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HIV and Enteropathy
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HIV and Smoking
Smoking is among the most prevalent problems affecting HIV-infected patients. CDC estimates that in 2009, 42 percent of HIV-infected Americans in care smoked cigarettes1 one of the highest rates reported for any subgroup. Smoking poses a special hazard to persons living with HIV infection. It inhibits effective CD4+ T lymphocyte function2,3 increasing susceptibility to infectious diseases, especially pulmonary infections4,5. Additionally, emerging science finds that even in persons with well-controlled HIV infection, HIV also stimulates chronic immune activation6. This inflammatory state increases risk for a set of illnesses for which smoking is a well-established risk and that appear to be on the rise. 

These illnesses include cardiovascular disease, chronic obstructive pulmonary disease, low bone mineral density and associated fragility fracture, and a variety of non-AIDS-defining cancers of infectious etiology, notably of the lung, liver, anus, and oropharynx7-11. In other words, HIV infection adds to the risk for smoking-related illnesses while smoking adds to the injury caused by HIV infection.

For HIV-infected smokers, antiretroviral therapy shifts the risk of death dramatically away from HIV and towards smoking-related causes12-14. The hard-earned life-years gained from effective HIV treatment are squandered on cigarettes at great personal and societal cost.  In this context, smoking cessation should be a priority for HIV-infected persons; in addition to achieving effective antiretroviral therapy, smoking cessation could likely produce the greatest increase in quality and length of life.

With the increased life expectancy now afforded by remarkable advances in care, the need and opportunity to address smoking cessation have grown.  Smoking cessation has become a cornerstone of primary care practice. We can take this extensive experience and build on it by tailoring interventions to the unique needs of HIV-infected smokers. Progress has been mostly modest15 but recent success with novel strategies16-18promises effective cessation programs for HIV-infected smokers are possible.

The current care model and work force for HIV infection are well suited to address smoking cessation. The frequency of care-related visits necessitated by HIV infection creates repeated opportunities to address smoking status, which benefits from repeated interventions and quit attempts. HIV specialists have experience administering behavioral interventions such as adherence and risk-reduction counseling, which is directly applicable to smoking cessation. For primary care practitioners, who in the changing healthcare landscape are expected to take on more of routine management of HIV infection, smoking cessation is already part of basic good clinical practice. Reassuringly, the pharmacologic interventions available for smoking cessation are generally safe to use with antiretrovirals.

HIV-infected smokers may be more ready and willing to quit than we expect. In various surveys, 84 percent have expressed an interest in quitting, 40-60 percent have contemplated quitting, and 70percent have made at least one quit attempt 19, 20. After quitting, HIV-infected smokers experience not only significant reduction in risk for pulmonary and cardiovascular diseases21-23but significant improvement in HIV-related symptoms24.

There are multiple resources to help busy clinical practices help their patients quit, including a dedicated webpage for health care providers from CDC's Tips from Former Smokers campaign and a specific handbook for HIV-infected smokers produced by the Veterans Administration.

The counseling fundamentals we know work in clinical settings is straightforward, and validated in numerous clinic-based trials over decades: 
·         Ensure that tobacco use status is routinely collected at clinic visits as a “vital sign”;
·         Provide brief advice to patients encouraging quitting, ideally with tailoring to their circumstances;
·         Determine interest in quitting, and if interested, provide assistance either in-office or by referral to community resources. Assistance can include brief counseling and cessation medications. If in-house resources are not available or acceptable, consider referring to 1-800-QUITNOW, which provides phone counseling in all 50 states as well as community referrals. If not interested, explore reasons for lack of interest. Regularly remind patients as needed that smoking adds to the harm caused by HIV, undermining the benefits of antiretroviral treatment; and
·         As with other key aspects of HIV treatment, track smoking or quit status at follow-up visits, and provide support based on patient characteristics.
 
By: John T. Brooks, MD and Tim McAfee, MD, on behalf of the CDC Anti-Smoking Campaign
Disclaimer: The findings and conclusions of this paper are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
 
References
 
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