How to address smoking cessation in HIV patients

COPD in People with HIV: Epidemiology, Pathogenesis, Management, and Prevention Strategies

Chronic obstructive pulmonary disease (COPD) is a progressive respiratory disorder characterized by airflow limitation and persistent respiratory symptoms. People with HIV (PWH) are particularly vulnerable to COPD development; PWH have demonstrated both higher rates of COPD and an earlier and more rapid decline in lung function than their seronegative counterparts, even after accounting for differences in cigarette smoking. Factors contributing to this HIV-associated difference include chronic immune activation and inflammation, accelerated aging, a predilection for pulmonary infections, alterations in the lung microbiome, and the interplay between HIV and inhalational toxins. In this review, we discuss what is known about the epidemiology and pathobiology of COPD among PWH and outline screening, diagnostic, prevention, and treatment strategies.

Developing and pre-testing a digital decision-tree smartphone application for smoking prevention and cessation among HIV care providers

Objectives

The diagnosis and continuous care of chronic conditions such as HIV infection present potential teachable moments for delivering smoking prevention and cessation interventions for patients. We designed and pre-tested a prototype of a smartphone application(app), Decision-T, specifically designed to assist healthcare providers when providing personalized smoking prevention and cessation services to their patients.

Methods

We developed the Decision-T app based on transtheoretical algorithm for smoking prevention and cessation following the 5-A's model. We employed a mixed-methods approach among 18 HIV-care providers recruited from Houston Metropolitan Area for pre-testing the app. Each provider participated in three mock sessions, and the average time spent at each session was measured. We measured accuracy by comparing the smoking prevention and cessation treatment offered by the HIV-care provider using the app to that chosen by the tobacco specialist who designed the case. The system usability scale (SUS) was used to assess usability quantitatively , while individual interview transcripts were analyzed to determine usability qualitatively. STATA-17/SE and Nvivo-V12 were used for quantitative and qualitative analysis, respectively.

Results

The average time for completing each mock session was 5 min 17 s. The participants achieved an overall average accuracy of 89.9%. The average SUS score achieved was 87.5(±10.26). After analyzing the transcripts, five themes (app's contents are beneficial and straightforward, design is easy to understand, user's experience is uncomplicated, tech is intuitive, and app needs improvements) emerged.

Conclusions

The decision-T app can potentially increase HIV-care providers' engagement in offering smoking prevention and cessation behavioral and pharmacotherapy recommendations to their patients briefly and accurately.

Low Rates of Lung Cancer Screening Referrals in Patients With Human Immunodeficiency Virus: A Correlational Study

People living with HIV (PLWH) have an increased risk of lung cancer compared to the general population. In 2013, the United States Preventive Services Task Force (USPSTF) released their lung cancer screening (LCS) guidelines. However, the impact of these guidelines has not been well established in PLWH. The objective of this retrospective descriptive study is to evaluate the frequency of lung cancer screening referrals and factors associated with LCS referrals using the 2013 USPSTF screening guidelines in at-risk PLWH. We collected demographic and clinical information on PLWH from electronic medical records from July 2016 to July 2018. Descriptive statistics, chi-square tests, t-tests, Wilcoxon rank sum tests, and Fisher’s exact tests were used for analysis. Only 14% of patients who met 2013 USPSTF screening guidelines were referred for screening. Patients who received a referral were more likely to have received tobacco cessation counseling. Patients who received and completed a referral were more likely to have hepatitis C infection. Quality improvement strategies are needed to improve rates of LCS in PLWH.

Is It Feasible to Impact on Smoking Habits in HIV-Infected Patients? Mission Impossible From the STOPSHIV Project Cohort

OBJECTIVE

Assessment of the feasibility and effectiveness of a brief intervention for smoking cessation in people living with HIV (PLWH).

SETTING

Multicenter cohort prospective study involving PLWH from 10 Italian infectious disease centers.

METHODS

During routine HIV care, clinicians delivered the 5As brief intervention (Ask, Advise, Assess, Assist, Arrange) to each patient who enrolled in the study, following the European AIDS Clinical Society guidelines. At study end, participating clinicians evaluated their own adherence to intervention: "standard" if counseling was delivered in at least half of the follow-up visits, "soft" if less. The main outcome measure was smoking abstinence ≥6 months. Abstinence predictors were evaluated using a Cox-proportional hazard regression model.

