July2024

TobaccoandHIV

WHOtobaccoknowledgesummaries

?PrevalenceoftobaccouseamongpeoplelivingwithHIVismorethandoublethatofthegeneralpopulation.

?AccesstoantiretroviraltherapyhascontributedtoincreaseinlifeexpectancyratesforpeoplelivingwithHIV;highratesoftobaccouseareunderminingthosegainsinlifeexpectancy.

?TheexcessmortalityrateamongsmokerslivingwithHIVisonaveragethreetimeshigherthanthatofthegeneralpopulation.

?PrematuredeathamongsmokerslivingwithHIVisduetohigherratesofbothcommunicableand

noncommunicablediseases–includingtuberculosis,pneumonia,cancer,cardiovasculardiseaseandchronicobstructivelungdisease–ascomparedtotheirnon-smokingcounterparts.

?HIVprogrammeshaveanimportantroletoplayinpreventingandassessingtobaccousestatus,andinitiatingtobaccocessationinterventions.

?Evidence-basedpoliciescansupporttheintegrationandscalingupoftobaccocessationservicesthroughtrainingandsystemchangesthatleveragetheexistingHIVcareinfrastructure.

WhatisHIV?

Tobaccodefinitions

Smokedtobaccoproducts:anyproductmadeorderivedfromtobaccothatgeneratessmoke.Exam-plesincludemanufacturedcigarettes,roll-your-owntobacco,cigars,shisha(alsoknownaswaterpipe),kreteksandbidis.

Second-handsmoke(SHS):thesmokeemittedfromtheburningendofacigaretteorothertobaccoprod-ucts,usuallyincombinationwiththesmokeexhaledbythesmoker.

Smokelesstobacco:anyproductthatconsistsofcut,ground,powderedorotherwisealteredtobaccothatisintendedtobeplacedintheoralornasalcav-ity.Examplesincludesnuff,chewingtobacco,gutka,mishriandsnus.

Heatedtobaccoproducts(HTPs):productsthatemitaerosolscontainingnicotineandtoxicchemicalswhentobaccoisheatedorwhenadevicecontainingtobaccoisactivated.Theseaerosolsareinhaledbysuckingorsmokingandinvolveadevice.Theycon-tainthehighlyaddictivesubstancenicotine,aswellasnon-tobaccoadditives,andareoftenflavoured.

HIV(humanimmunodeficiencyvirus)isavirusthatattacksthebody’simmunesystemwhich,untreat-ed,increasestheriskofinfectionsliketuberculosis(TB)andpneumoniaandsomecancers(1,2,3).Acquiredimmunodeficiencysyndrome(AIDS)isthemostadvancedstageofthedisease(2).HIVistransmittedfromthebodyfluidsofapersonliv-ingwithHIV,includingblood,breastmilk,semenandvaginalfluids.Antiretroviraltherapy(ART)iseffectiveintreatingHIVthroughviralsuppression.TakingARTasprescribedreducesboththeriskoftransmissionandofdiseaseprogression(3).IfthepersonlivingwithHIVtakesARTasprescribed,theviralloadcandecreasetoalevelthatisundetect-able,meaningzeroriskoftransmissiontosexualpartnersandminimalriskofmother-to-childtrans-mission(3).

ThisdocumentsummarizestheexcessburdenofdiseaseassociatedwithtobaccouseamongpeoplelivingwithHIV,reviewsthecurrentliteratureoneffectivetobaccocessationinterventions,andde-scribesapproachesforintegratingtobaccocontrolinthecontextofHIVcare.Thisbriefspecificallyfocusesoneffectivetobaccocessationinterven-tionsforpeoplelivingwithHIV.

Thehealthimpactoftobacco

PathophysiologyoftobaccouseandthedevelopmentofHIV

ThereisevidencethattobaccosmokingaffectsthelikelihoodofacquiringHIVwhenexposedtothevirus,duetothenegativeimpactoftobaccosmok-ingontheinnateandadaptiveimmunesystem,whichmayincreasesusceptibilitytoHIVandotherinfections(19,20).Comparedtonon-smokers,to-baccosmokershaveapoorerimmuneresponsewhenonART,resultinginmorerapidprogresstoadvancedHIVdiseaseandAIDS(21).Duetotheabove-mentionedeffectontheimmunesystem,smokingalsoincreasestheriskofsexuallytrans-mittedinfections,whichinturnincreasestheriskofHIVtransmission(19).Additionally,druguse,whichisstronglyassociatedwiththelikelihoodofacquiringHIV,ismorecommonamongpeoplewhosmoketobaccothanpeoplewhodonot(29).

