This report was produced by the Ontario HIV Treatment Network’s Rapid Response Service. You can read the report online here.

The Question: What research has been conducted regarding smoking cessation programs/interventions geared specifically towards people with HIV/AIDS (PHAs) who smoke? 

Key Take-Home Messages

• Tobacco smoking is much more common among PHAs than in the HIV-negative population (1-5)
• While most medical providers offer some form of smoking cessation services, AIDS Service Organizations (ASOs) are less likely to do so (5)
• Additional research is needed to develop a clear set of clinical guidelines that addresses the issue of smoking as it relates specifically to PHAs.(6;7)
• The majority of PHAs express a desire to learn more about smoking and its impact on their HIV status and their medication regimen.(8)
• Due to psychosocial differences and special needs, smoking cessation efforts for PHAs are more complex than for the general population.(9) 

The Issue and Why It’s Important

Nicotine (the addictive substance in tobacco products) dependence is thought to be the most frequent chemical dependence in the U.S. (1) with some suggesting it is as addictive as cocaine or heroin.(10;11) Smoking rates have been found to be significantly higher among PHAs than the general population (1-5) with estimates in the U.S. finding prevalence rates of 50-70% among PHAs (three times the national average) (3;5); and approximately 64% in Spain (double the national average).(4) Similar levels have been found among PHAs in Canada. For example, the smoking rate among patients visiting the HIV clinic at The Ottawa Hospital is estimated to be between 43-49% (2) compared to a smoking rate of 12% in Ottawa’s general population. In addition, the OHTN cohort study found that 54% of PHAs living in Ontario smoke (2), which is much higher than smoking rates among HIV-negative adults in Canada, which have fallen below 20% of the population. (12)

PHAs who smoke face may also face an increased risk of bacterial pneumonia, chronic obstructive pulmonary disease (COPD), cardiovascular disease, malignancies, and lower health-related quality of life.(13-15) With increased availability of antiretroviral medications, PHAs are living longer, thus the long-term health implications of smoking have become more salient.(3) Within the PHA community, there is a strong belief in the health benefits of quitting smoking and general agreement about the need to be more actively promoting smoking cessation.(16) For example, 75% of respondents in a recent survey in New York indicated they had an interest in quitting while 64% had tried to quit at least once in the past year.(5) However, in another study, 33% of participants reported that they had not made a quit attempt since being diagnosed with HIV.(17) A reluctance to provide PHAs with smoking cessation programs that meet their unique needs has been suggested as one factor contributing to high smoking rates. (18) Others have pointed to a reluctance among PHAs to quit smoking as they felt it would not actually improve their health, referencing a perception held by some that “death from AIDS is the only inevitable outcome of a diagnosis of HIV infection.”(7)

What We Found

Smoking cessation interventions are for the general population

According to the US Department of Health and Human Services Clinical Practice Guideline (Treating Tobacco Use and Dependence: 2008 Update), tobacco dependence treatments are effective across a broad range of populations. (19) Individual, group and telephone counseling are effective and their effectiveness increases with treatment intensity. This guide highlights two forms of counseling that are highly effective - practical counseling (problem-solving/skills training) and social support .

Numerous effective medications are available for tobacco dependence. Seven first-line medications (5 nicotine and 2 non-nicotine) reliably increase long-term smoking abstinence rates. These include Bupropione SR, Nicotine gum, Nicotine inhalers, Nicotine lozenges, Nicotine nasal sprays, Nicotine patches, and Varenicline.

Counseling and medication are effective when used by themselves for treating tobacco dependence, but using them in combination is most effective.Telephone quitline counseling is effective with diverse populations as well.

If a tobacco user currently is unwilling to make a quit attempt, motivational treatment should be used for future quit attempts.

