Smoking and HIV: confronting the epidemic

A clinical overview of people living with HIV and genitourinary cancer care

The number of people living with HIV infection has been increasing globally. Administration of antiretroviral therapy is effective in controlling the infection for most patients and, as a consequence, people living with HIV (PLWH) now often have a long life expectancy. However, their risk of developing cancer - most notably virus-related cancers - has been increasing. To date, few studies have assessed the risk of genitourinary cancers in PLWH, and robust scientific data on their treatment-related outcomes are lacking. Previous studies have noted that PLWH are at a reduced risk of prostate cancer; however, low adoption and/or availability of prostate cancer screening among these patients might be confounding the validity of this finding. In genitourinary cancers, advanced stage at diagnosis and reduced cancer-specific mortality have been reported in PLWH. These data likely reflect, at least in part, the inequity of health care access for PLWH. Notably, systemic chemotherapy and/or radiotherapy could decrease total CD4+ cell counts, which could, therefore, increase the risk of morbidity and mortality from cancer treatments in PLWH. Immune checkpoint inhibitors have become the therapeutic backbone for many advanced malignancies in the general population; however, most studies validating their efficacy have excluded PLWH owing to concerns of severe adverse effects from immune checkpoint inhibitors themselves and/or related to their immunosuppressed status. To our knowledge, no genitourinary cancer survivorship programme exists that specifically caters to the needs of PLWH. By including PLWH in ongoing cancer trials, we can gain invaluable insights that will help to improve cancer care specifically for PLWH.

Factors Associated with Periodontitis in Patients with and without HIV

Purpose

The aim of this study was to compare clinical periodontal conditions in HIV-positive people on HAART with an HIV-negative group, in addition to investigating factors associated with periodontitis in the entire sample.

Methods

This was a cross-sectional study. Data were collected by oral clinical examination for the diagnosis of periodontitis, review of medical records, and application of a questionnaire containing personal data, deleterious habits, and oral hygiene habits for the other variables. The results were analyzed by Pearson's χ ² test and Student's t-test. A logistic regression model was constructed for the multivariate analysis and periodontitis was defined as a dependent variable. The analysis was performed on the entire sample (HIV+ and HIV-) and also on the group consisting of only people living with HIV.

Results

Individuals older than 43 years old and with HIV were more likely to develop moderate and severe periodontitis (47.80 and 4.84 times, respectively). When analyzing only HIV+, in addition to age (OR = 2.795; CI = 1.080-7.233), the use of nonnucleoside reverse transcriptase inhibitors (NNRTIs) (OR = 2.841; CI = 1.135-7.112) was also associated with moderate and severe periodontitis.

Conclusion

It was possible to observe a higher prevalence of periodontitis among individuals with HIV, showing an association between the virus, advanced age, and moderate or severe periodontitis.

Tobacco use and cessation in the context of ART adherence: Insights from a qualitative study in HIV clinics in Uganda

Sub-Saharan Africa carries a disproportionate burden of human immunodeficiency virus (HIV). Tobacco use amongst people living with HIV is higher than in the general population even though it increases the risk of life-threatening opportunistic infections including tuberculosis (TB). Research on tobacco use and cessation amongst people living with HIV in Africa is sparse and it is not clear what interventions might achieve lasting cessation. We carried out qualitative interviews in Uganda in 2019 with 12 current and 13 former tobacco users (19 men and 6 women) receiving antiretroviral therapy (ART) in four contrasting locations. We also interviewed 13 HIV clinic staff. We found that tobacco use and cessation were tied into the wider moral framework of ART adherence, but that the therapeutic citizenship fashioned by ART regimes was experienced more as social control than empowerment. Patients were advised to stop using tobacco; those who did not concealed this from health workers, who associated both tobacco and alcohol use with ART adherence failure. Most of those who quit tobacco did so following the biographical disruption of serious TB rather than HIV diagnosis or ART treatment, but social support from family and friends was key to sustained cessation. We put forward a model of barriers and facilitators to smoking cessation and ART adherence based on engagement with either ‘reputation’ or ‘respectability’. Reputation involved pressure to enjoy tobacco with friends whereas family-oriented respectability demanded cessation, but those excluded by isolation or precarity escaped anxiety and depression by smoking and drinking with their peers.

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People living with HIV in Uganda hid their tobacco use from health workers.

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The experience of tuberculosis was the most common trigger to quit smoking.

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Engagement with ‘respectable’ masculinity promoted smoking cessation.

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Engagement with ‘reputational’ masculinity made it hard to quit.

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This model has wider applicability for antiretroviral therapy adherence.

Cancer Screening Patterns Among Current, Former, and Never Smokers in the United States, 2010-2015

IMPORTANCE

National guidelines recommend screening for several cancer types, yet screening rates remain below target. To date, cancer screening patterns by smoking status, a major cancer risk factor, are unknown.

