Screening for Chronic Obstructive Pulmonary Disease (COPD) in an Urban HIV Clinic: A Pilot Study

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.

Pathogenesis and management of emphysema in people with HIV

INTRODUCTION

Since early in the HIV epidemic, emphysema has been identified among people with HIV (PWH) and has been associated with increased mortality. Smoking cessation is key to risk reduction. Health maintenance for PWH and emphysema should ensure appropriate vaccination and lung cancer screening. Treatment should adhere to inhaler guidelines for the general population, but inhaled corticosteroid (ICS) should be used with caution. Frontiers in treatment include targeted therapeutics. Major knowledge gaps exist in the epidemiology of and optimal care for PWH and emphysema, particularly in low and middle-income countries (LMIC).

AREAS COVERED

Topics addressed include risk factors, pathogenesis, current treatment and prevention strategies, and frontiers in research.

EXPERT OPINION

There are limited data on the epidemiology of emphysema in LMIC, where more than 90% of deaths from COPD occur and where the morbidity of HIV is most heavily concentrated. The population of PWH is aging, and age-related co-morbidities such as emphysema will only increase in salience. Over the next 5 years, the authors anticipate novel trials of targeted therapy for emphysema specific to PWH, and we anticipate a growing body of evidence to inform optimal clinical care for lung health among PWH in LMIC.

Screening for impaired pulmonary function using peak expiratory flow: Performance of different interpretation strategies

BACKGROUND

Spirometry is the gold standard for diagnosis of impaired pulmonary function, but is often unavailable in resource-constrained settings. Some authors have suggested using peak expiratory flow (PEF) to screen for impaired pulmonary function when spirometry is unavailable, but with no consensus on how to define abnormally low PEF. Strategies have included cutoffs based on absolute value of PEF, PEF in percent predicted, PEF Z-score, PEF × height^-2, and gender-specific cutoffs of absolute PEF. The objective of this paper is to determine the PEF interpretation strategy with the highest predictive ability for low pulmonary function, with spirometry as the gold standard.

METHODS

We analyzed data on individuals aged 40-79 years in the United States National Health and Nutrition Examination Survey 2007-2012. 6,144 individuals fulfilled inclusion criteria for the main analysis. For each PEF interpretation strategy, we calculated the area under the receiver operating curve (AUC) for the detection of low pulmonary function (defined by FEV₁ Z-score < -1.645, < -2, < -2.5 or < -3).

RESULTS

The AUC was substantially and statistically significantly higher for PEF in percent predicted and PEF Z-score than for absolute value and PEF × height^-2, including after stratification by gender. There was no difference in AUC between PEF in percent predicted and PEF Z-score.

CONCLUSION

If using PEF to screen adults aged 40 years or older for impaired pulmonary function defined by low FEV₁ Z-score, basing cutoffs on PEF in percent predicted or PEF Z-score may result in improved predictive ability. As percent predicted is a mathematically simpler term than Z-score, it may be preferable to use cutoffs based on PEF in percent predicted.

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.

Most Early-Treated Children With Perinatally Acquired HIV Have Preserved Lung Function at School Age

BACKGROUND

Impaired lung function is common among older children with perinatally acquired HIV (PHIV) who initiated antiretroviral therapy (ART) late in childhood. We determined the prevalence of abnormal spirometry and cofactors for impaired lung function among school-age children with PHIV who initiated ART when aged 12 months or younger.

SETTING

Children who received early ART in the Optimizing Pediatric HIV-1 Therapy study in Kenya and underwent spirometry at school age.

METHODS

Forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) were measured. Abnormal spirometry was defined as follows: obstructive (FEV1/FVC <1.64 z score [zFEV1/FVC]) and restricted (zFVC <1.64 with zFEV1/FVC ≥1.64). Characteristics, including anthropometric and HIV-related data, were ascertained in infancy and at school age. Caregiver carbon monoxide exposure served as a proxy for school-age child exposure. Linear regression determined associations of cofactors with lung function.

