Background. Long-term survivors of vertically acquired human immunodeficiency virus (HIV) infection are reaching adolescence in large numbers in Africa and are at high risk of delayed diagnosis and chronic complications of untreated HIV infection. Chronic respiratory symptoms are more common than would be anticipated based on the HIV literature.Methods.Consecutive adolescents with presumed vertically acquired HIV attending 2 HIV care clinics in Harare, Zimbabwe, were recruited and assessed with clinical history and examination, CD4 count, pulmonary function tests, Doppler echocardiography, and chest radiography (CXR). Those with suspected nontuberculous chronic lung disease (CLD) were scanned using high-resolution computed tomography (HRCT).Results.Of 116 participants (43 male; mean age, 14 ± 2.6 years, mean age at HIV diagnosis, 12 years), 69 were receiving antiretroviral therapy. Chronic cough and reduced exercise tolerance were reported by 66 and 21 of participants, respectively; 41 reported multiple respiratory tract infections in the previous year, and 10 were clubbed. More than 40 had hypoxemia at rest (13) or on exercise (29), with pulmonary hypertension (mean pulmonary artery pressure >25 mm Hg) in 7. Forced expiratory volume in 1 second (FEV1) was <80 predicted in 45, and 47 had subtle CXR abnormalities. The predominant HRCT pattern was decreased attenuation as part of a mosaic attenuation pattern (31 of 56 ), consistent with small airway disease and associated with bronchiectasis (Spearman correlation coefficient (r2 = 0.8) and reduced FEV1 (r2 =-0.26).Conclusions.Long-term survivors of vertically acquired HIV in Africa are at high risk of a previously undescribed small airway disease, with >40 of unselected adolescent clinic attendees meeting criteria for severe hypoxic CLD. This condition is not obvious at rest. Etiology, prognosis, and response to treatment are currently unknown. © 2012 The Author.