Pulmonary Infections in Patients with Human Immunodeficiency Virus Infection

Abstract

Pulmonary infection is an important cause of hospitalization, morbidity, and mortality in people living with human immunodeficiency virus (HIV; PWH) infection, especially in those with significant immunosuppression. Pneumonia, including Pneumocystis jirovecii and Mycobacterium tuberculosis etiologies, continues to be the most frequent pulmonary infection in PWH. However, identifying the etiology of pulmonary infection in PWH is challenging because of the overlap in clinical features and the frequency of co-infection. This review focuses on the current scientific evidence regarding pulmonary infection in PWH, including its epidemiology, clinical presentation, diagnosis, and management.

Keywords

pulmonary infection - human immunodeficiency virus - antiretroviral therapy

Publication History

Received: 27 August 2025

Accepted: 17 October 2025

Accepted Manuscript online:
23 October 2025

Article published online:
04 November 2025

• References

• 1 UNAIDS data. 2024 | UNAIDS. Accessed October 28, 2025 at: https://www.unaids.org/en/resources/documents/2024/2024_unaids_data
• 2 Balakrishna S, Wolfensberger A, Kachalov V. et al; Swiss HIV Cohort Study. Decreasing incidence and determinants of bacterial Pneumonia in people with HIV: the Swiss HIV Cohort Study. J Infect Dis 2022; 225 (09) 1592-1600
• 3 2024 global AIDS report—The Urgency of Now: AIDS at a Crossroads | UNAIDS. Accessed October 28, 2025 at: https://www.unaids.org/en/resources/documents/2024/global-aids-update-2024
• 4 Global HIV & AIDS statistics—Fact sheet | UNAIDS. Accessed October 28, 2025 at: https://www.unaids.org/en/resources/fact-sheet
• 5 Wolder Ejlersen E, Loft JA, Gelpi M. et al. Incidence of confirmed influenza and Pneumococcal infections and vaccine uptake among virologically suppressed people living with HIV. Vaccines (Basel) 2025; 13 (04) 358
• 6 De P, Farley A, Lindson N, Aveyard P. Systematic review and meta-analysis: influence of smoking cessation on incidence of pneumonia in HIV. BMC Med 2013; 11: 15
• 7 Richards GA, Zamparini J, Kalla I. et al. Critical illness due to infection in people living with HIV. Lancet HIV 2024; 11 (06) e406-e418
• 8 Cillóniz C, Dominedò C, Álvarez-Martínez MJ. et al. Pneumocystis pneumonia in the twenty-first century: HIV-infected versus HIV-uninfected patients. Expert Rev Anti Infect Ther 2019; 17 (10) 787-801
• 9 Moir S, Buckner CM, Ho J. et al. B cells in early and chronic HIV infection: evidence for preservation of immune function associated with early initiation of antiretroviral therapy. Blood 2010; 116 (25) 5571-5579
• 10 Boyd MA, van Bockel D, Munier CML, Kelleher AD. Navigating the complexity of chronic HIV-1 associated immune dysregulation. Curr Opin Immunol 2022; 76: 102186
• 11 Justice AC, Goetz MB, Stewart CN. et al. Delayed presentation of HIV among older individuals: a growing problem. Lancet HIV 2022; 9 (04) e269-e280
• 12 Cilloniz C, Dy-Agra G, Pagcatipunan Jr RS, Torres A. Viral Pneumonia: from influenza to COVID-19. Semin Respir Crit Care Med 2024; 45 (02) 207-224
• 13 Garcia Garrido HM, Mak AMR, Wit FWNM. et al. Incidence and risk factors for invasive pneumococcal disease and community-acquired Pneumonia in human immunodeficiency virus-infected individuals in a high-income setting. Clin Infect Dis 2020; 71 (01) 41-50
