Interventions for tobacco use cessation in people living with HIV and AIDS

Perspectives on Clinical Pharmacist-Delivered Contingency Management to Promote Smoking Abstinence Among Individuals with HIV: A Qualitative Study

Contingency management (CM), an evidence-based behavioral strategy that rewards positive behavior change including tobacco cessation, is rarely offered to support people with HIV (PWH) who smoke. In this study, we explored perspectives among patients and research staff engaged in a multi-site randomized clinical trial involving clinical pharmacist-delivered CM within HIV clinics. Between February and September 2023, we conducted 1:1 interviews with 12 PWH randomized to receive CM and one focus group with 8 staff (i.e., clinical pharmacists and research coordinators). Qualitative data collection and analysis were grounded in the Promoting Action on Research Implementation in Health Services (PARIHS) implementation science framework to understand barriers and facilitators related to evidence (perspectives on CM for smoking cessation), context (HIV clinics), and facilitation (promoting effectiveness and sustainability). Regarding evidence, PWH and staff had limited prior experience with CM and supported the use of exhaled carbon monoxide to promote accountability. PWH and staff thought CM was useful in bolstering internal motivation, but differed on ideal target behaviors (i.e., cessation vs. reduction). Regarding context, clinical pharmacist-delivered tobacco treatment within HIV clinics was viewed favorably, with mixed perspectives regarding optimal visit schedules and utility of remote CM. Regarding facilitation, PWH and research staff discussed strategies to increase participant engagement and retention such as incorporating behavioral counseling services. PWH endorsed application of CM beyond smoking cessation and for people without HIV. Future efforts should consider expanding the use of CM to target smoking cessation and related health behaviors and tailoring the intervention to individual needs and goals.

Interventions for tobacco use cessation in people living with HIV

BACKGROUND

The prevalence of tobacco use among people living with HIV (PLWH) is up to four times higher than in the general population. Unfortunately, tobacco use increases the risk of progression to AIDS and death. Individual- and group-level interventions, and system-change interventions that are effective in helping PLWH stop using tobacco can markedly improve the health and quality of life of this population. However, clear evidence to guide policy and practice is lacking, which hinders the integration of tobacco use cessation interventions into routine HIV care. This is an update of a review that was published in 2016. We include 11 new studies.

OBJECTIVES

To assess the benefits, harms and tolerability of interventions for tobacco use cessation among people living with HIV. To compare the benefits, harms and tolerability of interventions for tobacco use cessation that are tailored to the needs of people living with HIV with that of non-tailored cessation interventions.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialised Register, CENTRAL, MEDLINE, Embase, and PsycINFO in December 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of individual-/group-level behavioural or pharmacological interventions, or both, for tobacco use cessation, delivered directly to PLWH aged 18 years and over, who use tobacco. We also included RCTs, quasi-RCTs, other non-randomised controlled studies (e.g. controlled before and after studies), and interrupted time series studies of system-change interventions for tobacco use cessation among PLWH. For system-change interventions, participants could be PLWH receiving care, or staff working in healthcare settings and providing care to PLWH; but studies where intervention delivery was by research personnel were excluded. For both individual-/group-level interventions, and system-change interventions, any comparator was eligible.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods, and used GRADE to assess certainty of the evidence. The primary measure of benefit was tobacco use cessation at a minimum of six months. Primary measures for harm were adverse events (AEs) and serious adverse events (SAEs). We also measured quit attempts or quit episodes, the receipt of a tobacco use cessation intervention, quality of life, HIV viral load, CD4 count, and the incidence of opportunistic infections.

MAIN RESULTS

We identified 17 studies (16 RCTs and one non-randomised study) with a total of 9959 participants; 11 studies are new to this update. Nine studies contributed to meta-analyses (2741 participants). Fifteen studies evaluated individual-/group-level interventions, and two evaluated system-change interventions. Twelve studies were from the USA, two from Switzerland, and there were single studies for France, Russia and South Africa. All studies focused on cigarette smoking cessation. All studies received funding from independent national- or institutional-level funding. Three studies received study medication free of charge from a pharmaceutical company. Of the 16 RCTs, three were at low risk of bias overall, five were at high risk, and eight were at unclear risk. Behavioural support or system-change interventions versus no or less intensive behavioural support Low-certainty evidence (7 studies, 2314 participants) did not demonstrate a clear benefit for tobacco use cessation rates in PLWH randomised to receive behavioural support compared with brief advice or no intervention: risk ratio (RR) 1.11, 95% confidence interval (CI) 0.87 to 1.42, with no evidence of heterogeneity. Abstinence at six months or more was 10% (n = 108/1121) in the control group and 11% (n = 127/1193) in the intervention group. There was no evidence of an effect on tobacco use cessation on system-change interventions: calling the quitline and transferring the call to the patient whilst they are still in hospital ('warm handoff') versus fax referral (RR 3.18, 95% CI 0.76 to 13.99; 1 study, 25 participants; very low-certainty evidence). None of the studies in this comparison assessed SAE. Pharmacological interventions versus placebo, no intervention, or another pharmacotherapy Moderate-certainty evidence (2 studies, 427 participants) suggested that varenicline may help more PLWH to quit smoking than placebo (RR 1.95, 95% CI 1.05 to 3.62) with no evidence of heterogeneity. Abstinence at six months or more was 7% (n = 14/215) in the placebo control group and 13% (n = 27/212) in the varenicline group. There was no evidence of intervention effects from individual studies on behavioural support plus nicotine replacement therapy (NRT) versus brief advice (RR 8.00, 95% CI 0.51 to 126.67; 15 participants; very low-certainty evidence), behavioural support plus NRT versus behavioural support alone (RR 1.47, 95% CI 0.92 to 2.36; 560 participants; low-certainty evidence), varenicline versus NRT (RR 0.93, 95% CI 0.48 to 1.83; 200 participants; very low-certainty evidence), and cytisine versus NRT (RR 1.18, 95% CI 0.66 to 2.11; 200 participants; very low-certainty evidence). Low-certainty evidence (2 studies, 427 participants) did not detect a difference between varenicline and placebo in the proportion of participants experiencing SAEs (8% (n = 17/212) versus 7% (n = 15/215), respectively; RR 1.14, 95% CI 0.58 to 2.22) with no evidence of heterogeneity. Low-certainty evidence from one study indicated similar SAE rates between behavioural support plus NRT and behavioural support only (1.8% (n = 5/279) versus 1.4% (n = 4/281), respectively; RR 1.26, 95% CI 0.34 to 4.64). No studies assessed SAEs for the following: behavioural support plus NRT versus brief advice; varenicline versus NRT and cytisine versus NRT.

AUTHORS' CONCLUSIONS

There is no clear evidence to support or refute the use of behavioural support over brief advice, one type of behavioural support over another, behavioural support plus NRT over behavioural support alone or brief advice, varenicline over NRT, or cytisine over NRT for tobacco use cessation for six months or more among PLWH. Nor is there clear evidence to support or refute the use of system-change interventions such as warm handoff over fax referral, to increase tobacco use cessation or receipt of cessation interventions among PLWH who use tobacco. However, the results must be considered in the context of the small number of studies included. Varenicline likely helps PLWH to quit smoking for six months or more compared to control. We did not find evidence of difference in SAE rates between varenicline and placebo, although the certainty of the evidence is low.

Cardiac and Renal Comorbidities in Aging People Living With HIV

Contemporary World Health Organization data indicates that ≈39 million people are living with the human immunodeficiency virus. Of these, 24 million have been reported to have successfully accessed combination antiretroviral therapy. In 1996, the World Health Organization endorsed the widespread use of combination antiretroviral therapy, transforming human immunodeficiency virus infection from being a life-threatening disease to a chronic illness characterized by multiple comorbidities. The increased access to combination antiretroviral therapy has translated to people living with human immunodeficiency virus (PLWH) no longer having a reduced life expectancy. Although aging as a biological process increases exposure to oxidative stress and subsequent systemic inflammation, this effect is likely enhanced in PLWH as they age. This narrative review engages the intricate interplay between human immunodeficiency virus associated chronic inflammation, combination antiretroviral therapy, and cardiac and renal comorbidities development in aging PLWH. We examine the evolving demographic profile of PLWH, emphasizing the increasing prevalence of aging individuals within this population. A central focus of the review discusses the pathophysiological mechanisms that underpin the heightened susceptibility of PLWH to renal and cardiac diseases as they age.

Behavioural interventions for tobacco cessation in India: A systematic review and meta-analysis

Tobacco consumption is an area of public health concern in India. One of the unmet needs of many low-resource countries is to provide cost-effective tobacco cessation interventions for reducing tobacco-related mortality. This article reviews studies on non-pharmacological interventions for tobacco cessation in India. A systematic review by PICO (population, intervention, comparison, outcome) of behavioural intervention-based tobacco cessation studies that met the inclusion criteria, with a minimum 1-month follow-up, reporting outcomes in terms of frequencies or percentages published between 2010 and 2020 was performed. Following the review stages, 16 studies comprising 9,613 participants were included in the review. A pooled estimate was derived using both fixed-effects and random-effects models. The intervention showed good overall efficacy for any tobacco user (relative risk [RR] = 1.73 [95% confidence interval [CI]: 1.58-1.90) (fixed-effect model)] and (RR = 2.02 [95% CI: 1.64-2.48] [random-effects model]). Behavioural intervention studies targeted towards only smokers (RR of 1.81 [95% CI: 1.55-2.11] and 1.96 [95% CI: 1.52-2.53]) and combined smoking and smokeless tobacco users (RR of 1.69 [95% CI: 1.50-1.90] and 2.12 [95% CI: 1.49-3.01]) were equally efficacious. The review provides the effectiveness of behavioural interventions in quitting tobacco among users of both smoking and smokeless forms of tobacco. The review findings are of particular significance to inform health policy decisions on the integration of cost-effective brief behavioural intervention into existing health care services in resource-constrained countries.

