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Respiratory Disease May Be Underdiagnosed in Men With HIV
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19th Conference on Retroviruses and Opportunistic Infections, March 5-8, 2012, Seattle
Mark Mascolini
Although respiratory symptoms and diagnoses were more common in HIV-positive men than HIV-negative men in the Multicenter AIDS Cohort Study (MACS), men with HIV did not undergo respiratory testing more often than men without HIV [1]. Those findings led MACS investigators to suggest that respiratory disease may be underdiagnosed in this population. The study also found that HIV-positive men taking combination antiretroviral therapy (ART) had a higher prevalence of respiratory symptoms than untreated HIV-positive men.
MACS is an ongoing prospective study of US men who have sex with men (MSM) with HIV and at risk of HIV infection. This cross-sectional analysis of 1896 HIV-positive and negative men included all cohort members who had a study visit in 2008. Participants completed a pulmonary-specific questionnaire, and MACS workers recorded each man's smoking status and cumulative pack-years among smokers.
Of the 1896 men who completed the questionnaire, 907 were HIV-positive and 989 HIV-negative. Average age was younger in the HIV group (49.2 versus 52.3 years, P < 0.001), and men with HIV had a significantly lower average body mass index (25.6 versus 27.2 kg/m(2), P < 0.001). The HIV group included a larger proportion of African Americans (32.8% versus 18.7%, P < 0.001) and Hispanics (10.8% versus 7.3%, P = 0.007).
Men with HIV included a higher proportion of current smokers (31.1% versus 22.8%), a lower proportion of former smokers (44.1% versus 50.9%), and a similar proportion of never-smokers (24.8% versus 26.3%). A higher proportion of men with HIV ever injected drugs (16% versus 8.9%, P < 0.001) and ever used cocaine (57.3% versus 43.2%, P < 0.001). Significantly more men with HIV ever had bacterial pneumonia (12% versus 4.3%, P < 0.001). Most men with HIV (78.4%) took combination ART; HIV-positive men had an average CD4 count of 572 and an average viral load of 40 copies.
Matthew Gingo (University of Pittsburgh) and MACS colleagues reported that current smokers had a higher prevalence dyspnea, cough, phlegm, and wheezing than former or never-smokers regardless of HIV status. In multivariate analysis, current smokers had a 33% higher risk of reporting any symptoms compared with former smokers (OR 1.33, 95% CI 1.08 to 1.63, P = 0.006). HIV infection independently raised the risk of dyspnea 43% (OR 1.43, 95% CI 1.06 to 1.94, P = 0.02) and nonsignificantly raised the risk of cough 20% (OR 1.20, 95% CI 0.97 to 1.47, P = 0.09).
Every additional 10 pack-years of smoking raised the risk of any respiratory symptom 15% (OR 1.15, 95% CI 1.08 to 1.23, P < 0.001). Every 3 units higher body mass index upped the symptom risk 16% (OR 1.16, 95% CI 1.09 to 1.23, P < 0.001).
Although men with HIV were younger and had a lower body mass index than men without HIV, they had a 66% higher risk of obstructive sleep apnea than men without HIV (OR 1.66, 95% CI 1.19 to 2.31, P = 0.003). Higher body mass index (OR 1.59 per 3 units, 95% CI 1.45 to 1.74, P < 0.001) and every 5 years of age (OR 1.3, 95% CI 1.19 to 1.43, P < 0.001) also independently raised the risk of obstructive sleep apnea.
Men with HIV were no more likely than HIV-negative men to report asthma or chronic obstructive pulmonary disease, but possibly because they did not undergo pulmonary function testing more than men without HIV (OR 1.1, 95% CI 0.89 to 1.34, P = 0.38).
Analyses restricted to HIV-positive men determined that those taking ART were significantly more likely to report cough (P = 0.01) or any respiratory symptom (P = 0.03) than men not on ART. The MACS investigators noted that those findings are consistent with earlier work documenting increased airflow obstruction among HIV-positive people taking ART than not taking ART [2]. Current CD4 count, nadir CD4 count, and viral load were not associated with respiratory symptoms or diagnoses in the MACS study.
"Although HIV-positive participants reported more symptoms," the MACS team concluded, "typical testing methods for evaluation of chronic respiratory complaints such as pulmonary function tests and echocardiograms were not more frequent" in men with HIV. As a result, they suggested that "respiratory disease may be underdiagnosed in this population."
Recently published research in a Baltimore cohort of current and former injection drug users found that obstructive lung disease is "substantially underrecognized" in this population and is associated with lack of respiratory symptoms [2]. The researchers warned clinicians that relying on respiratory symptoms to signal the need for spirometry in this population may result in underdiagnosis.
References
1. Gingo M, Balasubramani G, Kingsley L, et al. HIV infection and prevalence of pulmonary disease: Multicenter AIDS Cohort Study. 19th Conference on Retroviruses and Opportunistic Infections. March 5-8, 2012. Seattle. Abstract 818. http://www.retroconference.org/2012b/PDFs/818.pdf.
2. Drummond MB, Kirk GD, Astemborski J, et al. Prevalence and risk factors for unrecognized obstructive lung disease among urban drug users. Int J Chron Obstruct Pulmon Dis. 2011;6:89-95. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048084/?tool=pubmed
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