The conjunction of small airway disease with parenchymal destruction (emphysema) results in airway obstruction and possibly chronic obstructive pulmonary disease (COPD). Prevalence of this condition in the HIV-infected population is high, partly related to a high prevalence of predisposing conditions, such as smoking [1–3] and history of lung infections [4–7]. Some studies have also found an association between HIV-related factors and COPD, including plasma HIV RNA more than 200 000 copies/ml , use of antiretroviral therapy , and lower lymphocyte CD4+ cell counts .
Studies have shown higher prevalence of COPD in comparison to HIV-unexposed study participants [9–11]. However, in these studies, COPD diagnosis was based on ICD codes or self-report [9,10], smoking data were sometimes incomplete , and HIV was not always associated with COPD after adjusting for confounders . Thus, we  compared the prevalence of airway obstruction in an all smoking HIV-infected cohort (exposed group) with an all smoking age and sex-matched HIV-uninfected population, and  explored whether HIV was independently associated with airway obstruction after adjusting for multiple confounders using spirometry to measure airway obstruction.
HIV-infected study participants participating in the ANRS EP48 HIV CHEST study, a pilot study of early lung cancer diagnosis with low-dose chest tomography in a HIV-infected population with a heavy smoking history  (N° ID-RCB: 2010-A00781–38, clinical trials number NCT01207986). Inclusion criteria were an age of 40 years or more, having a smoking history of at least 20 pack-years, a CD4+ T-lymphocyte nadir cell count less than 350/μl, and a last CD4+ T-cell count more than 100 cells/μl. Study participants were included if they were active smokers, or had quitted in the 3 years prior to inclusion. Study participants were excluded if they had active cancer or an AIDS classifying disease, a history of lung infection in the last 2 months, were pregnant, breastfeeding, or had a contraindication to thoracic surgery.
HIV-unexposed study participants participated in the CONSTANCES cohort, a randomly selected population-based epidemiological cohort of 200 000 adults aged between 18 and 69 (http://www.constances.fr/index_EN.php). Study participants from the CONSTANCES cohort were aged 40 years or older and smoked more than 20 pack-years, possibly stopped in the 3 years prior to inclusion. Age (5 years categories) and sex-matched study participants were randomly selected to reach a matching ratio of 2 : 1 with the HIV cohort.
Procedures, variables, and outcomes
Spirometry was systematically offered to all volunteers in both cohorts. In the CONSTANCES cohort, only prebronchodilator measures of forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) were performed. Predicted FEV1 was calculated using the Official Statement of the European Respiratory Society (ERS) Standardization of Lung Function Tests equations. , as predicted for the nonsmoking Caucasian population.
The GOLD criteria (http://goldcopd.org/gold-2017-global-strategy-diagnosis-management-prevention-copd/) or the ERS Society Standardization of Lung Function Tests equation of normal FEV1/FVC ratio  could not be used as an outcome because of lack of postbronchodilator measurements of FEV1 and FVC in the CONSTANCES cohort. We used the FEV1 to the FVC ratio as the primary outcome, and the FEV1/FVC ratio less than 0.70 and FEV1 value less than 80% of the theoretical value  as a proxy measure of moderate to severe COPD for a secondary outcome, as previously published [15,16]. Linear regression models explored the association of the FEV1/FVC ratio with HIV status, age, sex, BMI, smoking (in pack-years), active or past smoking status, cannabis inhalation, and hepatitis C virus (HCV) status. Logistic regression models were used to evaluate the association of the secondary outcome with the same factors.
In total, 352 people living with HIV (PLWH) had undertaken spirometry satisfying quality criteria. As all study participants were aged less than 70 years in the CONSTANCES cohort, the one study participants over 70 years of age in the ANRS EP48 study was excluded from analysis. In the CONSTANCES cohort, 1666 study participants satisfied our inclusion criteria and had valid spirometric measures, and we randomly matched 702 study participants to 351 PLWH (Table 1).