A systematic review of 23 studies found that group behavioural therapy [odds ratio (OR) 2.17, confidence interval (CI) 1.37–3.45], bupropion (OR 2.06, CI: 1.77–2.40), intensive physician advice (OR 2.04, Cl: 1.71–2.43), nicotine replacement therapy (OR 1.77, CI: 1.66–1.88), individual counselling (OR 1.56, CI: 1.32–1.84), telephone counseling (OR 1.56, CI: 1.38–1.77), nursing interventions (OR 1.47, CI: 1.29–1.67) and tailored self-help interventions (OR 1.42, CI: 1.26–1.61) were all effective in increasing cessation rates. (20) According to the same review, comprehensive clean indoor laws increased quit rates by 12–38%.(20)

Another systematic review comparing nicotine effectiveness of Nicotine Replacement Therapy [NRT], bupropion, and varenicline found that all provide therapeutic effects in assisting with smoking cessation but varenicline was identified to be more effective than placebo, bupropion and NRT (in indirect comparison) (21).

General medical providers vs. ASOs

U.S. Public Health Service has a clear set of clinical guidelines to aid people in quitting smoking, known as the “5 A’s”: Ask, Advise, Assess, Assist, and Arrange. However, no set of similar guidelines exists specifically for PHAs who smoke.(6) One study indicated that there are not enough smoking cessation promotion activities in ASOs and that adherence to the “5 A’s” guidelines has been extremely low among PHAs.(16) Given that ASOs may have less knowledge regarding the smoking habits of their patients than general medical providers (22) (although this may not be universally true), some recommendations for increasing the uptake of smoking cessation among PHAs include stronger collaboration between ASOs and tobacco control researchers, who are better versed in population-specific tobacco cessation strategies.(23) Another study pointed out that all ASOs should be aware that tobacco quitlines exist throughout the U.S. and that their patients should be referred to such services when applicable.(24) According to another study, the nature of HIV care puts it in a unique and favourable position to offer smoking cessation programs because of the abundance of follow-up appointments and interdisciplinary care that PHAs receive. (6)

PHAs and quitting smoking

PHAs may face greater challenges to quitting smoking due to a unique set of social, economic, psychiatric, and medical needs that may affect their smoking habits and their ability to quit (6) The resulting overlap between treatment, care and support for HIV/AIDS, substance use, and mental illness makes smoking cessation among PHAs a more difficult proposition than in the general population.(5) As a result, less intensive interventions such as giving advice may not be enough for some PHAs to quit smoking. Therefore, some may benefit from more intensive interventions such as repeated counselling, nicotine replacement as well as psychiatric assistance.(9) According to one study, only 14% of respondents reported that they were both motivated to quit smoking and living without a codependency (cannabis or alcohol) or depressive symptoms. For these respondents, a standard tobacco cessation plan could be proposed but for those who may lack motivation and/or have another codependence a more intensive approach is likely required.(25)

Smoking cessation strategies

While there was a wide range of cessation strategies discussed in the literature, the main message was that more research needs to be conducted regarding smoking cessation programs tailored specifically to PHAs.(6) According to one qualitative study with HIV+ participants, there was an overwhelming desire for the creation of support groups exclusively comprised of PHAs who want to quit smoking, but the effectiveness of such groups has not been investigated .(8) A meta-analysis of 43 studies on effectiveness of various intensity levels of session length found that brief interventions (three minutes or less) led to abstinence rates of 13% of participants while longer interventions (10 minutes or more) led to abstinence rates of 22%. (19;26;27) In terms of the percentage likelihood of smoking cessation after six months, one study found increased abstinence from interventions providing advice (9%), counselling (12%), and nicotine gum (17%).(9) In some cases, smoking cessation involving medication (such as bupropion and varenicline) resulted in significantly higher abstinence rates than cessation involving counselling.(9) In addition, due to their broad reach and efficacy for smoking cessation, quitlines for smokers have been found to be cost-effective.(6) However, consistent access to a telephone may be a barrier for some low-income households.(6) Another study recommended a cellular telephone intervention as some individuals do not have adequate access to a vehicle or telephone service. The advantages of using a cell phone are convenience, flexibility, and confidentiality and the study suggests that cell phone counselling may provide a cost-effective solution to access-to-care barriers.(18) Lastly, some data suggests that a combination of counselling and nicotine replacement therapy (NRT) may help decrease tobacco use among PHAs (6) while another claims that NRT doubles the quit rate compared to no treatment.(28)

