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General Considerations

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The lungs are major target organs in patients infected with the human immunodeficiency virus (HIV) and in patients with acquired immunodeficiency syndrome (AIDS). In the United States and Europe use of highly active antiretroviral therapy (HAART) and prophylaxis for Pneumocystis carinii pneumonia (PCP), cytomegalovirus, and Mycobacterium avium complex (MAC) have changed the incidence and spectrum of diseases affecting the lungs. There has been a decline in the incidence of opportunistic infection, progression to AIDS, and mortality from the disease. The epidemiology of HIV infection has also changed in the United States. In new cases of AIDS patients are increasingly likely to have acquired HIV from intravenous drug use or heterosexual contact.

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Pathogenesis/Epidemiology of HIV/AIDS

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Infection with HIV produces multiple defects in the immune system resulting in dysfunction of humoral, cell-mediated, and phagocytic immunity. Thus patients with HIV/AIDS are at greater risk for infection with a variety of bacterial, mycobacterial, and fungal organisms. They are also predisposed to a variety of noninfectious diseases of the lungs such as Kaposi’s sarcoma and non-Hodgkin’s lymphoma. Because of the widespread use of HAART in the United States since 1996, the number of persons diagnosed with AIDS has declined substantially. At the same time, the number of people living with AIDS has steadily climbed. This has and will continue to place a greater burden on the health care system. The incidence of AIDS increased rapidly in the 1980s and peaked in the 1990s. The peak in new diagnoses was in 1993 with over 80,000 new cases. In 1996, a sharp decline in new cases was observed for the first time and since 1998 the incidence has leveled off at about 40,000 new cases per year. Mortality from AIDS has also declined over the past 5 years to about 40%. The number of new cases has declined most dramatically in men who have sex with men and to a lesser degree in intravenous drug users. During this time, however, the number of new cases attributable to heterosexual contact has increased.

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As of December 2000 there were about 350,000 people with AIDS living in the United States. The proportion of African-American patients, heterosexual females, residents of the South, and persons acquiring AIDS via heterosexual contact has increased. AIDS also is disproportionately affecting subgroups that have poor access to health care and preventive care. Because almost one-quarter of persons with AIDS are not aware of their diagnosis and an additional third are aware of it but are not receiving care, it is expected that there will continue to be patients with PCP, tuberculosis, and other mycobacterial infections despite availability of HAART.

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Almost 65% of persons with AIDS in the pre-HAART era had evidence of pulmonary disease. PCP was the most common cause, followed by other fungi, bacteria, Mycobacterium tuberculosis, and MAC. Viral pneumonia due to cytomegalovirus (CMV) was distinctly uncommon despite evidence of almost 100% prior ...

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