• 14 Venturas JP, Richards GA, Feldman C. Severe community-acquired pneumonia at a tertiary academic hospital in Johannesburg, South Africa. Respir Med 2024; 234: 107823
• 15 Maphula RW, Laher AE, Richards GA. Patterns of presentation and survival of HIV-infected patients admitted to a tertiary-level intensive care unit. HIV Med 2020; 21 (05) 334-341
• 16 Pulsipher AM, Vikram HR, Gotway MB. et al. An observational analysis of a large cohort of Pneumocystis jirovecii Pneumonia. Open Forum Infect Dis 2025; 12 (07) ofaf390
• 17 Kolbrink B, Scheikholeslami-Sabzewari J, Borzikowsky C. et al. Evolving epidemiology of pneumocystis pneumonia: findings from a longitudinal population-based study and a retrospective multi-center study in Germany. Lancet Reg Health Eur 2022; 18: 100400
• 18 Tuberculosis (TB). Accessed October 28, 2025 at: https://www.who.int/news-room/fact-sheets/detail/tuberculosis
• 19 Zhang S-X, Wang J-C, Yang J. et al. Epidemiological features and temporal trends of the co-infection between HIV and tuberculosis, 1990-2021: findings from the global burden of disease study 2021. Infect Dis Poverty 2024; 13 (01) 59
• 20 Cillóniz C, García-Vidal C, Moreno A, Miro JM, Torres A. Community-acquired bacterial pneumonia in adult HIV-infected patients. Expert Rev Anti Infect Ther 2018; 16 (07) 579-588
• 21 Crothers K, Huang L, Goulet JL. et al. HIV infection and risk for incident pulmonary diseases in the combination antiretroviral therapy era. Am J Respir Crit Care Med 2011; 183 (03) 388-395
• 22 Melliez H, Mary-Krause M, Guiguet M. et al. Risk of severe bacterial infection in people living human immunodeficiency virus infection in the combined antiretroviral therapy era. J Infect Dis 2020; 222 (05) 765-776
• 23 Attia EF, McGinnis KA, Feemster LC. et al. Association of COPD with risk for pulmonary infections requiring hospitalization in HIV-infected Veterans. J Acquir Immune Defic Syndr 2015; 70 (03) 280-288
• 24 Johnston PI, Wright SW, Orr M. et al. Worldwide relative smoking prevalence among people living with and without HIV. AIDS 2021; 35 (06) 957-970
• 25 De Socio GV, Pasqualini M, Ricci E. et al; CISAI study group. Smoking habits in HIV-infected people compared with the general population in Italy: a cross-sectional study. BMC Public Health 2020; 20 (01) 734
• 26 Tron L, Lert F, Spire B, Dray-Spira R. ANRS-Vespa2 study group. Tobacco smoking in HIV-infected versus general population in France: heterogeneity across the various groups of people living with HIV. PLoS One 2014; 9 (09) e107451
• 27 Ahlström MG, Knudsen A, Ullum H. et al. Association between smoking status assessed with plasma-cotinine and inflammatory and endothelial biomarkers in HIV-positive and HIV-negative individuals. HIV Med 2018; 19 (10) 679-687
• 28 Baskaran V, Murray RL, Hunter A, Lim WS, McKeever TM. Effect of tobacco smoking on the risk of developing community acquired pneumonia: a systematic review and meta-analysis. PLoS One 2019; 14 (07) e0220204
• 29 Poudel KC, Poudel-Tandukar K, Bertone-Johnson ER, Pekow P, Vidrine DJ. Inflammation in relation to intensity and duration of cigarette smoking among people living with HIV. AIDS Behav 2021; 25 (03) 856-865
• 30 Nieman RB, Fleming J, Coker RJ, Harris JR, Mitchell DM. The effect of cigarette smoking on the development of AIDS in HIV-1-seropositive individuals. AIDS 1993; 7 (05) 705-710