The FEV1/FVC ratio mean value was 0.77 in the CONSTANCES cohort (SD 0.08), versus 0.72 (SD 0.10) in the HIV-infected cohort (P < 0.0001). Airway obstruction, our secondary outcome (prebronchodilator FEV1/FVC ratio <0.70 and FEV1 value <80% of the theoretical value ), was diagnosed in 60 (9%) of the HIV-uninfected study participants, versus 68 (19%) of PLWH (P < 0.0001). In linear regression models with FEV1/FVC as outcome (Table 2), we found that HIV was strongly associated with lower FEV1/FVC values in univariate analysis [β −4.65; 95% CI (−5.77; −3.53)]. In multivariate analysis, we found that HIV [β−2.19; 95% CI (−3.52; −0.87)], age [per 10 years increase; β −2.81; 95% CI (−3.72; −1.90)], tobacco use [per 5 pack-years increase; β −0.34; 95% CI (−0.58; −0.09)], and HCV [β −2.50; 95% CI (−4.33; −0.67)] were negatively associated with FEV1/FVC, whereas being a woman [β 1.57; 95% CI (0.17; 2.98)] and increasing BMI [per one point increase; β 0.29; 95% CI (0.16; 0.43)] were significantly associated with an increase in FEV1/FVC. Use of inhaled cannabis and quitting smoking within 3 years prior to inclusion were not associated with FEV1/FVC.
In a first post-hoc analysis, HIV remained significantly associated with FEV1/FVC after excluding study participants with a history of tuberculosis or pneumocystosis (P = 0.006; data not shown). In a second analysis, we analysed the association of FEV1/FVC with the same variables in PLWH with a nadir CD4+ level between 200 and 350 cells/μl only, 148 HIV-infected study participants were matched to 296 study participants from the CONSTANCES cohort. In multivariate analysis, HIV was not associated with FEV1/FVC, though the association was close to statistical significance [β−1.90; 95% CI (−3.83; 0.04)] (data not shown).
HIV [odds ratio (OR) 2.57; 95% confidence interval (CI; 1.76; 3.74)] was also significantly associated with airway obstruction, as measured by FEV1/FVC ratio less than 0.70 and FEV1 value less than 80% of the theoretical value . In the multivariate analysis, factors independently associated with airway obstruction were HIV infection [OR 1.72; 95% CI (1.08; 2.73)], age (per 10 years increase; OR 1.77; 95% CI (1.28; 2.43)], and tobacco use [per 5 pack-years increase; OR 1.11; 95% CI (1.03; 1.20)]. Sex, BMI, smoking cessation within 3 years prior to inclusion, history of cannabis inhalation, and HCV status were not associated with airway obstruction (data not shown).
In this age and sex-matched study of HIV-infected and uninfected study participants, we found that HIV infection was independently associated with lower FEV1/FVC ratios. HIV was also associated with an increased prevalence of airway obstruction as measured by prebronchodilator FEV1/FVC ratio less than 0.70 and FEV1 value less than 80% of the theoretical value . To our knowledge, this is the first matched-control study undertaken in an all-smoking population over 40 years of age, a population in which screening for COPD is suggested by the GOLD recommendations (http://goldcopd.org/gold-2017-global-strategy-diagnosis-management-prevention-copd/).
Our study provides insights to what may be the differential results in both populations in terms of FEV1/FVC and prevalence of airway obstruction when screening at risk study participants with spirometry, and how much HIV infection itself can be considered as a risk factor of lower FEV1/FVC and of airway obstruction. PLWHIV are at increased risk of lung bacterial infection, pneumocystosis, tuberculosis, conditions which have all been associated with airway obstruction or emphysema [4,17,18]. However, other mechanisms may be implicated, as suggested by the persisting association between HIV and lower FEV1/FVC ratio after excluding study participants with a history of tuberculosis or pneumocystis infection. An interaction between HIV, increased lung immune activation despite antiretroviral therapy and smoking could increase levels of oxidative stress, local inflammation, and parenchyma destruction in comparison with the general population, though this hypothesis needs to be assessed.
Other factors associated with the presence of airway obstruction in our study are known risk factors in the general population. Smoking is the primary health hazard causing airway obstruction. Smoking cessation within 3 years prior to inclusion, however, was not firmly associated to outcomes, but a short duration of smoking cessation was probably insufficient to significantly modify FEV1 decline. Smoking and airway obstruction are also linked through recurrent and increased risk of pneumonia episodes in the general population . Age is a well known factor of airway obstruction in the general population, as FEV1 declines with time faster than FVC . The increase in FEV1/FVC ratio with female sex in our study remains to be explained, and data recently showed that COPD prevalence was similar in men and women . BMI was associated with lower FEV1/FVC ratio. Cachexia and limb atrophy are common features in COPD, because of induced muscle atrophy inactivity, chronic inflammation, increased oxidative stress, muscular metabolic alterations, nutritional imbalance, and hypoxia [20,21]. Finally, inhaled cannabis consumption and HCV were both associated with a decline of FEV1/FVC only. Significant cannabis consumption was based on subjective clinical evaluation, suggesting that interpretation of our results must be cautious. Cannabis has been associated with a dose-related impairment of large airways function resulting in airway obstruction [22–24] and pulmonary hyperinflation [23–25]. The association between HCV and FEV1/FVC may well result from confounding factors in the HCV coinfected, such as intravenous drug use  and socioeconomic conditions.
