In the absence of specific guidelines on management of COPD in HIV patients, clinicians should follow the management guidelines proposed for the general population. Management of COPD is driven by symptoms and history of exacerbations, rather than the severity of airflow limitation or FEV1% predicted (31). There are a number of symptom assessment tools available for use including the Medical Research Council (MRC) Dyspnoea score, COPD Control Questionnaire (CCQ) or COPD Assessment Test (CAT) (35). Smoking cessation should be prioritised for all patients with HIV, and specifically those with COPD to prevent further progression of disease (31). All patients with COPD should receive the recommended pneumococcal vaccines and yearly recombinant influenza vaccine as per the Australian Immunisation Guideline (36).
Pharmacotherapy for symptomatic COPD includes inhaled bronchodilators or in those with regular symptoms long-acting bronchodilators (31). When choosing an agent, drug interactions with antiretroviral agents needs to be considered. Long-acting muscarinic antagonists (LAMA’s), eg. tiotropium do not have known drug-drug interactions with antiretrovirals and are often be used as a first-line bronchodilator therapy in patients with HIV and COPD. An inhaled long-acting beta-agonist (LABA) is an alternative, although there can be some drug-drug interaction with some agents such as salmeterol. If symptoms persist on monotherapy, a combination of LAMA and LABA may be used. Inhaled corticosteroids (ICS) are reserved for patients who develop exacerbation of COPD, though drug-drug interaction, particularly with protease inhibitor such as ritonavir can be problematic. Careful monitoring is also required as high-dose ICS are associated with increased risk of oral candidiasis, bacterial pneumonia,(37) and tuberculosis (38) The regular use of systemic steroids for COPD in people with HIV should preferably be avoided.
COPD is associated with poor physical function in patients with HIV (39). Participation in pulmonary rehabilitation programme should be encouraged in patients with HIV and COPD. Pulmonary rehabilitation programs have shown to improve physical functioning in all patients with COPD, and the gains are largest in those who are symptomatic and have more severe disease (31).
COPD is often associated with several comorbidities such as cardiovascular disease, muscle wasting, osteoporosis, depression/anxiety and lung cancer that will need to be managed or screened for appropriately. Many of these conditions occur in patients with HIV irrespective of their COPD status Notably, many of these conditions also occur with increased frequency in PLWH. As survival of patients is improved with anti-retroviral therapy, COPD is likely to complicate the care and to adversely impact health-related quality of life, functional status, and mortality in an increasing proportion of patients with HIV (40).