HIV-associated lung disease

Lung disease encompasses acute, infectious processes and chronic, non-infectious processes such as chronic obstructive pulmonary disease, asthma and lung cancer. People living with HIV are at increased risk of both acute and chronic lung diseases. Although the use of effective antiretroviral therapy has diminished the burden of infectious lung disease, people living with HIV experience growing morbidity and mortality from chronic lung diseases. A key risk factor for HIV-associated lung disease is cigarette smoking, which is more prevalent in people living with HIV than in uninfected people. Other risk factors include older age, history of bacterial pneumonia, Pneumocystis pneumonia, pulmonary tuberculosis and immunosuppression. Mechanistic investigations support roles for aberrant innate and adaptive immunity, local and systemic inflammation, oxidative stress, altered lung and gut microbiota, and environmental exposures such as biomass fuel burning in the development of HIV-associated lung disease. Assessment, prevention and treatment strategies are largely extrapolated from data from HIV-uninfected people. Smoking cessation is essential. Data on the long-term consequences of HIV-associated lung disease are limited. Efforts to continue quantifying the effects of HIV infection on the lung, especially in low-income and middle-income countries, are essential to advance our knowledge and optimize respiratory care in people living with HIV.

Pathogenesis and management of emphysema in people with HIV

INTRODUCTION

Since early in the HIV epidemic, emphysema has been identified among people with HIV (PWH) and has been associated with increased mortality. Smoking cessation is key to risk reduction. Health maintenance for PWH and emphysema should ensure appropriate vaccination and lung cancer screening. Treatment should adhere to inhaler guidelines for the general population, but inhaled corticosteroid (ICS) should be used with caution. Frontiers in treatment include targeted therapeutics. Major knowledge gaps exist in the epidemiology of and optimal care for PWH and emphysema, particularly in low and middle-income countries (LMIC).

AREAS COVERED

Topics addressed include risk factors, pathogenesis, current treatment and prevention strategies, and frontiers in research.

EXPERT OPINION

There are limited data on the epidemiology of emphysema in LMIC, where more than 90% of deaths from COPD occur and where the morbidity of HIV is most heavily concentrated. The population of PWH is aging, and age-related co-morbidities such as emphysema will only increase in salience. Over the next 5 years, the authors anticipate novel trials of targeted therapy for emphysema specific to PWH, and we anticipate a growing body of evidence to inform optimal clinical care for lung health among PWH in LMIC.

Adapting a tobacco cessation treatment intervention and implementation strategies to enhance implementation effectiveness and clinical outcomes in the context of HIV care in Vietnam: a case study

BACKGROUND

Smoking rates remain high in Vietnam, particularly among people living with HIV/AIDS (PLWH), but tobacco cessation services are not available in outpatient HIV clinics (OPCs). The research team is conducting a type II hybrid randomized controlled trial (RCT) comparing the cost-effectiveness of three tobacco cessation interventions among PLWH receiving care in HIV clinics in Vietnam. The study is simultaneously evaluating the implementation processes and outcomes of strategies aimed at increasing the implementation of tobacco dependence treatment (TDT) in the context of HIV care. This paper describes the systematic, theory-driven process of adapting intervention components and implementation strategies with demonstrated effectiveness in high-income countries, and more recently in Vietnam, to a new population (i.e., PLWH) and new clinical setting, prior to launching the trial.

METHODS

Data collection and analyses were guided by two implementation science frameworks and the socio-ecological model. Qualitative interviews were conducted with 13 health care providers and 24 patients in three OPCs. Workflow analyses were conducted in each OPC. Qualitative data were analyzed using rapid qualitative analysis procedures. Based on findings, components of the intervention and implementation strategies were adapted, followed by a 3-month pilot study in one OPC with 16 patients randomized to one of two intervention arms.

RESULTS

The primary adaptations included modifying the TDT intervention counseling content to address barriers to quitting among PLWH and Vietnamese sociocultural norms that support smoking cessation. Implementation strategies (i.e., training and system changes) were adapted to respond to provider- and clinic-level determinants of implementation effectiveness (e.g., knowledge gaps, OPC resource constraints, staffing structure, compatibility).

CONCLUSIONS

Adaptations were facilitated through a mixed method, stakeholder (patient and health care provider, district health leader)-engaged evaluation of context-specific influences on intervention and implementation effectiveness. This data-driven approach to refining and adapting components aimed to optimize intervention effectiveness and implementation in the context of HIV care. Balancing pragmatism with rigor through the use of rapid analysis procedures and multiple methods increased the feasibility of the adaptation process.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05162911 . Registered on December 16, 2021.

Estimating the changing disease burden attributable to smoking in South Africa for 2000, 2006 and 2012

Background. Ongoing quantification of the disease burden attributable to smoking is important to monitor and strengthen tobacco control policies.Objectives. To estimate the attributable burden due to smoking in South Africa for 2000, 2006 and 2012.Methods. We estimated attributable burden due to smoking for selected causes of death in South African (SA) adults aged ≥35 years for 2000, 2006 and 2012. We combined smoking prevalence results from 15 national surveys (1998 - 2017) and smoking impact ratios using national mortality rates. Relative risks between smoking and select causes of death were derived from local and international data. Results. Smoking prevalence declined from 25.0% in 1998 (40.5% in males, 10.9% in females) to 19.4% in 2012 (31.9% in males, 7.9% in females), but plateaued after 2010. In 2012 tobacco smoking caused an estimated 31 078 deaths (23 444 in males and 7 634 in females), accounting for 6.9% of total deaths of all ages (17.3% of deaths in adults aged ≥35 years), a 10.5% decline overall since 2000 (7% in males; 18% in females). Age-standardised mortality rates (and disability-adjusted life years (DALYs)) similarly declined in all population groups but remained high in the coloured population. Chronic obstructive pulmonary disease accounted for most tobacco-attributed deaths (6 373), followed by lung cancer (4 923), ischaemic heart disease (4 216), tuberculosis (2 326) and lower respiratory infections (1 950). The distribution of major causes of smoking-attributable deaths shows a middle- to high-income pattern in whites and Asians, and a middle- to low-income pattern in coloureds and black Africans. The role of infectious lung disease (TB and LRIs) has been underappreciated. These diseases comprised 21.0% of deaths among black Africans compared with only 4.3% among whites. It is concerning that smoking rates have plateaued since 2010. Conclusion. The gains achieved in reducing smoking prevalence in SA have been eroded since 2010. An increase in excise taxes is the most effective measure for reducing smoking prevalence. The advent of serious respiratory pandemics such as COVID-19 has increased the urgency of considering the role that smoking cessation/abstinence can play in the prevention of, and post-hospital recovery from, any condition.

Recipe for primary prevention of delirium in hospitalized older patients

Delirium is an acute fluctuating syndrome characterized by a change in consciousness, perception, orientation, cognition, sleep-wake rhythm, psychomotor skills, and the mood and feelings of a patient. Delirium and delirium prevention remain a challenge for healthcare professionals, especially nurses who form the basis of patient care. It also causes distress for patients, their caregivers and healthcare professionals. However, delirium is preventable in 30-40% of cases. The aim of this article is to summarize the delirium risk models, delirium screening tools, and (non-pharmacological) delirium prevention strategies. A literature search of review articles supplemented by original articles published in PubMed, Cinahl, and Cochrane between 1 January 2000 and 31 December 2020 was carried out. Among the older patients, delirium is a common condition with major consequences in terms of mortality and morbidity, but prevention is possible. Despite the fact that delirium risk models, delirium screening scales and non-pharmacological prevention are available for the development of a hospital delirium prevention programme, such a programme is still not commonly used on a daily basis.

A Smoking Cessation Mobile App for Persons Living With HIV: Preliminary Efficacy and Feasibility Study

BACKGROUND

The prevalence of smoking in the United States general population has gradually declined to the lowest rate ever recorded; however, this has not been true for persons with HIV.

OBJECTIVE

We conducted a pilot test to assess the feasibility and efficacy of the Lumme Quit Smoking mobile app and smartwatch combination with sensing capabilities to improve smoking cessation in persons with HIV.

METHODS

A total of 40 participants were enrolled in the study and randomly assigned 1:1 to the control arm, which received an 8-week supply of nicotine replacement therapy, a 30-minute smoking cessation counseling session, and weekly check-in calls with study staff, or to the intervention arm, which additionally received the Lumme Quit Smoking app and smartwatch.

RESULTS

Of the 40 participants enrolled, 37 completed the follow-up study assessments and 16 used the app every day during the 56-day period. During the 6-month recruitment and enrollment period, 122 people were screened for eligibility, with 67.2% (82/122) deemed ineligible. Smoking criteria and incompatible tech were the major reasons for ineligibility. There was no difference in the proportion of 7-day point prevalence abstinence by study arm and no significant decrease in exhaled carbon monoxide for the intervention and control arms separately. However, the average exhaled carbon monoxide decreased over time when analyzing both arms together (P=.02).

CONCLUSIONS

Results suggest excellent feasibility and acceptability of using a smoking sensor app among this smoking population. The knowledge gained from this research will enable the scientific community, clinicians, and community stakeholders to improve tobacco cessation outcomes for persons with HIV.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04808609; https://clinicaltrials.gov/ct2/show/NCT04808609.

Tobacco Use among HIV-Positive and HIV-Negative Women and Men in Zambia-Demographic and Health Survey, 2018

Country-specific estimates of tobacco use among people living with HIV (PLWH) are lacking for much of sub-Saharan Africa. We aim to evaluate the association between the HIV status and tobacco product use status, frequency, and intensity, using nationally representative data from Zambia. We analyzed data from the 2018 Demographic and Health Survey conducted in Zambia among women aged 15–49 years and men aged 15–59 years. We performed logistic regression to assess the associations of HIV status, selected sociodemographic, and other characteristics with indicators of tobacco use (i.e., status, frequency, and intensity). Among women, 14.3% tested positive for HIV and 2.7% reported current smoking or tobacco use; women living with HIV were more likely to report currently smoking or using tobacco than women living without HIV (4.4% vs. 2.4%; aPR: 1.46). Among men, 8.4% tested positive for HIV and 19.5% reported current smoking; men living with HIV were more likely than men living without HIV to report current smoking (27.8% vs. 18.7%; aPR: 1.22). Several sociodemographic characteristics were associated with tobacco use, including age, residence (urban/rural), education level, employment status, and wealth index. The frequency and intensity of smoking among men who currently smoked did not differ by HIV status. Tobacco use was more likely in PLWH than those without HIV in Zambia. Our findings highlight the need to encourage and support tobacco cessation among PLWH, possibly by offering cessation services at existing intersections with health care or integrating cessation support into mHealth and other alternative models of care.

