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.

Why Smoking Cessation Why Smoking Cessation Should Be a Priority in HIV Should Be a Priority in HIV

Care Today…Care Today…

Why Smoking Cessation Why Smoking Cessation Should Be a Priority in HIV Should Be a Priority in HIV

Care Today…Care Today…

Alvaro Carrascal, MD, MPHOffice of the Medical DirectorAIDS InstituteAI is a Local Performance Site of the NY/NJ AETC

ObjectivesObjectivesObjectivesObjectives

Review the changing paradigm of HIV Review the changing paradigm of HIV diseasedisease

Review the association between smoking Review the association between smoking and HIVand HIV

Describe the importance of addressing Describe the importance of addressing tobacco use among PLWHAtobacco use among PLWHA

HIV Disease: Changing HIV Disease: Changing ParadigmParadigm

HIV Disease: Changing HIV Disease: Changing ParadigmParadigm

Reduced mortalityReduced mortality

Chronic diseaseChronic disease PLWH/AIDS living longer, healthier and more PLWH/AIDS living longer, healthier and more

productive livesproductive lives

Changing morbidity/mortalityChanging morbidity/mortality Cancer, CVD, diabetes, liver disease, etc.Cancer, CVD, diabetes, liver disease, etc.

MortalityMortalityMortalityMortality

55615561 pats., HOPS, 1996-2002pats., HOPS, 1996-2002

19961996 20022002 DeathsDeaths

6.3 /100 person-yrs 6.3 /100 person-yrs 2.2 2.2

OI rates: OI rates: 23 /100 person-yrs 23 /100 person-yrs 6 6

Reductions in MortalityReductions in MortalityReductions in MortalityReductions 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 HAARTUse of HAARTUse of HAARTUse of HAART

0

20

40

60

80

100

1996 2002

HAART No HAART

% o

f pa

tient

s


.. and Change in Causes of .. and Change in Causes of DeathDeath

.. and Change in Causes of .. and Change in Causes of DeathDeath

0102030405060708090

100

1996 2002

Non-HIV related HIV-related

% o

f de

aths


Changes in Causes of DeathChanges in Causes of DeathSouthern Alberta, Canada, 1984-2003Southern Alberta, Canada, 1984-2003

Changes in Causes of DeathChanges in Causes of DeathSouthern Alberta, Canada, 1984-2003Southern Alberta, Canada, 1984-2003

0

5

10

15

20

25

30

35

Pre-HAART HAART

7%

32%

Cohort: 1987 patients Total # of deaths= 560

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

% o

f de

aths

, no

n-A

IDS

rel

ated

cau

ses

Increases in Non-AIDS Related Increases in Non-AIDS Related Causes of Death Causes of Death

Southern Alberta, Canada, 1984-2003Southern Alberta, Canada, 1984-2003

Increases in Non-AIDS Related Increases in Non-AIDS Related Causes of Death Causes of Death

Southern Alberta, Canada, 1984-2003Southern Alberta, Canada, 1984-2003

Causes of DeathCauses of Death 1984-961984-96 1997-031997-03

Accidental deathsAccidental deaths 2.2%2.2% 17%17%(drug overdose)(drug overdose)

Liver diseaseLiver disease <1<1 8.48.4

Non-HIV CancersNon-HIV Cancers <1<1 77

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

HIV-related and Non-HIV related HIV-related and Non-HIV related deaths among PLWHAdeaths among PLWHA

NYC 1988-2003NYC 1988-2003

HIV-related and Non-HIV related HIV-related and Non-HIV related deaths among PLWHAdeaths among PLWHA

NYC 1988-2003NYC 1988-2003

0%

20%

40%

60%

80%

100%

Perc

ent of

dea

ths

Non-HIV related deaths HIV-related deaths

Source: HIV Epidemiology Program 1st Quarter Report (Jan 2005), NYC Dept. of Health and Mental Hygiene

HAART

Living LongerLiving LongerLiving LongerLiving Longer

PLWHA Are Getting Older…PLWHA Are Getting Older…PLWHA Are Getting Older…PLWHA Are Getting Older…NY: HIV/AIDS hospital discharges among PLWHA NY: HIV/AIDS hospital discharges among PLWHA

