HIV and Smoking - AIDS Education and Training Centers

1、Why Smoking Cessation Should Be a Priority in HIV Care Today,Alvaro Carrascal, MD, MPH Office of the Medical Director AIDS Institute AI is a Local Performance Site of the NY/NJ AETC,Objectives,Review the changing paradigm of HIV disease Review the association between smoking and HIV Describe the imp

2、ortance of addressing tobacco use among PLWHA,HIV Disease: Changing Paradigm,Reduced mortality Chronic disease PLWH/AIDS living longer, healthier and more productive lives Changing morbidity/mortality Cancer, CVD, diabetes, liver disease, etc,Mortality,5561 pats., HOPS, 1996-2002 19962002 Deaths 6.3

3、 /100 person-yrs 2.2 OI rates: 23 /100 person-yrs 6,Reductions in Mortality,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. Abs. 872,Use of HAART, of patients,Palella FJ et al. Mortality

4、and morbidity in the HAART era: Changing causes of death and disease in the HIV Outpatient study. 11th CROI; San Francisco, CA 2004. Abs. 872,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 Outpatien

5、t study. 11th CROI; San Francisco, CA 2004. Abs. 872,Changes in Causes of DeathSouthern Alberta, Canada, 1984-2003,7,32,Cohort: 1987 patientsTotal # of deaths= 560,Krents, HB et al. Changing mortality rates and causes of death for HIV-infected individuals living in Southern Alberta, Canada, from 198

6、4 to 2003. HIV Medicine 2005; 6:99106, of deaths, non-AIDS related causes,Increases in Non-AIDS Related Causes of Death Southern Alberta, Canada, 1984-2003,Causes of Death1984-961997-03 Accidental deaths2.2%17% (drug overdose) Liver disease18.4 Non-HIV Cancers17,Krents, HB et al. Changing mortality

7、rates and causes of death for HIV-infected individuals living in Southern Alberta, Canada, from 1984 to 2003. HIV Medicine 2005; 6:99106,HIV-related and Non-HIV related deaths among PLWHA NYC 1988-2003,Source: HIV Epidemiology Program 1st Quarter Report (Jan 2005), NYC Dept. of Health and Mental Hyg

8、iene,HAART,Living Longer,PLWHA Are Getting Older,NY: HIV/AIDS hospital discharges among PLWHA 50 years of age or older,Source: SPARCS database, NYSDOH, of HIV/AIDS discharges,PLWHA Are Getting Older,NY: Medicaid Recipients with HIV/AIDS, Age 50,Source: Medicaid Claims database, of HIV/AIDS recipient

9、s,Changing Morbidity,Changing MorbidityCardiovascular Diseases,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

10、therapy and the risk of myocardial infarction. N Engl J Med 2003; 349:19932003,Incidence of MI according to the duration of exposure to CART,The Writing Committee of the D:A:D Study Group. Cardio- and cerebrovascular events in HIV-infected persons. AIDS 2004; 18:18111817,Myocardial infarction Among

11、Patients with HIV Infection,Holmberg et al. Trends in rates of myocardial infarction among patients with HIV N Engl J Med 2004; 350:730-731,Acute Myocardial Infarction NY: Discharges among PLWHA,Source: SPARCS database, NYSDOH,Cigarette smoking is the most important modifiable cardiovascular risk fa

12、ctor among HIV-infected patients.,Greenspoon, S. Carr, A. Cardiovascular risk and body-fat abnormalities in HIV-infected adults. N Engl J Med 2005; 352:4862,Cessation of smoking is more likely to reduce cardiovascular risk than either the choice of antiretroviral therapy or the use of any lipid-lowe

13、ring therapy.,Greenspoon, S. Carr, A. Cardiovascular risk and body-fat abnormalities in HIV-infected adults. N Engl J Med 2005; 352:4862,.Im 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 Cadenhea

