Among 116 HIV-positive Zimbabwean adolescents, more than 40% had chronic lung disease that was often not obvious without testing. Two thirds of these teens had chronic cough.

Research indicates that 2% to 3% of all 10-year-olds in southern Africa may be HIV-positive children infected perinatally and that most of them remain undiagnosed. These children have a high risk of chronic complications of untreated HIV infection. Because researchers in London, Harare, and other sites suspected chronic respiratory symptoms may be more common than anticipated in these children, they undertook this study.

The researchers enrolled consecutive HIV-positive adolescents attending two HIV clinics in Harare, Zimbabwe. They presumed that all children were vertically infected. All children were examined and underwent pulmonary function tests, Doppler echocardiography, and chest radiography. Children with suspected nontuberculous chronic lung disease were scanned by high-resolution computed tomography.

Age averaged 14 years in these 116 youngsters, 57% of whom were girls. Age at HIV diagnosis averaged 12 years, and 69% were receiving antiretroviral therapy. Median CD4 count stood at 384 cells/µL (interquartile range 180 to 584) and did not differ substantially between youngsters taking or not taking antiretrovirals.

Chronic cough and reduced exercise tolerance affected 66% and 21% of participants, and 41% had multiple respiratory tract infections in the previous year.

While 29% had hypoxemia (low blood oxygen) during exercise, 13% had hypoxemia at rest; 7% had pulmonary hypertension (average pulmonary artery pressure above 25 mm Hg). While 45% of children had forced expiratory volume in 1 second (FEV1) below 80%, 47% had subtle chest x-ray abnormalities.

The predominant pattern seen on high-resolution computed tomography was decreased attenuation as part of a mosaic attenuation pattern, in 31 of 56 children tested (55%). This pattern is consistent with small airway disease and was positively associated with bronchiectasis (destruction and widening of the large airway) (r2 = 0.8) and negatively associated with reduced FEV1 (r2 = −0.26).

“Long-term survivors of vertically acquired HIV in Africa are at high risk of a previously undescribed small airway disease,” the authors conclude. They stress that “this condition is not obvious at rest.”

Notably, this high burden of chronic lung disease affected children with relatively high CD4 counts after several years of antiretroviral therapy.

The authors propose that “earlier diagnosis of HIV infection may be crucial to preventing the development of chronic lung disease and suggests that international recommendations (which currently do not support immediate initiation of ART [antiretroviral therapy] in children diagnosed over the age of 2 years) need to take the high risk of chronic lung disease and potential for prevention with early ART initiation into account.”