Pulmonary Complications of HIV Infection in the Era of Antiretroviral Therapy
The following is an abstract of the above lecture to be given at the Presidential Symposium on Wednesday 22nd November 2006 by:
Mark J. Rosen
President-Elect, American College of Chest Physicians
Chief, Divisions of Pulmonary, Critical Care and Sleep Medicine, North Shore Health System, New York, USA
Professor of Medicine, Albert Einstein College of Medicine, New York, USA
The AIDS epidemic is one of the most important global health problems of the last century. In developed nations, the rates of opportunistic infections and death in persons with AIDS have declined dramatically since 1995 because of advances in the treatment of human immunodeficiency virus (HIV), and there is hope that AIDS may not be uniformly fatal. Nevertheless, even in developed nations thousands are infected with HIV each year, and in many communities, AIDS-related diseases are still the leading causes of death among young adults. Despite the apparent success of highly active antiretroviral therapy, its cost makes it unavailable to millions around the world. The lung is a frequent site of opportunistic infection in immunocompromised patients, and noninfectious pulmonary disorders associated with HIV infection and antiretroviral treatments are increasingly common.
Pneumonia caused by P jiroveci (formerly classified as P carinii) was the first opportunistic infection described in AIDS, and has always been a major cause of illness and death. The term "PCP" has been used for decades, and rather than changing our terminology to "PJP" to reflect the new nomenclature, there is a consensus that PCP be used to refer to Pneumocystis pneumonia. Once thought to be a parasite, genomic analysis revealed that P jiroveci is in fact a fungus that infects only humans while P. carinii is pathogenic only in immunodeficient rats.
Although Pneumocystis pneumonia is still a common cause of opportunistic infection, its incidence has declined rapidly since 1995, while other disorders are increasingly common. The incidence of pulmonary hypertension similar to idiopathic pulmonary arterial hypertension in HIV-negative persons is increasing, perhaps related to co-infection with HHV-8. The immune reconstitution syndrome occurs when antiretroviral therapy leads to an increase in the number and activity of blood CD4+ lymphocytes, causing inflammation and clinical illness that may have been otherwise clinically silent "Paradoxical worsening" of tuberculosis and Pneumocystis have been described in patients who develop deteriorating clinical status after apparent successful treatment of these infections, followed by antiretroviral therapy. HIV infection also seems to predispose to the development of COPD and lung cancer. In recent years, HIV-infected persons are more likely to die of complications of hepatitis C, end-stage liver disease and sepsis than of opportunistic infection.
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