14、d Infected with HIV for 18 years. Has had Hep B, C, toxoplasmosis,New York Times, Aug. 17, 2004,Changing MorbidityCancer,Trends in AIDS-Defining and NonAIDS-Defining Malignancies among HIV-Infected Patients 19892002,Cases per 1000 pat-years,Years,Bedimo, R et al. Trends in AIDS-defining and non-AIDS

15、-defining malignancies among HIV-infected patients: 1989-2002. Clin Inf Dis 2004;39:1380-1384,Cancers of the larynx and oropharynx among PLWHA discharged from hospitals in NY, 1994-2002,Discharges from hospitals,Source: NY SPARCS,Source: NY Medicaid,Cancers of the larynx and oropharynx among PLWHA,

16、Medicaid recipients, NY, 1993-2001,Source: NY SPARCS,Cancers of the lung and trachea among PLWHA discharged from hospitals in NY, 1994-2002,Source: NY Medicaid Claims database,Cancers of the lung and trachea among PLWHA, Medicaid recipients, NY, 1993-2001,Causes of death among HIV-infected adults in

17、 France, 2000,Lewden C et al. Causes of death among HIV-infected adults in the era of potent antiretroviral therapy: emerging role of hepatitis and cancers, persistent role of AIDS. Int J Epidemiol 2005;34:121-130,N=964, of all deaths,Causes of death among HIV-infected adults in France, 2000,Prevent

18、ion, screening, and management of non-Hodgkins lymphoma and of non-AIDS related cancers, especially lung cancer, prevention of CVDs, and management of viral hepatitis should be considered public health priorities Specific programs for smoking cessation should be developed for the HIV-infected,Lewden

19、 C et al. Causes of death among HIV-infected adults in the era of potent antiretroviral therapy: emerging role of hepatitis and cancers, persistent role of AIDS. Int J Epidemiol 2005;34:121-130,Now that HAART-regimens have considerably improved the life expectancy in HIV-infected populations in indu

20、strialized countries, efforts to reduce smoking and alcohol consumption must be a priority in HIV medicine.,Zwahlen M, Lundgren, JD. Commentary: Death in the era of potent antiretroviral therapy: shifting causes, new challenges. Int J Epidemiol 2005;34:130-131,Incidence Rate Ratios of Non-AIDS Defin

21、ing Malignancies1992-2002,Incidence rate ratio Standardized HIV: Observed SEER,Patel P et al. Incidence of AIDS-defining and non-AIDS defining malignancies among HIV infected persons. CROI 2006,Incidence Rate Ratios of Non-AIDS Defining Malignancies1992-2002,The incidence of many non-ADM were signif

22、icantly higher suggesting that HIV-infected persons are at higher risk of developing certain cancers In addition to encouraging tobacco cessation, health care providers should consider enhanced monitoring for these malignancies in their HIV-infected patients.,Patel P et al. Incidence of AIDS-definin

23、g and non-AIDS defining malignancies among HIV infected persons. CROI 2006,Lung Cancer in PLWHA,5,238 pats., Moore Clinic, 1989-2003 19,061 person-years of follow up 33 cases identified (85% current smokers 12% former smokers) SIR Detroit gen. pop. = 4.7 US pop. = 6.9,Engels, EA et al. Elevated inci

24、dence of lung cancer among HIV-infected individuals. J Clin Oncol 2006; 24: 138388,Lung Cancer in PLWHA,Elevated incidence of lung cancer As people with HIV live longer and age, clinicians should be alert to the possible diagnosis of lung cancer in HIV-inf. patients Need to develop effective interve

25、ntions to assist individuals in their attempts to quit smoking Smoking might not entirely explain the excess of lung ca. among HIV-inf. persons, hence the need for research regarding pathogenesis,Engels, EA et al. Elevated incidence of lung cancer among HIV-infected individuals. J Clin Oncol 2006; 2

26、4: 138388,Other Conditions,Chronic Bronchitis and Emphysemaamong PLWHA Discharged from Hospitals in NY,Source: SPARCS database, NYSDOH,Oral Health,HIV+ smokers are more likely to develop Oral candidiasis Periodontitis Oral hairy leukoplakia Cancers,Oral Health,HIV Cost and Services Utilization Study

