HIV and Smoking: The Time to Quit is Now: HIV and Smoking: The Time to Quit is Now
HIV Disease: New Paradigm: HIV Disease: New Paradigm Decreased mortality
Increases in non-HIV related deaths
Chronic disease
PLWH/AIDS living longer, healthier and more productive lives
Changing picture of mortality/morbidity
Cancer, CVD, diabetes, liver disease, etc.
Changing Mortality: Changing Mortality
Changes in Mortality: 5561 pats., HOPS, 1996-2002
1996 2002
Deaths
6.3 /100 person-yrs 2.2
OI rates:
23 /100 person-yrs 6
HAART use:
48% 80% Palella FJ et al. Mortality and Morbidity in the HAART Era: Changing Causes of Death and Disease in the HIV Outpatient Study. 11th CROI; San Francisco, CA 2004. Abstract 872 Changes in Mortality
Use of HAART: Use of HAART Palella FJ et al. Mortality and Morbidity in the HAART Era: Changing Causes of Death and Disease in the HIV Outpatient Study. 11th CROI; San Francisco, CA 2004. Abstract 872 % of patients
.. and Change in Causes of Death: .. and Change in Causes of Death Palella FJ et al. Mortality and Morbidity in the HAART Era: Changing Causes of Death and Disease in the HIV Outpatient Study. 11th CROI; San Francisco, CA 2004. Abstract 872 % of deaths
Non-AIDS Related Causes of Death Southern Alberta, Canada, 1984-2003: Non-AIDS Related Causes of Death Southern Alberta, Canada, 1984-2003 7% 32% Cohort: 1987 patients Total # of deaths= 560 Krents, HB et al. Changing mortality rates and causes of death for HIV-infected individuals living in Southern Alberta, Canada, from 1984 to 2003. HIV Medicine 2005; 6:99–106 % of deaths, non-AIDS related causes
Increases in non-AIDS Related Causes of Death Southern Alberta, Canada, 1984-2003: Increases in non-AIDS Related Causes of Death Southern Alberta, Canada, 1984-2003 Causes of Death 1984-96 1997-03
Accidental deaths 2.2% 17%
(drug overdose)
Liver disease <1 8.4
Non-HIV Cancers <1 7 Krents, HB et al. Changing mortality rates and causes of death for HIV-infected individuals living in Southern Alberta, Canada, from 1984 to 2003. HIV Medicine 2005; 6:99–106
HIV-related and Non-HIV related deaths in PLWHA NYC 1988-2003: HIV-related and Non-HIV related deaths in PLWHA NYC 1988-2003 Source: HIV Epidemiology Program 1st Quarter Report (Jan 2005), NYC Dept. of Health and Mental Hygiene HAART
Living Longer: Living Longer
PLWHA Cohort, Southern Alberta: PLWHA Cohort, Southern Alberta PLWHA, 40 years of age or older
Pre-HAART period (1984-96)
28%
HAART period (1997-2003)
51%
Krents, HB et al. Changing mortality rates and causes of death for HIV-infected individuals living in Southern Alberta, Canada, from 1984 to 2003. HIV Medicine 2005; 6:99–106
PLWHA Are Getting Older…: PLWHA Are Getting Older… HIV/AIDS Discharges among PLWHA, 50 years of age or older
1994 10%
2003 23%
Medicaid Recipients with HIV/AIDS, Age 50+
1993 6%
2002 18% Source: SPARCS database, NYSDOH Source: Medicaid Claims database
Changing Morbidity: Changing Morbidity
Slide16: “..I’m doing pretty well. I think my chances are better of going of a heart attack than of AIDS. My biggest problem now is , What do I do when I retire?” James Cadenhead
Infected with HIV for 18 years. Has had Hep B, C, toxoplasmosis. New York Times, Aug. 17, 2004
Slide18: Prospective observational cohort
23,468 HIV+ pats,
Incidence of myocardial infarction (MI) increased by an average of 26% per year of exposure to CART, over the first 6 years of exposure The D:A:D Study Group. Combination antiretroviral therapy and the risk of myocardial infarction. N Engl J Med 2003; 349:1993–2003
Myocardial Infarction: Incidence and Risk Factors Among Persons Receiving ART: Myocardial Infarction: Incidence and Risk Factors Among Persons Receiving ART Greenspoon, S. Carr, A. Cardiovascular risk and body-fat abnormalities in HIV-infected adults. N Engl J Med 2005; 352:48–62
Slide20: The Writing Committee of the D:A:D Study Group. Cardio- and cerebrovascular events in HIV-infected persons. AIDS 2004; 18:1811–1817
Myocardial infarction: Myocardial infarction Holmberg et al. Trends in rates of Myocardial infarction among patients with HIV
N Engl J Med 2004; 350:730-731
Slide22: Acute Myocardial Infarction
Source: SPARCS database, NYSDOH
Chronic Bronchitis and Emphysema: Chronic Bronchitis and Emphysema Source: SPARCS database, NYSDOH
Slide24: “Cigarette smoking is the most important modifiable cardiovascular risk factor among HIV-infected patients.”