50 years of age or older50 years of age or older

0

5

10

15

20

25

1994 2003

50 yo/olderSource: SPARCS database, NYSDOH

% o

f H

IV/A

IDS

dis

char

ges

PLWHA Are Getting Older…PLWHA Are Getting Older…PLWHA Are Getting Older…PLWHA Are Getting Older…

02468

101214161820

1993 2002

50 yo/older

NY: Medicaid Recipients with HIV/AIDS, NY: Medicaid Recipients with HIV/AIDS, Age 50+Age 50+

Source: Medicaid Claims database

% o

f H

IV/A

IDS

rec

ipie

nts

Changing MorbidityChanging MorbidityChanging MorbidityChanging Morbidity

Changing MorbidityChanging MorbidityCardiovascular DiseasesCardiovascular Diseases

Changing MorbidityChanging MorbidityCardiovascular DiseasesCardiovascular 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 therapy and the risk of myocardial infarction. N Engl J Med 2003; 349:1993–2003

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; 18:1811–1817

Myocardial infarction Among Myocardial infarction Among Patients with HIV InfectionPatients with HIV Infection

Myocardial infarction Among Myocardial infarction Among Patients with HIV InfectionPatients with HIV Infection

0

0.5

1

1.5

2

2.5

3

3.5

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Ra

te p

er

10

00

pa

tien

t-yr

s

Holmberg et al. Trends in rates of myocardial infarction among patients with HIVN Engl J Med 2004; 350:730-731

0

100

200

300

400

500

600

700

800

1994 1995 1996 1997 1998 1999 2000 2001 2002

per 1

00,0

00 H

IV/A

IDS

disc

harg

es

Acute Myocardial Infarction

NY: Discharges among PLWHA

Source: SPARCS database, NYSDOH

“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

“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

“..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?”

James Cadenhead

Infected with HIV for 18 years. Has had Hep B, C, toxoplasmosis.

New York Times, Aug. 17, 2004

Changing MorbidityChanging MorbidityCancerCancer

Changing MorbidityChanging MorbidityCancerCancer

Trends in AIDS-Defining and Non–AIDS-Defining Malignancies among HIV-Infected Patients 1989–2002

Trends in AIDS-Defining and Non–AIDS-Defining Malignancies among HIV-Infected Patients 1989–2002

0

5

10

15

20

25

30

35

40

89-96 97-02

ADM non-ADM

Ca s

es p

er 1

000

p at-

year

s

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

0

25

50

75

100

125

150

1994 1995 1996 1997 1998 1999 2000 2001 2002

Pe

r 1

00

,00

0 H

IV/A

IDS

dis

cha

rge

s

Cancers of the larynx and oropharynxamong PLWHA discharged from hospitals in NY, 1994-2002

Cancers of the larynx and oropharynxamong PLWHA discharged from hospitals in NY, 1994-2002

Dis

char

ges

from

hos

pita

ls

Source: NY SPARCS

0

20

40

60

80

100

120

140

160

1993 1994 1995 1996 1997 1998 1999 2000 2001

Per

100,0

00 r

eci

pie

nts

with

HIV

/AID

S

Oropharynx Larynx

Source: NY Medicaid

Cancers of the larynx and oropharynxamong PLWHA, Medicaid recipients, NY, 1993-2001

Cancers of the larynx and oropharynxamong PLWHA, Medicaid recipients, NY, 1993-2001

0

100

200

300

400

500

600

700

800

1994 1995 1996 1997 1998 1999 2000 2001 2002

Per

100

,000

HIV

/AID

S d

isch

arge

s

Lung, TracheaSource: NY SPARCS

Cancers of the lung and trachea among PLWHA discharged from hospitals in NY, 1994-2002

Cancers of the lung and trachea among PLWHA discharged from hospitals in NY, 1994-2002

0

100

200

300

400

500

600

1993 1994 1995 1996 1997 1998 1999 2000 2001

Per

100,

000

reci

pien

ts w

ith H

IV/A

IDS

Lung&TracheaSource: NY Medicaid Claims database

Cancers of the lung and tracheaamong PLWHA, Medicaid recipients, NY, 1993-2001

Cancers of the lung and tracheaamong PLWHA, Medicaid recipients, NY, 1993-2001

0

5

10

15

20

25

30

35

40

45

50

AIDS Cancer HCV CVD

Causes of death among HIV-Causes of death among HIV-infected adults in France, 2000infected adults in France, 2000Causes of death among HIV-Causes of death among HIV-

infected adults in France, 2000infected adults in 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