TobaccosmokingandHIV-relatedcomplicationsandcomorbidities

TobaccouseamongpeoplelivingwithHIVsub-stantiallyincreasestheriskofmorbidityandmor-talitycomparedwithpeoplewhodonotuseorhaveneverusedtobacco(15,17,18,23).ADanishstudyshowedthatcurrenttobaccosmokershadanexcessmortalityratethatwasmorethanthreetimesthatofpeoplelivingwithHIVwhoneversmoked(15).SimilarimpactsonlifeexpectancyamongpeoplelivingwithHIVhavebeenreportedfromotherEuropeancountriesandNorthAmerica(15).Theconsequencesofthecumulativeharm-fuleffectsofHIVandtobaccosmokingontheim-munesystemandthesuppressionoflungdefencesincludeanincreasedriskofacquiringbacterialpneumonia,acutebronchitis,TB,andhigherratesofTB-relatedmortality(19,24–26).Inaddition,smokingincreasestheriskofnon-AIDS-relatednoncommunicable(NCDs)diseasesinthispopu-lation,includingcancer,cardiovasculardisease,diabetes,andchronicobstructivelungdisease,ascomparedwithpeoplelivingwithHIVwhodonotsmoke(16,18,23,26).AnanalysisofdatafromtheARTCohortCollaborationfoundthatdeathsfromnon-AIDSrelatedmalignancies(forexample,

onpeoplelivingwithHIV

2

Worldwide,therearearound1.25billionpeoplewhousetobaccowithover1billiontobaccous-ersresidinginlow-andmiddle-incomecountries(LMICs)(5).Smokingprevalenceamongpeopleliv-ingwithHIVistwotothreetimeshigherthanthatofthegeneralpopulation,acrossregionsandcountryincomelevel(6–13).Sub-SaharanAfricaistheregionmostaffectedbyHIV,accountingforaround70%ofHIVinfections(4).InSouthAfricaalone,therewere160000newHIVinfectionsin2022,contributingtoanoverallprevalenceof17.8%(6).Simultaneously,thecountryisfacingadoubleburden,since20.3%ofpeopleaged15yearsandolderareestimatedtobecurrenttobaccosmokers(5).Notably,Leso-thohasthesecondhighestglobalHIVprevalence,estimatedat19.3%(7),anda41.1%prevalenceoftobaccouseamongmenlivingwithHIV(8).RecentresearchinLMICsrevealedthatamongwomenlivingwithHIV,1.3%engageintobaccosmoking,2.1%usesmokelesstobacco,and3.6%partakeinsomeformoftobaccouse(8).WhatisparticularlyalarmingisthattheseratesaresignificantlyhighercomparedtotheirHIV-negativecounterparts.Theriskoftobaccosmoking,forinstance,is1.90timesgreateramongwomenlivingwithHIVthanamongthosewithoutHIV(8).Similarly,amongmenlivingwithHIV,theprevalenceoftobacco-relateduseisnotablyhigh.With24.4%engagingintobaccosmok-ing,3.4%usingsmokelesstobacco,andanoveralltobaccouseprevalenceof27.1%,itisevidentthattobacco-relatedchallengespersistwithinthisde-mographic(8).Comparatively,theprevalenceratesforanytobaccouse(RR1.41)andtobaccosmok-ing(RR1.46)aresignificantlyelevatedinmenliv-ingwithHIVwhencomparedtotheirHIV-negativecounterparts(8).Additionally,studiesamongpeoplelivingwithHIVintheUnitedStateshavereportedratesoftobaccouseashighas46–76%(9,10,13).WidespreadaccesstoARThastransformedHIVintoamanageablelong-termcondition.However,highratesoftobaccousethreatenthosegainsinlong-termsurvival,particularlyinLMICswheretheburdenofHIVandtobaccoareincreasinglyconcen-trated(13–17,18).

