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Smoking status and HIV in low-income and middle-income countries

In high-income settings, the prevalence of tobacco use has been shown to be significantly higher in people living with HIV than among HIV-negative individuals of the same age and sex distribution. This at-risk pattern is one of the biggest threats to the number of years of life saved with antiretroviral therapy (ART).1,2 Extrapolation of these findings to low-income and middle-income countries (LMICs) is risky because social, cultural, and behavioural factors influencing tobacco use differ widely across different regions. The epidemiology of tobacco use in HIV-positive individuals in LMICs has been sparsely reported, with limited representativeness and no or biased control populations.3–5 In The Lancet Global Health, Noreen Mdege and colleagues6 report an unprecedented estimation of tobacco use in people living with HIV, using nationally representative samples extracted from the Demographic and Health Surveys (DHS) from 28 countries on three continents. In addition to depicting the burden and diversity of tobacco use, the authors show significantly higher figures of tobacco use in people living with HIV compared with their HIV-negative counterparts, regardless of gender. These results confirm what has already been reported in high-income settings, and emphasise the need for adapted preventive measures and tobacco cessation programmes in LMICs.

Countries highly affected by the HIV epidemic usually have underfunded health-care systems and are overburdened with other major epidemics such as malaria and tuberculosis, and are therefore less inclined to invest in preventive measures against non- communicable diseases and their determinants. In this context, smoking-targeted preventive and cessation programmes are often limited or nonexistent. HIV care programmes represent by far the largest chronic care programmes rolled out in LMICs, potentially paving the way for an integrated panel of services targeting non- communicable diseases. Measures directed towards smoking avoidance and cessation can then be introduced and piloted before their extension and adaption to a larger set of health facilities.

Although Mdege and colleagues’ analysis6 of publicly available data provides a comprehensive presentation

of prevalence estimates of tobacco use in HIV-positive individuals in LMICs, the number of people living with HIV in the study represents less than 0·001% of the estimated 34 million people living with HIV in 2014 in these parts of the world; this limited size might lead to imprecision and potential bias in the prevalence estimates of tobacco use, especially outside of Africa.7 Although the data were fairly representative of the African region, data for southeast Asia were only available for India, leaving important uncertainties concerning the association between tobacco use and HIV infection in countries particularly affected by tobacco smoking—especially China. This report6 comes at a time when LMICs represent a major target for the tobacco industry.8 Southeast Asia is the widest market for the tobacco industry, and the Chinese tobacco market represents more cigarettes than all other LMICs combined.9

Additional data sources on tobacco use are needed for people living with HIV in LMICs. Achievements made by the international community to enable universal access to ART were accompanied by initiatives providing worldwide data on the follow-up of patients initiating ART. The International Epidemiology Databases to Evaluate AIDS (IeDEA), funded by the US National Institutes of Health, is a unique platform that has so far gathered data on more than 1 700 000 people living with HIV on ART, most of whom live in LMICs. This platform has successfully collected core information on ART exposure, and harmonisation is underway to standardise the collection of basic behavioural risk factors such as tobacco use. Data from observational cohorts participating in IeDEA have already provided regional estimates on tobacco use from west Africa,4 and in the future could contribute to a more robust and complementary estimation of tobacco use in people living with HIV, especially in the context of universal ART.10

Nevertheless, the DHS offer a good opportunity to access a somewhat representative control group of HIV- uninfected people and can be repeated over time using the same methodological approach. This use of DHS data is therefore a unique framework to conduct sound

For more on IeDEA see http://www.iedea.org

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analyses for identification of trends in tobacco use and to measure the effect of smoking prevention and cessation programmes according to HIV infection status. To expand their analysis, Mdege and colleagues could also consider prevalence estimates of tobacco use in younger age groups because these groups are the most susceptible to smoking initiation. Additionally, the low prevalence of tobacco smoking reported in women compared with men in LMICs makes women—along with young people—a particular target for the tobacco industry, whether they live with HIV or not.8

Antoine Jaquet, *François Dabis Institut de Santé Publique, d’Epidémiologie et de Développement, University of Bordeaux, and Inserm, Bordeaux Population Health Research Center, UMR 1219, F-33000 Bordeaux, France [email protected]

We are investigators of the West Africa IeDEA collaboration, and declare no competing interests.

Copyright © The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

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10 WHO. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach, 2nd edn. Geneva: World Health Organization, 2016.