Our study has limitations. The cross-sectional design can only reveal associations between factors and COPD, and not causality. Second, our study did not use the GOLD outcome (http://goldcopd.org/gold-2017-global-strategy-diagnosis-management-prevention-copd/) or the ERS Society Standardization of Lung Function Tests equation of normal FEV1/FVC ratio ; thus, our results may not be generalized to these outcomes. Third, ORs that reached significance are relatively small, and significance may be because of unmeasured confounders. In particular, we could not adjust on exposing particles other than tobacco smoking and cannabis inhalation. Fourth, differences in methods of inclusion in both cohorts may partly explain the association between HIV and airway obstruction, as healthier study participants from the general population may be more willing to volunteer for the CONSTANCES cohort. Finally, PLWH had a history of CD4+ T lymphocyte value less than 350 cells/μl. Low nadir has been associated with a CD4+/CD8− ratio less than 1 , a marker of persisting immune suppression correlated with emphysema  or severe bacterial infections, independently of last CD4+ value . Thus, the association between HIV and airway obstruction may not been as important in other PLWHIV at risk with higher nadir T CD4+ cell levels.
In conclusion, our study found a higher prevalence of measured airway obstruction in PLWHIV with a history of important immunodeficiency than in an age and sex-matched control group of smokers aged 40 years of age or more.
We thank the trial participants and the coordinators, engineers, and technicians who made this study possible: Suzanne Izard, Jonathan Lalet, Sandrine Couffin-Cadiergues, Mylène Quesnoy, Carole Damien, and Bruno Granouillac.
The authors thank the National Health Insurance Fund (‘Caisse nationale d’assurance maladie des travailleurs salaries’, CNAMTS) and its health screening centres (‘Centres d’examens de santé’), which are collecting a large part of the data, and ClinSearch in charge of the data quality control.
The Constances Cohort Study is supported by the Caisse nationale d’assurance maladie des travailleurs salariés (CNAMTS). The Constances Cohort Study benefits from a grant from ANR (ANR-11-INBS-0002) and it is also partly funded by MSD, AstraZeneca, and Lundbeck.
The ANRS EP48 HIV CHEST Study Team Hôpital Gustave Dron de Tourcoing: Yazdan Yazdanpanah, A.C., Faïza Ajana, Isabelle Alcaraz, Véronique Baclet, Hugues Melliez, Michel Valette, Nathalie Viget, Xavier De La Tribonniere, Thomas Huleux, Séverine Bonne Séverine, Raphaël Biekre, Armelle Pasquet, Christophe Allienne, Jean Marie Behra, Agnès Meybeck, Emmanuelle Aissi. Hôpital Avicenne de Bobigny: S.A., Olivier Bouchaud, Régine Barruet, François Rouges, Tania Kandel, Fréderic Mechai, Pierre-Yves Brillet, Michel Brauner, Hôpital l’Archet de Nice: Pierre Dellamonica, Francine De Salvador, Eric Cua, Anne Leplatois, Alissa Naqvi, Jacques Durant, Carole Ceppi, Frédéric Sanderson, Eric Rosenthal, Madleen Chassang, Patrick Chevallier, Brigitte Dunais. Hôpital Pontchailloux de Rennes: P.T., Hervé Lena, Pierre-Axel Lentz, Christian Michelet, Cédric Arvieux, Mathieu Revest, Faouzi Soula, Jean-Marc Chapplain, Hélène Leroy, Catherine Meunier. Hôpital Ste Marguerite de Marseille: I.P-M., Olivia Faucher, Amélie Menard, Sylvie Bregigeon, Perrine Geneau de Lamarliere, Pierre Champsaur, Olivier durieux, Nicolas Cloarec. Hôpital Hotel Dieu de Nantes: F.R., Clotilde Allavena, Nicolas Feuillebois, Olivier Mounoury, Sabelline Bouchez, Eric Billaud, Véronique Reliquet, Bénédicte bonnet, Cécile Brunet, Patrick Point, David Boutoille, Pascale Morineau Le Houssine, Anne Sophie Delemazure. Hôpital Necker de Paris: Claudine