Decreased awareness of current smoking among health care providers of HIV-positive compared to HIV-negative veterans

Moving from viral suppression to comprehensive patient-centered care: the high prevalence of comorbid conditions and health risk factors in HIV-1-infected patients in Australia

HIV clinicians today need to move from focusing on viral suppression to a chronic disease model in which comorbid conditions and risk factors are comprehensively identified and addressed to reduce rates of serious non-AIDS-related morbidity and mortality. This study aimed to determine the prevalence of comorbid conditions in an Australian HIV-positive population. Of 180 patients included, there was a median CD4 count of 0.520 cells/mm(3). The majority (88%) of patients were currently receiving highly active antiretroviral therapy (HAART). There were high rates of failure to attend clinical appointments (30%), current smoking (42%), hypertension (16%), and dyslipidemia (17%). Significant rates of dipstick-positive proteinuria (16%) and elevated blood glucose (15%) were recorded. Risk factors were commonly not addressed by the treating clinician. There is an urgent need to systematize detection and management of high-prevalence comorbid conditions to prevent premature mortality associated with serious non-AIDS events.

Rates of cardiovascular disease following smoking cessation in patients with HIV infection: results from the D:A:D study(*)

OBJECTIVES

The aim of the study was to estimate the rates of cardiovascular disease (CVD) events after stopping smoking in patients with HIV infection.

METHODS

Patients who reported smoking status and no previous CVD prior to enrolment in the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) study were included in this study. Smoking status is collected at each visit as current smoker (yes/no) and ever smoker (yes/no). Time since stopping smoking was calculated for persons who had reported current smoking during follow-up and no current smoking subsequently. Endpoints were: myocardial infarction (MI); coronary heart disease (CHD: MI plus invasive coronary artery procedure or death from other CHD); CVD (CHD plus carotid artery endarterectomy or stroke); and all-cause mortality. Event rates were calculated for never, previous and current smokers, and smokers who stopped during follow-up. Incidence rate ratios (IRRs) were determined using Poisson regression adjusted for age, sex, cohort, calendar year, family history of CVD, diabetes, lipids, blood pressure and antiretroviral treatment.

RESULTS

A total of 27 136 patients had smoking status reported, with totals of 432, 600, 746 and 1902 MI, CHD, CVD and mortality events, respectively. The adjusted IRR of CVD in patients who stopped smoking during follow-up decreased from 2.32 within the first year of stopping to 1.49 after >3 years compared with those who never smoked. Similar trends were observed for the MI and CHD endpoints. Reductions in risk were less pronounced for all-cause mortality.

CONCLUSION

The risk of CVD events in HIV-positive patients decreased with increasing time since stopping smoking. Smoking cessation efforts should be a priority in the management of HIV-positive patients.

Mechanisms and genes involved in enhancement of HIV infectivity by tobacco smoke

HIV infection is more common among smokers than nonsmokers, and, remarkably, HIV-infected individuals are about 3 times more likely to smoke than the uninfected general population. However, the relationship between tobacco smoking and HIV/AIDS disease progression remains controversial. In this study, we demonstrate a potent enhancing effect of aqueous tobacco smoke extract (TSE) on HIV infectivity that is nicotine-independent. This increased infectivity is neither NF-κB mediated nor a direct result of oxidative stress, as it cannot be blocked by antioxidants. On the contrary, TSE itself was found to possess significant antioxidant potential, enabling it to protect the viability of both infected cells and HIV virions in the presence of peroxide. Assessment of TSE-induced alterations in cellular gene expression that may be involved in increasing HIV infectivity in T cells showed that TSE up-regulates some genes known to be capable of enhancing HIV and HCV infection, or protecting HIV, but down-regulates several genes involved in cellular defense and antigen presentation. These results demonstrate that tobacco smoke can enhance HIV infectivity, possibly by a combination of direct (antioxidant) and indirect (gene-based) mechanisms. This raises the concern that smoking may thereby increase the risk of acquisition or progression of HIV infection.

Pulmonary function abnormalities in HIV-infected patients during the current antiretroviral therapy era

RATIONALE

Before the introduction of combination antiretroviral (ARV) therapy, patients infected with HIV had an increased prevalence of respiratory symptoms and lung function abnormalities. The prevalence and exact phenotype of pulmonary abnormalities in the current era are unknown. In addition, these abnormalities may be underdiagnosed.

OBJECTIVES

Our objective was to determine the current burden of respiratory symptoms, pulmonary function abnormalities, and associated risk factors in individuals infected with HIV.

METHODS

Cross-sectional analysis of 167 participants infected with HIV who underwent pulmonary function testing.

MEASUREMENTS AND MAIN RESULTS

Respiratory symptoms were present in 47.3% of participants and associated with intravenous drug use (odds ratio [OR] 3.64; 95% confidence interval [CI], 1.32-10.046; P = 0.01). Only 15% had previous pulmonary testing. Pulmonary function abnormalities were common with 64.1% of participants having diffusion impairment and 21% having irreversible airway obstruction. Diffusion impairment was independently associated with ever smoking (OR 2.46; 95% CI, 1.16-5.21; P = 0.02) and Pneumocystis pneumonia prophylaxis (OR 2.94; 95% CI, 1.10-7.86; P = 0.01), whereas irreversible airway obstruction was independently associated with pack-years smoked (OR 1.03 per pack-year; 95% CI, 1.01-1.05; P < 0.01), intravenous drug use (OR 2.87; 95% CI, 1.15-7.09; P = 0.02), and the use of ARV therapy (OR 6.22; 95% CI, 1.19-32.43; P = 0.03).