Factors that May Impact Local Applicability

The literature dealt almost exclusively with data and research conducted in high-income countries (U.S., Canada and Spain) except for one study that reported on findings from India.(9) While these findings may be generalizable to the Canadian setting, countries cited in the literature have different smoking rates, HIV infection rates, smoking culture, regulations and availability of smoking cessation interventions. Therefore, some findings should be interpreted with caution.

What We Did

We searched Medline using a combination of search terms: Smoking Cessation (MeSH term) AND HIV (text term). We did not limit the search results by date of publication or study jurisdiction. We also searched the Cochrane Library for any potentially relevant systematic reviews using the following text terms: HIV AND (smoking OR tobacco), www.Health-Evidence.ca using the following search terms: HIV (text term) AND [Smoking cessation (category) OR tobacco use (category)], and DARE database (limited to 1996-2011) using the following search terms: HIV AND (smoking OR tobacco). Lastly, we reviewed the references in the studies found. All searches were conducted on 1 August 2012.

About OHTN’s Rapid Response Servoce

The OHTN Rapid Response Service offers HIV/AIDS programs and services in Ontario quick access to research evidence to help inform decision making, service delivery and advocacy.

In response to a question from the field, the Rapid Response Team reviews the scientific and grey literature, consults with experts, and prepares a brief fact sheet summarizing the current evidence and its implications for policy and practice.

Suggested Citation:

Rapid Response Service. Rapid response: Rapid HIV Testing in Correctional Facilities Ontario HIV Treatment Network; August 2012

References

1. American Society of Addiction Med-icine. Public Policy Statement on Nicotine Dependence and Tobacco. Chevy Chase, MD: American Socie-ty of Addiction Medicine; 2010.

2. Balfour L, MacPherson P. HIV and Cardiovascular Risk: The Ottawa HIV Quit Smoking Study. The OHTN Conference. 2010.

3. Chander G, Stanton C, Hutton HE, Abrams DB, Pearson J, Knowlton A et al. Are smokers with HIV using information and communication technology? Implications for behav-ioral interventions. AIDS & Behavior 2012;16(2):383-8.

4. Fuster M, Estrada V, Fernandez-Pinilla MC, Fuentes-Ferrer ME, Tellez MJ, Vergas J et al. Smoking cessation in HIV patients: rate of success and associated factors. HIV Medicine 2009;10(10):614-9.

5. Tesoriero JM, Gieryic SM, Carrascal A, Lavigne HE. Smoking among HIV positive New Yorkers: prevalence, frequency, and opportunities for cessation. AIDS & Behavior 2010;14(4):824-35.

6. Nahvi S, Cooperman NA. Review: the need for smoking cessation among HIV-positive smokers. AIDS Education & Prevention 2009;21(3:Suppl):Suppl-27.

7. Niaura R, Shadel WG, Morrow K, Tashima K, Flanigan T, Abrams DB. Human immunodeficiency virus infection, AIDS, and smoking cessa-tion: the time is now. Clinical Infec-tious Diseases 2000;31(3):808-12.

8. Robinson W, Moody-Thomas S, Gruber D. Patient perspectives on tobacco cessation services for persons living with HIV/AIDS. AIDS Care 2012;24(1):71-6.

9. Kumar SR, Swaminathan S, Flani-gan T, Mayer KH, Niaura R. HIV & smoking in India. Indian Journal of Medical Research 2009;130(1):15-22.

10. U.S.Department of Health and Human Services. Surgeon Gen-eral's Report-How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease. 2010.