TobaccoandHIV

TobaccocessationandHIV

3

Withintheliteratureencompassedbythissumma-ry,moststudiesrelateto“smoking”and“smokingcessation”,whichconstitutesasubsetwithinthebroadercategoryoftobaccouse.Itiscrucialtorecognize,however,thattheterm“tobaccouse”extendsbeyondcombustiblecigaretteuse,toin-cludevariousformssuchasothersmokedtobaccoproducts,smokelesstobaccouse,andheatedto-baccoproducts.Throughoutthissummarythesetermsareusedinalignmentwiththeterminologyprevalentintherespectivestudies.

lungcancer)andcardiovasculardiseaseaccountformostoftheexcessdeathsamongpeopleliv-ingwithHIVwhosmoke(15,28,30).TheincreasedprevalenceofNCDsamongpeoplelivingwithHIVreflectsacombinationoffactors,includingaging,agreaterprevalenceoftraditionalNCDriskfactorssuchasalcoholuse,andthedirectconsequencesofHIVinfectionandspecificARTsoncardiovascularriskfactors(18,26).However,itisestimatedthattobaccosmokingamongpeoplelivingwithHIVwhoaretakingARTmayaccountfor25%oftotalmortality(18).

Second-handsmokeandHIV

Alargeinternationaltrialfoundthattobaccocessa-tionhasthepotentialtoreduceall-causemortalityforpeoplelivingwithHIVby15.6%,majorcardio-vasculardiseaseeventsby17%,non-AIDScancers(forexample,lung)by34%,andpneumoniaby18%(18).Afterquitting,peoplethatarelivingwithHIVreportadecreaseinHIV-relatedsymptomburden,depressionandanxiety,andreportimprovementsinqualityoflife(35,36).TobaccocessationisalsoassociatedwithbettercontrolofHIV(37,38).Peo-plelivingwithHIVarelesslikelytoquitthanthegeneralpopulationoftobaccousers(39,41–43).Obstaclestoachievingsuccessinquittinginteractwiththoseassociatedwithtobaccouse,includinghigherlevelsofnicotineaddiction,higherratesofdepressionandpolysubstanceuse,socialisolation,andtheburdenofenduringstigmaanddiscrimi-nation(26).Therefore,addressingmentalhealthissuesisanintegralpartofreducingtobaccouseamongpeoplelivingwithHIV(85,86).BeliefsheldbypeoplelivingwithHIVmayleadtocontinuedto-baccouse.TobaccouserslivingwithHIVminimizehealthrisksassociatedwithtobaccouseandreportasenseoffatalismaboutHIVthatmayreducetheirchancesofsuccessinquittingtobacco(39–41).TherearealsostructuralbarriersthatincludealackofaccesstotobaccocessationservicesinthecontextofHIVcare.

Second-handsmokecanhavesignificantimplica-tionsforpeoplelivingwithHIV,potentiallyexertingdirecteffectsonbloodvessels(32).Theseeffects,inturn,increasetheriskofcardiovasculardisease(31).Exposuretosecond-handsmokecanfurtherweakentheirimmunesystem,makingthemmoresusceptibletoinfectionsandillnesses.Second-handsmokecanirritatetherespiratorysystem,leadingtowheezingandshortnessofbreath.ThesesymptomscanbemoresevereinpeoplewithHIV,particularlyiftheyhavepre-existinglungissueslikeTBorpneumonia(31,32).

SmokelesstobaccoandHIV

DespitelimitedevidenceonsmokelesstobaccoandHIV,astudyinSouthAfricashowsthatsmokelesstobacco,drynasalsnuffinparticular,isextremelyprevalentamongwomenlivingwithHIV,nearlysixtimeshigherthanthegeneralpopulation.Fur-thermore,inthispopulationsnuffuseisclearlyassociatedwithTBdiagnosisandhaspotentiallyserioushealthimplications(33).Similarly,inIndia,theprevalenceofsmokelesstobaccoisveryhigh,andpeoplewithHIVthatarecurrentsmokelesstobaccousersareathighriskoforalmalignantdis-ordersandpotentiallyoralcancer,estimatedat27timesthatofthegeneralpopulation(34).