% o

f all

deat

hs

Causes of death among HIV-Causes of death among HIV-infected adults in France, 2000infected adults in France, 2000Causes of death among HIV-Causes of death among HIV-

infected adults in France, 2000infected 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

“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

0

2

4

6

8

10

12

14

16

18

20

Anal Hodgkin's Liver

Testicular Melanoma Oropharyngeal

Lung Colorectal

Incidence Rate Ratios of Non-AIDS Incidence Rate Ratios of Non-AIDS Defining MalignanciesDefining Malignancies

1992-20021992-2002


1992-20021992-2002Incidence 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


1992-20021992-2002


1992-20021992-2002

““The incidence of many non-ADM were The incidence of many non-ADM were significantly higher … suggesting that HIV-significantly higher … suggesting that HIV-infected persons are at higher risk of developing infected persons are at higher risk of developing certain cancerscertain cancers

In addition to encouraging tobacco cessation, In addition to encouraging tobacco cessation, health care providers should consider enhanced health care providers should consider enhanced monitoring for these malignancies in their HIV-monitoring for these malignancies in their HIV-infected patients.”infected patients.”

Patel P et al. Incidence of AIDS-defining and non-AIDS defining malignancies among HIV infected persons. CROI 2006

Lung Cancer in PLWHALung Cancer in PLWHALung Cancer in PLWHALung Cancer in PLWHA

5,238 pats., Moore Clinic, 1989-20035,238 pats., Moore Clinic, 1989-2003 19,061 person-years of follow up19,061 person-years of follow up 33 cases identified (85% current smokers 33 cases identified (85% current smokers

12% 12% former smokers)former smokers)

SIR Detroit gen. pop. = 4.7SIR Detroit gen. pop. = 4.7

US pop. = 6.9US pop. = 6.9Engels, EA et al. Elevated incidence of lung cancer among HIV-infected individuals. J Clin Oncol 2006; 24: 1383–88

Lung Cancer in PLWHALung Cancer in PLWHALung Cancer in PLWHALung 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

Other ConditionsOther ConditionsOther ConditionsOther Conditions

Chronic Bronchitis and EmphysemaChronic Bronchitis and Emphysemaamong PLWHA Discharged from among PLWHA Discharged from

Hospitals in NYHospitals in NY

Chronic Bronchitis and EmphysemaChronic Bronchitis and Emphysemaamong PLWHA Discharged from among PLWHA Discharged from

Hospitals in NYHospitals in NY

0

200

400

600

800

1000

1200

1400

1994 1995 1996 1997 1998 1999 2000 2001 2002

per 1

00,0

00 H

IV/A

IDS

dis

char

ges

Chronic Bronchitis Emphysema

Source: SPARCS database, NYSDOH

Oral HealthOral HealthOral HealthOral Health

HIV+ smokers are more likely to HIV+ smokers are more likely to developdevelop Oral candidiasisOral candidiasis PeriodontitisPeriodontitis Oral hairy leukoplakiaOral hairy leukoplakia CancersCancers

Oral HealthOral HealthOral HealthOral Health

HIV Cost and Services Utilization Study. HIV Cost and Services Utilization Study. National probability sample of HIV inf. Adults in National probability sample of HIV inf. Adults in the USthe US

Self-reported, 3 sets of interviewsSelf-reported, 3 sets of interviews Smokers were 62% more likely to report “oral Smokers were 62% more likely to report “oral

white patches” than non-smokerswhite 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

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 Impact of Smoking on Outcome in the HIV Outcome in the HIV

InfectedInfected

Impact of Smoking on Impact of Smoking on Outcome in the HIV Outcome in the HIV

InfectedInfected

Women: Cigarrette Smoking Women: Cigarrette Smoking and HIV Prognosis in the and HIV Prognosis in the