OBJECTIVE

To assess cancer screening patterns among individuals who never smoked (never smokers), formerly smoked (former smokers), and currently smoke (current smokers) in the United States.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study assessed data from the National Health Interview Survey years 2010, 2013, and 2015. Adult participants (aged ≥18 years) who had never reported a cancer diagnosis were included in the analysis. Data were analyzed from August 1, 2018, through February 1, 2019.

EXPOSURES

Receipt of cancer screening, including colonoscopy, mammography, prostate-specific antigen testing, and Papanicolaou test per the US Preventive Services Task Force guidelines.

MAIN OUTCOMES AND MEASURES

Multivariable logistic regression defined adjusted odds ratios (AORs) and 95% CIs for undergoing cancer screening by smoking status. Among participants who received a specific screening test, AORs and 95% CIs of receiving the test within guideline-recommended intervals were also assessed.

RESULTS

Among 83 176 participants (45 851 [55.1%] women; mean [SD] age, 47 [18] years), 51 014 (61.3%) were never smokers; 17 235 (20.7%), former smokers; and 14 927 (17.9%), current smokers. Compared with never smokers, current smokers were less likely to ever have received a colonoscopy (43.8% vs 57.7%; AOR, 0.74; 95% CI, 0.68-0.82; P < .001), mammogram (88.8% vs 93.3%; AOR, 0.70; 95% CI, 0.57-0.87; P = .001), or prostate-specific antigen test (46.1% vs 60.8%; AOR, 0.76; 95% CI, 0.64-0.90; P = .001). Among those who had ever received a specific screening test, current smokers were less likely to have undergone colonoscopy (92.1% vs 95.1%; AOR, 0.75; 95% CI, 0.59-0.96; P = .02), mammography (62.4% vs 79.4%; AOR, 0.52; 95% CI, 0.45-0.60; P < .001), or Papanicolaou test (80.9% vs 90.8%; AOR, 0.61; 95% CI, 0.56-0.67; P < .001) within the recommended time frame compared with never smokers. Former smokers were more likely than never smokers to undergo any of the screening studies evaluated, with the exception of prostate-specific antigen screening (colonoscopy, 65.2% vs 57.7%; AOR, 1.20; 95% CI, 1.12-1.30; P < .001; mammography, 95.7% vs 93.3%; AOR, 1.35; 95% CI, 1.07-1.70; P = .01; Papanicolaou test, 97.6% vs 91.4%; AOR, 2.51; 95% CI, 1.93-3.26; P < .001).

CONCLUSIONS AND RELEVANCE

This study found that current smokers appeared to be less likely to receive guideline-concordant screening studies for breast, prostate, and colorectal cancer compared with never smokers. Further research is needed to identify barriers to screening among current smokers with the goal of increasing acceptance and uptake of cancer screening among this population at high risk of cancer.

A Face-Aging App for Smoking Cessation in a Waiting Room Setting: Pilot Study in an HIV Outpatient Clinic

BACKGROUND

There is strong evidence for the effectiveness of addressing tobacco use in health care settings. However, few smokers receive cessation advice when visiting a hospital. Implementing smoking cessation technology in outpatient waiting rooms could be an effective strategy for change, with the potential to expose almost all patients visiting a health care provider without preluding physician action needed.

OBJECTIVE

The objective of this study was to develop an intervention for smoking cessation that would make use of the time patients spend in a waiting room by passively exposing them to a face-aging, public morphing, tablet-based app, to pilot the intervention in a waiting room of an HIV outpatient clinic, and to measure the perceptions of this intervention among smoking and nonsmoking HIV patients.

METHODS

We developed a kiosk version of our 3-dimensional face-aging app Smokerface, which shows the user how their face would look with or without cigarette smoking 1 to 15 years in the future. We placed a tablet with the app running on a table in the middle of the waiting room of our HIV outpatient clinic, connected to a large monitor attached to the opposite wall. A researcher noted all the patients who were using the waiting room. If a patient did not initiate app use within 30 seconds of waiting time, the researcher encouraged him or her to do so. Those using the app were asked to complete a questionnaire.

RESULTS

During a 19-day period, 464 patients visited the waiting room, of whom 187 (40.3%) tried the app and 179 (38.6%) completed the questionnaire. Of those who completed the questionnaire, 139 of 176 (79.0%) were men and 84 of 179 (46.9%) were smokers. Of the smokers, 55 of 81 (68%) said the intervention motivated them to quit (men: 45, 68%; women: 10, 67%); 41 (51%) said that it motivated them to discuss quitting with their doctor (men: 32, 49%; women: 9, 60%); and 72 (91%) perceived the intervention as fun (men: 57, 90%; women: 15, 94%). Of the nonsmokers, 92 (98%) said that it motivated them never to take up smoking (men: 72, 99%; women: 20, 95%). Among all patients, 102 (22.0%) watched another patient try the app without trying it themselves; thus, a total of 289 (62.3%) of the 464 patients were exposed to the intervention (average waiting time 21 minutes).

CONCLUSIONS

A face-aging app implemented in a waiting room provides a novel opportunity to motivate patients visiting a health care provider to quit smoking, to address quitting at their subsequent appointment and thereby encourage physician-delivered smoking cessation, or not to take up smoking.