In reply to: ''Executive summary of the GeSIDA consensus document on control and monitoring of HIV-infected patients''

Dear Editor,

We have carefully read the letter sent to EIMC [Enfermedades Infecciosas y Microbiología Clínica (Infectious Diseases and Clinical Microbiology)]¹ regarding the "Executive summary of the GeSIDA consensus document on control and monitoring of HIV-infected patients" drafted by the AIDS study group (GeSIDA) of Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC) [Spanish Society of Infectious Diseases and Clinical Microbiology].² We believe the authors are correct in pointing to chronic obstructive pulmonary disease (COPD) as a relevant comorbidity in patients infected with the human immunodeficiency virus (HIV).

As the authors note, COPD is a frequent comorbidity both in the general population and in HIV-infected patients. The prevalence of COPD in Spain is estimated at 9.1% in the general population, predominating in men,³ with a progressive increase in incidence. According to the estimates of the World Health Organization (WHO), by 2030, COPD will be the cause of 7.9% of all deaths (the third cause after cancer and cardiovascular disease).⁴

Previous studies indicate a higher incidence of COPD in HIV-infected patients.⁵ In the Strategic Timing of AntiRetroviral Treatment (START) clinical trial, pulmonary function tests were carried out systematically. The general prevalence of COPD, using the FEV ₁/FVC < 0.7 ratio as an indicator in the spirometry test, after bronchodilation, was 5.5%, with smoking being the best predictor of COPD. The prevalence of COPD in the group of active smokers was 12%.⁶

However, tobacco exposure is not the only cause of COPD in HIV-infected patients. Although its pathogenesis is not clear, low levels of CD4⁺ lymphocytes or the presence of detectable viral load have been associated with an increased risk of COPD.⁷ In addition, the history of pneumonia due to Pneumocystis jirovecii (PCP) seems to be associated with irreversible deterioration of the FEV₁/FVC⁸ ratio. Likewise, colonisation by PCP seems to be associated with worse lung function, regardless of smoking.⁹

Furthermore, one Spanish study analysed hospitalisations in the public health system and compared COPD patients who were and were not infected with HIV, finding a higher inpatient mortality in those who were infected. Furthermore, contrary to what was observed in patients not infected with HIV, mortality of HIV-infected COPD patients has increased in recent years.⁵

For all these reasons, we share the authors' point of view and consider it necessary to include COPD as a relevant comorbidity in the next update of the "Documento de consenso de GeSIDA sobre el control y la monitorización de la infección por el VIH" [GeSIDA Consensus Document on Control and Monitoring of HIV Infection]

Meanwhile, it seems reasonable to follow the recommendations of the international guidelines. The Global Initiative for Chronic Obstructive Lung Disease (GOLD)¹⁰ recommends performing a spirometriy test in any patient with dyspnoea, chronic cough, sputum production, recurrent respiratory tract infections or exposure to toxins associated with the development of COPD (mainly tobacco). Likewise, the European AIDS Society¹¹ recommends COPD screening using spirometry in HIV-infected patients older than 40 years, who have smoked more than 10 pack-years in their life and who present with respiratory symptoms: dyspnoea when walking, cough or sputum production. The presence of an FEV₁/FVC < 0.70 ratio, indicates persistent airflow limitation.⁹

Finally, we must promote the cessation of smoking in our patients, reporting its risks, identifying those patients who wish to give up, and offering support to those who request it through support groups, pharmacological treatment and assessment in specific departments.