ImpactofselectedtobaccocontrolinterventionsonHIV

counselingandpharmacotherapyintobaccoces-sationforpeoplelivingwithHIV.Athirdrandom-izedcontrolledtrialcomparedtheeffectivenessofvareniclineandcytisinewithnicotinereplacementtherapyforreducingsmokingamongindividualswithHIVwhoengageinriskydrinking(60).

4

Box1.Interventionstoassist

tobaccocessation

Behaviouralinterventions

?Briefadvicefromhealthcareworker

?In-personmultisessioncounselling

?Telephonecounselling

?Mhealth(suchastextmessagingpro-grammes,mobilephoneapps)

?Websites

?Printedself-helpmaterial

Pharmacotherapy

?Varenicline

?Nicotinereplacementtherapy

?Cytisine

?Bupropion

Thestudyfoundthatallthreemedications,vareni-cline,cytisineandnicotinereplacementtherapy,achievedsix-monthcessationratesthatwerecon-sistentwiththoseofprevioustrialsamongpeoplewhosmokebutarenotinfectedwithHIV,rangingfrom17to19%.Thisstudyofferedfurtherevi-dencethatthesemedicationsmaybeusedsafelyandeffectivelyforsmokingcessationamongindi-vidualswithHIVwhohaveahistoryofsubstanceuseoractivesubstanceusedisorders(60).

Healthsysteminterventionstofacilitatetobaccocessation

Currentguidelinesrecommendthathealthcareworkersaskalladultsabouttobaccouse,advisethemtoquit,assess,assistandarrange(5As)andprovidebehaviouralinterventionsandpharma-cotherapyforcessation,orbyreferringpatienttopopulation-basedinterventions(suchasnationalquit-lines,mHealthprogrammesandcessationclinics)[Box2](51,61,62).

Thereisstrongevidencethatbriefadvicetoquitdeliveredbyaphysician,healthprofessionalornon-healthpersonnel,behaviouralinterventions(forexample,telephonecounsellingandinterven-tionsdeliveredviashorttextmessaging),andphar-macotherapy,areeffectiveinincreasingabstinencecomparedtoplacebo/nointerventionamonggen-eralpopulationsofsmokers[Box1](44–51).Nico-tinereplacementtherapy,bupropion,vareniclineandcytisinecanallaidquittingtobaccowithorwithoutbehaviouralsupport.However,thelikeli-hoodofasuccessfulquitattemptisincreasedifcounsellingisprovidedincombinationwithmedi-cation(45,47).Althoughmostofthisevidenceisderivedfromstudiesconductedinhighincomecountries,asystematicreviewandmeta-analysisofstudiesconductedinLMICssimilarlyconcludedthatnicotinereplacementtherapy,behaviouralcounsellingandbriefadviceareeffectiveinaidingtobaccocessationinLMICs(52).Theevidencesug-geststhattobaccocessationinterventionsareef-fectiveforpeoplelivingwithHIV.A2016Cochranemeta-analysisof12studiesfoundthatcounselingcombinedwithpharmacotherapyincreasedshort-termsmokingabstinencecomparedtocontrolgroups(55).Behavioralinterventions,deliveredthroughvariousmodalities,showedthehighestimpactwhenconductedviatelephone(56).Tai-loringinterventionstotheuniquechallengesofpeoplelivingwithHIVyieldedinconsistentresults(55,56).Ameta-analysisindicatedthatdeliveringeightcounselingsessionswasassociatedwithhigh-ersmokingabstinenceratesthanofferingfewersessions(53).Recenttrialsdemonstratedlonger-termimpact,includinganinteractiveweb-basedinterventionpromotingsix-monthcessationandthesafetyandefficacyofvareniclinecombinedwithbehaviouralsupport.Onetrialreportedasignificantincreasein48-weekcontinuoussmok-ingabstinence,whileanothershowedvareniclinedoublingquitratesatthreemonths,thoughtheeffectdeclinedovertime(58).Overall,thesefindingsunderscoretheeffectivenessoftailoredinterventions,emphasizingtheimportanceof

TobaccoandHIV

bothimplementationandsystemsscience,Box3outlinesaprocessforoptimizingtheintegrationoftobaccousetreatmentinHIVcaresystems(69–72).Theimplementationofeffective,evidence-basedtobaccocessationinterventionsforpeoplelivingwithHIVinLMICshaspotentialtobringsubstantialbenefitstohealthoutcomesamongpeoplelivingwithHIV,particularlyinareaswheretheburdenofbothHIVandtobaccouseishigh(80).