RESULTS

One thousand eighty-seven PLWH-patients (age 47.9 ± 10.8, male 73.5%) were followed for a median of 23 months (interquartile range 21-25). At baseline, current smokers were 561 (51.6%). Standard intervention was performed in 4 of 10 centers and included 343 smokers; soft intervention was performed in 6 centers (218 smokers). At last visit, 35 patients in standard (10.8%) and 6 in soft intervention (2.8%) achieved self-reported tobacco abstinence ≥6 months (P = 0.0009). Overall, the 5As intervention led to 7.3% 6-month interruptions. In the multivariable analysis, significant predictors for 6-month smoking cessation were: lower Fagerström score, stage of change (preparation/contemplation vs. precontemplation), and standard intervention.

CONCLUSION

Adherence to the 5As brief intervention emerged as a critical factor for success. In fact, compared with soft intervention, the standard intervention significantly increased abstinence, highlighting that clinicians need more time and supporting tools to encourage PLWH to quit smoking.

A Cross-Sectional Analysis of Tobacco Use and Concurrent Alcohol and Substance Use Among Patients Living with HIV/HCV Co-infection: Findings from a Large Urban Tertiary Center

This study aimed to assess the prevalence of and factors associated with tobacco use among patients living with HIV/HCV co-infection. Patient reported outcomes (PROs) were analyzed of patients living with HIV/HCV co-infection (n = 313) who presented for clinical evaluation and treatment of HCV between 2013 and 2017 at a university-affiliated HIV/HCV Co-infection Clinic. The prevalence of tobacco use in patients living with HIV/HCV co-infection was 48%. Compared to non-smokers, a higher proportion of tobacco smokers had substance use disorders and concurrent alcohol and substance use. In the multivariate analysis, concurrent alcohol and substance use was positively associated with tobacco use. The findings suggest clinical interventions are urgently needed to reduce tobacco use among patients living with HIV/HCV co-infection—a doubly-vulnerable immunocompromised population. Otherwise, failed efforts to dedicate resources and targeted behavioral interventions for this respective population will inhibit survival—especially considering the recent and evolving COVID-19 pandemic.

Smoking and cessation treatment among persons with and without HIV in a U.S. integrated health system

BACKGROUND

Persons with HIV (PWH) are more likely to smoke and are more susceptible to the harmful effects of smoking than persons without HIV. We examined smoking patterns and use of cessation treatment among PWH and persons without HIV in a U.S. integrated health system.

METHODS

We identified adults (≥18 years) with HIV and demographically-matched persons without HIV between July 2013 and December 2017. Smoking status and cessation treatment were ascertained from health records. We calculated age-standardized annual prevalence of smoking and evaluated trends using Cochran-Armitage tests and Poisson regression. Factors associated with cessation treatment during the study period, and smoking in the last year of the study, were evaluated by HIV status using multivariable Poisson models.

RESULTS

The study included 11,235 PWH and 227,320 persons without HIV. Smoking prevalence was higher among PWH across all years but declined for both groups (from 16.6% to 14.6% in PWH and 11.6% to 10.5% in persons without HIV). Among smokers, PWH were more likely to initiate cessation treatment compared to persons without HIV (17.9% vs. 13.3%, covariate-adjusted prevalence ratio of 1.31, 95% CI = 1.15-1.50), with few differences in cessation treatment across subgroups of PWH. In 2017, smoking prevalence remained higher in PWH, especially among those who were younger or who had diagnoses of depression or substance use disorder.

CONCLUSION

In a setting with access to cessation resources, smoking prevalence decreased both in PWH and persons without HIV. PWH had greater uptake of cessation treatment, which is encouraging for smoking reduction and improved health.

Smoking habits in HIV-infected people compared with the general population in Italy: a cross-sectional study

Background

Tobacco use is a leading cause of preventable diseases and death for all individuals, even more so for people living with HIV (PLWH), due to their status of chronic inflammation. To date, in Italy no study was performed to compare smoking habits in PLWH and the general population. We aimed to investigate smoking habits in PLWH, as compared to the general population.