Behavioral and Genetic Factors Associated with Successful Long-Term Cessation in Persons with HIV Who Smoke Cigarettes

Background

Persons with HIV (PWH) smoke cigarettes at much higher rates than the general population in the US, and smoking is now the leading cause of death in US PWH. Efforts to control the tobacco use epidemic in PWH have met with limited success, and the factors associated with successful cessation are not well delineated. There is a particular dearth of knowledge regarding PWH ex-smokers who have successfully quit smoking cigarettes for the long term.

Methods

We pooled data from three separate sources of PWH smokers and ex-smokers (reporting complete abstinence for ≥ one year with biochemical verification at the time of data collection) from New York City, collected sociodemographic and behavioral information from them in structured interviews, and obtained their DNA samples. Univariate and rigorous multivariate analytic strategies were employed to determine the sociobehavioral and genetic factors that distinguished PWH smokers from ex-smokers.

Results

We compared 142 current/recent smokers to 52 biochemically confirmed ex-smokers. The mean age of the participants was 53.3 ± 9.9 years, 49.5% were female, and 76.3% were Black/African American. Successful quitters had significantly lower anxiety scores and were less likely to report hazardous alcohol use or to use marijuana or cocaine. On multivariate analysis utilizing a conservative analytic approach, of 156 single nucleotide variants (SNV) within 12 a priori candidate genes, only the 37148248 T->C variant of gene SLC25A21 on chromosome 14 was associated with long-term cessation.

Conclusions

In this study, we report behavioral variables associated with long-term abstinence in PWH ex-smokers, and we also report the first genetic correlation of successful cessation in a PWH population yet described.

Persons living with HIV who do not smoke cigarettes: A comparison of ex-smokers and never smokers

Background and Aims

Approximately half of persons living with HIV (PLWH) in the US smoke cigarettes. Large surveys show that 16.9%–37.3% of PLWH are never smokers compared to 57.5% of US adults. Similar proportions of PLWH and general population adults describe themselves as ex-smokers (20.3% vs 21.9% respectively). Little research has been done to characterize PLWH non-smokers. In this study, we compared a group of well characterized PLWH ex-smokers (i.e., no cigarettes for at least 5 years) to PLWH never smokers with the aim of developing a clearer understanding of the characteristics of these groups and the differences between them.

Design

Cross-sectional interview study employing audio computer-assisted self-interview (ACASI).

Setting

Comprehensive HIV care center in New York City.

Participants

In 2018–2019, we recruited a sample of PLWH never smokers (N = 54) and long-term ex-smokers (no cigarettes for at least 5 years, N = 36). Non-smoking status of participants was verified by exhaled carbon monoxide.

Measurements

We collected a range of sociodemographic, historical, clinical, and psychobehavioral data pertaining to tobacco use.

Results

Compared to never smokers, ex-smokers were older, more likely to have heterosexually acquired HIV and less likely to have same-sex-acquired infection, more likely to have parents and/or siblings who smoked, more likely to have current smoker/s in their households, and more likely to have ever used marijuana, cocaine, and/or heroin.

Conclusions

We describe important demographic and sociobehavioral differences between PLWH never smokers and ex-smokers that may be useful in crafting an effective response to the cigarette smoking epidemic in US PLWH.

Cigarette Smoking Behaviors and Beliefs in Persons Living With HIV in Nairobi, Kenya

Introduction

Persons living with HIV (PLWH) use tobacco at higher rates than the general population in both high-income countries and low- and middle-income countries. Tobacco use rates are increasing in sub-Saharan Africa, the home to most of the world’s PLWH. As the reach of antiretroviral therapy (ART) expands and HIV-related morbidity and mortality wanes, tobacco use is emerging as a leading cause of disease and death in PLWH. A better understanding of tobacco use behaviors in various settings will be crucial to designing optimal tobacco control strategies.

Methods

In late 2019, we enrolled 50 PLWH cigarette smokers from 6 clinical sites in Nairobi, Kenya (4 HIV care clinics and 2 methadone maintenance programs) for one-on-one interviews focusing on their behaviors and beliefs related to tobacco use.

Results

Fifty PLWH smokers completed the interviews. The mean age was 38.5 ± 9.7 years (range 20-57 years) and 68% were male. All were currently receiving ART. They smoked a mean of 14.9 ± 12.4 cigarettes per day, and 82% reported smoking every day. Only 6% reported dual use of smokeless tobacco products. Nicotine dependence was moderate or high in 74%. More than a third (36%) reported a prior history of tuberculosis. In our sample, use of other substances was common, especially alcohol, marijuana, and methadone. On the motivation to quit scale, 90% were at least in the contemplation stage, but only 2% had ever received behavioral cessation counseling, and only 8% had ever used pharmacotherapy (exclusively nicotine replacement therapy). Participants reported significant concern about developing smoking-related illness, exposing others to secondary smoke, and the financial burden associated with their tobacco use. Measures of intrinsic and extrinsic motivation to quit, smoker and abstainer self-concept, and social support yielded encouraging results regarding the possibility of successful quitting.

Conclusions

Tobacco use is an important health concern in PLWH in Kenya. A more thorough understanding of their tobacco use behaviors and beliefs will provide critical information for providers, public health officials, and policy makers as they redouble their efforts to confront this urgent health challenge.

[Nonpharmaceutical concepts for prevention and treatment of delirium]

BACKGROUND

Cognitive impairment is common among older patients in German hospitals (40%). Dementia, other brain diseases and frailty significantly increase the risk of delirium and pose great challenges to interdisciplinary and interprofessional teams. Delirium prevention is achievable but requires complex interdepartmental strategies with specific components for timely recognition of the individual delirium risk, to carry out structured and sustained implementation of appropriate measures for delirium prevention as well as prompt etiological diagnostics and immediate treatment when delirium occurs.

OBJECTIVE

The present work aims to shed light on the role of interprofessional and interdisciplinary collaboration in evidence-based, nonpharmacological delirium prevention programs.

MATERIAL AND METHODS

Narrative review of international best practice programs.

RESULTS

Nonpharmacological prevention of delirium is effective but requires differentiated risk identification, regular delirium screening and daily targeted cognitive activation and sleep promotion. This can only be achieved in close interprofessional collaboration and is mostly carried out interdepartmentally by specialized teams.

DISCUSSION

Interprofessional multicomponent programs for delirium prevention hold the potential to reduce delirium and complication rates in older high-risk patients in regular care, thereby improving treatment and long-term quality of life. Additional interprofessional delirium prevention teams are deployed in different settings simultaneously and provide regular training on optimal delirium management. Demonstration of the effectiveness of cross-setting programs requires large multicenter studies and is therefore particularly laborious.

Evaluating the Efficacy of Automated Smoking Treatment for People With HIV: Protocol for a Randomized Controlled Trial

Background

Smoking prevalence rates among people with HIV are nearly 3 times higher than those in the general population. Nevertheless, few smoking cessation trials targeting smokers with HIV have been reported in the literature. Efforts to develop and evaluate sustainable, low-cost, and evidence-based cessation interventions for people with HIV are needed. Given the widespread proliferation of mobile phones, the potential of using mobile health apps to improve the reach and efficacy of cessation interventions is promising, but evidence of efficacy is lacking, particularly among people with HIV.

Objective

This study will consist of a 2-group randomized controlled trial to evaluate a fully automated smartphone intervention for people with HIV seeking cessation treatment.

Methods

Participants (N=500) will be randomized to receive either standard treatment (ST; 250/500, 50%) or automated treatment (AT; 250/500, 50%). ST participants will be connected to the Florida Quitline and will receive nicotine replacement therapy in the form of transdermal patches and lozenges. This approach, referred to as Ask Advise Connect, was developed by our team and has been implemented in numerous health systems. ST will be compared with AT, a fully automated behavioral treatment approach. AT participants will receive nicotine replacement therapy and an interactive smartphone-based intervention that comprises individually tailored audiovisual and text content. The major goal is to determine whether AT performs better in terms of facilitating long-term smoking abstinence than the more resource-intensive ST approach. Our primary aim is to evaluate the efficacy of AT in facilitating smoking cessation among people with HIV. As a secondary aim, we will explore potential mediators and moderators and conduct economic evaluations to assess the cost and cost-effectiveness of AT compared with ST.

Results

The intervention content has been developed and finalized. Recruitment and enrollment will begin in the fall of 2021.

Conclusions

There is a critical need for efficacious, cost-effective, and sustainable cessation treatments for people with HIV who smoke. The AT intervention was designed to help fill this need. If efficacy is established, the AT approach will be readily adoptable by HIV clinics and community-based organizations, and it will offer an efficient way to allocate limited public health resources to tobacco control interventions.

Trial Registration

ClinicalTrials.gov NCT05014282; https://clinicaltrials.gov/ct2/show/NCT05014282

International Registered Report Identifier (IRRID)

PRR1-10.2196/33183

Harm reduction for smokers living with HIV

Tobacco use is now a leading cause of death in people living with HIV in the USA. Increasing cessation rates in this group is a public health priority, yet the results of clinical trials aimed at optimising tobacco treatment strategies have been largely disappointing. Combinations of behavioural and pharmacological cessation therapies in people living with HIV have yielded increases in short-term quit rates, but few have shown long-term efficacy. Even with aggressive therapy combining intensive behavioural treatment with pharmacological agents, most smokers living with HIV continue to smoke. The generalised approach to tobacco treatment that prevails in guidelines and in clinical practices might do a disservice to these individuals, who represent a sizable segment of the population of people living with HIV. Harm reduction is a sensible and needed approach for smokers living with HIV who are unable or unwilling to quit. In this Viewpoint, we take an expansive view of harm reduction to include not only cutting down on cigarette intake for persistent smokers, but also reducing smoking's downstream health effects by increasing lung cancer screening and by controlling concurrent cardiovascular risk factors, especially hypertension and hyperlipidaemia.

Views and preferences of people living with HIV about smoking, quitting and use of nicotine products

AIMS AND BACKGROUND

People living with HIV (PLHIV) have a higher rate of smoking and experience a greater burden of tobacco-related disease than the general population. This study aimed to understand the role smoking plays in the lives of PLHIV, participants' views of traditionally available nicotine products (e.g., nicotine replacement therapy or NRT) and novel nicotine products (e.g., nicotine vaping products or NVPs) as both short-term quit aids and long-term substitutes for cigarettes.