• 31 Brown JL, Winhusen T, DiClemente RJ. et al. The association between cigarette smoking, virologic suppression, and CD4+ lymphocyte count in HIV-Infected Russian women. AIDS Care 2017; 29 (09) 1102-1106
• 32 Winhusen T, Feaster DJ, Duan R. et al. Baseline cigarette smoking status as a predictor of virologic suppression and CD4 cell count during one-year follow-up in substance users with uncontrolled HIV infection. AIDS Behav 2018; 22 (06) 2026-2032
• 33 Konstantinidis I, Crothers K, Kunisaki KM. et al. HIV-associated lung disease. Nat Rev Dis Primers 2023; 9 (01) 39
• 34 Kershaw CD, Guidot DM. Alcoholic lung disease. Alcohol Res Health 2008; 31 (01) 66-75
• 35 Jung MK, Callaci JJ, Lauing KL. et al. Alcohol exposure and mechanisms of tissue injury and repair. Alcohol Clin Exp Res 2011; 35 (03) 392-399
• 36 Szabo G, Saha B. Alcohol's effect on host defense. Alcohol Res 2015; 37 (02) 159-170
• 37 Jolley SE, Alkhafaf Q, Hough C, Welsh DA. Presence of an alcohol use disorder is associated with greater pneumonia severity in hospitalized HIV-infected patients. Lung 2016; 194 (05) 755-762
• 38 Reynolds PM, Afshar M, Wright GC. et al. Association between substance misuse and outcomes in critically iii patients with Pneumonia. Ann Am Thorac Soc 2023; 20 (04) 556-565
• 39 Haw NJL, Lesko CR, Ng DK. et al; North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD). Incidence of non-AIDS defining comorbidities among young adults with perinatally acquired HIV in North America. AIDS 2024; 38 (09) 1366-1374
• 40 Zhabokritsky A, Klein M, Loutfy M. et al. Non-AIDS-defining comorbidities impact health related quality of life among older adults living with HIV. Front Med (Lausanne) 2024; 11: 1380731
• 41 Community-Acquired Pneumonia. Adult and Adolescent OIs | NIH. 2022 ; Accessed October 28, 2025 at: https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/community-acquired
• 42 Cilloniz C, Torres A, Polverino E. et al. Community-acquired lung respiratory infections in HIV-infected patients: microbial aetiology and outcome. Eur Respir J 2014; 43 (06) 1698-1708
• 43 Andrews B. Surviving sepsis in high HIV prevalence settings. Med J Zambia 2010; 37 (02) 104-110
• 44 Wiewel MA, Huson MA, van Vught LA. et al; MARS Consortium. Impact of HIV infection on the presentation, outcome and host response in patients admitted to the intensive care unit with sepsis; a case control study. Crit Care 2016; 20 (01) 322
• 45 Chew KW, Yen IH, Li JZ, Winston LG. Predictors of pneumonia severity in HIV-infected adults admitted to an urban public hospital. AIDS Patient Care STDs 2011; 25 (05) 273-277
• 46 Camon S, Quiros C, Saubi N. et al. Full blood count values as a predictor of poor outcome of pneumonia among HIV-infected patients. BMC Infect Dis 2018; 18 (01) 189
• 47 Tilahun M, Gebretsadik D, Seid A. et al. Bacteriology of community-acquired pneumonia, antimicrobial susceptibility pattern and associated risk factors among HIV patients, Northeast Ethiopia: cross-sectional study. SAGE Open Med 2023;11:20503121221145569
• 48 Schleenvoigt BT, Ankert J, Barten-Neiner G. et al; CAPNETZ Study Group. Pathogen spectrum of community acquired pneumonia in people living with HIV (PLWH) in the German CAPNETZ-cohort. Infection 2024; 52 (01) 129-137
• 49 Ochoa-Gondar O, Torras-Vives V, de Diego-Cabanes C. et al. Incidence and risk factors of pneumococcal pneumonia in adults: a population-based study. BMC Pulm Med 2023; 23 (01) 200