Duvivier, Emilie Catherinot, Michka Shoai Tehrani, Sylvain Poiree. Hôpital Foch de Suresnes: D.Z., Catherine Majerholc, Louis-Jean Couderc, François Mellot, Antoine Sherrer. Hôpital La Croix Rousse de Lyon: T.F., Joseph Koffi, André Boibieux, Patrick Miailhes, Laurent Cotte, Thomas Perpoint, Joanna Lippman, Claude Augustin Norman, Francois biron, Agathe Senechar, Florence Ader. Hôpital Tenon de Paris: G.P., Thomas L’Yavanc, Laurence Slama, Julie Chas, Sophie Le Nagat, Antoine Khalil, Marie France Carette. Hôpital St André de Bordeaux: F.B., Philippe Morlat, Denis Lacoste, Marie Vandenhende, Marie Catherine Receveur, Francois Paccalin, Sabrina Caldato, Noëlle Bernard, Mojgan Hessemfar, Thierry Pistone, Denis Malvy, Pierre thibaut, Marie Carmen Pertusa, Olivier Cornelou, Francois Laurent, Patrick Mercie, Isabelle Faure, Denis Dondia, Cedric Martell, Pierre Duffau. Hôpital Carémeau de Nîmes: Jean Marc Mauboussin, Claudine Barbuat, Isabelle Rouanet, Liliane Metge. Hôpital Gui de Chauliac de Montpellier: J.R., V.L.M., Jean-Marc Jacquet, Nadine Atoui, Mickael Loriette, David Morquin, Vincent Fauchere, Carine Favier, Corinne Merle, Vincent Baillat, Antoine Da Silva, Rachid Mansouri, Sébastien Bommart, Hélène Kovacsik-Vernhet, Jean-Louis Pujol, Xavier Quantin, M.H.
A.M. was the lead investigator, designed the trial, developed the protocol, interpreted the statistical analysis and wrote the manuscript. S.E-D. did the statistical analysis. V.L.M. and M.H. thoroughly reviewed the study protocol and results. All other authors participated in study accrual, and reviewed, revised, and approved the final manuscript.
Conflicts of interest
There are no conflicts of interest.
1. Roux P, Demoulin B, Sogni P, Carrieri P, Dray-Spira R, Spire B, et al. Coinfection with hepatitis C virus in people living with HIV
: data from the ANRS-VESPA2 survey. Bulletin épidémiologique hebdomadaire. 2013;N° 26-27(2 juillet 2013):314–20.
2. Tesoriero JM, Gieryic SM, Carrascal A, Lavigne HE. Smoking among HIV positive New Yorkers: prevalence, frequency, and opportunities for cessation
. AIDS Behav
3. Makinson A, Hayot M, Eymard-Duvernay S, Quesnoy M, Raffi F, Thirard L, et al. ANRS EP48 HIV
CHEST Study Team. High prevalence of undiagnosed COPD in a cohort of HIV-infected smokers
. Eur Respir J
4. Samperiz G, Guerrero D, Lopez M, Valera J, Iglesias A, Rios A, et al. Prevalence of and risk factors for pulmonary abnormalities in HIV-infected patients treated with antiretroviral therapy
. HIV Med
5. George MP, Kannass M, Huang L, Sciurba FC, Morris A. Respiratory symptoms and airway obstruction in HIV-infected subjects in the HAART era
. PloS One
6. Morris A, Alexander T, Radhi S, Lucht L, Sciurba FC, Kolls JK, et al. Airway obstruction is increased in pneumocystis-colonized human immunodeficiency virus-infected outpatients
. J Clin Microbiol
7. Risso K, Guillouet-de-Salvador F, Valerio L, Pugliese P, Naqvi A, Durant J, et al. COPD in HIV-infected patients: CD4 cell count highly correlated
. PloS One
8. Drummond MB, Kirk GD, Astemborski J, Marshall MM, Mehta SH, McDyer JF, et al. Association between obstructive lung disease and markers of HIV infection in a high-risk cohort
9. Crothers K, Butt AA, Gibert CL, Rodriguez-Barradas MC, Crystal S, Justice AC. Increased COPD among HIV-positive compared to HIV-negative veterans
10. Crothers K, Huang L, Goulet JL, Goetz MB, Brown ST, Rodriguez-Barradas MC, et al. HIV infection and risk for incident pulmonary diseases in the combination antiretroviral therapy era
. Am J Respir Crit Care Med
11. Madeddu G, Fois AG, Calia GM, Babudieri S, Soddu V, Becciu F, et al. Chronic obstructive pulmonary disease: an emerging comorbidity in HIV-infected patients in the HAART era?