HAART EraHAART Era


HAART EraHAART 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


HAART EraHAART Era


HAART EraHAART 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

Cumulative percentage remaining free from an AIDS-defining condition, by smoking status before HAART initiation

Impact of Cigarette Smoking Impact of Cigarette Smoking on Mortality and QOL Among on Mortality and QOL Among

PLWHAPLWHA

Impact of Cigarette Smoking Impact of Cigarette Smoking on Mortality and QOL Among on Mortality and QOL Among

PLWHAPLWHA 867 HIV+ from Veterans Aging Cohort 3 Site 867 HIV+ from Veterans Aging Cohort 3 Site

StudyStudy 63% current smokers, 22% former smokers63% current smokers, 22% former smokers Current smokers had highest VL (compared to Current smokers had highest VL (compared to

form. or never smokers. p=.001)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

0

1

2

3

4

5

6

Impact of Cigarette Smoking on Impact of Cigarette Smoking on Mortality Mortality

Impact of Cigarette Smoking on Impact of Cigarette Smoking on Mortality Mortality

Una

djus

ted

mor

talit

y ra

te p

er 1

00 p

erso

n-ye

ars

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 smokers (hazard ratio [HR] 1.99, 95% CI1.03 to 3.86).


Cigarette Smoking and QOLCigarette Smoking and QOLCigarette Smoking and QOLCigarette Smoking and QOL

36

37

38

39

40

41

42

43

44

45

Smokers Former smokers Never smokers

N=549

N=189

N=129

QO

L


How Serious is the How Serious is the Problem?Problem?

How Serious is the How Serious is the Problem?Problem?

Prevalence of smoking among people with HIV Prevalence of smoking among people with HIV --- estimated to be --- estimated to be higherhigher than among the than among the general populationgeneral population

New England clinics: More than 70% of HIV+ New England clinics: More than 70% of HIV+ smokesmoke

Swiss HIV Cohort StudySwiss HIV Cohort Study 72% are current/former smokers72% are current/former smokers 96% among IDUs96% 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 Antiretroviral Therapy. J Natl Cancer Inst 2005;97:425-432

New YorkNew YorkNew YorkNew York

482 HIV+ Medicaid recipients, NYC482 HIV+ Medicaid recipients, NYC Age: 22-75 Age: 22-75 59% males59% males 53% African Americans53% African Americans

30% Latinos30% Latinos HS education or less : 87%HS education or less : 87%

66% current smokers (mean=16 cig./day)66% current smokers (mean=16 cig./day) 18% former smokers18% former smokers Current smokersCurrent smokers

Greater use of illicit substancesGreater use of illicit substances Lower state of healthLower state of health Lower perceived health risk of continued smokingLower 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

Survey collected: Demographics Current and past tobacco use. Frequency. Perceptions regarding tobacco use Cessation history. Intentions/readiness to quit

Smoking Prevalence among Smoking Prevalence among PLWHA Receiving Care in NYSPLWHA Receiving Care in NYS

20052005

NYS DOH AIDS InstituteNYS DOH AIDS Institute

Upstate NY RegionUpstate NY Region Erie County Medical Center*Erie County Medical Center* Nassau University*Nassau University* Strong Memorial Hospital*Strong Memorial Hospital* SUNY Syracuse*SUNY Syracuse* United Health Services*United Health Services* Westchester County Medical Westchester County Medical

Center*Center*

* Designated AIDS Care Center* Designated AIDS Care Center**Adult Day Health Center**Adult Day Health Center

NYC RegionNYC Region Bronx Lebanon*Bronx Lebanon* Harlem United**Harlem United** Housing Works 13Housing Works 13thth Street** Street** Housing Works 98Housing Works 98thth Street** Street** NY Hospital of Queens*NY Hospital of Queens* PROMESA**PROMESA** Saint Vincent Medical Center*Saint Vincent Medical Center* SUNY Brooklyn*SUNY Brooklyn* Village Center**Village Center**



20052005

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Hisp Afr.Amer White Other


Target Sample: Target Sample: 12281228

Surveys Surveys completed: 1094completed: 1094

Return rate: 89%Return rate: 89%


20052005

10010010771077TotalTotal

16.316.3175175Never UsedNever Used

24.524.5264264Used in the PastUsed in the Past

59.259.2638638Currently UseCurrently Use%%NNUse StatusUse Status

NYS DOH AIDS Institute, OMD/OPERNYS DOH AIDS Institute, OMD/OPER


20052005

Percentage Correct on Smoking Percentage Correct on Smoking Knowledge StatementsKnowledge Statements

