Brown, James; (2019) Understanding respiratory illness in an HIV positive population with a high uptake of antiretroviral therapy. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

The availability of effective antiretroviral therapy (ART) means that HIV infection is now a manageable chronic condition. However, although AIDS-related conditions are now rare in people living with HIV (PLWH) using ART, this population may be at greater risk of some non-AIDS conditions (such as cardiovascular disease) than the general population. The respiratory health of PLWH using ART has been less well explored. This thesis provides novel insights into respiratory illness among PLWH in a population with a high uptake of antiretroviral therapy. I have summarised existing evidence in a narrative literature review of respiratory illness in PLWH and systematic review of studies comparing respiratory symptoms in people with and without HIV. I have evaluated the prevalence of respiratory illness and carriage of respiratory bacterial and viral pathogens in cross-sectional data. I used molecular microbiology techniques to explore the carriage of pathogenic respiratory bacteria in PLWH. I have completed a 12-month prospective study of a cohort of HIV positive and negative participants to determine the frequency of acute respiratory illness and factors associated with illness incidence and severity in this population. I found that respiratory symptoms are more common among HIV positive than negative people despite ART and that this difference is only partly explained by established risk factors such as tobacco smoking. In the population studied, the frequency of objective respiratory impairment as measured by spirometry was lower than that reported in many other HIV positive populations. I found no difference in the frequency of acute respiratory illnesses between HIV positive and negative individuals, however PLWH reported more severe symptoms and were more likely to seek healthcare when these illnesses occurred. In collaboration with colleagues, I have assessed interventions to improve or maintain respiratory health among PLWH. We evaluated the uptake of influenza immunisation and referral to smoking cessation services and identified barriers to these cost-effective interventions. In summary, PLWH remain at greater risk of respiratory illness than the general population despite ART. In part this is due to greater exposure to known risk factors such as tobacco smoking, but even after adjustment for these, an independent effect of HIV status remains. We need a better understanding of the causes of this and interventions to improve the respiratory health of this population.

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