27、. National probability sample of HIV inf. Adults in the US Self-reported, 3 sets of interviews Smokers were 62% more likely to report “oral white patches” than non-smokers,Marcus, M. et al. Oral white patches in a national sample of medical HIV patients in the era of HAART. Community Dent Oral Epide

28、miol 2005; 33: 99106,Minkoff H et al. Relationship between smoking and Human Papillomavirus infections in HIV-infected and -uninfected women. J Infect Dis 2004;189:1821-8,Impact of Smoking on Outcome in the HIV Infected,Women: Cigarrette Smoking and HIV Prognosis in the HAART Era,Feldman JG, Minkoff

29、 H et al. The association of cigarette smoking with HIV prognosis among women in the HAART eraA report from the Womens Interagency HIV Study. Am J Public Health 2006;96(6):1-6,Women: Cigarrette Smoking and HIV Prognosis in the HAART Era,Feldman JG, Minkoff H et al. The association of cigarette smoki

30、ng with HIV prognosis among women in the HAART eraA report from the Womens Interagency HIV Study. Am J Public Health 2006;96(6):1-6,Cumulative percentage remaining free from an AIDS-defining condition, by smoking status before HAART initiation,Impact of Cigarette Smoking on Mortality and QOL Among P

31、LWHA,867 HIV+ from Veterans Aging Cohort 3 Site Study 63% current smokers, 22% former smokers Current smokers had highest VL (compared to form. or never smokers. p=.001) Smoking was strongly associated with increased respiratory symptoms (cough, dyspnea), noninfectious pulmonary disease (COPD 20:114

32、2-45,Impact of Cigarette Smoking on Mortality,Unadjusted mortality rate per 100 person-years,Smokers,Never smokers,After adjusting for age, race/ethnicity, baseline CD4 cell count, VL, hemoglobin, illegal drug/alcohol use, mortality was significantly increased in current smokers compared with never

33、smokers (hazard ratio HR 1.99, 95% CI 1.03 to 3.86,Crothers, K et al. The impact of cigarette smoking on mortality, quality of life, and comorbid illness among HIV-positive veterans. J Gen Intern Med 2005;20:1142-45,Cigarette Smoking and QOL,N=549,N=189,N=129,QOL,Crothers, K et al. The impact of cig

34、arette smoking on mortality, quality of life, and comorbid illness among HIV-positive veterans. J Gen Intern Med 2005;20:1142-45,How Serious is the Problem,Prevalence of smoking among people with HIV - estimated to be higher than among the general population New England clinics: More than 70% of HIV

35、+ 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 Antiretrovi

36、ral Therapy. J Natl Cancer Inst 2005;97:425-432,New York,482 HIV+ Medicaid recipients, NYC Age: 22-75 59% males53% African Americans30% Latinos HS education or less : 87% 66% current smokers (mean=16 cig./day) 18% former smokers Current smokers Greater use of illicit substances Lower state of health

37、 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):511-522,3-page self-administered survey Input from NYSDOH Tobacco Control Program Instruments used to measure tobacco use

38、Survey collected: Demographics Current and past tobacco use. Frequency. Perceptions regarding tobacco use Cessation history. Intentions/readiness to quit,Smoking Prevalence among PLWHA Receiving Care in NYS 2005,NYS DOH AIDS Institute,Upstate NY Region Erie County Medical Center* Nassau University*

39、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 Medi

40、cal Center* SUNY Brooklyn* Village Center,NYS DOH AIDS Institute,Smoking Prevalence among PLWHA Receiving Care in NYS 2005,NYS DOH AIDS Institute,Target Sample: 1228 Surveys completed: 1094 Return rate: 89,Smoking Prevalence among PLWHA Receiving Care in NYS 2005,NYS DOH AIDS Institute, OMD/OPER,Smoking Prevalence among PLWHA Receiving Care in NYS 2005,Percentage Correct on Smoking Knowledge Statements,NYS DOH AIDS Institute, OMD/OPER,Willingness to Quit,Stopped smoking for one day or longer during the past 12