Background:  During the emergence of the HIV epidemic in the United States, it was recognized that the burden of invasive pneumococcal disease was increased as much as 100-fold among HIV-infected people. This burden of disease has diminished following the introduction of HAART. Developing countries, and particularly Africa, now harbor the major burden of pneumococcal disease associated with HIV infection. The reservoir of pneumococcal infections in the community is nasopharyngeal carriage in children. HIV-infected women are thus at particular risk for the acquisition of the disease. The distribution of serotypes among HIV-infected adults reflects their acquisition from children. Antimicrobial resistance is more common among pneumococci isolated from HIV-infected adults and children, than from controls.

Conclusions:  While mortality and multilobar disease are related to diminishing CD4 counts, mortality comparisons with HIV-uninfected patients are confounded by severity of disease and age. Response to appropriate antimicrobial therapy is generally good if such therapy is instituted early. While trimethoprim–sulphamethoxazole prophylaxis confers significant protection from mortality, the effect of this prophylaxis on pneumococcal disease is controversial as resistance emerges rapidly. The polysaccharide pneumococcal vaccine is not protective in HIV-infected adults who are not receiving ART, but studies are underway to evaluate the protective efficacy of pneumococcal conjugates in adults. Among HIV-infected children, pneumococcal conjugate vaccine protects against invasive disease due to vaccine serotypes and has been shown to reduce the burden of lower respiratory tract infections and clinical pneumonia.