11. National Institute on Drug Abuse. Research Reports: Tobacco Addic-tion. Bethesda, MD: National Insti-tutes of Health, National Institute on Drug Abuse; 2009.

12. Health Canada, Controlled Sub-stances and Tobacco Directorate. Canadian Tobacco Use Monitoring Survey, Smoking Prevalence 1999 - 2010. 2010.

13. Kohli R, Lo Y, Homel P, Flanigan TP, Gardner LI, Howard AA et al. Bacte-rial pneumonia, HIV therapy, and disease progression among HIV-infected women in the HIV epidemi-ologic research (HER) study. Clin Infect Dis 2006;43(1):90-8.

14. Crothers K, Goulet JL, Rodriguez-Barradas MC, Gibert CL, Oursler KA, Goetz MB et al. Impact of ciga-rette smoking on mortality in HIV-positive and HIV-negative veterans. AIDS Educ Prev 2009;21(3 Suppl):40-53.

15. Lifson AR, Neuhaus J, Arribas JR, van dB-W, Labriola AM, Read TR. Smoking-related health risks among persons with HIV in the Strategies for Management of Antiretroviral Therapy clinical trial. Am J Public Health 2010;100(10):1896-903.

16. Shuter J, Salmo LN, Shuter AD, Nivasch EC, Fazzari M, Moadel AB. Provider beliefs and practices relat-ing to tobacco use in patients living with HIV/AIDS: a national survey. AIDS & Behavior 2012;16(2):288-94.

17. Burkhalter JE, Springer CM, Chha-bra R, Ostroff JS, Rapkin BD. To-bacco use and readiness to quit smoking in low-income HIV-infected persons. Nicotine & Tobacco Re-search 2005;7(4):511-22.

18. Lazev A, Vidrine D, Arduino R, Gritz E. Increasing access to smoking cessation treatment in a low-income, HIV-positive population: the feasibility of using cellular tele-phones. Nicotine & Tobacco Re-search 2004;6(2):281-6.

19. Fiore, M. C. U.S. Department of Health and Human Services. Treat-ing tobacco use and dependence 2008. Clinical Practice Guideline. 2008.

20. Lemmens V, Oenema A, Knut IK, Brug J. Effectiveness of smoking cessation interventions among adults: a systematic review of re-views. Eur J Cancer Prev 2008;17(6):535-44.

21. Wu P, Wilson K, Dimoulas P, Mills EJ. Effectiveness of smoking cessa-tion therapies: a systematic review and meta-analysis. BMC Public Health 2006;6:300.

22. Crothers K, Tindle HA. Prevention of bacterial pneumonia in HIV infec-tion: focus on smoking cessation. Expert Review of Antiinfective Ther-apy 2011;9(7):759-62.

23. Harris JK. Connecting discovery and delivery: the need for more evidence on effective smoking cessation strategies for people living with HIV/AIDS. American Journal of Public Health 2010;100(7):1245-9.

24. Drach L, Holbert T, Maher J, Fox V, Schubert S, Saddler LC. Integrating smoking cessation into HIV care. AIDS Patient Care & Stds 2010;24(3):139-40.

25. Benard A, Bonnet F, Tessier JF, Fossoux H, Dupon M, Mercie P et al. Tobacco use in HIV infection. AIDS Patient Care & Stds 2007;21(7):458-68.

26. Reus VI, Smith BJ. Multimodal techniques for smoking cessation: a review of their efficacy and utili-sation and clinical practice guide-lines. Int J Clin Pract 2008;62(11):1753-68.

27. Kwong J, Bouchard-Miller K. Smok-ing cessation for persons living with HIV: a review of currently available interventions. Journal of the Associ-ation of Nurses in AIDS Care 2010;21(1):3-10.

28. Ingersoll KS, Cropsey KL, Heckman CJ. A test of motivational plus nico-tine replacement interventions for HIV positive smokers. AIDS & Be-havior 2009;13(3):545-54.