METHODS

Semi-structured focus groups were conducted with PLHIV who smoked. Focus groups were transcribed and analysed using a combination of deductive and inductive thematic analysis. A brief questionnaire of nicotine product use and interest was also completed and the quantitative data presented using descriptive statistics.

RESULTS

Fifty-four participants took part in 11 focus groups. Participants' views of smoking, quitting and nicotine products were diverse. Commitment to smoking and interest in quitting were categorised into three groups across a smoking-quitting continuum: committed to smoking, ambivalent about smoking and reluctantly smoking. NRT was criticised for a range of side effects and primarily considered as a short-term cessation aid. NVPs generated debate. NVPs that closely resembled cigarettes were viewed as the most acceptable product and were considered to be more suitable than NRT for long-term use.

DISCUSSION AND CONCLUSIONS

Understanding the unique needs, goals and views of PLHIV related to smoking, quitting smoking and using nicotine products could inform development of novel and tailored smoking interventions for PLHIV. NVPs should be further examined as potential long-term substitutes for PLHIV who are ambivalent about smoking. However, traditional smoking cessation assistance (approved cessation aids and counselling) is likely to be most appropriate for PLHIV who are reluctantly smoking.

Tobacco Smoking and Associated Factors Among People Living With HIV in Uganda

INTRODUCTION

The prevalence of smoking among people living with HIV (PLWH) in Uganda is high.

AIMS AND METHODS

We assessed the smoking patterns, behaviors, and associated factors among PLWH in Uganda through a cross-sectional survey. Descriptive statistics were used to describe smoking patterns and behaviors. Logistic regression was used to identify factors associated with current smoking status.

RESULTS

We recruited 777 participants between October and November 2019: 387 (49.8%) current smokers and 390 (50.2%) nonsmokers. 60.9% were males, and the mean age was 40.5 (SD 10.7) years. In multivariate logistic regression, the following increased the odds of being a current smoker: being male (odds ratio [OR] 6.60 [95% confidence interval, CI = 4.34-10.04]), having at least two smokers among five closest friends (OR 3.97 [95% CI = 2.08-7.59]), living in smoking-permitted households (OR 5.83 [95% CI = 3.32-10.23]), alcohol use (OR 3.96 [95% CI = 2.34-6.71]), a higher perceived stress score (OR 2.23 [95% CI = 1.50-3.34]), and higher health-related quality of life (OR 5.25 [95% CI = 1.18-23.35]). Among smokers, the mean Fagerström Test for Nicotine Dependence score was 3.0 (SD 1.9), and 52.5% were making plans to quit. Self-efficacy to resist smoking and knowledge of the impact of smoking on PLWH's health were low.

CONCLUSIONS

Being male, having at least two smokers among five closest friends, living in smoking-permitted households, alcohol use, higher perceived stress scores, and higher health-related quality of life were associated with being a current smoker. Smokers had low to moderate nicotine dependence, high willingness to quit, and low self-efficacy.

IMPLICATIONS

Future behavioral smoking cessation interventions for PLWH should address co-consumption with alcohol and comorbid mental health conditions that are common among PLWH such as stress. In addition, they should take into account the lack of knowledge among this population of the impact of smoking on their health, and low self-efficacy. Given the relatively low levels of nicotine dependency and high levels of willingness to quit in our sample, smoking cessation interventions, if offered, are likely to support this population in achieving long-term smoking abstinence.

Pilot Randomized Controlled Trial of a Digital Storytelling Intervention for Smoking Cessation in Women Living With HIV

BACKGROUND

People living with HIV in the USA smoke at a rate nearly three times that of the general population, and Black women are disproportionately affected by HIV infection.

PURPOSE

This study was conducted to test the preliminary efficacy of a digital storytelling intervention for smoking cessation in U.S. women living with HIV.

METHODS

Participants in the treatment arm viewed a film in which women living with HIV talk about quitting smoking, and those in the control arm viewed an attention-control film in which women talk about living with HIV infection. Participants in both arms received eight weekly video-call counseling sessions focused on smoking cessation and nicotine patches or gum during the same period. Participants were followed on a monthly basis from quit day for 3 months.

RESULTS

Of the 53 participants randomized, four withdrew before receiving any intervention, one dropped out during the intervention, and 48 (90.6%) completed the study. No difference was found in the baseline characteristics between the two arms with the exception that the treatment arm had higher nicotine dependence scores [t(1.51) = 2.30, p = .03] than the control arm. Seven day point-prevalence abstinence rates at 3 month follow-up were not found to differ between the two arms. However, the odds of achieving 3 month prolonged abstinence were four times greater (odds ratio = 4.23, 95% confidence interval = 1.10, 16.23) in the treatment arm than the control arm when the analysis was performed with those (n = 49, 92.5%) who received any part of the allotted intervention.

CONCLUSIONS

A digital storytelling intervention seems to be a valuable strategy to enhance the effect of conventional tobacco dependence treatment for women living with HIV. However, the underlying mechanism of the effect of digital storytelling necessitates further investigations in a large RCT.Clinical Trials Registration No. NCT03289676.

Self-control and smoking in a sample of adults living with HIV/AIDS: A cross-sectional survey

INTRODUCTION

Cigarette smoking prevalences are very high in persons living with HIV (PLWH). Identifying variables among PLWH that are linked to smoking in community samples (e.g., self-control) can inform smoking treatments for PLWH. The current study examined the association of self-reported self-control and smoking (e.g., smoking status, cigarette dependence) in a sample of PLWH.

METHODS

Adult PLWH were recruited from the Center for Positive Living (Montefiore Medical Center, Bronx, New York, US). All participants completed measures of demographics, cigarette smoking, and self-control. Participants who reported current cigarette smoking completed measures of cigarette dependence; intolerance for smoking abstinence; and motivation, confidence, and desire to quit smoking.

RESULTS

The overall sample included 285 PLWH (49.1% cigarette users, 55.4% male, 52.7% Black race, 54.8% Latino/a ethnicity). PLWH with current cigarette smoking reported lower self-control than PLWH with no current cigarette smoking (M = 116.88, SD = 17.07 versus M = 127.39, SD = 20.32; t = -4.15, df = 211, p < 0.001). Among PLWH with current cigarette smoking, lower self-control was associated with greater cigarette dependence (ρ = -0.272, p < 0.01), and lower confidence in quitting smoking cigarettes (ρ = 0.214, p < 0.05). Lower self-control was associated with greater overall smoking abstinence intolerance (ρ = -0.221, p < 0.05) and withdrawal intolerance (ρ = -0.264, p < 0.01).

DISCUSSION

Among a sample of PLWH, lower self-control was related to cigarette smoking (versus no smoking), greater cigarette dependence, lower confidence in quitting smoking, and greater intolerance for smoking abstinence. It may be useful to target self-control among PLWH to increase confidence in quitting and abstinence intolerance with the goal of improving smoking cessation outcomes.

Experiences With Smoking Cessation Attempts and Prior Use of Cessation Aids in Smokers With HIV: Findings From a Focus Group Study Conducted in Durham, North Carolina

Cigarette smoking remains disproportionately prevalent and is increasingly a cause of death and disability among people with HIV (PWH). Many PWH are interested in quitting, but interest in and uptake of first-line smoking cessation pharmacotherapies are varied in this population. To provide current data regarding experiences with and perceptions of smoking cessation and cessation aids among PWH living in Durham, North Carolina, the authors conducted five focus group interviews (total n = 24; 96% African American) using semistructured interviews. Interviews were recorded, transcribed, coded, and thematically analyzed. Major themes included ambivalence and/or lack of interest in cessation; presence of cessation barriers; perceived perceptions of ineffectiveness of cessation aids; perceived medication side effects; and conflation of the harms resulting from use of tobacco products and nicotine replacement therapy. Innovative and effective interventions must account for the aforementioned multiple barriers to cessation as well as prior experiences with and misperceptions regarding cessation aids.

Barriers and Facilitators of Smoking Cessation among Latinos Living with HIV: Perspectives from Key Leaders of Community-Based Organizations and Clinics

The purpose of this study was to identify the perspectives from key leaders of community-based organizations (CBOs) and clinics serving people living with HIV on barriers and facilitators of smoking cessation among Latino smokers living with HIV. Semi-structured interviews were conducted in English and Spanish with 10 key leaders. Using a social ecological model, qualitative theoretical analysis was used to analyze the results. Participants identified barriers at the individual (e.g., low education level, HIV, and financial stress), interpersonal (e.g., language barriers, low social support), organizational (e.g., lack of smoking cessation resources and targeted interventions), community (e.g., HIV and mental health stigma), and policy (e.g., paperwork for insurance) level. Participants identified facilitators at the individual (e.g., high participation in trials, good medication adherence), interpersonal (e.g., no smoking in social circles), organizational (e.g., bilingual staff, culturally competent care), community (e.g., providing transportation, the coronavirus disease 2019 as an opportunity for smoking cessation), and policy level (e.g., existence of funding, comprehensive insurance programs). These results provide operational strategies to address smoking disparities among Latino smokers living with HIV. Further research is needed on how to integrate these perspectives into effective smoking cessation interventions.