Methods

Multi-center cross-sectional study. Smoking habits were compared between PLWH and the general population. PLWH were enrolled in the STOPSHIV Study. The comparison group from the general population was derived from a survey performed by the National Statistics Institute (ISTAT), with a stratified random sampling procedure matching 2:1 general population subjects with PLWH by age class, sex, and macro-area of residence.

Results

The total sample consisted of 1087 PLWH (age 47.9 ± 10.8 years, male 73.5%) and 2218 comparable subjects from the general population. Prevalence of current smokers was 51.6% vs 25.9% (p < 0.001); quitting smoking rate was 27.1% vs. 50.1% (p < 0.001) and the mean number of cigarettes smoked per day was 15.8 vs. 11.9 (p < 0.001), respectively for PLWH and the general population. Smoking and heavy smoking rates amongst PLWH were significantly higher even in subjects who reported diabetes, hypertension and extreme obesity (p < 0.001). Logistic regressions showed that PLWH were more likely current smokers (adjusted Odds Ratio, aOR = 3.11; 95% Confidence Interval (CI) =2.62–3.71; p < 0.001) and heavy smokers (> 20 cigarettes per day) (aOR = 4.84; 95% CI = 3.74–6.27; p < 0.001). PLWH were less likely to have quitted smoking (aOR = 0.36; 95% CI = 0.29–0.46; p < 0.001).

Conclusion

HIV-infected patients showed a higher rate of current smokers, a larger number of cigarettes smoked and a lower quitting rate than the general population. Our findings emphasize the need for smoking cessation strategies targeting HIV persons.

Acceptability of electronic nicotine delivery systems (ENDS) among HIV positive smokers

Electronic nicotine delivery systems (ENDS) have the potential to help smokers living with HIV/AIDS (PLWHA) to reduce harms from tobacco use. However, little is known about ENDS use among PLWHA. This study's aim was to evaluate the acceptability of two types of ENDS among PLWHA not planning to quit smoking. The study utilized a cross-over design where participants used two ENDS in a random order as smoking substitutes during two use periods separated by 7 days. Exhaled carbon monoxide (CO) was analyzed and participants reported daily cigarette and ENDS use and completed ratings on ENDS acceptability. Participants (n = 17) were a mean age of 49.1 years (SD = 8.8), were 53% white, and 59% male. All participants had controlled HIV disease status. Participants smoked a mean of 16.9 (SD = 7.9) CPD at baseline. Overall, CPD significantly decreased during both ENDS use periods (p < .01) but there were no differences in reduction between the different devices. CO decreased from baseline to follow-up only during the button-activated ENDS use period (p = .03), but there were no differences between ENDS devices. There were no significant differences in ratings of acceptability between ENDS devices. These results suggest that ENDS could be a harm reduction tool for smokers with HIV.

The relationship between health-related variables and increases in smoking among recently diagnosed HIV+ people who inject drugs in Vietnam

BACKGROUND

In Vietnam tobacco smoking is prevalent among people living with HIV (PLHIV) and causes excess mortality in this population. Injection drug use is a driver of HIV infections in Vietnam. Changes in HIV disease state may correlate to changes in smoking among PLHIV. This study investigates the relationship between increases in smoking and health-related variables among recently diagnosed HIV+ people who inject drugs (PWID) in Vietnam.

METHODS

We analyzed longitudinal data from 323 recently diagnosed HIV+ PWID in a randomized controlled trial from 2009 to 2013 in Thai Nguyen province, Vietnam. The outcome was an increase of >one cigarette/day from baseline visit cigarette smoking. A generalized estimating equation for repeated measures was used to estimate bivariable and multivariable associations between participant characteristics and smoking increases. We collected qualitative data to enhance our understanding of quantitative results, from 16 HIV+ PWID who smoke.

RESULTS

Ninety three point 5% of participants reported some smoking at baseline. Smoking fewer cigarettes, higher health related quality of life (QOL), and higher CD4 counts were predictive of increases in smoking at future visits in a multivariable model. Qualitative data showed smoking increases were tied to improved perceived health, and counseling during respiratory illnesses may increase intention to quit.

CONCLUSION

HIV+ PWID in Vietnam smoke at a very high rate. Increases in their smoking are correlated to increases in heath-related QOL, and increases in perceptions of health. Any tobacco-use intervention should account for internal tobacco use triggers faced by HIV+ PWID.