UWW reports the unConference is like speed-dating around one common theme. It is designed to make friends fast, learn what they do and how you can collaborate on HIV research on gay/bi/trans/queer men in Canada. in Canada. It is intended for frontline workers in HIV and health care, under/graduate students in all disciplines, health policy makers, teachers, and academic/community based researchers.

This unConference starts with a “plenary” on Home-based rapid HIV testing, presented by: Alex Carballo-Diéguez, Ph,D.  That is followed by online break-out groups for those who want to discuss different aspects of this theme. For example Risk and HIV testing: A gal's inside perspective working with the boys, facilitated by Sarah Chown, Sexual radicals, barebackers, pigs and home based-testing, facilitated by Mikiki and Home-based testing and government policy in Ontario facilitated by Frank McGee.

Read more about it and learn what you’ll need to get ready for the unConference here.

For those of us who work or volunteer in the HIV sector, there are often opportunities to attend workshops and conferences about new developments in HIV prevention and treatment and, for those of us living with HIV, on managing our heath in all of its dimensions - physical, emotional and spiritual. For most other HIVers though, such opportunities are not as readily available, due to cost, time, location or inclination.

This is where the Community Health Forums put on by the AIDS Committee of Toronto (ACT) come in. Held seven times a year, these free workshops are accessible not only to HIVers living in the Toronto region but also, because they are webcast, to those living across the country and around the world. 

In order to learn more about these forums, I went to ACT a couple of weeks ago to talk with the program’s coordinator, Robin Rhodes. This charming man, who was born and grew up in Britain, has worked with people living with HIV and AIDS since the beginning of the epidemic. A staff member of ACT for 13 years, Robin oversees a variety of client-centred programs at that organization. Here’s our conversation. 

John McCullagh: Welcome, Robin, to PositiveLite.com. I’d like to start by asking you what exactly are ACT’s Community Health Forums? 

Robin Rhodes: They’re really open workshops for anybody that’s living with HIV to help them to better understand treatment issues and self-care, from a holistic point of view. It’s an educational opportunity, a chance for people to sit, listen, ask questions and learn. 

John: In terms of those who attend, are they primarily people living with HIV or can anyone come? 

Robin: We advertise it as a forum for people living with HIV but people don’t necessarily have to be a client of ACT or of any other ASO. 

John: What’s the experience like, attending one of the forums? 

Robin: They run between six and nine at night and we always offer a free buffet meal to start because it’s a long evening. Another reason to have food available is because some people need to take their medication with food. 

The actual presentations themselves start at seven o’clock. There are usually two speakers. We try to find a specialist, a professional, whatever it may be, who’s an expert in the specific topic being presented and complement that with the second speaker - or first speaker depending on which - who’s somebody living with HIV who’s familiar with or has lived experience of the topic under discussion. Sometimes, both speakers may be people living with HIV. But that’s not necessarily the criterion. The criterion is to offer an exemplary and high-standard presentation around the topic of the evening. We also build in time for questions from those attending. 

John: Do people just come up and ask questions or do they hand them to you in writing? 

Robin: Well, more often than not it’s direct from the floor. But if someone is more comfortable in writing their question down and handing it to me to read, that’s okay.  

John: You hold the forums in an hotel, not at ACT. Why is that? 

Robin: Because it’s a neutral environment. It’s not a space associated with the gay or HIV communities or anything else. Some of those who attend may not be out about their status or not comfortable in coming into an ASO and/or not comfortable asking their doctor questions. So it’s a neutral space that’s accessible to anyone from any walk of life, from any diversity, any background, cultural or otherwise. There’s no registration required either, again to protect anonymity. 

John: Robin, give me some sense of some of the topics that you’ve presented in the past and also your plans for this upcoming year. 

