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Why Smoking Cessation Should Be a Priority in HIV Care Today…

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

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Why Smoking Cessation Should Be a Priority in HIV Care Today…

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  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

  2. Objectives • Review the changing paradigm of HIV disease • Review the association between smoking and HIV • Describe the importance of addressing tobacco use among PLWHA

  3. 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.

  4. Mortality

  5. Reductions in Mortality • 5561pats., HOPS, 1996-2002 1996 2002 • Deaths • 6.3 /100 person-yrs 2.2 • OI rates: • 23 /100 person-yrs 6 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

  6. 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. Abs. 872

  7. .. 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. Abs. 872

  8. Changes in 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

  9. 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

  10. HIV-related and Non-HIV related deaths among PLWHANYC 1988-2003 HAART Source: HIV Epidemiology Program 1st Quarter Report (Jan 2005), NYC Dept. of Health and Mental Hygiene

  11. Living Longer

  12. PLWHA Are Getting Older… NY: HIV/AIDS hospital discharges among PLWHA 50 years of age or older % of HIV/AIDS discharges Source: SPARCS database, NYSDOH

  13. PLWHA Are Getting Older… NY: Medicaid Recipients with HIV/AIDS, Age 50+ % of HIV/AIDS recipients Source: Medicaid Claims database

  14. Changing Morbidity

  15. Changing MorbidityCardiovascular Diseases

  16. 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 Incidence of MI according to the duration of exposure to CART The D:A:D Study Group. Combination antiretroviral therapy and the risk of myocardial infarction. N Engl J Med 2003; 349:1993–2003

  17. The Writing Committee of the D:A:D Study Group. Cardio- and cerebrovascular events in HIV-infected persons. AIDS 2004; 18:1811–1817

  18. Myocardial infarction Among 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

  19. Acute Myocardial Infarction NY: Discharges among PLWHA Source: SPARCS database, NYSDOH

  20. “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

  21. “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

  22. 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

  23. Changing MorbidityCancer

  24. Trends in AIDS-Defining and Non–AIDS-Defining Malignancies among HIV-Infected Patients1989–2002 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

  25. Cancers of the larynx and oropharynx among PLWHA discharged from hospitals in NY, 1994-2002 Discharges from hospitals Source: NY SPARCS

  26. Cancers of the larynx and oropharynx among PLWHA, Medicaid recipients, NY, 1993-2001 Source: NY Medicaid

  27. Cancers of the lung and trachea among PLWHA discharged from hospitals in NY, 1994-2002 Source: NY SPARCS

  28. Cancers of the lung and trachea among PLWHA, Medicaid recipients, NY, 1993-2001 Source: NY Medicaid Claims database

  29. Causes of death among HIV-infected adults in France, 2000 N=964 % of all deaths 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

  30. Causes of death among HIV-infected adults in France, 2000 • Prevention, screening, and management of non-Hodgkin’s 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 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

  31. “Now that HAART-regimens have considerably improved the life expectancy in HIV-infected populations in industrialized 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

  32. Incidence Rate Ratios of Non-AIDS Defining 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

  33. Incidence Rate Ratios of Non-AIDS Defining Malignancies1992-2002 • “The incidence of many non-ADM were significantly 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-defining and non-AIDS defining malignancies among HIV infected persons. CROI 2006

  34. 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 incidence of lung cancer among HIV-infected individuals. J Clin Oncol 2006; 24: 1383–88

  35. 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 interventions 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; 24: 1383–88

  36. Other Conditions

  37. Chronic Bronchitis and Emphysemaamong PLWHA Discharged from Hospitals in NY Source: SPARCS database, NYSDOH

  38. Oral Health • HIV+ smokers are more likely to develop • Oral candidiasis • Periodontitis • Oral hairy leukoplakia • Cancers

  39. Oral Health • HIV Cost and Services Utilization Study. 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 Epidemiol 2005; 33: 99–106

  40. Minkoff H et al. Relationship between smoking and Human Papillomavirus infections in HIV-infected and -uninfected women. J Infect Dis 2004;189:1821-8

  41. Impact of Smoking on Outcome in the HIV Infected

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

  43. Women: Cigarrette Smoking and HIV Prognosis in the HAART Era Cumulative percentage remaining free from an AIDS-defining condition, by smoking status before HAART initiation Feldman JG, Minkoff H et al. The association of cigarette smoking with HIV prognosis among women in the HAART era—A report from the Women’s Interagency HIV Study. Am J Public Health 2006;96(6):1-6

  44. Impact of Cigarette Smoking on Mortality and QOL Among PLWHA • 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 &/or asthma), and bacterial pneumonia 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

  45. Impact of Cigarette Smoking on Mortality 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 smokers (hazard ratio [HR] 1.99, 95% CI 1.03 to 3.86). Unadjusted mortality rate per 100 person-years Smokers Never smokers 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

  46. Cigarette Smoking and QOL N=129 QOL N=189 N=549 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

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