5

Box2.5As

Ask:Askeverypatientabouttheirtobaccousestatusandnotethisintheirmedicalrecords.

Advise:Advisepatientstoquitinaclear,strong,personalizedmanner:“Quittingsmokingstrength-ensyourimmunesystemandallowsyoutofullybenefitfromART.”

Assess:Assesstobaccousers’readinesstoquit

Assist:Ifreadytoquit,supportthemtomakeaquitplanorprovideinformationonspecialistsupport

Arrange:Arrangeforfollowupviaface-to-facecontactorbyphoneorrefertospecialist

Box3.RecommendedSystem

Interventions(49)

?Implementasystemtoconsistently

identifytobaccousersanddocumentuseinallHIVservices

?Assigndedicatedstafftocoordinatetobaccousepreventionandtreatment

?Trainallstaffandhealthcareworkersanddefineandcommunicateduties

?Monitorperformanceandprovidefeedback

?Developandpromoteaprogrammepolicytosupportscreeningandtreatment

?Includeevidence-basedtobacco

dependencetreatments(bothcounsellingandpharmacotherapy)aspaidorcoveredservicestoremovebarrierstotreatment

IntegratingandscalingtobaccousetreatmentinHIVcare

Existingresources,suchasnationalquit-linesin40LMICs,mobilehealthprogrammesandextensivenetworksofcommunityhealthworkerssupportingHIVprogrammes,providetheinfrastructureforathree-stepframeworktofacilitatetreatmentinte-gration:1)AskallclientsusingHIVservicesabouttobaccouse;2)Provideclearadvicetoquitaswellastailoredbriefcounsellingand3)Connectpatienttotreatment(AAC)(62,73–75).Population-basedresourcesprovideasustainableandscalableoptionforconnectingpeoplelivingwithHIVtotreatment.Nationalhealthcarepoliciesandinfrastructurewillinformthelargerpolicydecisionsaboutwhattypesofintegrationmodelsareselected(forexample,integrationintoHIVcare,integrationintoHIVandcoordinationwithexternalresources)(76).

TheWorldHealthOrganizationFrameworkConven-tiononTobaccoControl(WHOFCTC)establishesaminimumstandardforactionontobaccocontrol.Article14oftheWHOFCTCstatesthatPartiestothetreaty“shalldevelopandtakeeffectivemeasurestopromotecessationoftobaccouseandadequatetreatmentfortobaccodependence”(63).TheWHOFCTCalsocallsforintegratingtobaccocontrolintoexistinghealthsysteminfrastructureincludingHIVservices.ImportantbarrierstoimplementingtheWHOFCTCincludelowpoliticalpriority,andalackoffundingandinfrastructuretosupportNCDpreventionandtreatmentinthesesettings(64).However,largeinvestmentsinHIVservicedeliverycreateaplatformforextendingchroniccaremodelsformanagingHIVtoincludetobaccousetreatment.HIVtreatmentrequiresmultipleinteractionswiththehealthsystem,providinghealthcareworkerswithfrequentopportunitiestoscreen,diagnoseandtreattobaccodependence.Inaddition,manyofthehealthsysteminterventionsthatwereusedtoscaleupARTresourcesinpoorcountries,suchasstandardizedtreatmentprotocols,registriestotrackadherencetoguidelines,task-sharing,andcounsel-lingreferrals,canfacilitateeffectivemanagementoftobaccodependence16,65,66–68).Borrowingfrom

6

Contributors

ShelleyD,1AarsandR,2VitoriaM,3CantrellJ,1NamusisiK,1AnamFR,4SealeA,3DalalS,3StelzleD,3LebedevaE,5CiobanuA,5FuD,6FayokunR,6SchotteK,6KaurJ.7

1NewYorkUniversity,SchoolofGlobalPublicHealth,DepartmentofPublicHealthPolicyandManagement

2WorldHealthOrganization,DepartmentofDigitalHealthandInnovation

3WorldHealthOrganization,GlobalHIV,HepatitisandSexuallyTransmittedInfectionsProgrammes

4TheGlobalNetworkofPeopleLivingwithHIV(GNP+)

5WorldHealthOrganizationRegionalOfficeforEurope

6WorldHealthOrganization,DepartmentofHealthPromotion,NoTobaccoUnit

7WorldHealthOrganizationRegionalOfficeforSouth-EastAsia

Potentialnextsteps

Research

?Morestudiesareneededtoexamineinterven-tionsconcentratingonthesocio-behaviouralandenvironmentalfactorsthatmayimpedetobaccocessationamongpeoplelivingwithHIVinLMICs.