12. Makinson A, Eymard-Duvernay S, Raffi F, Abgrall S, Bommart S, Zucman D, et al. Feasibility and efficacy of early lung cancer diagnosis with chest computed tomography in HIV-infected smokers
13. Quanjer PH, Stanojevic S, Cole TJ, Baur X, Hall GL, Culver BH, et al. ERS Global Lung Function Initiative. Multi-ethnic reference values for spirometry for the 3-95-yr age range: the global lung function 2012 equations
. Eur Respir J
14. Quanjer PH, Enright PL, Miller MR, Stocks J, Ruppel G, Swanney MP, et al. The need to change the method for defining mild airway obstruction
. Eur Respir J
15. Bohadana A, Nilsson F, Martinet Y. Detecting airflow obstruction in smoking cessation trials: a rationale for routine spirometry
16. Omori H, Yoshimoto D, Kumar M, Goren A. Prevalence, awareness, characteristics, and health outcomes associated with COPD at-risk status among adults in Japan
. Expert Rev Pharmacoecon Outcomes Res
17. Sogaard OS, Lohse N, Gerstoft J, Kronborg G, Ostergaard L, Pedersen C, et al. Hospitalization for pneumonia among individuals with and without HIV infection, 1995-2007: a Danish population-based, nationwide cohort study
. Clin Infect Dis
18. Morris AM, Huang L, Bacchetti P, Turner J, Hopewell PC, Wallace JM, et al. Permanent declines in pulmonary function following pneumonia in human immunodeficiency virus-infected persons. The Pulmonary Complications of HIV Infection Study Group
. Am J Respir Crit Care Med
19. Pirie K, Peto R, Reeves GK, Green J, Beral V. Million Women Study C. The 21st century hazards of smoking and benefits of stopping: a prospective study of one million women in the UK
20. Vermeeren MA, Creutzberg EC, Schols AM, Postma DS, Pieters WR, Roldaan AC, et al. Prevalence of nutritional depletion in a large out-patient population of patients with COPD
. Respir Med
21. Maltais F, Decramer M, Casaburi R, Barreiro E, Burelle Y, Debigare R, et al. An Official American Thoracic Society/European Respiratory Society Statement: update on limb muscle dysfunction in chronic obstructive pulmonary disease
. Am J Respir Crit Care Med
22. Taylor DR, Fergusson DM, Milne BJ, Horwood LJ, Moffitt TE, Sears MR, et al. A longitudinal study of the effects of tobacco and cannabis exposure on lung function in young adults
23. Aldington S, Williams M, Nowitz M, Weatherall M, Pritchard A, McNaughton A, et al. Effects of cannabis on pulmonary structure, function and symptoms
24. Tan WC, Lo C, Jong A, Xing L, Fitzgerald MJ, Vollmer WM, et al. Vancouver Burden of Obstructive Lung Disease (BOLD) Research Group. Marijuana and chronic obstructive lung disease: a population-based study
25. Hancox RJ, Poulton R, Ely M, Welch D, Taylor DR, McLachlan CR, et al. Effects of cannabis on lung function: a population-based cohort study
. Eur Respir J
26. Goldstein DS, Karpel JP, Appel D, Williams MH Jr. Bullous pulmonary damage in users of intravenous drugs
27. Caby F, Guihot A, Lambert-Niclot S, Guiguet M, Boutolleau D, Agher R, et al. Determinants of a low CD4/CD8 ratio in HIV-1-infected individuals despite long-term viral suppression
. Clin Infect Dis
28. Triplette M, Attia EF, Akgun KM, Soo Hoo GW, Freiberg MS, Butt AA, et al. A low peripheral blood CD4/CD8 ratio is associated with pulmonary emphysema in HIV
. PloS One
29. Collin A, Le Marec F, Vandenhende MA, Lazaro E, Duffau P, Cazanave C, et al. ANRS CO3 Aquitaine Cohort Study Group. Incidence and risk factors for severe bacterial infections in people living with HIV. ANRS CO3 Aquitaine Cohort, 2000–2012
. PloS One