High prevalence of tobacco use among HIV-positive individuals in low- and middle-income countries

There is a high prevalence of tobacco use among HIV-positive adults in low- and middle-income countries (LMICs), investigators report in The Lancet Global Health. Overall, 27% of HIV-positive men and 4% of HIV-positive women reported tobacco use, significantly higher than the rates seen in the general population. The authors call for targeted policy and interventions to promote tobacco cessation among HIV-positive individuals in LMICs.

“This study is the largest to our knowledge to provide up-to-date, regional (specifically African region) and overall prevalence estimates for tobacco smoking, smokeless tobacco use, and any tobacco use among people living with HIV using nationally representative samples,” comment the researchers. “Our study shows that tobacco use prevalence in LMICs is generally higher for people living with HIV than for HIV-negative individuals, both men and women.”

Research conducted in wealthy countries has shown a high prevalence of smoking among HIV-positive people, with tobacco use associated with an increased risk of serious illness and death. Comparatively little is known about the level of tobacco use among HIV-positive individuals in LMICs, settings hardest hit by both HIV- and tobacco-related illness.

To address this knowledge gap, an international team of investigators analysed data collected via household surveys conducted in 28 LMICs between 2003 and 2014. Prevalence of smoking was compared nationally, regionally and overall between HIV-positive and HIV-negative men and women. Data were available for 24 (54%) LMICs in Africa, 2 (8%) of 26 in the Americas, 1 (9%) of 11 in Southeast Asia and 1 (6%) of 18 in the Western Pacific. Therefore, as an accompanying editorial highlights, the data were far from complete.

The study population comprised 6729 HIV-positive men, 11,495 HIV-positive women and 193,763 HIV-negative men and 222,808 HIV-negative women.

Overall, 27% of HIV-positive men reported any tobacco use. At the country level, prevalence ranged from 10% in Ethiopia to 68% in India. Regional prevalence in Africa was 26%. Tobacco smoking was reported by 24% of HIV-positive men overall, with prevalence in individual countries ranging between 10% (Ethiopia) and 55% (The Gambia). In Africa, tobacco smoking was reported by 24% of men with HIV. Overall, 3% of HIV-positive men said they used smokeless tobacco, with prevalence reaching 41% in India. Regionally, 3% of HIV-positive men in Africa used smokeless tobacco.

When compared to HIV-negative men, overall prevalence of any tobacco use (RR = 1.41; 95% CI, 1.26-1.57) and smoking (RR = 1.46; 95% CI, 1.30-1.65) was higher among men with HIV. At the regional level, men with HIV in Africa had significantly higher rates of any tobacco use and smoking compared to HIV-negative men.

For HIV-positive women, overall prevalence of tobacco use was a little over 1% for smoking, just over 2% for smokeless tobacco use and 4% for any use of tobacco. Prevalence of smoking was highest in the Dominican Republic (10%) with Lesotho (16%) having the highest rate of smokeless tobacco use. Pooled data from Africa showed that 1% of women with HIV smoked with 2% reporting smokeless tobacco use.

“Tobacco smoking was much more prevalent among men than women – an observation consistent with findings from elsewhere,” note the authors.

Prevalence of any tobacco use (RR = 1.36; 95% CI, 1.10-1.69), smoking (RR = 1.90; 95% CI, 1.38-2.62) and smokeless tobacco use (RR = 1.32; 95% CI, 1.03-1.69) was higher among women with HIV compared to HIV-negative women.

“Countries with a high prevalence of tobacco use among HIV-positive populations, as highlighted in our study, should prioritise the introduction of tobacco cessation in their HIV treatment plans,” conclude the authors. “Future research action to improve the health of [the HIV-positive] population could…include exploring effective and cost-effective tobacco cessation interventions for people living with HIV that are sustainable and scalable in low-resource settings.”