?Researchisneededtoinformthedesignofinter-ventionsthataddressco-occurringaddictionandcomorbiditiesthatarecommonamongpeople

livingwithHIVwhosmoke,toevaluateifthecur-rentevidencefortreatingcigaretteuseappliestoothertobaccoproductssuchaswaterpipe/hookah,smokelesstobacco,e-cigarettesandbidis,andtoevaluatetheeffectivenessofdigitalinterventionsforpeoplelivingwithHIV.

?Researchisneededtodeterminethebestpossiblestrategiesandmodelsforintegratingtobaccoces-sationtreatmentintothecontextofHIVservices.

Practice

?InvolvingcommunitiesofpeoplelivingwithHIVinthedesignanddeliveryofservices.

?Immediateactiontointegratescreeningfortobaccouse,assessingwillingnesstoquit,andofferingbriefadvice,andsupportingtheinitiationofpharmaco-therapyaspartofstandardHIVcarepractice.

?Integratingquit-linereferralsystemsinHIVhealthprogrammeswillincreasethereachofsmokingcessationservices.

Policy

?GlobalandnationalpoliciesmustdefinestandardsofcarefortreatingtobaccouseinthecontextofHIVcare(65).Thisshouldincludeincreasingaccesstonicotinereplacementtherapy,whichisaWHOessentialmedication.

?Briefadvicefromahealthcareworker,quit-line,

automatedtextmessaging,printedself-helpmateri-alsandnicotinereplacementtherapyandcytisinearegloballyaffordablehealthcareinterventionstopromoteandassisttobaccocessation(50,77).

?Internationalpartnersshouldincludereporting

requirementsthatclearlydefineperformance

measuresforscreeningandtreatmentandincludeanevaluationoftobaccousetreatmentinHIV

reportedsystems.

TobaccoandHIV

7

References

16.ParascandolaM,etal.CollidingEpidemics:ResearchGapsandImple-mentationScienceOpportunitiesforTobaccoUseandHIV/AIDSinLow-andMiddle-IncomeCountries.JSmokCessat.2022:6835146.PMID:35821759;24.

DOI:10.1155/2022/6835146

.

17.ReddyKP,ParkerRA,LosinaE,etal.ImpactofcigarettesmokingandsmokingcessationonlifeexpectancyamongpeoplewithHIV:aUS-basedmodelingstudy.JInfectDis2016;214:1672–81

(/10.1093/infdis/jiw430

,accessed15August2023).

18.LifsonA.R.,NeuhausJ.,ArribasJ.R.,VanBerg-WolfM.D.,LabriolaA.M.,ReadT.R.H.Smoking-relatedhealthrisksamongpersonswithHIVinthestrategiesformanagementofantiretroviraltherapyclinicaltrial.AmJPubHealth.2010;100(10):1896–1903.

DOI:10.2105/AJPH.2009.188664

.

19.JianC,ChenQ,XieM.Smokingincreasestheriskofinfectiousdiseases:AnarrativereviewChenTobInducDis.2020;18(July):60

(/10.18332/tid/123845

,accessed15August2023).

20.HalseyNAetal.Sexualbehavior,smoking,andHIV-1infectioninHaitianWomenJAMA1992Dec23-30;268(24):3434

DOI:10.1001/

jama.1992.03480150068039

.

21.FeldmanJG,etal.AssociationofcigarettesmokingwithHIVprognosisamongwomenintheHAARTera:areportfromthewomen’sinteragencyHIVstudy.AmJPubHealth.2006;96:1060-1065

(/10.2105/AJPH.2005.062745

,accessed15August2023).