Global burden of active smoking among people living with HIV on antiretroviral therapy: a systematic review and meta-analysis

BACKGROUND

Although the high burden of both active smoking and human immunodeficiency virus (HIV) is clearly known, the relationship between them is still not well characterized. Therefore, we estimated the global prevalence of active smoking in people living with HIV (PLHIV) on antiretroviral therapy (ART) and investigated the association between exposure to active smoking and risk for suboptimal adherence to ART. Main text: We searched PubMed, Embase, and Web of Science to identify articles published until September 19, 2019. Eligible studies reported the prevalence of active smoking in PLHIV on ART or investigated the association between active smoking and ART adherence; or enough data to compute these estimates. We used a random-effects model to pool data and quantified heterogeneity (I2). The global prevalence of active smoking was 36.1% (95% CI: 33.7-37.2; 329 prevalence data; 462 104 participants) with substantial heterogeneity. The prevalence increased with level of country income; from 10.1% (95% CI: 6.8-14.1) in low-income to 45.2% (95% CI: 42.7-47.7) in high-income countries; P < 0.0001. With regards to the Joint United Nations Programme on HIV/AIDS (UNAIDS) regions, the prevalence was higher in West and Central Europe and North America 45.4% (42.7-48.1) and lowest in the two UNAIDS regions of sub-Saharan Africa: Eastern and Southern Africa 10.7% (95% CI: 7.8-14.0) and West and Central Africa 4.4% (2.9-6.3); P < 0.0001. Globally, we estimated that there were 4 110 669 PLHIV on ART who were active smokers, among which the highest number was from Eastern and Southern Africa (35.9%) followed by Asia and the Pacific (25.9%). Active smoking was significantly associated with suboptimal ART adherence: pooled odds ratio 1.57 (95% CI: 1.37-1.80; I2 = 56.8%; 19 studies; 48 450 participants); even after considering adjusted estimates: 1.67 (95% CI: 1.39-2.01; I2 = 53.0%; 14 studies).

CONCLUSIONS

This study suggests a high prevalence of active smoking in PLHIV on ART and an association between active smoking and ART suboptimal adherence. As such, healthcare providers and policy makers should focus on adopting and implementing tobacco harm reduction strategies in HIV care, especially in sub-Saharan Africa known as epicenter of HIV pandemic with highest number of active tobacco smoking among PLHIV on ART.

Barriers and facilitators to smoking cessation among HIV-infected people who inject drugs (PWID) in Hanoi, Vietnam: a qualitative study

INTRODUCTION

In Vietnam, 60% of men living with HIV smoke tobacco, and 92% of HIV-infected people who inject drugs (PWID) smoke tobacco. Tobacco use increases mortality through increased health risks including tuberculosis and malignancy in HIV-infected smokers. However, tobacco use treatment is not widely available in Vietnam. The objective was to examine current barriers and facilitators of smoking cessation and tobacco use treatment for HIV-infected PWID in Hanoi, Vietnam.

METHODS

Native speaking ethnographers conducted semi-structured qualitative interviews about tobacco use and tobacco use treatment with sixteen HIV-infected PWID and eight healthcare providers, recruited from four HIV-Methadone Maintenance Treatment (MMT) clinics in Hanoi, Vietnam. Interviews were recorded, transcribed, and translated for thematic analysis in Dedoose.

RESULTS

Clients and providers had learned the general health risks of smoking from public awareness campaigns. Half had tried to quit previously, often motivated by advice from family members but not by HIV providers' advice. Almost all clients did not want to quit, citing the low price of tobacco, prevalence of smoking in Vietnam, and physical cravings. HIV provider's counseling was brief, inconsistent, and limited by low provider knowledge and competing burdens of HIV and injection drug use. Providers recently trained by NGO-led seminars on tobacco prioritized tobacco use treatment.

CONCLUSIONS

Smoking cessation efforts for people living with HIV/AIDS (PLHA) and PWID smokers in Hanoi, Vietnam could benefit from further community public awareness campaigns, and exploring increased tobacco taxation. Tobacco use treatment at HIV clinics could benefit from involving family and friends in cessation, and training providers in treatment methods.

The relationship of smoking and unhealthy alcohol use to the HIV care continuum among people with HIV in an integrated health care system

INTRODUCTION

Smoking tobacco and unhealthy alcohol use may negatively influence HIV care continuum outcomes but have not been examined in combination.

METHODS

Participants were people with HIV (PWH) in Kaiser Permanente Northern California. Predictors included smoking status and unhealthy alcohol use (exceeding daily and/or weekly limits) reported by patients during primary care screening (index date). Outcomes were based on not achieving the following steps in the care continuum: linkage to HIV care (≥1 visit within 90 days of newly identified HIV diagnosis), retention (2+ in-person visits, 60+ days apart) and HIV RNA control (<75 copies/mL). Adjusted odds ratios (ORs) were obtained from separate logistic regression models for each outcome associated with smoking and unhealthy alcohol use independently and combined.

RESULTS

The overall sample (N = 8958) had a mean age of 48.0 years; was 91.3 % male; 54.0 % white, 17.6 % Latino, 15.1 % black, and 9.6 % other race/ethnicity. Smoking was associated with higher odds of not being linked to HIV care (OR = 1.60 [95 % CI 1.03-2.48]), not retained (OR = 1.30 [95 % CI 1.13-1.50]), and HIV RNA not in control (OR = 1.91 [95 % CI 1.60-2.27]). Alcohol measures were not independently associated with outcomes. The combination of unhealthy alcohol use and smoking (versus neither) was associated with higher odds of not being linked to care (OR = 2.83 [95 % CI 1.40-5.71]), although the interaction did not reach significance (p = 0.18).

CONCLUSIONS

In this large sample of PWH in an integrated health care system, smoking, both independently and in combination with unhealthy alcohol use, was associated with worse HIV care continuum outcomes.

Quitline Treatment Enrollment and Cessation Outcomes Among Smokers Linked With Treatment via Ask-Advise-Connect: Comparisons Among Smokers With and Without HIV

INTRODUCTION

Given that people living with HIV (PLWH) are disproportionately burdened by tobacco-related morbidity and mortality, it is critically important to understand the degree to which evidence-based cessation interventions are utilized by and are effective among PLWH.

AIMS AND METHODS

This secondary data analysis aimed to examine differences in Quitline treatment enrollment and 6-month cessation outcomes among smokers seeking care at 1 HIV clinic and 12 non-HIV clinics that were part of a large healthcare system in the greater Houston, Texas metropolitan area, United States. Data were from a 34-month (April 2013-February 2016) one-group implementation trial that evaluated the Ask-Advise-Connect (AAC) approach to linking smokers with Quitline treatment. Primary outcomes included (1) treatment enrollment and (2) 6-month self-reported and biochemically confirmed abstinence.

RESULTS

The smoking status of 218 915 unique patients was recorded in the electronic health record; 5285 (2.7%) of these patients were seen at the HIV clinic where the smoking prevalence was 45.9%; smoking prevalence at the non-HIV clinics was 17.9%. The proportion of identified smokers who enrolled in treatment was 10.8% at the HIV clinic and 11.8% at the non-HIV clinics. The self-reported abstinence rate was 18.7% among HIV clinic patients and 16.5% among non-HIV clinic patients. Biochemically confirmed abstinence was lower at 4.2% and 4.5%, respectively (all ps > .05).

CONCLUSIONS

AAC resulted in rates of Quitline treatment enrollment and abstinence rates that were comparable among patients seen at an HIV clinic and non-HIV clinics. Findings suggest that AAC should be considered for widespread implementation in HIV clinics.

IMPLICATIONS

PLWH were as likely as other patients to enroll in evidence-based tobacco cessation treatment when it was offered in the context of a primary care visit. Cessation outcomes were also comparable. Therefore, standard care for PLWH should include routine screening for smoking status and referrals to cessation treatment.

Chronic obstructive pulmonary disease in HIV

Introduction: Chronic obstructive pulmonary disease (COPD) is more prevalent in people with HIV (PWH) than in the general population and leads to an increased burden of morbidity and mortality in this population. The mechanisms behind COPD development and progression in PWH are not fully elucidated, and there are no PWH-specific guidelines for COPD management. Areas covered: The goal of this broad narrative review is to review the epidemiology of COPD in PWH globally, highlight proposed pathways contributing to increased COPD prevalence and progression in PWH, discuss structural and functional changes in the lungs in this population, assesses the excess mortality and comorbidities in PWH with COPD, and address management practices for this unique population. Expert opinion: Understanding how a chronic viral infection leads to COPD, independent of cigarette smoking, is of critical scientific importance. Further research should focus on the pathophysiology of the interaction between HIV and COPD, and determine the role of disease-modifying risk factors such as opportunistic pneumonia and air pollution, as well as generate data from randomized clinical trials on the safety and efficacy of specific therapies for this vulnerable patient population.

Working with HIV clinics to adopt addiction treatment using implementation facilitation (WHAT-IF?): Rationale and design for a hybrid type 3 effectiveness-implementation study

BACKGROUND

Tobacco, alcohol and opioid misuse are associated with substantial morbidity and mortality among people with HIV (PWH). Despite existence of evidence-based counseling and medications for addiction, these treatments are infrequently offered in HIV clinics. The Working with HIV clinics to adopt Addiction Treatment using Implementation Facilitation (WHAT-IF?) study was conducted to address this implementation challenge. The study's goals were to conduct a formative evaluation of barriers to and facilitators of implementing addiction treatment for PWH followed by an evaluation of the impact of Implementation Facilitation (IF) on promoting adoption of addiction treatments and clinical outcomes.

METHODS

The study was conducted at four HIV clinics in the northeast United States, using a hybrid type 3 effectiveness-implementation stepped wedge design and guided by the Promoting Action on Research Implementation in Health Services Research (PARiHS) framework. A mixed-methods approach was used to identify evidence, context, and facilitation-related barriers to and facilitators of integration of addiction treatments into HIV clinics and to help tailor IF for each clinic. An evaluation was then conducted of the impact of IF on implementation outcomes, including provision of addiction treatment (primary outcome), organizational and clinician and staff readiness to adopt addiction treatment, and changes in organizational models of care used to deliver addiction treatment. The evaluation also included IF's impact on effectiveness outcomes, specifically HIV-related outcomes among patients eligible for addiction treatment.

CONCLUSIONS

Results will generate important information regarding the impact of IF as a reproducible strategy to promote addiction treatment in HIV clinics.

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.

Contribution of Behavioral Health Factors to Non-AIDS-Related Comorbidities: an Updated Review

PURPOSE OF REVIEW

We summarize recent literature on the contribution of substance use and depression to non-AIDS-related comorbidities. Discussion of recent randomized clinical trials and implementation research to curtail risk attributed to each behavioral health issue is provided.

RECENT FINDINGS

Smoking, unhealthy alcohol use, opioid use, and depression are common among PWH and individually contribute to increased risk for non-AIDS-related comorbidities. The concurrence of these conditions is notable, yet understudied, and provides opportunity for linked-screening and potential treatment of more than one behavioral health factor. Current results from randomized clinical trials are inconsistent. Investigating interventions to reduce the impact of these behavioral health conditions with a focus on implementation into clinical care is important. Non-AIDS-defining cancers, cardiovascular disease, liver disease, and diabetes are leading causes of morbidity in people with HIV. Behavioral health factors including substance use and mental health issues, often co-occurring, likely contribute to the excess risk of non-AIDS-related comorbidities.

