We read with great interest the “Executive summary of the GeSIDA consensus document on control and monitoring of HIV-infected patients” of the AIDS Study Group (GeSIDA) of the Spanish Society of Infectious Diseases and Clinical Microbiology.1 It is a magnificent summary on the main topics related with the control and monitoring of patients infected with the human immunodeficiency virus (HIV) and their continuous follow up, providing clear and useful recommendations.
As stated in this consensus, due to the increasing knowledge regarding HIV medicine, treatment and comorbidities, there is a growing complexity in assessing people living with HIV (PLWH), with a necessary demand for highly specialized units. Although we recognize the difficulties of a comprehensive evaluation of these patients, we miss in this consensus a specific mention of chronic obstructive pulmonary disease (COPD) in PLWH.
Different reviews have described COPD in PLWH, showing an increasing prevalence of COPD in PLWH compared to general population as it happens with other comorbidities.2 Smoking is the major predictor of COPD appearance 3 and smoking habit is increased in PLWH.2 Nevertheless, the relation between COPD and HIV is not limited to tobacco exposure, as exposure to HIV is a predisposing factor for COPD independently from tobacco consumption.4 The prevalence of COPD in PLWH can be higher than 10%,4 making it a medical condition that implies a considerate burden in quality of life and mortality.5 However, COPD in PLWH seems to be largely undiagnosed.6
Even though the underlying pathogenesis of COPD in PLWH is not entirely clear, it seems that immune variations such as a low CD4 cell count, a low CD4 nadir, or low CD4/CD8 ratio, that contribute to accelerated aging and are associated with the risk of cardiovascular, renal or neurological comorbidities, are also involved in COPD development.7 Decline of respiratory function seems to be higher in PLWH than in HIV negative individuals.8 Both lower CD4 cell counts and higher HIV viral load were associated with an accelerated decline of respiratory function (FEV1 and FVC).2,8 Additionally, PLHW suffering from COPD, compared to those without such comorbidity, present a higher number of hospitalizations for a respiratory-related condition, a higher incidence of community-acquired bacterial pneumonia,7 and higher mortality rates.9
On the light of the evidence described, we believe that COPD prevention, diagnosis and treatment in PLWH deserves a more relevant position. We suggest to follow the European AIDS Clinical Society Guidelines regarding chronic lung disease screening in PLWH.10 These guidelines identify risk patients to be screened as those having three conditions: (1) being 40 years or older, (2) an accumulated smoking history of 10 pack years, and (3) to present in a regular basis respiratory symptoms such as shortness of breath, productive or non-productive cough and wheezing. Patients with these three conditions should be assessed with spirometry with bronchodilation study and CO diffusion capacity test, in order to acknowledge the presence and reversibility of airflow limitations. Furthermore, inquiry regarding tobacco consumption is fundamental for the implementation of risk reduction policies and information about the health benefits of smoking cessation should be provided and encouraged.1,10
In conclusion, we believe that, in addition to other comorbidities, COPD is an important condition for PLWH with relevant implications on life expectancy and quality of life. Unfortunately, it is largely underdiagnosed in PLWH, which might reflect a lack of awareness of its relevance in this population. We believe that the importance of COPD diagnosis and prevention in PLWH should be underlined and that future consensus should include COPD evaluation in their recommendations, as physicians’ awareness on its prevention and diagnosis would improve the care we provide to PLWH.