Robin: So we have seven forums a year, from September to March. The topics themselves are pretty broad-based. We try and cover both pure medicine as well as taking a more holistic approach. So for instance, we’ve covered HIV and healthy relationships, we’ve presented on addiction issues, on healthy sexuality (whether with single or multiple partners), the theory of practice of neurocognitive health, HIV drug interactions, HIV drug toxicities, HIV stigma and discrimination, hepatitis A, B and C, co-infection, transmission and treatment, PEP and PrEP. 

John: That’s a very broad spectrum of topics. 

Robin: Yes, it’s a very rich tapestry. 

John: And for this coming year, starting in September? 

Robin: Well John, this coming year we’re broadening the net, as they say. We’re looking into new insights into HIV management strategies for a cure, and will be presenting on the new Canadian HIV pregnancy planning guidelines. We’re going to look in depth at HIV and mental health, the new thinking and the new strategies around mental illness, about optimizing mental health and how that improves compliance with HIV medication and reduces the risk in other activities. And because we’ve just had the world AIDS conference in Washington, we’ll be providing a complete overview of that event and everything it entailed. 

John: That’ll be interesting. 

Robin: Absolutely. And then we’re going to talk about HIV among newcomers to Canada, about cultural diversity issues, getting into the health care system and navigating the system. We’ll also be presenting on the resiliences and challenges of sexually transmitted and opportunistic infections, new and existing STIs, overcoming sexual health challenges. There’s also going to be a session about anal cancer and dysplasia, which we’re noticing is getting more and more prevalent among people living with HIV. And then, finally in this particular series, we’re going to be talking about HIV and fatigue and hormone issues for both men and women and the use of supplements and testosterone and looking at energy levels and how best to manage these.

John: Robin, a wealth of topics there. How do you decide what to present? 

Robin: Well, John, we’re very fortunate in having an amazing advisory committee comprising members of the community, staff and members of ASOs and also the supporting pharmaceutical companies. So we have a wealth of people who provide their input. 

Then at the end of each forum we have an evaluation form on which we ask people what topic they would like to see presented in the future. For our annual series of seven monthly forums, we usually take four of the topics from the evaluation forms while the other three are decided by the advisory committee through the knowledge that they have both professionally and through their work in the communities of areas that people living with HIV may not necessarily be aware of and which we think it would be helpful if they did. 

John: Do the pharmaceutical companies dictate what topics are to be presented? 

Robin: Not at all. They are there as partners to the advisory committee and as sponsors of the forums. They can offer suggestions and they do. They do tend to know what’s coming down the pipeline in terms of research and they can be a great help to me in finding the right speakers. 

John: Is that where the funding for the forums comes from, the drug companies? 

Robin: They do support us, yes, but it’s not the overall funding source by any means. We receive support from a pharmacy as well. And ACT contributes from its own budget. So funding is broad-based.  

John: Now you have a very exciting new development this year, as I understand it, in that you’re going to be televising the forums over the internet. 

Robin: Opening up the forums to participants who, for whatever reason, cannot attend in person has been a dream of mine for a long time. The forums have grown from very small and humble beginnings, with eight or ten or fifteen participants. 

John: What, ten or 14 years ago? 

Robin: Yes, and now we get around 50 attending. But it’s always been my desire to share beyond our city the opportunity for learning that people in centres of HIV excellence such as Toronto, Montréal and Vancouver are able to access. So I spoke with Mark Fisher at the OHTN, who’s the director of IT there, and we tested different webcasting formats. We found one that appeared suitable and, as a result, last year we started webcasting an audio feed of the forums along with showing the powerpoint presentations. There were a few wrinkles at first but, generally speaking, from the feedback we received, it proved to be successful. 

Several people said that, while it was wonderful to hear the speakers and to see the powerpoint, would it be possible to see the presenters as well? So I went back to Mark and we looked at this again and we think we’ve come up with the remedy. We’ve done some testing and it seems to be working. So the new exciting piece is that, in this coming series, people not physically at the forum will be able to see the presenters as well. Albeit in a small box at the side, because we still need to present the powerpoint slides.  

John: That’s a wonderful, exciting addition. 