• 50 Cillóniz C, Torres A, Manzardo C. et al. Community-acquired Pneumococcal Pneumonia in virologically suppressed HIV-infected adult patients: a matched case-control study. Chest 2017; 152 (02) 295-303
• 51 Albrich WC, Madhi SA, Adrian PV. et al. Pneumococcal colonisation density: a new marker for disease severity in HIV-infected adults with pneumonia. BMJ Open 2014; 4 (08) e005953
• 52 Swathirajan CR, Rameshkumar MR, Solomon SS, Vignesh R, Balakrishnan P. Changing drug resistance profile in Pseudomonas aeruginosa infection among HIV patients from 2010-2017: a retrospective study. J Glob Antimicrob Resist 2019; 16: 274-277
• 53 Allen SH, Brennan-Benson P, Nelson M. et al. Pneumonia due to antibiotic resistant Streptococcus pneumoniae and Pseudomonas aeruginosa in the HAART era. Postgrad Med J 2003; 79 (938) 691-694
• 54 Wooten DA, Winston LG. Risk factors for methicillin-resistant Staphylococcus aureus in patients with community-onset and hospital-onset pneumonia. Respir Med 2013; 107 (08) 1266-1270
• 55 Torres A, Cilloniz C, Niederman MS. et al. Pneumonia. Nat Rev Dis Primers 2021; 7 (01) 25
• 56 Cillóniz C, Miguel-Escuder L, Pedro-Bonet ML. et al; Legionella-HIV Researchers. Community-acquired Legionella Pneumonia in human immunodeficiency virus-infected adult patients: a matched case-control study. Clin Infect Dis 2018; 67 (06) 958-961
• 57 Figueiredo-Mello C, Naucler P, Negra MD, Levin AS. Prospective etiological investigation of community-acquired pulmonary infections in hospitalized people living with HIV. Medicine (Baltimore) 2017; 96 (04) e5778
• 58 Bai AD, Srivastava S, Martinez Cajas JL, Razak F, Verma AA. Community-acquired Pneumonia in people with HIV during the current era of effective antiretroviral therapy: a multicenter retrospective cohort study. Clin Infect Dis 2025; 80 (02) 397-403
• 59 Christensen D, Feldman C, Rossi P. et al; Community-Acquired Pneumonia Organization Investigators. HIV infection does not influence clinical outcomes in hospitalized patients with bacterial community-acquired pneumonia: results from the CAPO international cohort study. Clin Infect Dis 2005; 41 (04) 554-556
• 60 Malinis M, Myers J, Bordon J. et al. Clinical outcomes of HIV-infected patients hospitalized with bacterial community-acquired pneumonia. Int J Infect Dis 2010; 14 (01) e22-e27
• 61 Venturas JP, Titus A, Richards GA, Feldman C. Severe community-acquired Pneumonia: impact of HIV on Clinical presentation, microbiological and laboratory findings, and outcome. J Intensive Care Med 2025; 40 (11) 1204-1213
• 62 Tan B, Webster H, Krishnaswamy S, MacPhail A, Pilcher D. Outcomes of critical illness in peoples with Advanced HIV Disease: 30 years of binational data. Clin Infect Dis 2025; ciaf362
• 63 Søgaard OS, Lohse N, Gerstoft J. et al. Mortality after hospitalization for pneumonia among individuals with HIV, 1995-2008: a Danish cohort study. PLoS One 2009; 4 (09) e7022
• 64 Restrepo MI, Faverio P, Anzueto A. Long-term prognosis in community-acquired pneumonia. Curr Opin Infect Dis 2013; 26 (02) 151-158
• 65 Bordon J, Kapoor R, Martinez C. et al. CD4+ cell counts and HIV-RNA levels do not predict outcomes of community-acquired pneumonia in hospitalized HIV-infected patients. Int J Infect Dis 2011; 15 (12) e822-e827
• 66 Zifodya JS, Duncan MS, So-Armah KA. et al. Community-acquired Pneumonia and risk of cardiovascular events in people living with HIV. J Am Heart Assoc 2020; 9 (23) e017645