Delivery and implementation of an algorithm for smoking cessation treatment for people living with HIV and AIDS

Compared to the general population, persons living with HIV (PLWH) have higher rates of tobacco use and an increased risk of morbidity from tobacco-related diseases. We conducted a single-arm pilot study of the real-world feasibility of integrating a smoking cessation decisional algorithm within routine clinic visits to engage non-treatment-seeking smokers in smoking cessation therapies. Smokers had an initial study visit during routine care followed by phone contacts at one and three months. Participants completed a baseline survey, followed by the algorithm which resulted in a recommendation for a smoking cessation medication, which was prescribed during the visit. Follow-up phone surveys assessed changes in smoking behavior and use of cessation medications at 1 and 3 months. Participants' (N = 60) self-reported smoking decreased from a baseline average of 14.4 cigarettes/day to 7.1 cigarettes/day at 3 months (p = .001). Nicotine dependence (FTND) decreased from 5.6 at baseline to 3.6 at 3 months (p < .001). Twenty-seven (45%) made a 24-h quit attempt and 39 (65%) used cessation medication. Insurance prior-authorization delayed medication receipt for seven participants and insurance denial occurred for one. Motivational status did not significantly influence outcomes. The algorithm was successful in engaging participants to use cessation medications and change smoking behaviors.

Substance Use Among Older People Living With HIV: Challenges for Health Care Providers

Older people living with HIV (OPLWH) have higher rates of substance use (tobacco, alcohol, and other drugs) than their HIV-negative peers. Addressing health care needs of OPLWH who use substances is more challenging than for those who do not: they are highly impacted by comorbid conditions, substance use can interact with other medications (including antiretroviral therapy-ART) and reduce their effectiveness, and substance use has been associated with reduced adherence to ART and increased risky behaviors (including sexual risks). People who use substances also suffer disparities along the HIV continuum of care, resulting in lower viral suppression rates and poorer health outcomes. They are especially impacted by stigma and stress, which have implications for HIV treatment and care. Recommendations for health care providers working with OPLWH who use substances include: (1) the need to screen and refer for multiple associated conditions, and (2) training/continuing education to enhance care management and maximize health outcomes.

Use of Smoking Cessation Aids in a Convenience Sample of PLHIV in a Canadian Tertiary Care Clinic

Background:

Tobacco smoking is among the most significant predictors of cardiovascular disease and lung cancer in People Living with HIV (PLHIV). Smoking rates in this population are high, necessitating more effective smoking cessation strategies. We conducted a descriptive analysis of tobacco-related clinical and sociodemographic characteristics of smokers at a tertiary care HIV clinic in Montreal and an exploratory analysis of smoking cessation methods in order to identify potential areas of improvement in the clinic’s approach to smoking cessation.

Methods:

A convenience sample of patients completed a 10-minute questionnaire on tobacco-related behaviours and outcomes. Use of smoking cessation methods was compared using McNemar’s exact test with a Bonferroni correction for multiple testing (p<0.01 considered significant).

Results:

Seventy-two PLHIV participated. Two-thirds of our total participants were interested in quitting within six months, but the use of effective cessation strategies was low, particularly for counseling and oral therapy. Overall, oral therapy (e.g. varenicline) (16.7%) and counseling for cessation (5.6%) were used less than nicotine patches (50.0%) or ‘other’ methods (50.0%), which included abstinence and nicotine gum (p<0.001).

Conclusion:

Despite a small and potentially unrepresentative sample of HIV positive tobacco smokers at our clinic, this study could help guide further research aiming to determine and address barriers to smoking cessation and access to effective smoking cessation aids in PLHIV. Future studies might consider factors that affect motivation to quit, such as co-morbid mental health and substance use disorders, or the attitudes of HIV healthcare providers.

Cancer screening in women living with HIV infection

The number of women living with HIV continues to increase. Thirty years into the AIDS epidemic, we now expect those with access to highly active antiretroviral to survive into their seventh decade of life or beyond. Increasingly, the focus of HIV care is evolving from preventing opportunistic infections and treating AIDS-defining malignancies to strategies that promote longevity. This holistic approach to care includes detection of malignancies that are associated with certain viral infections, with chronic inflammation, and with lifestyle choices. The decision to screen an HIV-infected women for cancer should include an appreciation of the individualized risk of cancer, her life expectancy, and an attempt to balance these concerns with the harms and benefits associated with specific cancer screening tests and their potential outcome. Here, we review cancer screening strategies for women living with HIV/AIDS with a focus on cancers of the lung, breast, cervix, anus, and liver.

