Prevention of bacterial pneumonia in HIV infection: focus on smoking cessation

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.

The clinical implications of HIV infection and aging

The objectives of this study, presented as part of a plenary session at WW7 in Hyderabad, India were to review (i) the epidemiology and current clinical issues of HIV infection with regard to HIV and older populations and (ii) models for increased morbidity and mortality in older HIV-positive individuals with implications for clinical care. HIV infection for those in treatment has become a complex chronic disease in which end-organ injury and resulting morbidity, functional decline, and mortality do not have a single etiology but reflect cumulative loss of organ system reserve from multiple interacting sources leading to functional decline, organ system failure, and death. Emerging guidelines and recommendations suggest a need for increased awareness and treatment of the multifaceted needs of the aging HIV-infected patient.

HIV-related pneumococcal disease prevention in adults

INTRODUCTION

HIV-infected persons are particularly susceptible to the development of severe pneumococcal disease, even in the setting of combination antiretroviral therapy (cART), due to slow, incomplete recovery of anti-pneumococcal host defenses. This risk is increased by avoidable aspects of lifestyle, particularly smoking, which intensify immunosuppression. Clearly, more effective preventive measures are needed to counter this threat. Areas covered: This is a detailed review of the published literature focusing on currently available strategies for prevention of pneumococcal infection in HIV-infected patients, including cotrimoxazole prophylaxis, cART, pneumococcal vaccination, and smoking cessation strategies. This is preceded by a consideration of the epidemiology, clinical presentation, risk factors, and outcome of pneumococcal disease. Expert commentary: Cotrimoxazole prophylaxis has been shown to reduce morbidity and mortality in HIV-infected patients, although there is inconsistent data on the preventive efficacy against pneumococcal infections. Some recent studies have documented unchanged incidences of IPD in adult patients in the cART era. With regard to pneumococcal vaccination, routine acceptance of the efficacy of the PCV13/PPV23 sequential administration prime-boost strategy awaits the outcome of clinical trials in those with HIV infection. Smoking cessation, and discontinuation of excessive alcohol consumption and intravenous drug abuse, are priority strategies to prevent severe pneumococcal infection.

Impact of HIV infection and smoking on lung immunity and related disorders

HIV-infected persons not only have higher rates of smoking than the general population, but are also unusually vulnerable to the associated adverse health effects, both infective and noninfective in origin. Indeed, in the setting of well-organised care and availability of highly active antiretroviral therapy, HIV-infected smokers lose more life-years to smoking than to HIV infection per se, presenting a major challenge to healthcare providers. Not surprisingly, the respiratory system is particularly susceptible to the damaging interactive chronic inflammatory and immunosuppressive effects of HIV and smoking, intensifying the risk of the development of opportunistic infections, as well as lung cancer and obstructive lung disorders. The impact of smoking on the immunopathogenesis and frequencies of these respiratory conditions in the setting of HIV infection, as well as on the efficacy of antiretroviral therapy, represent the primary focus of this review.

Interventions to address chronic disease and HIV: strategies to promote smoking cessation among HIV-infected individuals

Tobacco use, especially cigarette smoking, is higher than average in persons living with HIV/AIDS (PLWHA). The Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence states that, during every medical encounter, all smokers should be offered smoking cessation counseling, along with approved medications. The Guideline also recognizes PLWHA as a priority population, given the scarcity of research on effective cessation treatments in this group. The scant evidence suggests that conventional treatments, though worthwhile, are not as successful as might be hoped for. The reasons for this are not entirely clear, but may have to do with the complex array of medical and psychosocial factors that complicate their lives. Clinicians should consider re-treatment strategies for those patients who encounter difficulty when quitting smoking with conventional approaches, switching or augmenting treatments as needed to minimize adverse experiences, and to maximize tolerability, adherence, and cessation outcomes.

Vanishing lung syndrome and HIV infection: an uncommon yet potentially fatal sequela of cigarette smoking

Persons with HIV infection have a higher risk of infectious pulmonary complications, chronic obstructive pulmonary disease, lung cancer, pulmonary hypertension, and pulmonary fibrosis than individuals not infected with HIV. Herein, we describe the clinical course of a patient with longstanding and well-controlled HIV infection and multiple previous pneumothoraces who presented to medical attention with insidious onset of shortness of breath and was diagnosed with vanishing lung syndrome (VLS). The VLS or giant bullous emphysema is a distinct clinical syndrome characterized by large bullae, predominantly in the upper lobes, occupying at least one third of the hemithorax and compressing surrounding normal lung parenchyma. It is a progressive disorder that typically occurs in young men, the majority of whom are smokers. As people with HIV/AIDS are now surviving well into middle age and beyond, clinicians are more likely to encounter VLS and severe obstructive lung disease, which are potentially fatal but preventable conditions.