Robin: Yes, it is. And people viewing via the internet will also be able to anonymously email questions for the presenters to answer. Obviously, we won’t be able to take every question, but it’s another way of reaching out so that people in other areas will feel as though they’re participating in the event. 

John: And those webcasts are not only going to be presented in real time but will also be recorded for later viewing.  

Robin: Absolutely, it’s recorded and then within 24 hours its on a URL using exactly the same link on to the archives so people in different time zones across Canada and around the world can watch any of the previous forums and indeed the one from the night before. 

John: So, Robin, what’s some of the feedback that you’ve received about the forums both from those who attended locally and those who logged in via the internet? 

Robin: Well, John, for example, to quote from some of the people who filled out the evaluation forms we pass out at the end of each forum:  

Personally, it was all really relevant to me and I can begin to put my life back together again.                 

The Q and A was really helpful; the speakers were fantastic and presented in a way I really understood.                 

These meetings always make a difference to me and better enable me  to talk with my doctor.                 

My health and aging were what I had to know about - scary but very good. 

And then web feedback: 

I viewed with my partner, thanks it was great.                 

At last we were able to learn what you people in Toronto have.              

I heard about this from my agency support group; we all watched, thank you.                 

Our service users are really enjoying this valuable opportunity to gain knowledge.                 

John: At the end of the day, this is the kind of feedback all of us who present or write on issues concerning HIV hope to hear. Are there any challenges that remain? 

Robin: There are always challenges, John. They include keeping the topics fresh, finding the right speakers and scheduling them around their availability. Another challenge is finding a person living with HIV who’s comfortable speaking about the topic at hand, because, as I mentioned at the beginning, we always try to have one of the two speakers be a PHA who has knowledge of and/or lived experience of the topic under discussion. 

John: Any final thoughts to share with PositiveLite.com readers, Robin? 

Robin:  My passion - and I came into this work many, many years ago, John, and I run several other programs at ACT besides the community health forums - what drives me is that I’m constantly moved by the strength, the knowledge, the tenacity, the wisdom of people living with HIV. They are who motivate me to do to do the job I do. All I hope is that someone has benefitted in some small way from the work I do. 

John: Well, as an HIVer and as a regular participant at the community health forums, I know that through them I’ve learned a lot about issues that are important to me and, as a result, am better able to manage the challenges of living with HIV. 

Robin: Thank you, John, I appreciate knowing that. 

This interview has been edited and condensed.

ACT’s 2012-2013 series of Community Heath Forums will be held on September 12, October 10, November 14, December 5, January 9, February 13 and March 13. Presentations last two hours, starting at 7:00 pm Eastern Time.

You can log in at the above times to www.actoronto.org/forum to view the forums live. The webcasts will be archived at the same link within 24 hours following each forum.  At that link, you can also find information about the next forum in the series and watch previous forums that have been webcast.

Beginning in 1985, the International AIDS Conference (IAC) is the most attended conference on HIV/AIDS in the world. Held annually until 1994 and biennially since then, this year's edition, AIDS 2012, is being held in Washington, D.C. from July 22nd to the 27th.

In 2009, President Barack Obama announced that the 22-year-old travel ban on people living with HIV/AIDS would be lifted, paving the way for the conference to return to the U.S. for the first time in 22 years. "If we want to be the global leader in combatting HIV/AIDS, we need to act like it," Obama told the press at the time. The ban was officially lifted in January, 2010.

As always, the amount of Canadian content at the conference is impressive. The theme of this year's conference is Turning the Tide Together and it represents the 19th edition of the event.

Thanks to the Canadian Aboriginal AIDS Network (CAAN) and the Public Health Agency of Canada (PHAC), the issue of AIDS in Aboriginal populations will be discussed for the first time ever as part of the main conference program.

To help you better navigate this impressive conference, our friends at the Ontario HIV Treatment Network (OHTN) have put together a list of all OHTN-related research that will be presented at AIDS 2012, as well as a schedule of all Canadian-related research.

