No physician in the past 20 years is likely to have escaped the impact of HIV/AIDS infection forward the practice of medicine.

No physician in the past 20 years is likely to have escaped the impact of HIV/AIDS infection forward the practice of medicine. As we record the third decade of the AIDS epidemic, the human toll is staggering. As of June 2001 almost 800000 patients in the United States have discloseed AIDS. Over half of these have died, the overwhelming majority in a less degree than age 45. (1) Over 900000 folks are estimated to be living with HIV infection. (2) Worldwide, the statistics are smooth more sobering. As of December 2001 there were more than 40 million the public infected with HIV, most living in sub-Saharan Africa and Asia. across 22 million people have died, including 3 million in 2001 alone. (2) In parts of southern Africa, the prevalence of HIV infection in pregnant women go too fars 30%. HIV/AIDS has reduced life expectancy through one third in several sub-Saharan African countries, and it is now the fourth leading cause of death worldwide. Cases continue to accumulate, with an estimated 5 million of recent origin infections in 2001. (2)

The pulmonary complications of HIV infection are well documented and diverse, and they constitute a major cause of morbidity and mortality. (3-5) Infection with HIV causes predictable immunologic changes in the lung In addition to the los of CD4+ T confined apartments a lymphocytic alveolitis with CD8+ T small rooms activation of pulmonary macrophages, and increased production of cytokines can all be seen leading to progressive impairment in the two cell-mediated and humoral immunity, (3) Respiratory complaints are of frequent occurrence in patients who are HIV-positive. (56) Spirometry, while typically normal in asymptomatic individuals, is affected by way of both bacterial pneumonia and opportunistic infection with Pneumocystis carinii. Permanent reductions in FE[Vsub1] FVC FE[Vsub1]/FVC and diffusing capacity for carbon monoxide have been noted following incidences of pneumonia (7) as well as dysfunction of small airways (8) and an increased prevalence of bronchial hyperresponsiveness. (6) The clinical implications vary with the standing of immunosuppression, ranging from an increased incidence of bronchitis and sinusitis, with CD4 deems above 500/[micro]L, to P carinii pneumonia (PCP) and Kaposi sarcoma, with CD (4) casts below 200/[micro]L. (5)

Advances in our understanding of the immunologic impact of HIV forward disease progression have led to improved care and incremental increases in survival. Prophylaxis for opportunistic infections, corticosteroids for P carinii pneumonia, and the growth of antiretroviral therapies provided a certain quantity of initial successes in the battle against HIV/AIDS. The general era of antiretroviral therapy began in late 1995 with the introduction of highly active antiretroviral therapy (HAART). HAART, defined as a combination therapy with put drugs into regimens including protease inhibitors, nucleoside reverse-transcriptase inhibitors, and/or nonnucleoside reverse-transcriptase inhibitors, has had a significant impact forward viral load, C[D.sup.4+] cell cast and HIV-related mortality. Studies in the pair adult (9) and pediatric populations (10) report 75% and 67% reductions, respectively, in the risk of death with HAART. Similar reductions in the incidence of the pair community-acquired pneumonia (11) and opportunistic infections, including Mycobacterium tuberculosis, cytomegalovirus, and PCP have all been lately reported with HAART. (9,12,13)

In this issue of CHEST (see page 878) Taggart and coworkers add to our understanding of the impact of HAART upon pulmonary disease in HIV infected individuals. In a retrospective review of their experience using bronchoscopy in the treatment of patients positive for HIV and presenting with respiratory symptoms, Taggart et al confirmed what principally of us in centers with large HIV--positive populations have noted in our clinical practices--bronchoscopies for HIV-related pulmonary disease have dropp precipitously since the institution of HAART. In their reflection despite progressive increases in patients who were followed in-clinic, the rates of bronchoscopy malignant slightly, from 13% at the start of the research in 1989 to 10% in the early 1990 when rates stabilized. With the introduction of HAART in 1996 the rates savage again to 4%. This very little does not appear to be to be paid to changes in practice patterns. The indications for bronchoscopy remained largely unchanged above the time period, with > 85% of conducts done to rule out opportunistic infection, and there was little change in diagnostic yield post-HAART. This decline mirrors those reported through Balfe and Mohsenifar (14) in sees Angeles, and by Murri et al (15) in Rome who noted 59% and 69% declines, respectively, in HIV-related bronchoscopies in their respective institutions across similar time periods.

Translating these issues to most centers in the United States would likely issue in even fewer procedures, as the authors had a fairly gentle threshold for bronchoscopy. Almost the same third of patients undergoing the conduct had normal chest radiographs. The author's institution also used bronchoscopy and BAL as its principal means for diagnosing PCP still the greatest in number commonly diagnosed opportunistic infection, smooth with HAART. This is unlike many center in North America, which have increasingly relied forward induced sputum with monoclonal antibody staining and now PCR technologies to diagnose PCP (16) unruffled further reductions in bronchoscopies could potentially have occurr with the use of other testing, in the same state [i]or[/i] condition as high-resolution CT for symptomatic patients with normal chest radiographs (17) or diagnostic algorithms employing measurements of the diffusing capacity of the lung for carbon monoxide. (18)

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