Chronic Pulmonary Aspergillosis in People Living with HIV: An Uncommon and Under-Recognized Association

Chronic pulmonary aspergillosis (CPA) is a progressive fungal disease that primarily affects individuals with preexisting lung conditions. The clinical presentation, radiological characteristics, and outcomes of CPA in people living with HIV (PLHIV) remain poorly understood. We conducted a retrospective study at Hospital das Clínicas, University of São Paulo, Brazil, reviewing medical records of CPA patients from January 2010 to November 2024. HIV-infected and HIV-negative CPA patients were compared in terms of clinical features, diagnostic findings, treatment strategies, and outcomes. CPA diagnosis was based on European Society for Clinical Microbiology and Infectious Diseases and European Respiratory Society criteria. A total of 96 CPA patients were included, of whom 8 (8%) were PLHIV. Compared to HIV-negative patients, PLHIV were younger (median age: 44 vs. 52 years, p = 0.13) and more likely to have active pulmonary TB (38% vs. 4.5%, p = 0.013). Itraconazole was the most used antifungal in both groups (57% vs. 79%, p = 0.2). One-year mortality also did not differ significantly between PLHIV and HIV-negative patients (13% vs. 4%, p = 0.3). Notably, 50% of PLHIV experienced clinical failure despite prolonged antifungal therapy and/or surgery. In conclusion, CPA in PLHIV is frequently associated with active TB and presents with a high rate of clinical failure despite treatment. Our findings highlight the need for optimized diagnostic and therapeutic strategies for CPA in this under-recognized population. Further prospective studies are warranted to better define prognostic factors and improve management approaches.