22.PenkowerL.etal.Behavioral,HealthandPsychosocialFactorsandRiskforHIVInfectionamongSexuallyActiveHomosexualMen:TheMulticenterAIDSCohortStudy,AmJPubHealth.1991;81:194-196

(/10.2105/ajph.81.2.194

,accessed20August2023).

23.USSurgeonGeneralReporttheHealthConsequencesofSmoking:50YearsofProgress.AReportoftheSurgeonGeneral.Atlanta,GA:U.S.DepartmentofHealthandHumanServices,CentersforDiseaseControlandPrevention,NationalCenterforChronicDiseasePreventionandHealthPromotion,OfficeonSmokingandHealth,2014

(/books/NBK179276/

pdf/Bookshelf_NBK179276.pdf,

accessed21November2023).

24.BatesBM.KhalakdinaA,PaiM,ChangL,LessaF,SmithKR.Riskoftuberculosisfromexposuretotobaccosmoke:asystematicreviewandmeta-analysis.ArchInternalMedicine.2007;167(4):335–342.PMID:1725294

(/10.1001/archinte.167.4.335

,ac-cessed5August2023).

25.BasuS,StucklerD,BittonA,GlantzSA.Projectedeffectsoftobaccosmokingonworldwidetuberculosiscontrol:mathematicalmodel-linganalysis.BMJ.2011;343:d5506.

DOI:10.1136/bmj.d5506

.

26.ReynoldsNR.CigarettesmokingandHIV:Moreevidenceforaction.AIDSEduPrev.2009;21:(Suppl3):106-121

(https://doi.

org/10.1521/aeap.2009.21.3_supp.106

,accessed5August2023).

27.deSocioGLV,MartinelliL,MorosiS,etal.Isestimatedcardiovas-cularriskhigherinHIV-infectedpatientsthaninthegeneralpopu-lation?ScandJ

InfectiousDiseases.2007;39(9);805–812(https://

/10.1080/00365540701230884

,accessed15September2023).

28.AltekruseSFetal.CancerburdenattributabletocigarettesmokingamongHIV-infectedpeopleinNorthAmerica.AIDS.2018;32:513–521

(/10.1097/QAD.0000000000001721

,accessed

21November2023).

29.ConsolidatedguidelinesonHIV,viralhepatitisandSTIprevention,diagnosis,treatmentandcareforkeypopulations.Geneva:WorldHealthOrganization;2022

(/publications/i/

item/9789240052390

,accessed23July2024).

30.HellebergM,MayMT,IngleSM,DabisF,ReissP,F?tkenheuerG,

1.HIVandAIDS.Keyfacts.In:WorldHealthOrganization[website].Geneva:WorldHealthOrganization;2023

(/

news-room/fact-sheets/detail/hiv-aids

,accessed21November2023).

2.ConsolidatedguidelinesonHIVprevention,testing,treatment,servicedeliveryandmonitoring:recommendationsforapublichealthapproach.Geneva:WorldHealthOrganization;2021(

/publications/i/item/9789240031593

,accessed23July2024).

3.TheroleofHIVviralsuppressioninimprovingindividualhealthandreducingtransmission:policybrief.Geneva:WorldHealthOrganization;2023

(/publications/i/item/978

9240055179

,accessed23July2024).

4.ThepaththatendsAIDS:UNAIDSGlobalAIDSUpdate2023.Geneva:JointUnitedNationsProgrammeonHIV/AIDS;2023(

/wp-content/themes/unaids2023/

assets/files/2023_report.pdf,

accessed23July2024).

5.WHOglobalreportontrendsinprevalenceoftobaccouse2000–2030.Geneva:WorldHealthOrganization;2024

(https://iris.

/bitstream/handle/10665/375711/9789240088283-eng.

pdf?sequence=1

,accessed28May2024).

6.

UNAIDScountryprofileSouthAfrica(/en/reg

ionscountries/countries/southafrica

,accessed21November2023).

7.

UNAIDScountryprofileLesotho(/en/regions

countries/countries/lesotho,

accessed21November2023).

8.MdegeND,ShahS,Ayo-YusufOA,HakimJ,SiddiqiK.TobaccouseamongpeoplelivingwithHIV:analysisofdatafromDemographicandHealthSurveysfrom28low-incomeandmiddle-incomecountries.Lancet