Patterns of lapses and recoveries during a quit attempt using varenicline and behavioral counseling among smokers with and without HIV

Addressing tobacco use among HIV+ smokers is a priority. Lack of knowledge about how HIV+ smokers respond to tobacco use treatments limits our ability to effectively treat this population of smokers. Using data from 2 clinical trials that provided 12 weeks of varenicline and behavioral counseling, 1 with smokers with HIV (n = 89) and 1 with smokers without HIV (n = 179), we used mixed logistic regression modeling to compare point-prevalence abstinence rates and adherence to the initial target quit date (TQD) and Cox regression for repeated outcomes to evaluate lapse and recovery dynamics between the groups. Sixty percent of HIV- smokers refrained from smoking at the TQD while only 33% of HIV+ smokers did (odds ratio [OR] = 0.32, 95% CI [0.18, 0.56], p < .001). The point-prevalence abstinence rates at Week 12 were 31% (HIV-) and 28% (HIV+; OR = 0.7, 95% CI [0.42, 1.16], p = .16) and the point prevalence abstinence rates at Week 24 were 22% (HIV-) and 15% (HIV+; OR = 0.87, 95% CI [0.49, 1.57], p = .65). Although there was no interaction between HIV status and lapse risk, χ2(3) < 1, there was a significant interaction for the recovery model, (χ2(3) = 20.4, p < 0.001): as the number of events increased, the time to the next recovery became longer among smokers with HIV, compared to smokers without HIV. Although HIV+ smokers were treated effectively with varenicline, compared to HIV- smokers, they showed significantly lower initial cessation at the TQD and took increasingly longer to recover following lapses. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Implementation of strategies to prevent and treat postoperative delirium in the post-anesthesia caring unit : A German survey of current practice

Postoperative delirium is associated with worse outcome. The aim of this study was to understand present strategies for delirium screening and therapy in German Post-Anesthesia-Caring-Units (PACU). We designed a German-wide web-based questionnaire which was sent to 922 chairmen of anesthesiologic departments and to 726 anesthetists working in ambulatory surgery. The response rate was 30% for hospital anesthesiologists. 10% (95%-confidence interval: 8–12) of the anesthesiologists applied a standardised screening for delirium. Even though not on a regular basis, in 44% (41–47) of the hospitals, a recommended and validated screening was used, the Nursing Delirium Screening Scale (NuDesc) or the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). If delirium was likely to occur, 46% (43–50) of the patients were examined using a delirium tool. 20% (17–23) of the patients were screened in intensive care units. For the treatment of delirium, alpha-2-agonists (83%, 80–85) were used most frequently for vegetative symptoms, benzodiazepines for anxiety in 71% (68–74), typical neuroleptics in 77% (71–82%) of patients with psychotic symptoms and in 20% (15–25) in patients with hypoactive delirium. 45% (39–51) of the respondents suggested no therapy for this entity. Monitoring of delirium is not established as a standard procedure in German PACUs. However, symptom-oriented therapy for postoperative delirium corresponds with current guidelines.

Smoking and HIV in Sub-Saharan Africa: A 25-Country Analysis of the Demographic Health Surveys

BACKGROUND

Having HIV/AIDS has been associated with a higher prevalence of smoking. Moreover, evidence suggests that people with HIV/AIDS who smoke have poorer treatment and survival outcomes. The HIV-smoking relationship is understudied in sub-Saharan Africa, where tobacco use patterns and HIV prevalence differ greatly from other world regions.

METHODS

Cross-sectional data from the Demographic Health Surveys and AIDS Indicator Surveys, representing 25 sub-Saharan African countries, were pooled for analysis (n = 286850). The association between cigarette smoking and HIV status was analyzed through hierarchical logistic regression models. This study also examined the relationship between smokeless tobacco (SLT) use and HIV status.

RESULTS

Smoking prevalence was significantly higher among men who had HIV/AIDS than among men who did not (25.90% vs 16.09%; p < .0001), as was smoking prevalence among women who had HIV/AIDS compared with women who did not (1.15% vs 0.73%; p < .001). Multivariate logistic regression revealed that the odds of smoking among people who had HIV/AIDS was 1.12 times greater than among people who did not when adjusting for socioeconomic, demographic, and sexual risk factors (adjusted OR = 1.12, 95% CI = 1.04% to 1.21%; p < .001). Similarly, multivariate logistic regression revealed that HIV-positive individuals were 34% more likely to use SLT than HIV-negative individuals (adjusted OR = 1.34, 95% CI = 1.17% to 1.53%).

CONCLUSION

Having HIV was associated with a greater likelihood of smoking cigarettes as well as with using SLT in sub-Saharan Africa. These tobacco use modalities were also associated with male sex and lower socioeconomic status.

IMPLICATIONS

This study shows that in sub-Saharan Africa, as in more studied world regions, having HIV/AIDS is associated with a higher likelihood of smoking cigarettes when adjusting for demographic, socioeconomic, and sexual risk factors. This study also supports the literature stating that cigarette smoking is inversely associated with socioeconomic status, as evidenced by higher smoking prevalence among poorer individuals, less educated individuals, and manual and agricultural laborers.

The effect of varenicline on mood and cognition in smokers with HIV

RATIONALE

Barriers to smoking cessation, including negative affect and cognitive dysfunction, may contribute to high smoking rates among people living with HIV/AIDS (PLWH). Varenicline may help PLWH quit smoking by improving mood and cognition, yet this has not been explored.

OBJECTIVES

The goal of this study was to evaluate the effect of varenicline on mood and cognition among PLWH enrolled in a smoking cessation clinical trial.

METHODS

In this secondary analysis of a varenicline trial (NCT01710137), we assessed mood (depression, anxiety) and cognition (attention, working memory) at weeks 0 (baseline), 1, 3, and 12 (end-of-treatment, EOT). Primary outcomes were changes in mood and cognition from baseline to EOT. Secondarily, mood and cognition were evaluated as predictors of biochemically confirmed 7-day point-prevalence abstinence at EOT.

RESULTS

Overall, 173 subjects (87 varenicline, 86 placebo) were included. At EOT, varenicline reduced anxiety (P < 0.001), vs. placebo (P = 0.31; interaction P = 0.05). Across both treatment arms, reductions in anxiety from baseline to EOT were associated with a higher likelihood of abstinence (OR = 1.3, 95% CI 1.1 to 1.6, P = 0.01). There were no significant treatment by time interactions for cognition or depression.

CONCLUSIONS

These data suggest that varenicline operates, at least in part, by reducing anxiety. Anxiety should be an intervention target for smokers with HIV interested in quitting.

Understanding the Prevalence of Smoking Among People Living with HIV (PLHIV) in Australia and Factors Associated with Smoking and Quitting

Understanding contributors to smoking and quitting cigarettes is important to developing effective cessation programs and addressing smoking related morbidity and mortality among people living with HIV (PLHIV). Using data from a large cross-sectional study of Australian PLHIV we provide a smoking prevalence estimate and explore the relationship between socio-demographic variables and smoking status. We also explore the relationship between HIV diagnosis and antiretroviral therapy (ART) initiation and quitting smoking. Of the 1011 respondents included in the analysis, 30.6% were current smokers. The strongest predictor of smoking was regular cannabis use (AOR 6.2, 95% CI 3.6-10.8) while the strongest predictor of being a past smoker was receiving ART (AOR 2.4, 95% CI 1.2-4.7). Quitting also increased around the time of diagnosis and ART initiation, highlighting the potential for these events to be optimal times to address smoking among PLHIV.

Feasibility of a Smartphone-Based Tobacco Treatment for HIV-Infected Smokers

BACKGROUND

Cigarette smoking is common among persons living with HIV (PLWH) in the United States. It is the leading cause of mortality in this group, and efforts to promote cessation have been largely unsuccessful.

METHODS

From 2015 to 2017, we performed a randomized controlled trial of Positively Smoke Free-Mobile (PSF-M) versus standard care. PSF-M is a mobile Web site that offers a 42-day text message-based quit-smoking program with smartphone features including quit-day selection/calendar, educational/motivational videos, and HELP button for cravings.

RESULTS

One hundred individuals enrolled, 48 were randomized to PSF-M (mean age = 45 years, 54% male, 81% black, 31% Latino) and 52 to the standard care condition. All participants were offered a 3-month supply of nicotine patches. Participants randomized to the mobile intervention visited the PSF-M home page a mean of 83 times, viewed 5.6/8 videos, logged in on 13 of 42 possible days, and received 131 texts. Among them, 77% tapped HELP for cravings, and craving response options were used by the following proportions: phone-a-friend, 58%; play-a-game, 29%; play-a-song, 4%. Older age and nonblack race were both associated with higher levels of engagement with the site. Of participants, 61% rated PSF-M very or extremely helpful, and 98% would recommend PSF-M to PLWH family or friends. Abstinence at 3 months, quit attempts, and daily cigarette intake all favored PSF-M over standard care but did not achieve statistical significance in our pilot sample.

CONCLUSIONS

Smartphone-based tobacco treatment for PLWH was feasible and achieved moderate-high rates of engagement and satisfaction in a middle-aged, ethnic or racial minority group in the poorest urban community in the United States.

IMPLICATIONS

Cigarette smoking has emerged as the leading killer of PLWH. Behavioral interventions have achieved only limited success in promoting cessation in this population. In this study, we explore the feasibility and preliminary efficacy of a multimodal, Web-based, quit-smoking intervention delivered to PLWH smokers via their smartphones.

Incidence of chronic obstructive pulmonary disease in people with HIV in Ontario, 1996-2015: a retrospective population-based cohort study

BACKGROUND

Because of high smoking rates and HIV-related factors, people with HIV may be at high risk for chronic obstructive pulmonary disease (COPD); however, population-based estimates of the incidence of COPD among people with HIV are lacking, particularly for women. We compared the incidence of COPD among Ontario adults aged 35 years or more with and without HIV between Jan. 1, 1996, and Dec. 31, 2015.