RESULTS

Among 40 children, the median age was 5 months at ART initiation and 8.5 years at spirometry. The mean zFEV1, zFVC, and zFEV1/FVC (SD) were 0.21 (1.35), 0.31 (1.22), and -0.24 (0.82), respectively. Five (13%) children had abnormal spirometry. Spirometry z scores were significantly lower among children with pre-ART pneumonia, WHO HIV stage 3/4, higher HIV RNA at 6 months after ART initiation, low anthropometric z scores, and higher carbon monoxide exposure.

CONCLUSIONS

Most of the children with PHIV who initiated ART at age 12 months or younger had normal spirometry, suggesting that ART in infancy preserved lung function. However, 13% had abnormal spirometry despite early ART. Modifiable factors were associated with impaired lung function, providing potential targets for interventions to prevent chronic lung disease.

Diagnostic accuracy of screening tools for chronic obstructive pulmonary disease in primary health care: Rapid evidence synthesis

Background:

Chronic obstructive pulmonary disease (COPD) contributed significantly to burden of diseases in India, with missed, incorrect, and delayed diagnosis in primary care. We conducted a rapid evidence synthesis, to summarize the evidence on accuracy of the screening tests for COPD in primary health care on request form State Health Resource Centre, Chhattisgarh.

Methods:

Considering the rapid nature of decision making, our approach was to first search for existing systematic reviews. We identified one existing systematic review on the topic with the search conducted until 2014. We updated the review by searching in two major databases screened, title/abstracts, and full texts of studies as per eligibility criteria and extracted relevant data. A narrative synthesis was conducted.

Results:

We retrieved 7,007 and included five new studies, to add to 10 studies of the existing systematic review. Overall, 13 studies assessed diagnostic accuracy of screening questionnaires [e.g., COPD Diagnostic Questionnaire (CDQ)], five assessed handheld flow meters (COPD6 and PICO-6), and four assessed the combination of both the tests. The CDQ questionnaire using a score threshold ≥16.5 or >17 demonstrated comparatively a higher sensitivity both in pooled result for ever-smokers [87.5% (95% CI 83.1--90.9%)] and among the adults >35 years [73.8--93% (95% CI 69--98%)] when compared to a different score threshold of CDQ and other questionnaires. Handheld flow meters reported a pooled high sensitivity of 79.9% (95% CI 74.2--84.7%) in ever-smokers and 87.9% in adults with age >35 years.

Conclusions:

The need for better diagnosis of COPD in primary healthcare can be addressed by using of COPD Diagnostic Questionnaire alone or in combination with hand-held flow meters. There is scope for more implementation research on the domain.

Diagnosis and Management of HIV-Associated Pulmonary Diseases in a Ryan White-Funded Primary Care Setting

Despite widespread use of antiretroviral therapy (ART), people with HIV (PWH) continue to suffer substantial morbidity and mortality from pulmonary diseases. We sought to evaluate the prevalence of pulmonary symptoms, evaluations, and diagnoses (both infectious and noninfectious) among PWH receiving care at one of the largest HIV clinics in the United States. All PWH seen at the Infectious Disease Program in Atlanta, Georgia, from July 2013 to June 2018 were included. Multivariable logistic regression was used to assess the odds of all-cause mortality. Among 8387 patients, median age was 48 years, 35% had documented smoking, 74% were male, and the 47% with ≥1 pulmonary symptom or diagnosis were older and had higher rates of smoking compared to those without any symptoms or diagnoses (p-values <0.0001). Percent on ART was 97% and 81% for individuals with and without symptoms or diagnoses, respectively (p-value <0.0001). Patients with an infectious diagnosis were more likely to have a diagnostic test ordered than those with a noninfectious diagnosis (p-value <0.0001). After adjustment for demographic and clinical risk factors, odds of death were 2.1 times greater [95% confidence interval (CI) = 1.3-3.5] among those with a pulmonary symptom or diagnosis compared to those without. Despite a high prevalence of pulmonary symptoms and diagnoses in this large cohort of PWH, many did not have a complete diagnostic evaluation, particularly those with noninfectious diagnoses. Greater awareness of evaluation and treatment of noninfectious pulmonary diseases among HIV care providers will be critical to improving long-term outcomes for PWH.

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.