Greenspoon, S. Carr, A. Cardiovascular risk and body-fat abnormalities in HIV-infected adults. N Engl J Med 2005; 352:48–62 “Cessation of smoking is more likely to reduce cardiovascular risk than either the choice of antiretroviral therapy or the use of any lipid-lowering therapy.”
HIV and Cancer: HIV and Cancer
Trends in AIDS-Defining and Non–AIDS-Defining Malignancies among HIV-Infected Patients: 1989–2002: Trends in AIDS-Defining and Non–AIDS-Defining Malignancies among HIV-Infected Patients: 1989–2002 Cases per 1000 pat-years Years Bedimo, R et al. Trends in AIDS-defining and non-AIDS-defining malignancies among HIV-infected patients: 1989-2002. Clin Inf Dis 2004;39:1380-1384
Slide27: HAART Cancers of the larynx and oropharynx HAART
Slide28: Source: SPARCS Cancer of the lung/trachea per 100,000 HIV/AIDS discharges, 1994-2002
Cancer of the lung/trachea per 100,000 Medicaid recipients with HIV/AIDS, 1993-2001: Cancer of the lung/trachea per 100,000 Medicaid recipients with HIV/AIDS, 1993-2001 Source: Medicaid Claims database
Slide30: HAART Cancers of the colon, anus, liver & pancreas HAART
Cancer among People with HIV Switzerland, 1985-2002: Cancer among People with HIV Switzerland, 1985-2002 Standardized Incidence Ratios (SIRs) Clifford, GM et al. Cancer risk in the Swiss HIV Cohort Study: Associations with immunodeficiency, smoking and Highly Active Antiretroviral Therapy. J Natl Cancer Inst 2005;97:425-432
Cancer among People with HIV Switzerland, 1985-2002: All cancers of lip, mouth and pharynx, trachea, bronchus and lung (8) occurred among smokers
Cancer among People with HIV Switzerland, 1985-2002 Clifford, GM et al. Cancer risk in the Swiss HIV Cohort Study: Associations with immunodeficiency, smoking and Highly Active Antiretroviral Therapy. J Natl Cancer Inst 2005;97:425-432
How Big is the Problem?: How Big is the Problem? New England clinics: More than 70% of HIV+ smoke
Swiss HIV Cohort Study
72% are current/former smokers
96% among IDUs
Niaura R et al. Smoking among HIV-positive persons. Ann Behav Med 1999; 21(Suppl):S116 Clifford, GM et al. Cancer risk in the Swiss HIV Cohort Study: Associations with immunodeficiency, smoking and Highly Active Antiretroviral Therapy. J Natl Cancer Inst 2005;97:425-432
Low Income HIV+ in NYC: Low Income HIV+ in NYC 428 HIV+ Medicaid recipients, NYC
Age: 22-75 59% males 53% African Americans 30% Latinos
HS education or less : 87%
66% current smokers (mean=16 cig./day)
19% former smokers
Current smokers
Greater use of illicit substances
Lower state of health
Lower perceived health risk of continued smoking Burkhalter, JE et al. Tobacco use and readiness to quit smoking in low-income HIV-infected persons. Nicotine Tob Res 2005; 7(4):511-522
Tobacco Use Survey 2005 : Tobacco Use Survey 2005 Preliminary Results
(August 31, 2005)
NYS DOH AIDS Institute
Office of the Medical Director
Office of Program Evaluation and Research
Purpose:: Purpose: To ascertain smoking prevalence among PLHWA in care in New York State. 2 Sampling Strata
Designated AIDS Care Centers
Adult Day Health Centers
Target sample size for each facility/program related to caseload. Methodology: NYS DOH AIDS Institute, OMD/OPER
Slide38:
3-page self-administered survey
Input from NYSDOH Tobacco Control Program
Instruments used to measure tobacco use
Survey collected:
Demographics
Current and past tobacco use. Frequency.