METHODS

We conducted a population-based study using Ontario's health administrative databases. We compared the incidence of COPD between people with and without HIV using standardized incidence ratios and generalized estimating equations with a log link function.

RESULTS

We identified 1849 people with HIV and 1 168 727 HIV-negative people who were newly diagnosed with COPD between 1996 and 2015. People with HIV were younger than HIV-negative people (mean age 49.7 [standard deviation 10.4] yr v. 62.2 [standard deviation 14.8] yr; standardized difference 0.98). Rates of COPD were higher among people with HIV than among HIV-negative people (10.4 v. 9.0 cases per 1000 person-years; standardized incidence ratio 1.16, 95% confidence interval [CI] 1.10 to 1.21; adjusted rate ratio 1.34, 95% CI 1.27 to 1.41). In sex-stratified analyses, rates of COPD were higher among men with HIV (adjusted rate ratio 1.32, 95% CI 1.24 to 1.40) and women with HIV (adjusted rate ratio 1.54, 95% CI 1.37 to 1.72) than among men and women without HIV. In a sensitivity analysis, smoking explained observed differences in COPD incidence.

INTERPRETATION

People with HIV had higher rates of incident COPD than HIV-negative people. This may reflect the disproportionately higher prevalence of smoking among the former.

Bidirectional Associations among Nicotine and Tobacco Smoke, NeuroHIV, and Antiretroviral Therapy

People living with HIV (PLWH) in the antiretroviral therapy (ART) era may lose more life-years to tobacco use than to HIV. Yet, smoking rates are more than twice as high among PLWH than the general population, contributing not just to mortality but to other adverse health outcomes, including neurocognitive deficits (neuroHIV). There is growing evidence that synergy with chronic inflammation and immune dysregulation that persists despite ART may be one mechanism by which tobacco smoking contributes to neuroHIV. This review will summarize the differential effects of nicotine vs tobacco smoking on inflammation in addition to the effects of tobacco smoke components on HIV disease progression. We will also discuss biomarkers of inflammation via neuroimaging as well as biomarkers of nicotine dependence (e.g., nicotine metabolite ratio). Tobacco smoking and nicotine may impact ART drug metabolism and conversely, certain ARTs may impact nicotine metabolism. Thus, we will review these bidirectional relationships and how they may contribute to neuroHIV and other adverse outcomes. We will also discuss the effects of tobacco use on the interaction between peripheral organs (lungs, heart, kidney) and subsequent CNS function in the context of HIV. Lastly, given the dramatic rise in the use of electronic nicotine delivery systems, we will discuss the implications of vaping on these processes. Despite the growing recognition of the importance of addressing tobacco use among PLWH, more research is necessary at both the preclinical and clinical level to disentangle the potentially synergistic effects of tobacco use, nicotine, HIV, cognition and immune dysregulation, as well as identify optimal approaches to reduce tobacco use. Graphical Abstract Proposed model of the relationships among HIV, ART, smoking, inflammation, and neurocognition. Solid lines represent relationships supported by evidence. Dashed lines represent relationships for which there is not enough evidence to make a conclusion. (a) HIV infection produces elevated levels of inflammation even among virally suppressed individuals. (b) HIV is associated with deficits in cognition function. (c) Smoking rates are higher among PLWH, compared to the general population. (d) The nicotine metabolite ratio (NMR) is associated with smoking behavior. (e) HIV and tobacco use are both associated with higher rates of psychiatric comorbidities, such as depression, and elevated levels of chronic stress. These factors may represent other mechanisms linking HIV and tobacco use. (f) The relationship between nicotine, tobacco smoking, and inflammation is complex, but it is well-established that smoking induces inflammation; the evidence for nicotine as anti-inflammatory is supported in some studies, but not others. (g) The relationship between tobacco use and neurocognition may differ for the effects of nicotine (acute nicotine use may have beneficial effects) vs. tobacco smoking (chronic use may impair cognition). (h) Elevated levels of inflammation may be associated with deficits in cognition. (i) PLWH may metabolize nicotine faster than those without HIV; the mechanism is not yet known and the finding needs validation in larger samples. We also hypothesize that if HIV-infection increases nicotine metabolism, then we should observe an attenuation effect once ART is initiated. (j) It is possible that the increase in NMR is due to ART effects on CYP2A6. (k) We hypothesize that faster nicotine metabolism may result in higher levels of inflammation since nicotine has anti-inflammatory properties.

HIV infection and coronary heart disease: mechanisms and management

Antiretroviral therapy has largely transformed HIV infection into a chronic disease condition. As such, physicians and other providers caring for individuals living with HIV infection need to be aware of the potential cardiovascular complications of HIV infection and the nuances of how HIV infection increases the risk of cardiovascular diseases, including acute myocardial infarction, stroke, peripheral artery disease, heart failure and sudden cardiac death, as well as how to select available therapies to reduce this risk. In this Review, we discuss the epidemiology and clinical features of cardiovascular disease, with a focus on coronary heart disease, in the setting of HIV infection, which includes a substantially increased risk of myocardial infarction even when the HIV infection is well controlled. We also discuss the mechanisms underlying HIV-associated atherosclerotic cardiovascular disease, such as the high rates of traditional cardiovascular risk factors in patients with HIV infection and HIV-related factors, including the use of antiretroviral therapy and chronic inflammation in the setting of effectively treated HIV infection. Finally, we highlight available therapeutic strategies, as well as approaches under investigation, to reduce the risk of cardiovascular disease and lower inflammation in patients with HIV infection.

Rationale and design of a nurse-led intervention to extend the HIV treatment cascade for cardiovascular disease prevention trial (EXTRA-CVD)

Persons living with human immunodeficiency virus (PLHIV) are at increased risk of atherosclerotic cardiovascular disease (ASCVD). In spite of this, uptake of evidence-based clinical interventions for ASCVD risk reduction in the HIV clinic setting is sub-optimal. METHODS: EXTRA-CVD is a 12-month randomized clinical effectiveness trial that will assess the efficacy of a multi-component nurse-led intervention in reducing ASCVD risk among PLHIV. Three hundred high ASCVD risk PLHIV across three sites will be randomized 1:1 to usual care with generic prevention education or the study intervention. The study intervention will consist of four evidence-based components: (1) nurse-led care coordination, (2) nurse-managed medication protocols and adherence support (3) home BP monitoring, and (4) electronic health records support tools. The primary outcome will be change in systolic blood pressure and secondary outcome will be change in non-HDL cholesterol over the course of the intervention. Tertiary outcomes will include change in the proportion of participants in the following extended cascade categories: (1) appropriately diagnosed with hypertension and hyperlipidemia (2) appropriately managed; (3) at treatment goal (systolic blood pressure <130 mm Hg and non-HDL cholesterol < National Lipid Association targets). CONCLUSIONS: The EXTRA-CVD trial will provide evidence appraising the potential impact of nurse-led interventions in reducing ASCVD risk among PLHIV, an essential extension of the HIV care continuum beyond HIV viral suppression.

HIV Care Initiation: A Teachable Moment for Smoking Cessation?

Introduction

Tobacco use among persons living with HIV represents an important risk factor for poor treatment outcomes, morbidity, and mortality. Thus, efforts designed to inform the development of appropriate smoking cessation programs for this population remains a public health priority. To address this need, a study was conducted to longitudinally assess the relationship between intention to quit smoking and cessation over the 12-month period following initiation of HIV care.

Methods

Patients initiating HIV care at a large inner city safety net clinic were enrolled (n = 378) in a 12-month prospective study. Audio computer-assisted self-interviews were conducted at baseline, and at 3, 6, 9, and 12 months post-enrollment, and HIV-related clinical data were collected from participants' electronic medical records. Variables of interest included intention to quit smoking, 7-day point prevalence smoking abstinence (biochemically verified), and stage of HIV. Data were collected in Houston, Texas from 2009 to 2015.

Results

The sample was 75% male and 62% Black. Findings indicated that intention to quit smoking increased between baseline and 3 months, and subsequently trended downward from 3 to 12 months. Results from linear and generalized linear mixed models indicated that participants with advanced HIV disease (vs. not advanced) reported significantly (p < .05) higher intention to quit smoking at 3, 6, and 12 months post-study enrollment. A similar though nonsignificant pattern was observed in the smoking abstinence outcome.

Conclusions

HIV treatment initiation appears to be associated with increases in intention to quit smoking thus serves as a potential teachable moment for smoking cessation intervention.

Implications

This study documents significant increases in intention to quit smoking in the 3-month period following HIV care initiation. Moreover, quit intention trended downward following the 3-month follow-up until the 12-month follow-up. In addition, a marked effect for HIV disease stage was observed, whereby participants with advanced HIV disease (vs. those without) experienced a greater increase in intention to quit. HIV treatment initiation appears to be associated with increases in intention to quit smoking, thus serves as a crucial teachable moment for smoking cessation intervention for people living with HIV.

Placebo-controlled randomized clinical trial testing the efficacy and safety of varenicline for smokers with HIV

BACKGROUND

People living with HIV/AIDS (PLWH) smoke tobacco at higher rates and have more difficulty quitting than the general population, which contributes to significant life-years lost. The effectiveness of varenicline, one of the most effective tobacco dependence treatments, is understudied in HIV. We evaluated the safety and efficacy of varenicline for smoking cessation among PLWH.

METHODS

This was a single-site randomized, double-blind, placebo-controlled, phase 3 clinical trial (NCT01710137). PLWH on antiretroviral therapy (ART) who were treatment-seeking daily smokers were randomized (1:1) to 12 weeks of varenicline (n = 89) or placebo (n = 90). All participants were offered six smoking cessation behavioral counseling sessions. The primary outcome was 7-day point prevalence abstinence, confirmed with breath carbon monoxide, at Weeks 12 and 24. Continuous abstinence and time to relapse were secondary outcomes. Safety measures were treatment-related side effects, adverse events, blood pressure, viral load, and ART adherence.

RESULTS

Of the 179 smokers, 81% were African American, and 68% were male. Varenicline increased cessation at Week 12 (28.1% vs. 12.1%; OR = 4.54, 95% CI:1.83-11.25, P = .001). Continuous abstinence from Week 9 to 12 was higher for varenicline vs. placebo (23.6% vs. 10%; OR = 4.65, 95% CI:1.71-12.67, P = .003); at Week 24, there was no effect of varenicline for point prevalence (14.6% vs. 10%), continuous abstinence (10.1% vs. 6.7%), or time to relapse (Ps > .05). There were no differences between varenicline and placebo on safety measures (Ps > .05).