• 67 Sarkar P, Rasheed HF. Clinical review: respiratory failure in HIV-infected patients–a changing picture. Crit Care 2013; 17 (03) 228
• 68 Salwen B, Mascarenhas E, Horne DJ, Crothers K, Zifodya JS. Sequelae of immunocompromised host Pneumonia. Clin Chest Med 2025; 46 (01) 49-60
• 69 Uranga A, España PP. Long-term mortality in community-acquired Pneumonia. Arch Bronconeumol (Engl Ed) 2018; 54 (08) 412-413
• 70 Health NI of. Prevention C for DC and, Council (OARAC) HMA of the IDS of AP on G for the P and T of OI in A and A with H-AWG of the O of ARA. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. ClinicalInfoHIV.gov [Internet] US Department of Health and Human Services; 2025 . Accessed October 28, 2025 at: https://www.ncbi.nlm.nih.gov/books/NBK586304/
• 71 CDC. Interim Clinical Considerations for Use of COVID-19 Vaccines in the United States. COVID 2025;19. at Accessed October 28, 2025 at: https://www.cdc.gov/covid/hcp/vaccine-considerations/index.html
• 72 Liu Y, Su L, Jiang S-J, Qu H. Risk factors for mortality from pneumocystis carinii pneumonia (PCP) in non-HIV patients: a meta-analysis. Oncotarget 2017; 8 (35) 59729-59739
• 73 Wakefield AE, Lindley AR, Ambrose HE, Denis C-M, Miller RF. Limited asymptomatic carriage of Pneumocystis jiroveci in human immunodeficiency virus-infected patients. J Infect Dis 2003; 187 (06) 901-908
• 74 Liu Y, Fahle GA, Kovacs JA. Inability to culture Pneumocystis jirovecii. MBio 2018; 9 (03) e00939-e18
• 75 Giacobbe DR, Dettori S, Di Pilato V. et al; JIR-ICU Investigators (Collaborators), the Critically Ill Patients Study Group of the European Society of Clinical Microbiology and Infectious Diseases (ESGCIP), and the Fungal Infections Study Group of the European Society of Clinical Microbiology and Infectious Diseases (EFISG), JIR-ICU investigators (collaborators). Mortality of Pneumocystis jirovecii pneumonia in intensive care units: a post-hoc analysis of an international multicenter study by ESGCIP and EFISG. Ann Med 2025; 57 (01) 2511043
• 76 Ahmadpour E, Valilou S, Ghanizadegan MA. et al. Global prevalence, mortality, and main characteristics of HIV-associated pneumocystosis: a systematic review and meta-analysis. PLoS One 2024; 19 (03) e0297619
• 77 Limper AH, Adenis A, Le T, Harrison TS. Fungal infections in HIV/AIDS. Lancet Infect Dis 2017; 17 (11) e334-e343
• 78 Roux A, Canet E, Valade S. et al. Pneumocystis jirovecii pneumonia in patients with or without AIDS, France. Emerg Infect Dis 2014; 20 (09) 1490-1497
• 79 Liu C-J, Lee T-F, Ruan S-Y, Yu C-J, Chien J-Y, Hsueh P-R. Clinical characteristics, treatment outcomes, and prognostic factors of Pneumocystis pneumonia in non-HIV-infected patients. Infect Drug Resist 2019; 12: 1457-1467
• 80 Fujii T, Nakamura T, Iwamoto A. Pneumocystis pneumonia in patients with HIV infection: clinical manifestations, laboratory findings, and radiological features. J Infect Chemother 2007; 13 (01) 1-7
• 81 Tasaka S, Tokuda H, Sakai F. et al. Comparison of clinical and radiological features of pneumocystis pneumonia between malignancy cases and acquired immunodeficiency syndrome cases: a multicenter study. Intern Med 2010; 49 (04) 273-281
• 82 Ebner L, Walti LN, Rauch A. et al. Clinical course, radiological manifestations, and outcome of Pneumocystis jirovecii Pneumonia in HIV patients and renal transplant recipients. PLoS One 2016; 11 (11) e0164320
