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At the beginning of the AIDS epidemic it was clear that the lung of HIV infected patients was the major target for many infections and tumours.1 2 However, during the first decade of the disease it was shown that the occurrence of several infections might be prevented by the use of prophylaxis, which has a direct but temporary effect,3 and more recently the use of highly active antiretroviral therapy (HAART) has been shown to have an indirect (immune restoration) but long lasting effect.4-7 Thus, in a changing world, today we have three different situations.
First situation: HIV infected patients without access to prophylaxis for pulmonary infections and antiretroviral treatment
Unfortunately, this situation applies to the great majority of HIV infected patients in developing countries and, in developed countries, to those without knowledge of their HIV seropositivity or without appropriate follow up.
In this situation the natural history of HIV associated lung disorders is obviously the same as it was at the beginning of the AIDS epidemic. The range of pathogens possibly responsible for respiratory diseases is very wide with a high frequency of acute bronchitis, bacterial pneumonia, Pneumocystis carinii pneumonia (PCP), and tuberculosis.1 8 Similarly, the variety of non-infectious causes of respiratory disease is also very broad2 with Kaposi's sarcoma, lymphoid interstitial pneumonitis and, to a lesser degree, lymphoma, emphysema,9and primary pulmonary hypertension10. In contrast, a link between HIV infection and lung cancer,11 pulmonary embolism, or bronchial hyperreactivity still remains questionable. New clinical entities such as cytomegalovirus induced alveolar haemorrhage,12 primary pulmonary lymphoma,13and rapidly worsening airway obstruction associated with bronchiectasis14 have recently been reported in HIV infected patients.
The incidence and prevalence of each of these respiratory disorders are strongly related to two factors. The first is the level of immunosuppression—the relative risks for bacterial pneumonia, tuberculosis, PCP, or fungal infections …
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