Perceptions regarding tobacco use
Cessation history. Intentions/readiness to quit Methodology: NYS DOH AIDS Institute, OMD/OPER
Survey Administered in 15 Facilities/Programs, March 2005: Survey Administered in 15 Facilities/Programs, March 2005 Upstate NY Region
Erie County Medical Center*
Nassau University*
Strong Memorial Hospital*
SUNY Syracuse*
United Health Services*
Westchester County Medical Center*
* Designated AIDS Care Center
**Adult Day Health Center NYC Region
Bronx Lebanon*
Harlem United**
Housing Works 13th Street**
Housing Works 98th Street**
NY Hospital of Queens*
PROMESA**
Saint Vincent Medical Center*
SUNY Brooklyn*
Village Center** NYS DOH AIDS Institute, OMD/OPER
Table 1: Survey Return Rate : Table 1: Survey Return Rate *Just 41 subjects (3.4%) refused to completed the survey. NYS DOH AIDS Institute, OMD/OPER
Table 2: Race/Ethnicity (N=1045): Table 2: Race/Ethnicity (N=1045) NYS DOH AIDS Institute, OMD/OPER
Table 3: Tobacco Use (N=1077) Includes Cigarettes, Cigars, Pipes and Chewing Tobacco*: Table 3: Tobacco Use (N=1077) Includes Cigarettes, Cigars, Pipes and Chewing Tobacco* *631 cases in the “Currently Use” category are cigarette smokers. 255 cases in the “Used in the Past” category were cigarette smokers. NYS DOH AIDS Institute, OMD/OPER
Table 8: Percentage Correct on Smoking Knowledge Statements: Table 8: Percentage Correct on Smoking Knowledge Statements NYS DOH AIDS Institute, OMD/OPER
During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit? (N=584): During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit? (N=584) P=<.05 NYS DOH AIDS Institute, OMD/OPER
Table 13: Are you currently interested in stopping smoking? (N=572): Table 13: Are you currently interested in stopping smoking? (N=572) NYS DOH AIDS Institute, OMD/OPER
Smoking Cessation Are PLWHA Interested?: Smoking Cessation Are PLWHA Interested? Survey of patients (n=228), San Francisco General Hospital
Smokers=123 (54%)
Smokers interested in quitting = 77 (63%)
Mamary EM et al. Cigarette smoking and the desire to quit among individuals living
with HIV. AIDS Patient.Care STDS. 2002;16:39-42.
Table 14: If you decided to give up smoking altogether during the next year, how likely do you think you would be to succeed? (N=562): Table 14: If you decided to give up smoking altogether during the next year, how likely do you think you would be to succeed? (N=562) NYS DOH AIDS Institute, OMD/OPER
How Big is the Problem?: How Big is the Problem? BIG
HIV+ populations include the following overlapping conditions
Substance use
Mental health
Poverty, low educational attainment
Niaura R et al. Smoking among HIV-positive persons. Ann Behav Med 1999; 21(Suppl):S116
Smoking------Risk Factor for…: Smoking------Risk Factor for… Cardiovascular diseases
Cancers
Lung diseases
GI tract
Age-related disorders
….
Single most preventable cause of death
HIV Disease: New Paradigm: HIV Disease: New Paradigm Lifestyle-related risk factors
Smoking
Physical activity
Healthy diet
Alcohol, recreational drugs
Sexual activity
Conclusions: Conclusions Significant changes in mortality and morbidity among people with HIV
As people with HIV live longer, they are increasingly becoming ill or dying of non-HIV/AIDS related conditions
Smoking is highly prevalent among PLWHA
Smoking is the single most preventable cause of death and disease … even for people with HIV
Conclusions: Conclusions Treating tobacco dependence should be a priority for HIV clinicians
Clinicians should
Use evidence-based interventions to promote smoking cessation in HIV-infected patients
Routinely assess HIV-infected patients’ smoking status and readiness to quit.
Identify and discuss barriers to quitting smoking for HIV-infected smokers who are not interested in stopping in the immediate future, but may consider it at a later time (www.hivguidelines.org)
Slide57: For more HIV-related resources, please visit www.hivguidelines.org