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HIV & Aging Clinical Recommendations
Cigarette smoking is known to be a significant cause of morbidity and mortality in persons living with HIV (PWH). Tobacco use is associated with increased risk of cardiovascular disease, malignancies, pulmonary disease, as well as neurocognitive health.
While about 14% (CDC 2020) of the general population in the U.S. smokes, the prevalence of tobacco use among persons with HIV (PWH) has been estimated to be 2-3 times that of the general population ( Johnston, 2021). Older individuals, persons of color, those in lower education and socioeconomic levels, people who abuse substances, and those with depression are more likely to smoke (Mdodo 2015, Frazier 2018). Older HIV-infected MSM are more likely to have smoked, with only 28.6% having never smoked (Ompad 2014). In the ART era, HIV-infected persons who smoke have a lower quality of life and a doubling of their mortality, even when factors such as age, CD4 cell count, and HIV RNA level are controlled. Smoking increases mortality compared with non-smokers. Current smokers are less likely to achieve virologic suppression on ART (Cropsey 2016) although this does not appear to be related to poor adherence (Moreno 2015). Older women infected with HIV who have smoked tobacco are more likely to exhibit frailty (Gustafson 2016).
Smoking tobacco in persons with HIV infection produces enhanced oxidative stress which induces cellular damage via increased inflammation, altered immune response, early senescence and apoptosis. This mechanism produces atherosclerosis and neoplastic growth. In addition, smoking has effects on the central nervous system, bone metabolism and the reproductive system (Calvo 2015; Collini-2016).
The increased cardiovascular risk in patients infected with HIV is directly related to traditional risk factors, with smoking being the most important (Martin-Iguacel 2015). Up to 75% of all myocardial infarctions in HIV-infected patients occur in those who have smoked, whereas only 1 in 4 are associated with smoking in the general population (Rasmussen 2015, Abutaleb 2018). Smoking has been found to be an important additional risk factor for neurocognitive decline in older patients infected with HIV (Monnig 2016). Smoking is associated with the development of non-AIDS associated cancers (Franzetti 2019) with lung cancer the most common non-AIDS associated malignancy in this group.
The number of life-years lost because of smoking is higher than those lost to HIV-infection (Helleberg 2013; Helleberg 2015; Reddy 2016). The number of years lost to smoking-related cardiovascular disease was 7.9 years and for non-AIDS malignancies 5.9 years in 35-year-old HIV-infected men. There is little difference in life expectancy between virally suppressed never-smokers and the general population (Shirley 2013). Frailty, COPD, atherosclerosis, osteopenia, periodontal disease, and human papillomavirus infections are higher in HIV-infected patients who smoke (Allshouse 2015). Smoking cessation may ameliorate some of these adverse effects and may increase life expectancy.
Marijuana use in the current era of ART and its more liberal access may be associated with less healthy aging. Recent users of marijuana also tend to smoke tobacco (Allshouse 2015).
Screening for Tobacco Use
The U.S. Preventive Service Task Force (USPTF) and the Infectious Diseases Society of America (IDSA) recommends that clinicians screen for tobacco use, advise current smokers to stop smoking, and offer both non-pharmacologic and FDA approved pharmacologic medications to assist with smoking cessation (USPSTF, 2021, Thompson, 2020). One way to screen for tobacco use is to use the 5A framework. The 5A’s include these components: 1) Ask: Ask about tobacco use for every patient at every visit, 2) Advise: Strongly urge and advise smokers to quit, 3) Assess: Determine the patient’s willingness to quit within the next 30 days, 4) Assist: Provide assistance to patients who wish to quit, and 5) Arrange: Schedule a follow-up (in person or by telephone) shortly after the quit date to provide support and additional assistance as needed (CDC 2017.)
Nicotine addiction is particularly difficult to treat in the HIV-infected population. Traditional approaches, including behavior modification, motivational interviewing techniques, group therapy, nicotine replacement therapy (NRT), nicotine receptor-blockade, and nontraditional methods such as acupuncture have met with varying degrees of success (Calvo-Sanchez 2015). A recent Cochrane review showed moderate evidence that a combined approach to smoking cessation in HIV-infected patients was successful over long periods of time (Pool 2016). With regard to older adults and smoking cessation, data suggests that older adults may be less likely than younger smokers to attempt smoking, but those who do attempt to quit are typically more successful than younger smokers (NBHN, 2019).