Lung function in men with and without HIV

OBJECTIVES

Initial studies suggest HIV-positive persons may be at increased risk for chronic lung diseases such as chronic obstructive pulmonary disease, but have commonly relied on single-center designs, lacked HIV-negative controls, or assessed lung function with only spirometry. We tested differences in spirometry and single-breath diffusing capacity for carbon monoxide (DLCO) in persons with and without HIV.

DESIGN

Cross-sectional, observational study.

METHODS

Participants were enrolled from the Multicenter AIDS Cohort Study, a longitudinal cohort study of men who have sex with men (both HIV-positive and HIV-negative) at four sites in the United States. Standardized spirometry and DLCO testing were performed in all eligible, consenting participants at routine study visits. We tested associations between HIV status and spirometry and DLCO results, using linear and logistic regression.

RESULTS

Among 1067 men, median age was 57 years, prevalence of current marijuana (30%), and cigarette (24%) use was high, and another 45% were former cigarette smokers. Median forced expiratory volume in 1 s was 97% of predicted normal and DLCO was 85% of predicted normal. HIV-positive persons demonstrated no statistical difference in forced expiratory volume in 1 s compared with HIV-negative persons, but had worse DLCO (adjusted difference -2.6% of predicted; 95% confidence interval: -4.7 to -0.6%) and a higher risk of DLCO impairment (odds ratio for DLCO < 60% of predicted 2.97; 95% confidence interval: 1.36-6.47). Lower DLCO was associated with lower nadir CD4 cell counts.

CONCLUSION

HIV-positive men are at increased risk of abnormal gas exchange, indicated by low DLCO, compared with men without HIV.

Significant chronic airway abnormalities in never-smoking HIV-infected patients

OBJECTIVES

The aim of the study was to describe chronic lung disease in HIV-infected never-smokers by looking at clinical, structural and functional abnormalities.

METHODS

This comparative cross-sectional study included 159 HIV-infected never-smoking patients [mean (± standard deviation) age 54.6 ± 9.1 years; 13.2% female; 98.1% with undetectable viral load] and 75 nonmatched never-smoking controls [mean (± standard deviation) age 52.6 ± 6.9 years; 46.7% female]. We examined calcium scoring computer tomography (CT) scans or chest CT scans, all with a lung-dedicated algorithm reconstruction, to assess emphysema and airway disease (respiratory bronchiolitis and/or bronchial wall thickening), tested pulmonary function using spirometry, lung volumes and the diffusion lung capacity of carbon monoxide (DLCO), and assessed respiratory symptoms using the Chronic Obstructive Pulmonary Disease (COPD) Assessment Test (CAT).

RESULTS

Twenty-five (17.2%) of the HIV-infected patients versus two (2.7%) of the controls had a CAT score > 10. Only 5% of the HIV-infected patients showed FEV1% < 80%, and 25% had DLCO < 75% of the predicted value. Based on the CT scans, they had increased prevalences, compared with the controls, of airway disease (37% versus 7.9%, respectively) and emphysema (18% versus 4%, respectively), with more severe and more frequent centrilobular disease. After correction for age, sex and clinical factors, HIV infection was significantly associated with CAT > 10 [odds ratio (OR) 7.7], emphysema (OR 4), airway disease (OR 4.5) and DLCO < 75% of predicted (OR 4).

CONCLUSIONS

Although comparisons were limited by the different enrolment methods used for HIV-infected patients and controls, the results suggest that never-smoking HIV-infected patients may present with chronic lung damage characterized by CT evidence of airway disease. A minority of them showed respiratory symptoms, without significant functional abnormalities.

Associations between baseline biomarkers and lung function in HIV-positive individuals

OBJECTIVE

The aim of this study was to analyse the association of baseline biomarker data with cross-sectional lung function and subsequent decline in lung function in HIV-positive persons.

DESIGN

Lung function was modelled in all START pulmonary substudy participants who had baseline biomarker data and good-quality spirometry. In longitudinal analyses, we restricted to those participants with at least one good-quality follow-up spirometry test.

METHODS

We performed linear regression of baseline forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and FEV1/FVC and their longitudinal slopes on log2-transformed baseline biomarkers with adjustment for age, sex, race, region, smoking status, baseline CD4+ T-cell counts and baseline HIV-RNA. Biomarkers included D-dimer, high-sensitivity C-reactive protein (hsCRP), interleukin (IL)-6, IL-27, serum amyloid A, soluble intercellular adhesion molecule (sICAM)-1, soluble vascular cell adhesion molecule (sVCAM)-1, albumin and total bilirubin.

