telomere length. The association between HIV infection, demographic and clinical characteristics, and telomere length was assessed, as were the associations between telomere length, TB diagnosis and 2-month mortality. Variables with a P≤0.2 in bivariate analysis were included in multivariate models.

Results

No significant demographic or clinical differences were observed between the HIV-infected and HIV-uninfected subjects. Older age (P<0.0001), male gender (P = 0.04), total pack-years smoked (P<0.001), alcohol consumption in the past year (P = 0.12), and asthma (P = 0.08) were all associated (P≤0.2) with shorter telomere length in bivariate analysis. In multivariate analysis adjusting for these five variables, HIV-positive participants had significantly shorter telomeres than HIV-negative participants (β = -0.0621, 95% CI -0.113 to -0.011, P = 0.02). Shortened telomeres were not associated with TB or short-term mortality.

Conclusions

The association between HIV infection and shorter telomeres suggests that HIV may play a role in cellular senescence and biological aging and that shorter telomeres may be involved in age-associated health complications seen in this population. The findings indicate a need to further research the impact of HIV on aging.

Tobacco Use, Use Disorders, and Smoking Cessation Interventions in Persons Living With HIV

Cigarette smoking remains highly prevalent among persons living with human immunodeficiency virus (HIV), estimated to be 40-75 %, and is significantly higher than what is observed among the general population. Health risks of smoking in this population include cardiovascular disease; bacterial pneumonia, chronic obstructive pulmonary disease, and other respiratory conditions; lung cancer and other malignancies; adverse cognitive and neurological outcomes; low birth weight, preterm birth, and small-for-gestational-age infants; and overall mortality. Smokers with HIV now lose more life years to smoking than they do to the HIV itself. A majority of smokers living with HIV report being interested in cessation, and a significant proportion has made recent quit attempts. There is a general paucity of large, randomized controlled trials of smoking cessation interventions among smokers living with HIV, and among the existing research, cessation rates are suboptimal. Greater resources and effort should be allocated to developing and evaluating cessation treatment modalities for smokers living with HIV. Efforts to individualize and tailor treatments to address specific client needs and comorbidities are warranted. HIV care providers and other health professionals can play a key role in improving health among this population by regularly screening for smoking and promoting cessation.

Risk Factors Associated With Quantitative Evidence of Lung Emphysema and Fibrosis in an HIV-Infected Cohort

INTRODUCTION

The disease spectrum for HIV-infected individuals has shifted toward comorbid non-AIDS conditions including chronic lung disease, but quantitative image analysis of lung disease has not been performed.

OBJECTIVES

To quantify the prevalence of structural changes of the lung indicating emphysema or fibrosis on radiographic examination.

METHODS

A cross-sectional analysis of 510 HIV-infected participants in the multicenter Lung-HIV study was performed. Data collected included demographics, biological markers of HIV, pulmonary function testing, and chest computed tomographic examinations. Emphysema and fibrosis-like changes were quantified on computed tomographic images based on threshold approaches.

RESULTS

In our cohort, 69% was on antiretroviral therapy, 13% had a current CD4 cell count less than 200 cells per microliter, 39% had an HIV viral load greater than 500 copies per milliliter, and 25% had at least a trace level of emphysema (defined as >2.5% of voxels <-950HU). Trace emphysema was significantly correlated with age, smoking, and pulmonary function. Neither current CD4 cell count nor HIV viral load was significantly correlated with emphysema. Fibrosis-like changes were detected in 29% of the participants and were significantly correlated with HIV viral load (Pearson correlation coefficient = 0.210; P < 0.05); current CD4 cell count was not associated with fibrosis. In multivariable analyses including age, race, and smoking status, HIV viral load remained significantly correlated with fibrosis-like changes (coefficient = 0.107; P = 0.03).

CONCLUSIONS

A higher HIV viral load was significantly associated with fibrosis-like changes, possibly indicating early interstitial lung disease, but emphysematous changes were not related to current CD4 cell count or HIV viral load.

Chronic obstructive pulmonary disease and HIV: are we appropriately screening?

Individuals with human immunodeficiency virus (HIV) represent a population that is at a higher risk of developing chronic obstructive pulmonary disease (COPD). In this study, we sought to determine the effects of smoking on respiratory symptoms and diseases among HIV-positive patients and to determine if symptomatic patients are being appropriately screened for COPD. HIV-positive individuals completed a self-administered questionnaire. The effects of smoking on respiratory symptoms and diseases were reported as odds ratios (ORs). The COPD screening criteria were adapted from the Canadian Thoracic Society (CTS) guidelines. Two hundred and forty-seven participants were recruited. The median age was 49 years; 75% were male and 92% were on highly active antiretroviral therapy. Smokers represented 66% of the population. Smoking had a statistically significant effect on respiratory symptoms including wheeze (OR 4.8 [95% confidence interval (CI) 1.6-14.2]), phlegm production (OR 4.9 [95% CI: 2.2-10.5]), cough (OR 7.0 [95% CI: 3.0-16.2]), and dyspnea (OR 7.2 [95% CI: 1.7-31.2]). Smoking had a higher odds of respiratory diseases including COPD (OR 4.9 [95% CI: 1.1-21.9]) and bronchitis (OR 3.8 [95% CI: 1.9-7.7]). Among HIV-positive smokers, 40% met the CTS screening criteria, while only 12% self-reported a diagnosis of COPD. The burden of smoking in the HIV population is significant. HIV-positive smokers are more likely to report both respiratory symptoms and diseases than HIV-positive non-smokers. A discrepancy exists between patients who met the CTS screening criteria and those who were diagnosed with COPD, raising the concern for under-recognition and under-diagnosis of COPD in this population.

