A new modeling analysis looking at the risk of lung cancer death due to smoking for a person living with HIV concluded that “for people living with HIV who adhere to antiretroviral therapy (ART), smoking is a much greater threat to their health than HIV itself.” In fact, those who continued to smoke were six to 13 times more likely to die from lung cancer than from traditional AIDS-related causes, depending on how much they smoked and their gender. Although this is a grim and disheartening finding, it is a powerful reminder of the potency and effectiveness of current HIV treatments to prevent disease progression. 

Today, people living with HIV (PLWH) who are diagnosed early, start HIV medical care and treatment, and achieve and maintain viral suppression are expected to live nearly as long as their HIV-negative peers. As a result, the causes of death among people living with HIV have shifted from AIDS-related to non-AIDS-related causes. Better understanding those non-AIDS-related causes can help us better protect and preserve that health of people living with HIV. “As the population of PLWH in the United States ages, estimates of projected comorbidities can help guide where to direct attention and resources in HIV care,” the authors note. 

Smoking has become one of the key health risks among people living with HIV. This is, perhaps, not surprising given the relatively high prevalence of smoking among people living with HIV; over 40% of PLWH in the United States smoke cigarettes, according to several estimates. That’s a rate that is two to three times greater than the general population. This risk reflects the fact that some groups of people who are at increased risk for HIV infection, such as gay and bisexual men and people who inject drugs, are more likely to smoke. We also know that HIV increases the risk of lung cancer independent of smoking status. So it is not surprising that lung cancer has become a leading cause of death among people living with HIV. 

Combining their model-generated estimates with published epidemiological data on the number of people living with HIV in care in the United States, the authors project nearly 60,000 of the people will die from lung cancer deaths if smoking habits do not change. However, if just 20% of the current smokers quit, not only would their lung cancer risk decrease, but nearly 7,000 lung cancer deaths could be averted.  

We have long known that people living with HIV are more likely to be smokers than the general population. However, the effects of smoking were not easily seen and were not a priority before effective treatments became widely available starting in 1996. Since then, research has accumulated showing the negative effects of smoking on the health of people living with HIV and programs have started to respond. For example, CDC’s successful Tips from a Former Smoker campaign featured the experiences of Brian who is living with HIV. Similarly, HRSA’s Guide for HIV Clinical Care [PDF, 5.84MB] includes a chapter on Smoking Cessation and HRSA’s HIV/AIDS Bureau has a performance measure for grantees to encourage screening for tobacco use and cessation counseling when tobacco users are identified. The HRSA-supported AIDS Education and Training Centers offer training materials for clinicians on the topic, including Smoking and HIV: What Clinicians Need to KnowExit Disclaimer. And HIV.gov offers information on HIV and smoking. 

People who smoke, including people living with HIV, can and do quit and there are many evidence-based interventions that can assist those who wish to do so. Given the findings of this new analysis, we need to make sure that smoking screening and cessation support are a routine part of HIV care. Indeed, the authors suggest “Our results provide evidence for HIV care programs and policymakers to include smoking cessation interventions as a key component of the comprehensive care of PLWH.” They also propose that their analysis “can inform important conversations between clinicians and PLWH who smoke, helping both clinician and patient understand the patient’s risks of different diseases and the potential benefits of smoking cessation. Recognizing the increased risk of death from lung cancer vs. that from traditionally feared AIDS-related causes may motivate a smoker to quit smoking.” 

The NIH-supported study, “Lung Cancer Mortality Associated With Smoking and Smoking Cessation Among People Living With HIV in the United StatesExit Disclaimer,” was led by Krishna P. Reddy, M.D., of the Massachusetts General Hospital and was published online last month in JAMA Internal Medicine.