Several forms of NRT are available (patch, gum, lozenge, inhaler, and nasal spray). Bupropion and Varenicline are other pharmacologic options to assist smokers interested in smoking cessation. Varenicline has been found to be safe and effective in PWH (Mercie 2018). In an analysis of varenicline in PWH, data suggests that varenicline was associated with reduced anxiety in PWH and a higher likelihood of abstinence (Thompson, 2020). Additionally, PWH who were adherent with varenicline were more successful with cessation than those who were less adherent, which underscores the role of adherence counseling for PWH prescribed varenicline (Quinn, 2020). Guidelines for smoking cessation, published by the American Thoracic Society, support the use of a combination of varenicline and nicotine patch over use of a single agent (Leone, 2020). Varenicline is usually prescribed for 12-weeks, however extended treatment, up to 12 months may benefit tobacco users who are unable to achieve success at 12-weeks (Leone, 2020). Dosing of varenicline should be adjusted in persons with creatinine clearance <30 mL/min.
There is limited evidence to recommend the use of electronic cigarettes as a cessation aid (CDC 2020). There may be racial and ethnic differences in response to smoking cessation efforts (Zyambo, 2020). There are no specific data on smoking cessation in the older HIV-infected population.
Smoking cessation is critical to the management, health, and survival of patients infected with HIV. Healthcare providers need to continue to promote smoking cessation, and there is a need for more effective smoking cessation strategies designed specifically for patients with HIV/AIDS (Harris 2010).
Johnson PI, Write SW, Orr M, Pearce FA, Stevens JW, Hubbard RB, et al. Worldwide relative smoking prevalence among people living with and without HIV. AIDS 2021; 35(6):957-970.
Frazier EL, Sutton MY, Brooks JT, Shouse RL, Weiser J. Trends in cigarette smoking among adults with HIV compared with the general adult population, United States-2009-2014. Prev Med 2018; 111:231-234.
Franzetti M, Ricci E, Bonfanti P. The pattern of non-AIDS-defining cancers in the HIV population epidemiology, risk factors and prognosis. A review. Curr HIV Res 2019; 17(12):1-12.
USPSTF. Interventions for tobacco smoking cessation in adults, including pregnant persons 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions#:~:text=The%20USPSTF%20recommends%20that%20clinicians,nonpregnant%20adults%20who%20use%20tobacco.
Thompson MA, Horberg MA, Aguw AL, Colasanti JA, Jain MK, Short WR, et al. Primary care guidance for persons with human immunodeficiency virus 2020 update by the HIV Medicine Association of the Infectious Diseases Society of America Clin Infect Dis 2020.
National Behavioral Health Network (NBHN). Older adults, behavioral health and smoking: Why quitting smoking is still a conversation worth having. https://www.bhthechange.org/resources/older-adults-behavioral-health-and-smoking-why-quitting-smoking-is-still-a-conversation-worth-having/
Mercie P, Arsandaux J, Katlama C, Ferret, S, Beauscart A, Spadone C, et al. Efficacy and safety o f varenicline for smoking cessation in people living with HIV in France (ANRS144 Inter-ACTIVE) a randomized controlled phase 3 clinical trial. Lancet 2018, 5(3) 126-135.
Thompson M, Schnoll R, Serrano K, Leone F, Gross R, Collman RG, et al. The effect of varenicline on mood and cognition in smokers with HIV. Psychopharmacology 2020 237: 1223-1231.
Quinn MH, Bauer AM, Flitter A, Lubitz SF, Ashare RL, Thompson M, et al. Correlates of varenicline adherence among smokers with HIV and its association with smoking cessation. Addict Behav 2020; 102
Leone FT, Zhang Y, Evers-Casey, S, Evins AE, Eakin MN, Fathi J, et al. Initiating pharmacologic treatment in tobacco-dependent adults. An official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 202(2):e5-e31.
Zyambo, CM, Hendricks PS, Cropsey KL, Willig JH, Wilson CM, Gakumo CA, et al. Racial disparities and factors associated with prescription for smoking cessation medications among smokers receiving routine clinical care for HIV. AIDS Care 2020; 32(10):1207-1216.
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