RESULTS

Among 903 included participants, baseline median age was 36 years, CD4+ cell count was 647 cells/μl, and 28.5% were current smokers. In adjusted analyses, elevated markers of systemic inflammation (hsCRP, IL-6 and serum amyloid A) were associated with lower baseline FEV1 and FVC. Elevated D-dimer and IL-6 were associated with worse airflow obstruction (lower FEV1/FVC). Despite these cross-sectional associations at baseline, no associations were found between baseline biomarkers and subsequent longitudinal lung function decline over a median follow-up time of 3.9 years (3293 spirometry-years of follow-up).

CONCLUSION

Commonly available biomarkers, in particular markers of systemic inflammation, are associated with worse cross-sectional lung function, but do not associate with subsequent lung function decline among HIV-positive persons with early HIV infection and baseline CD4 T-cell counts more than 500 cells/μl.

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.

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.

Trends and Correlates of Cigarette Smoking and Its Impacts on Health-Related Quality of Life Among People Living with HIV: Findings from the Ontario HIV Treatment Network Cohort Study, 2008-2014

We sought to examine the trends of cigarette smoking, identify correlates of smoking, and examine the impacts of smoking on health-related quality of life (HRQOL) among people living with HIV in Ontario, Canada. Study sample included 4473 individuals receiving care and enrolled in the Ontario HIV Treatment Network Cohort Study. Self-report data on cigarette smoking, HRQOL, and demographic and sociobehavioral variables were collected between 2008 and 2014 through annual face-to-face interviews. Clinical data were abstracted from participants' medical records and enhanced through linkage with a provincial public health laboratory database. Analyses included descriptive statistics, generalized logit regression, and linear mixed-effects modeling. At first interview, 1760 participants (39.3%) were current cigarette smokers. Smoking prevalence declined annually by 1.6% between 2008 and 2014, but remained much higher than the prevalence in the general population. Current cigarette smokers were more likely to be younger, male, white or indigenous, Canadian-born, single, unemployed with lower education, heavy drinkers, nonmedicinal drug users, and to have current depression than former cigarette smokers or those who never smoked. Current cigarette smokers also had significantly (p < 0.001) worse SF-12 physical component summary (β = -2.07) and SF-12 mental component summary (β = -1.08) scores than those who never smoked after adjusting for demographic, socioeconomic, and HIV-related clinical variables. To reduce the burden of cigarette smoking, cessation interventions that take into account the complex social, economic, and medical needs of people living with HIV are needed urgently.

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.

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.

Implementation of a COPD Screening Questionnaire in an Outpatient HIV Clinic

Human immunodeficiency virus (HIV) is associated with increased risk for chronic obstructive pulmonary disease (COPD); yet substantial under-recognition of COPD exists. We administered a patient-completed, physician-reviewed COPD screening tool in an outpatient HIV clinic to determine whether screening is feasible or possible. Patients attending nonacute, routine HIV care visits were provided a brief COPD screening tool, which included three questions focused on age, respiratory symptoms, and smoking history. Providers were given completed forms for review and ordered spirometry at their discretion. Forms and medical records were subsequently reviewed to determine completion and results of spirometry testing. Of the 1,510 patients screened during the study period, 968 (64%) forms were completed. After excluding 79 incomplete forms, 889 (92%) unique patient forms were included in this analysis. Among these, 204 (23%) met criteria for spirometry referral, among whom physicians ordered spirometry in 64 (31%). At 6 months following study completion, 19 (30%) of the patients referred for spirometry had the test completed, with 5 (26%) demonstrating airflow obstruction. Nearly one out of four HIV patients met indication for screening spirometry and roughly one out of four undergoing spirometry had COPD. Critical drop-offs in the screening and diagnostic process occurred at questionnaire completion and spirometry ordering. Interventions tailored to these critical steps could improve the yield from COPD screening and help to optimize the identification of COPD in high-risk HIV-infected populations. COPD screening in a clinic focused on longitudinal HIV care can effectively identify COPD among those completing the screening continuum.