Clinical Characteristics and Outcomes Among Older Women with HIV

OBJECTIVES

To inform the development of HIV care strategies for older women with HIV infection, an understudied group, we compared the psychosocial, behavioral, and clinical characteristics of HIV-positive women aged ≥50 (older women) with those aged 18-49 (younger women).

METHODS

We examined factors among HIV-positive women in care using data from the 2009 through 2013 cycles of a nationally representative sample of HIV-positive adults in care (Medical Monitoring Project). We compared psychosocial, clinical, and behavioral factors among women aged ≥50 years at interview versus those aged <50 years. We calculated weighted frequency estimates and performed logistic regression to compute adjusted prevalence ratios (aPR) and 95% confidence intervals (CIs) for the comparison of characteristics among women aged ≥50 versus <50 years.

RESULTS

Of 22,145 participants, 6186 were women; 40.7% (CI 39.1-42.3) were ≥50 years, and 32.7% of older women reported being sexually active. Compared with women <50 years, women aged ≥50 years were more likely to be dose adherent (aPR = 1.19; CI 1.07-1.33), prescribed antiretroviral therapy and have sustained viral load suppression (aPR = 1.03; CI 1.00-1.18), and were less likely to report any depression (aPR = 0.92; CI 0.86-0.99), to report condomless sex with a negative or unknown partner if sexually active (aPR = 0.56; CI 0.48-0.67), and to have received HIV/sexually transmitted infection (STI) prevention counseling from a healthcare provider (aPR = 0.82; CI 0.76-0.88).

CONCLUSIONS

These data suggest that older women in HIV care have more favorable outcomes in some clinical areas, but may warrant increased HIV/STI prevention counseling from their care providers, especially if sexually active.

Effects of Cigarette Smoke Condensate on Oxidative Stress, Apoptotic Cell Death, and HIV Replication in Human Monocytic Cells

While cigarette smoking is prevalent amongst HIV-infected patients, the effects of cigarette smoke constituents in cells of myeloid lineage are poorly known. Recently, we have shown that nicotine induces oxidative stress through cytochrome P450 (CYP) 2A6-mediated pathway in U937 monocytic cells. The present study was designed to examine the effect of cigarette smoke condensate (CSC), which contains majority of tobacco constituents, on oxidative stress, cytotoxicity, expression of CYP1A1, and/or HIV-1 replication in HIV-infected (U1) and uninfected U937 cells. The effects of CSC on induction of CYP1 enzymes in HIV-infected primary macrophages were also analyzed. The results showed that the CSC-mediated increase in production of reactive oxygen species (ROS) in U937 cells is dose- and time-dependent. Moreover, CSC treatment was found to induce cytotoxicity in U937 cells through the apoptotic pathway via activation of caspase-3. Importantly, pretreatment with vitamin C blocked the CSC-mediated production of ROS and induction of caspase-3 activity. In U1 cells, acute treatment of CSC increased ROS production at 6H (>2-fold) and both ROS (>2 fold) and HIV-1 replication (>3-fold) after chronic treatment. The CSC mediated effects were associated with robust induction in the expression of CYP1A1 mRNA upon acute CSC treatment of U937 and U1 cells (>20-fold), and upon chronic CSC treatment to U1 cells (>30-fold). In addition, the CYP1A1 induction in U937 cells was mediated through the aromatic hydrocarbon receptor pathway. Lastly, CSC, which is known to increase viral replication in primary macrophages, was also found to induce CYP1 enzymes in HIV-infected primary macrophages. While mRNA levels of both CYP1A1 and CYP1B1 were elevated following CSC treatment, only CYP1B1 protein levels were increased in HIV-infected primary macrophages. In conclusion, these results suggest a possible association between oxidative stress, CYP1 expression, and viral replication in CSC-treated cells of myeloid lineage. This study warrants a closer examination of the role of CYP1B1 in smoking-mediated enhanced HIV replication.