Non-cigarette tobacco and poly-tobacco use among persons living with HIV drawn from a nationally representative sample

INTRODUCTION

Smoking is more prevalent among persons living with HIV (PLWH) than the general population. Little is known about the prevalence of non-cigarette tobacco and poly-tobacco use (PTU; using multiple tobacco products) among this population, which, in the general population is associated with poor health and cessation outcomes. We aimed to characterize the prevalence of cigarette and non-cigarette tobacco use, PTU, and correlates of tobacco use status among a nationally-representative sample of PLWH.

METHODS

Data came from 472 HIV-positive adults from the 2005-2013 National Survey on Drug Use and Health (NSDUH).

RESULTS

The prevalence of PTU overall was 8.7% (95% CI=5.6-13.2), and 16.6% (95% CI=10.2-25.7) among past-year tobacco users. In multinomial logistic regression analyses, participants with a high school education or greater (aRRR=2.03, 95% CI=1.03-4.00) were more likely to be non-tobacco users than single product users. Past year drug users (aRRR=0.35, 95% CI=0.19-0.66) and past month binge drinkers (aRRR=0.24, 95% CI=0.12-0.50) were less likely to be non-tobacco users than single product users. Compared to 18-25 year olds, individuals age 26-34 (aRRR=0.13, 95% CI=0.03-0.65) and 35+ (aRRR=0.24, 95% CI=0.09-0.63), and with lifetime anxiety disorder(s) (aRRR=0.18, 95% CI=0.06-0.57) were less likely to be PTUs as compared to single product users. Individuals who reported liking to test themselves by doing risky things were more likely to be PTUs than single product users (aRRR=2.95, 95% CI=1.27-6.84).

CONCLUSIONS

PTU was slightly higher than in the general population, and should be taken into account when developing cessation interventions tailored to tobacco users living with HIV.

Obstructive Lung Diseases in HIV: A Clinical Review and Identification of Key Future Research Needs

HIV infection has shifted from what was once a disease directly impacting short-term mortality to what is now a chronic illness controllable in the era of effective combination antiretroviral therapy (ART). In this setting, life expectancy for HIV-infected individual is nearly comparable to that of individuals without HIV. Subsequent to this increase in life expectancy, there has been recognition of increased multimorbidity among HIV-infected persons, with prevalence of comorbid chronic illnesses now approaching 65%. Obstructive lung diseases, including chronic obstructive pulmonary disease (COPD) and asthma, are prevalent conditions associated with substantial morbidity and mortality in the United States. There is overlap in risk factors for HIV acquisition and chronic lung diseases, including lower socioeconomic status and the use of tobacco and illicit drugs. Objectives of this review are to (1) summarize the current state of knowledge regarding COPD and asthma among HIV-infected persons, (2) highlight implications for clinicians caring for patients with these combined comorbidities, and (3) identify key research initiatives to reduce the burden of obstructive lung diseases among HIV-infected persons.

Risk factors associated with acute exacerbation of chronic obstructive pulmonary disease in HIV-infected and uninfected patients

OBJECTIVE

To determine the association between HIV infection and other risk factors for acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

DESIGN

Longitudinal, national Veterans Aging Cohort Study including 43 618 HIV-infected and 86 492 uninfected veterans.

METHODS

AECOPD was defined as an inpatient or outpatient COPD ICD-9 diagnosis accompanied by steroid and/or antibiotic prescription within 5 days. We calculated incidence rate ratios (IRR) and 95% confidence intervals (CI) for first AECOPD over 2 years and used Poisson regression models to adjust for risk factors.

RESULTS

Over 234 099 person-years of follow-up, 1428 HIV-infected and 2104 uninfected patients had at least one AECOPD. HIV-infected patients had an increased rate of AECOPD compared with uninfected (18.8 vs. 13.3 per 1000 person-years, P < 0.001). In adjusted models, AECOPD risk was greater in HIV-infected individuals overall (IRR 1.54; 95% CI 1.44-1.65), particularly in those with more severe immune suppression when stratified by CD4 cell count (cells/μl) compared with uninfected (HIV-infected CD4 < 200: IRR 2.30, 95% CI 2.10-2.53, HIV-infected CD4 ≥ 200-349: IRR 1.32, 95% CI 1.15-1.51, HIV-infected CD4 ≥ 350: IRR 0.99, 95% CI 0.88-1.10). HIV infection also modified the association between current smoking and alcohol-related diagnoses with risk for AECOPD such that interaction terms for HIV and current smoking or HIV and alcohol-related diagnoses were each significantly associated with AECOPD.

CONCLUSION

HIV infection, especially with lower CD4 cell count, is an independent risk factor for AECOPD. Enhanced susceptibility to harm from current smoking or unhealthy alcohol use in HIV-infected patients may also contribute to the greater rate of AECOPD.