CONCLUSIONS

Respiratory symptoms and pulmonary function abnormalities remain common in individuals infected with HIV. Smoking and intravenous drug use are still important risk factors for pulmonary abnormalities, but ARV may be a novel risk factor for irreversible airway obstruction. Obstructive lung disease is likely underdiagnosed in this population.

Smoking-related health risks among persons with HIV in the Strategies for Management of Antiretroviral Therapy clinical trial

OBJECTIVES

We sought to determine smoking-related hazard ratios (HRs) and population-attributable risk percentage (PAR%) for serious clinical events and death among HIV-positive persons, whose smoking prevalence is higher than in the general population.

METHODS

For 5472 HIV-infected persons enrolled from 33 countries in the Strategies for Management of Antiretroviral Therapy clinical trial, we evaluated the relationship between baseline smoking status and development of AIDS-related or serious non-AIDS events and overall mortality.

RESULTS

Among all participants, 40.5% were current smokers and 24.8% were former smokers. Adjusted HRs were higher for current than for never smokers for overall mortality (2.4; P < .001), major cardiovascular disease (2.0; P = .002), non-AIDS cancer (1.8; P = .008), and bacterial pneumonia (2.3; P < .001). Adjusted HRs also were significantly higher for these outcomes among current than among former smokers. The PAR% for current versus former and never smokers combined was 24.3% for overall mortality, 25.3% for major cardiovascular disease, 30.6% for non-AIDS cancer, and 25.4% for bacterial pneumonia.

CONCLUSIONS

Smoking contributes to substantial morbidity and mortality in this HIV-infected population. Providers should routinely integrate smoking cessation programs into HIV health care.

Smoking among HIV positive New Yorkers: prevalence, frequency, and opportunities for cessation

Tobacco use presents unique health risks for persons living with HIV/AIDS (PLWHA). There is an urgent need to characterize tobacco use among PLWHA, and to assess the capacity of HIV/AIDS service providers to deliver smoking cessation interventions. Questionnaires were administered to PLWHA in care in New York State (n = 1,094) and to State-funded HIV/AIDS service providers (n = 173) from 2005 to 2007. Current PLWHA smoking prevalence was 59%, three times the general population rate. Over 50% of current smokers were moderately or highly dependent on nicotine. Three-quarters of smokers indicated an interest in quitting, and 64% reported a least one quit attempt during the past year. Less than half of HIV/AIDS service providers reported always assessing tobacco use status, history, dependence, or interest in quitting at intake. Medical care providers were more likely to conduct assessments and provide services. Although 94% of providers indicated a willingness to incorporate tobacco cessation services, 65% perceived client resistance as a barrier to services. HIV/AIDS service providers are inadequately addressing the high smoking rate among PLWHA, despite being uniquely suited to do so. Efforts are needed to educate providers about the need for, and interest in, tobacco cessation.

Review: the need for smoking cessation among HIV-positive smokers

Most HIV-positive persons in the U.S. smoke cigarettes. Despite substantial clinical advances in HIV care in the era of highly active antiretroviral therapy (HAART), HIV-positive persons are at high risk of tobacco-related disease and death. HIV-positive persons have complex social, economic, psychiatric, and medical needs that may impact smoking behavior and response to smoking cessation interventions, but there is a dearth of research on smoking cessation interventions tailored to HIV-positive persons. HIV care providers should treat tobacco use with the array of evidence-based smoking cessation treatments available, updating their clinical practice as new data emerge. This article reviews the literature on the health consequences of tobacco use in HIV-positive persons, the treatment of tobacco dependence, and the research to date on smoking cessation interventions in HIV-positive persons, and it presents recommendations for future research and intervention.

Cigarette smoking and HIV: more evidence for action

As many as 50-70% of persons infected with HIV are current smokers. Compelling evidence concerning the risks of cigarette smoking to persons living with HIV urges the inclusion of smoking treatment protocols in contemporary models of HIV care. Yet in spite of growing awareness of this problem, persons living with HIV are not being effectively treated for tobacco use. To further an understanding of contributing factors and define directions for evidenced-based intervention, factors associated with smoking behavior among persons living with HIV are examined.

Chronic obstructive pulmonary disease in patients who have HIV infection

An increased prevalence of chronic obstructive pulmonary disease (COPD) among persons who have HIV infection has raised the possibility that HIV may predispose to the development or progression of COPD. This article reviews the evidence that supports an association between HIV infection and COPD-namely emphysema and chronic bronchitis-and studies that suggest an association between HIV infection and small airways abnormalities and nonspecific airway hyper-responsiveness. Risk factors for COPD and potential reasons for an increased risk for COPD in HIV-positive patients are discussed. In addition, issues in the management of COPD in HIV-positive patients are reviewed.