CONCLUSIONS

Varenicline is safe and efficacious for short-term smoking cessation among PLWH and should be used to reduce tobacco-related life-years lost in this population.

Use of the Phase-Based Model of Smoking Treatment to Guide Intervention Development for Persons Living with HIV Who Self-Identify as African American Tobacco Smokers

Cigarette smoking is highly prevalent among persons living with the human immunodeficiency virus (HIV) (PLWH), with rates as high 50% as compared to 14% in the general U.S. population. Tobacco use causes morbidity and mortality in PLWH, and tobacco-related harm is substantially higher in PLWH than smokers in the general population, providing the scientific premise for developing effective tobacco cessation interventions in this population. To better address this issue, we conducted six focus group sessions with 45 African American smokers who are living with HIV to understand the barriers to smoking cessation and the strategies that would be helpful to overcome these barriers. We organized our findings by the Phase-Based Model of Smoking Treatment to understand the intervention components that are needed at each phase to help PLWH successfully quit smoking. Participants in our focus group sessions articulated key components for incorporation into tobacco cessation intervention for PLWH: a personalized plan for quitting, reminders about that plan, and a support system. Participants thought that their HIV and tobacco use were disassociated. Participants described barriers to the use of pharmacotherapy, including adverse side effects of the gum and patch and concerns about the negative health effects of some oral medications. Substance use was identified as a commonly co-occurring condition as well as a barrier to successfully ceasing to smoke tobacco products. In summary, these findings offer information on the components of a tobacco cessation intervention for PLWH, namely reminders, a support system, substance use treatment, and monitoring to prevent relapse.

Comparison of mHealth and Face-to-Face Interventions for Smoking Cessation Among People Living With HIV: Meta-Analysis

BACKGROUND

The prevalence of smoking among people living with HIV (PLHIV) is higher than that reported in the general population, and it is a significant risk factor for noncommunicable diseases in this group. Mobile phone interventions to promote healthier behaviors (mobile health, mHealth) have the potential to reach a large number of people at a low cost. It has been hypothesized that mHealth interventions may not be as effective as face-to-face strategies in achieving smoking cessation, but there is no systematic evidence to support this, especially among PLHIV.

OBJECTIVE

This study aimed to compare two modes of intervention delivery (mHealth vs face-to-face) for smoking cessation among PLHIV.

METHODS

Literature on randomized controlled trials (RCTs) investigating effects of mHealth or face-to-face intervention strategies on short-term (4 weeks to <6 months) and long-term (≥6 months) smoking abstinence among PLHIV was sought. We systematically reviewed relevant RCTs and conducted pairwise meta-analyses to estimate relative treatment effects of mHealth and face-to-face interventions using standard care as comparison. Given the absence of head-to-head trials comparing mHealth with face-to-face interventions, we performed adjusted indirect comparison meta-analyses to compare these interventions.

RESULTS

A total of 10 studies involving 1772 PLHIV met the inclusion criteria. The average age of the study population was 45 years, and women comprised about 37%. In the short term, mHealth-delivered interventions were significantly more efficacious in increasing smoking cessation than no intervention control (risk ratio, RR, 2.81, 95% CI 1.44-5.49; n=726) and face-to-face interventions (RR 2.31, 95% CI 1.13-4.72; n=726). In the short term, face-to-face interventions were no more effective than no intervention in increasing smoking cessation (RR 1.22, 95% CI 0.94-1.58; n=1144). In terms of achieving long-term results among PLHIV, there was no significant difference in the rates of smoking cessation between those who received mHealth-delivered interventions, face-to-face interventions, or no intervention. Trial sequential analysis showed that only 15.16% (726/1304) and 5.56% (632/11,364) of the required information sizes were accrued to accept or reject a 25% relative risk reduction for short- and long-term smoking cessation treatment effects. In addition, sequential monitoring boundaries were not crossed, indicating that the cumulative evidence may be unreliable and inconclusive.

CONCLUSIONS

Compared with face-to-face interventions, mHealth-delivered interventions can better increase smoking cessation rate in the short term. The evidence that mHealth increases smoking cessation rate in the short term is encouraging but not sufficient to allow a definitive conclusion presently. Future research should focus on strategies for sustaining smoking cessation treatment effects among PLHIV in the long term.

The association between lifetime polytobacco use and intention to quit among HIV-positive cigarette smokers

BACKGROUND

This secondary analysis aims to describe, over time, the relationship between HIV disease progression and intention to quit cigarette smoking among current monocigarette users with and without a lifetime history of polytobacco use.

METHODS

Participants completed a baseline assessment at the time of HIV care initiation and four follow-up assessments (3, 6, 9, and 12-months). Assessments included biochemically verified smoking status and audio computer-assisted self-interviews assessing psychosocial, substance use, and clinical variables known to influence smoking behaviors. Using linear and generalized linear fixed-effects models, we modeled the covariance structure for the repeated outcome measures (intention to quit and 7-day point prevalence smoking abstinence) across the study time points and included a three-way interaction term to examine the effects of disease stage and tobacco product use.

RESULTS

Participants (N = 357) were 73.1% male, 67.3% black/African American, and had a mean (SD) age of 38.7 (10.6) years. At baseline, lifetime polytobacco users reported significantly worse HIV-related symptoms and burdens, illness perception, social support, and nicotine dependence. Intention to quit, but not smoking abstinence, was predicted by a three-way interaction between time from HIV care initiation, disease progression, and tobacco product use (p = .04). Overall, progressive HIV was associated with greater intention to quit smoking cigarettes. However, the relationship differed over time between the two tobacco product groups.

CONCLUSION

Future studies should consider tailoring the timing of cessation interventions upon disease stage and lifetime history of polytobacco use.

Smoking Predicts Food Insecurity Severity among Persons Living with HIV

Food insecurity is a key social and health issue among persons living with HIV (PLHIV). Food insecurity oftentimes co-occurs with substance use, but little is known about the relationship between tobacco use and food insecurity particularly among PLHIV. In this study, we prospectively examined the association of cigarette smoking with food insecurity in a cohort of 108 individuals seeking vocational rehabilitation services. Over the 12-month study period, smokers at baseline reported consistently higher levels of food insecurity compared to non-smokers. Smoking remained an independent risk factor for greater food insecurity, controlling for sociodemographic characteristics and known confounders (e.g., substance use, depression). Food insecurity is a key structural and socioeconomic barrier that may partially explain HIV-related health disparities observed among smokers. Further research is needed to characterize the bio-behavioral mechanisms linking smoking and food insecurity as well as test whether smoking cessation can reduce food insecurity in PLHIV who smoke.

Qualitative Exploration of a Smoking Cessation Trial for People Living With HIV in South Africa

Introduction

In South Africa, people living with HIV have a high prevalence of smoking, which undermines the beneficial effects of antiretroviral therapy. However, little is known about barriers to smoking cessation and what interventions work for people living with HIV in this setting.

Methods

A randomized trial comparing intensive anti-smoking counseling versus counseling and nicotine replacement therapy was recently concluded in Klerksdorp, South Africa. In a post-trial follow-up, 23 in-depth interviews with patients and one focus group discussion with counselors from the trial were conducted. A codebook was developed and codes were applied to the transcripts, which were analyzed using a thematic analysis.

Results

Barriers at the economic, social/interpersonal, and individual levels induced stress, which hindered smoking cessation. Economic stressors included unemployment and poverty. Social or interpersonal stressors were lack of social support for quitting smoking and lack of social support due to having HIV. Individual stressors were traumatic life events. Alcohol was used to cope with stress and frequently co-occurred with smoking. Managing cravings was a barrier unrelated to stress. Participants proposed income and employment opportunities, group counseling, and more frequent counseling as solutions to address stressors at different levels. Nicotine replacement therapy was helpful to mitigate cravings.

Conclusions

Future smoking cessation interventions need to target barriers at multiple levels. Increasing the supply and duration of nicotine replacement therapy may increase its effectiveness. Other behavioral approaches such as group counseling or peer counseling could hold promise in this setting but need to be tested for efficacy through randomized controlled trials.

Implications

To our knowledge, this is the first qualitative study examining barriers to smoking cessation for people living with HIV in South Africa. Smoking is highly prevalent among people with HIV in South Africa and cessation interventions are urgently needed. A better understanding of barriers to smoking cessation that people with HIV face will lead to the development of contextually appropriate interventions. This study also provides feedback on interventions from a recently concluded smoking cessation randomized trial and will help guide the design of future smoking cessation trials.

A randomized, controlled pilot study of warm handoff versus fax referral for hospital-initiated smoking cessation among people living with HIV/AIDS

INTRODUCTION

The prevalence of smoking among people living with HIV/AIDS (PLWHA) remains higher than the general population. Life expectancy among PLWHA has increased over the past decade, however, PLWHA who smoke will die younger than their non-smoking peers. The primary aim of this pilot study was to examine the effects of warm handoff versus fax referral to the quitline for smoking cessation among hospitalized smokers living with HIV/AIDS.

METHODS

25 smokers with a diagnosis of HIV/AIDS hospitalized at a Midwestern academic medical center in 2012-2013 (19 male; mean age=47.7; 48% African-American) were identified, approached, and randomized to one of two treatment arms. At the bedside for patients in warm handoff, staff telephoned the quitline for on-the-spot enrollment and counseling. Participants randomized to fax were fax-referred to the quitline on the day of discharge. The quitline provided continued outpatient counseling to participants in both conditions. The main outcome was verified tobacco abstinence at 6-months post randomization.

RESULTS

Enrollment and participation in quitline counseling was high among both warm handoff (100%) and fax-referred (71.4%) PLWHA participants. Nearly all completed follow up for outcome data collection at 6months. Verified abstinent rates were 45.5% in warm handoff versus 14.3% in fax referral at 6months (not significant).

CONCLUSIONS

Hospitalized smokers living with HIV/AIDS were highly engaged in quitline services. Warm handoff seems a promising intervention for hospitalized PLWHA that requires further exploration. Clinical Trials Registration NCT01305928.