Percentage Correct on Smoking Percentage Correct on Smoking Knowledge StatementsKnowledge Statements

64%64%Smoking isn’t any more dangerous for HIV positive Smoking isn’t any more dangerous for HIV positive individuals than it is to people without HIV. individuals than it is to people without HIV. N=1027 N=1027

63%63%

Because it takes many years for the effects of smoking to Because it takes many years for the effects of smoking to occur, smoking isn’t a serious health concern for HIV positive occur, smoking isn’t a serious health concern for HIV positive people. people. N=1027 N=1027

14%14%Nicotine is a cause of cancerNicotine is a cause of cancer. . N=1023N=1023

56%56%

If a person has smoked a pack of cigarettes a day for more If a person has smoked a pack of cigarettes a day for more than 20 years, there is little benefit to quitting smoking.than 20 years, there is little benefit to quitting smoking.

N=1039N=1039

% Correct% CorrectSmoking Knowledge StatementsSmoking Knowledge Statements


Willingness to QuitWillingness to QuitWillingness to QuitWillingness to Quit

Stopped smoking for one day or longer Stopped smoking for one day or longer during the past 12 months: during the past 12 months:

Currently interested in quitting: Currently interested in quitting:

64%

74%


How Big is the Problem?How Big is the Problem?How Big is the Problem?How Big is the Problem?

HUGE! HUGE! In NY, smoking is 3 times higher among In NY, smoking is 3 times higher among

PLWHA than among the general pop. PLWHA than among the general pop.

HIV+ populations include the following HIV+ populations include the following overlapping conditionsoverlapping conditions Substance useSubstance use Mental healthMental health Poverty, low educational attainmentPoverty, low educational attainment

2004 Surgeon General Report 2004 Surgeon General Report on Smoking on Smoking

2004 Surgeon General Report 2004 Surgeon General Report on Smoking on Smoking

Updates the health effects of smokingUpdates the health effects of smoking

Identifies substantial number of diseases that were Identifies substantial number of diseases that were not previously associated with smokingnot previously associated with smoking Cancer of the stomach, uterine cervix, pancreas, kidneyCancer of the stomach, uterine cervix, pancreas, kidney Acute myeloid leukemiaAcute myeloid leukemia PneumoniaPneumonia Abdominal aortic aneurysmAbdominal aortic aneurysm CataractsCataracts PeriodontitisPeriodontitis

Single most preventable cause of death and illnessSingle most preventable cause of death and illness

ConclusionsConclusionsConclusionsConclusions Significant changes in mortality and morbidity Significant changes in mortality and morbidity

among people with HIVamong people with HIV

PLWHA are living longer and increasingly PLWHA are living longer and increasingly becoming ill or dying of non HIV- related becoming ill or dying of non HIV- related conditionsconditions

Smoking is highly prevalent among PLWHASmoking is highly prevalent among PLWHA

Smoking cessation should be a priority in the Smoking cessation should be a priority in the medical management of PLWHAmedical management of PLWHA

ConclusionsConclusionsConclusionsConclusions Significant, and immediate, benefits for HIV+ Significant, and immediate, benefits for HIV+

individuals can be achieved by quittingindividuals can be achieved by quitting

Significant public health benefits can be Significant public health benefits can be derived from reducing smoking among derived from reducing smoking among PLWHAPLWHA

To further improve survival and quality of life To further improve survival and quality of life for PLWHA, we MUST promote smoking for PLWHA, we MUST promote smoking cessationcessation

AcknowledgementsAcknowledgementsAcknowledgementsAcknowledgements

Kumara Singaravelu, MD, MPHKumara Singaravelu, MD, MPH James Tesoriero, Ph.D.James Tesoriero, Ph.D. Susan GyericSusan Gyeric The AIDS Institute’s HIV and Smoking The AIDS Institute’s HIV and Smoking

WorkgroupWorkgroup

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.

Documents

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causes of death1984

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