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HIV and Smoking: The Time to Quit is Now. 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.

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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.
changes in mortality
Changes in Mortality
  • 5561pats., 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

use of haart
Use of HAART

% of patients

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

and change in causes of death
.. and Change in Causes of Death

% of deaths

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

non aids related causes of death southern alberta canada 1984 2003
Non-AIDS Related Causes of DeathSouthern Alberta, Canada, 1984-2003

Cohort: 1987 patients Total # of deaths= 560

% of deaths, non-AIDS related causes

32%

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

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 1984-961997-03

  • 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

HAART

Source: HIV Epidemiology Program 1st Quarter Report (Jan 2005), NYC Dept. of Health and Mental Hygiene

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

slide16

James Cadenhead

Infected with HIV for 18 years. Has had Hep B, C, toxoplasmosis.

“..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?”

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

Total cholesterol (per 1-mmol/liter increase)

Diabetes

Prior cardiovascular disease

Tryglicerides (per doubling)

Hypertension

Male sex

Exposure to combination antiretroviral therapy (per additional year)

Current or former smoker

Age (per additional 5 yr)

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.”

“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.”

Greenspoon, S. Carr, A. Cardiovascular risk and body-fat abnormalities in HIV-infected adults. N Engl J Med 2005; 352:48–62

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-InfectedPatients: 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

cancer of the lung trachea per 100 000 medicaid recipients with hiv aids 1993 2001
Cancer of the lung/tracheaper 100,000 Medicaid recipients with HIV/AIDS, 1993-2001

Source: Medicaid Claims database

cancer among people with hiv switzerland 1985 2002
Cancer among People with HIVSwitzerland, 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 20021
Cancer among People with HIVSwitzerland, 1985-2002
  • All cancers of lip, mouth and pharynx, trachea, bronchus and lung (8) occurred among smokers

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.

Methodology:

  • 2 Sampling Strata
    • Designated AIDS Care Centers
    • Adult Day Health Centers
  • Target sample size for each facility/program related to caseload.

NYS DOH AIDS Institute, OMD/OPER

slide38

Methodology:

  • 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

NYS DOH AIDS Institute, OMD/OPER

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**

Survey Administered in 15 Facilities/Programs, March 2005

NYS DOH AIDS Institute, OMD/OPER

table 1 survey return rate

Area

Target Sample

Size

Number

Returned

Percent of Target

Returned*

Upstate

426

399

94%

NYC

802

695

87%

Total

1228

1094

89%

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

Race/Ethnicity

(N)

%

Hispanic

281

26.9

White

158

15.1

African American

560

53.6

Other

46

4.4

Total

1045

100

*Other includes: Albanian (2) American Indian – Alaska Native (19) Asian (3) Australian (1) Canadian (1) French (1) Guyana (1) Haitian (6) Indian (2) Iranian (1) Native Hawaiian or Pacific (9)

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

Use Status

N

%

Currently Use

638

59.2

Used in the Past

264

24.5

Never Used

175

16.3

Total

1077

100

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

Smoking Knowledge Statements

% Correct

If a person has smoked a pack of cigarettes a day for more than 20 years, there is little benefit to quitting smoking.

N=1039

56%

Nicotine is a cause of cancer. N=1023

14%

The risk of having a heart attack is higher among people who smoke. N=1022

84%

The risk of getting lung cancer is higher among people who smoke. N=1017

86%

Because it takes many years for the effects of smoking to occur, smoking isn’t a serious health concern for HIV positive people. N=1027

63%

Smoking isn’t any more dangerous for HIV positive individuals than it is to people without HIV. N=1027

64%

Table 8: Percentage Correct on Smoking Knowledge Statements

NYS DOH AIDS Institute, OMD/OPER

slide44

N

%

Yes

372

63.7

No

212

36.3

Total

584

100

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

N

%

Yes

426

74.5

No

146

25.5

Total

572

100

Table 13: Are you currently interested in stopping smoking? (N=572)

NYS DOH AIDS Institute, OMD/OPER

smoking cessation are plwha interested
Smoking CessationAre 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.

slide47

N

%

Very likely

195

34.7

Somewhat likely

229

40.7

Somewhat unlikely

97

17.3

Very Unlikely

417

7.3

Total

562

100

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 problem1
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 paradigm1
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
conclusions1
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)

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