The potential of behavior-change interventions to improve the HIV/AIDS survivorship experience: the example of smoking cessation.

The concept of survivorship, generally defined as the physical, psychosocial, and economic impact of disease and treatment on an individual, is widely recognized as an important field of research. The focus on survivorship research is perhaps most visible within the oncology community. Government agencies, foundations, and advocacy groups frequently stress the importance of both a thorough consideration of the factors that can potentially influence the survivorship experience for individuals diagnosed with cancer, and the development and dissemination of interventions designed to improve that experience. While the term survivorship may not be commonly used in reference to persons living with HIV/AIDS, this perspective can help both clinicians and researchers identify areas in need of intervention. In addition, the significantly extended life expectancy made possible by highly active antiretroviral therapy (HAART) certainly brings the relevance of this perspective to the forefront.

It is from this standpoint that one can appreciate the importance of interventions addressing health-risk behaviors. Targeting of risky behaviors has a long history in the field of HIV research; the most common purpose of these behavioral interventions is to reduce the risk of primary or secondary HIV infection. While prevention is obviously still needed, behavioral interventions can also be used to improve the lives of persons already infected. For example, recent years have seen a growing number of interventions targeting diet and physical activity. This form of intervention has the potential to at least partially counter the increased risk of cardiovascular disease (CVD) seen in the HIV-positive population. Similarly, interventions designed to reduce illicit drug use and alcohol abuse can potentially lead to lower rates of secondary infection, improved medication adherence, and ultimately, to improved quality of life.

Cigarette smoking among individuals living with HIV/AIDS is a health-risk behavior that is of particular interest to me and has been a major focus of my research for the past 6 years. At the time that my colleagues, Roberto C. Arduino, MD, and Ellen R. Gritz, PhD, and I began our studies, very few research efforts had been made to understand the scope of the problem (ie, the prevalence of current smoking, interest in cessation treatment, and development of appropriate interventions). The existing literature, however, did clearly indicate that smokers with HIV/AIDS were at higher risk for numerous adverse outcomes, including pulmonary diseases, oral infections, and both AIDS- and non-AIDS-related malignancies. Thus, it seemed quite clear that efforts to target this population for smoking cessation treatment were warranted.

The reasons for the lack of published smoking cessation interventions involving the HIV-positive population were most likely driven by the historically poor prognosis. In fact, an all too common assumption from patients and health care providers alike has been that individuals living with HIV/AIDS were unlikely to survive long enough to be at risk for the diseases attributable to smoking. Other concerns included the possibility that over-burdening the population with a smoking cessation intervention might actually detract from other important focuses, such as medication adherence and secondary prevention. A final concern stems from the belief of some smokers that cigarettes promote relaxation at stressful times. On the surface, this would suggest that cessation efforts may actually increase distress levels by eliminating an effective stress-management practice.

More recently published evidence clearly elucidates the deleterious relationship between smoking and HIV/AIDS. The increasing incidence of CVD within the HIV-positive population is particularly alarming. Whether this increasing risk is caused by the metabolic changes associated with long-term use of HAART, a consequence of disease progression now more apparent because of longer life expectancies, or a combination of these 2 factors is not clear. However, what is clear is the strong, independent CVD risk associated with smoking cigarettes. Therefore, it appears that cessation treatment could become a crucial component in the long-term management of HIV-positive patients to reduce the morbidity and mortality associated with CVD.

The morbidity and mortality associated with malignancy among persons living with HIV/AIDS has also received more attention in recent years. During the HAART era, the mortality rate attributable to several AIDS-defining cancers has decreased, but the proportion of deaths due to smoking-related cancers has increased. (1) Also alarming is the increased risk of aerodigestive cancers (those affecting the organs of the respiratory and upper digestive tracts) observed in HIV-infected smokers compared to non-HIV-infected smokers, suggesting a synergistic relationship between smoking and HIV.

It is now evident that cigarette smoking is an important contributor to morbidity and mortality in the HIV-positive population and that reducing the prevalence of smoking would result in an improved survivorship experience characterized by better disease management, increased quality of life, and further improved survival rates. A demonstration of the effects of cigarettes can be observed in the recent findings from the Women's Interagency HIV Study, where current smokers had significantly poorer response to HAART (both viral and immunologic) and higher death risk compared to nonsmokers. (2) Perhaps based partly on these findings, the all-too-common reluctance to acknowledge the smoking problem within the HIV-positive population seems to be waning and the importance of introducing effective smoking cessation strategies into the HIV clinic seems to be far more accepted today.

Our first research efforts were descriptive and designed to gain a more complete picture of smoking behavior in this population. Our results, and those of several other groups conducting similar research across the country, indicated an alarmingly high prevalence of smoking. The proportion of individuals living with HIV/AIDS who are current smokers is estimated to be about 50%, which is more than double the proportion in the general US population--about 21%. (3) No single reason can account for this elevated rate. Rather, numerous factors known to be associated with smoking are disproportionately observed in the HIV-positive population. Specifically, increased prevalence of negative affect, low socioeconomic status, illicit drug and alcohol use, and non-heterosexual orientation are all associated with both smoking status and HIV infection.

Additional research efforts helped us to identify potential barriers to more traditional cessation interventions. Many of the barriers are not necessarily associated with HIV status, but rather with socioeconomic status. For example, we found that the majority of the population reported several household moves in the past year, a reliance on public transportation, and inconsistent or no access to a working telephone. Other potential barriers included the burden of numerous medical care appointments and fears regarding side effects from additional medication. While our sample of participants was drawn from the Houston metropolitan area, these barriers are likely common across the nation.

Based on our findings, we developed an intervention approach designed to overcome these barriers to treatment. This approach involved the systematic screening of all patients attending a large, county-funded HIV clinic. Smokers were offered cessation treatment consisting of either a usual care approach (brief physician advice to quit and recommendation of nicotine-based replacement patches) or an enhanced care approach that supplemented the usual care elements with proactive counseling delivered via prepaid cell phones that we provided. Our results were encouraging. Interest in quitting was high among the individuals screened--about two-thirds of people enrolled in the study. We also found that the addition of the cell phone component tripled the smoking abstinence rates at the 3-month follow-up. Currently, a larger efficacy trial, with long-term follow-up, is being conducted. Additional analyses will also be conducted to compare changes in markers of disease progression and functional status domains between those who successfully quit smoking and those who continue to smoke.

The use of cell phone-delivered counseling is certainly not the only smoking cessation treatment option for the HIV-positive population. Additional assessments of both traditional and innovative cessation treatment approaches (eg, educational, behavioral, and pharmacologic) are needed. And, efforts to tailor treatment type and intensity to the individual smoker will improve the likelihood of successful cessation.

The significantly decreased death rate and reduced risk of AIDS-related diseases brought about by HAART has dramatically changed the lives of persons living with HIV/AIDS. This disease is now much more accurately viewed as a long-term, medically manageable condition, and thus, the effects of health behaviors are now more relevant than ever. Integrating careful tobacco-use screening and treatment into routine clinical practice could significantly improve a variety of health outcomes, ranging from perceived symptom burden to mortality risk. Such an approach also offers the very real potential of significantly improving the survivorship experience of this ever-growing population.

References

(1.) Palella FJ, Jr., Baker RK, Moorman AC, et al. J Acquir Immune Defic Syndr. 2006;43:27-34.

(2.) Feldman JG, Minkoff H, Schneider MF, et al. Am J Public Health. 2006;96:1060-1065.

(3.) Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2006;55:1145-1148.

Damon J. Vidrine is Assistant Professor in the Department of Behavioral Science at The University of Texas MD Anderson Cancer Center in Houston.