• 83 Kanne JP, Yandow DR, Meyer CA. Pneumocystis jiroveci pneumonia: high-resolution CT findings in patients with and without HIV infection. AJR Am J Roentgenol 2012; 198 (06) W555-61
• 84 Azoulay E, Russell L, Van de Louw A. et al; Nine-i Investigators. Diagnosis of severe respiratory infections in immunocompromised patients. Intensive Care Med 2020; 46 (02) 298-314
• 85 Scharmann U, Kirchhoff L, Buer J. et al. Evaluation of the loop-mediated isothermal amplification assay (LAMP) Eazyplex Pneumocystis jirovecii. J Fungi (Basel) 2025; 11 (04) 300
• 86 Esteves F, Calé SS, Badura R. et al. Diagnosis of Pneumocystis pneumonia: evaluation of four serologic biomarkers. Clin Microbiol Infect 2015; 21 (04) 379.e1-379.e10
• 87 Jaramillo Cartagena A, Asowata OE, Ng D, Babady NE. An overview of the laboratory diagnosis of Pneumocystis jirovecii pneumonia. J Clin Microbiol 2025; 63 (03) e0036124
• 88 Schmidt JJ, Lueck C, Ziesing S. et al. Clinical course, treatment and outcome of Pneumocystis pneumonia in immunocompromised adults: a retrospective analysis over 17 years. Crit Care 2018; 22 (01) 307
• 89 Kamel T, Janssen-Langenstein R, Quelven Q. et al; PCP-MULTI Study group. Pneumocystis pneumonia in intensive care: clinical spectrum, prophylaxis patterns, antibiotic treatment delay impact, and role of corticosteroids. A French multicentre prospective cohort study. Intensive Care Med 2024; 50 (08) 1228-1239
• 90 Elango K, Mudgal M, Murthi S. et al. Trends in the epidemiology and outcomes of pneumocystis pneumonia among human immunodeficiency virus (HIV) hospitalizations. Int J Environ Res Public Health 2022; 19 (05) 2768
• 91 Bares SH, Swindells S. Latent tuberculosis and HIV infection. Curr Infect Dis Rep 2020; 22: 17
• 92 Mycobacterium tuberculosis: Adult and Adolescent OIs | NIH. 2024 . Accessed October 28, 2025 at: https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/mycobacterium
• 93 Lewinsohn DM, Leonard MK, LoBue PA. et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: diagnosis of tuberculosis in adults and children. Clin Infect Dis 2017; 64 (02) 111-115
• 94 Oda G, Lucero-Obusan C, Schirmer P, Chung J, Holodniy M. Risk factors for extrapulmonary tuberculosis among US veterans, 1990-2022. Open Forum Infect Dis 2024; 11 (12) ofae698
• 95 CDC. Clinical Overview of Tuberculosis Disease. Tuberculosis (TB) 2025. Accessed October 28, 2025 at: https://www.cdc.gov/tb/hcp/clinical-overview/tuberculosis-disease.html
• 96 WHO consolidated guidelines on tuberculosis: module 3: diagnosis: rapid diagnostics for tuberculosis detection, 2021 update. Accessed October 28, 2025 at: https://www.who.int/publications/i/item/9789240029415
• 97 CDC. Updated Guidelines on the Treatment of Drug-Susceptible and Drug-Resistant TB. Tuberculosis (TB) 2025. Accessed October 28, 2025 at: https://www.cdc.gov/tb/php/dear-colleague-letters/2025-treatment-guidelines.html
• 98 Saukkonen JJ, Duarte R, Munsiff SS. et al. Updates on the treatment of drug-susceptible and drug-resistant tuberculosis: an official ATS/CDC/ERS/IDSA Clinical Practice Guideline. Am J Respir Crit Care Med 2025; 211 (01) 15-33
• 99 WHO consolidated guidelines on tuberculosis Module 1: prevention - tuberculosis preventive treatment, second edition. Accessed October 28, 2025 at: https://www.who.int/publications/i/item/9789240096196