No need to fret if you can't make it to Washington, D.C. this year because AIDS 2012 will be webcasting select sessions. Both the opening and closing sessions of the conference, as well as 50 others, will be presented live via webcast at kff.org/aids2012  in both English and Spanish.

You can download a schedule of all Canadian-related research at AIDS 2012 by clicking here. 

PositiveLite.Com says: Of course we are biased, but watch out for this one from our own Megan DePutter, who writes about going to Washington here. 

"Show me the love": using community-based research to understand the barriers to sexual intimacy among people living with HIV and AIDS in Guelph, Canada

Presentation Type: Poster

Authors: Megan DePutter, Tom Hammond, Tanya Darisi, Tim Walker, Sarah Murray

Session Name: AIDS 2012 Poster Exhibtion

Time & Location:  Wednesday, July 25 2012, 9:00am - 6:00pm, Poster Exhibition area (Megan will be on hand to answer questions from from 12:30 - 2:30pm)

Overview: HIV diagnosis introduces challenges to sexual relationships that compromise health and wellbeing. This research identifies pertinent barriers to sexual intimacy and reveals insight into the complexities of negotiating sex and sexuality as an individual living with HIV & AIDS. This research also identifies opportunities to build on resilience through peer support and community-based initiatives in mid-sized urban and rural areas.

Photo © Joyb0218 | Dreamstime.com

Bob Leahy writes: I’ll try not to salivate at the prospect of one dose a day.  But I was diagnosed in 1993. In 1995-96 I took part in the clinical trial of  the first of the protease inhibitors, saquinavir, quickly becoming resistant to that class of drugs because of suboptimal doses that were prescribed back then.

Like it or not, past resistance issues, even in the most adherent of us, tend to lead to multiple drug cocktails. Until recently I was on five HIV drugs, but these have now been reduced to four – ritonavir, etravirine, darunavir and raltegravir. But what would they be without the drugs we take to counteract the side effects of the HIV drugs – in my case gabapentin for neuropathy and ramipril for kidney damage.  I’m afraid to count how many pills that is at a sitting, so I don’t.. Multiple by two – I take them at mid-day and then late at night - and that’s a lot of pills.

The question arises, of course, that if you have a heavy pill burden like this, are you more or less likely to be adherent?  Personally, it’s a moot issue, as taking pills at those set times I mentioned has become so ingrained  that I seldom, if ever, forget.  I mean, do you ever forget to go to bed at night?  It's the same thing. But I know only too well, in speaking to others, that adherence is a real issue. People need an arsenal of tricks to help them remember their pills.  If they only have to remember once each day, logic suggests they would be more adherent, with better health outcomes as a result, right?

Which is where the OHTN comes in. The OHTN Cohort Study, which I  wrote about here examined this issue last year and reported the results of their research in their Winter 2011 newsletter (available online here).

Here is what they said, direct from the newsletter. 

Once Daily Dosing Improves Adherence to Antiretroviral Therapy

What research question is addressed by “Once Daily Dosing Improves Adherence to Antiretroviral Therapy?”

Adherence (taking medications as prescribed) is critical to ensuring the effectiveness of antiretroviral therapy (ART). Measures of effectiveness include: reducing the amount of virus in the blood (known as viral load) below the limit of detection, reducing the likelihood of disease progression and reducing the likelihood of developing of drug resistance among people living with HIV (PHAs). This study examines the correlation between only once daily dosing and adherence. 

What was the study conclusion?

The study found that once daily dosing is associated with better adherence to ART regimens.

Why is this question important?

While ART has improved significantly since combination ART revolutionized care and treatment of HIV disease in 1996, current ART drug regimens require PHAs to take pills (or injections) daily or – depending on the regimen – two or three times daily, for the rest of their lives. This makes finding strategies to improve adherence important to maintaining treatment effectiveness. 

How was the study conducted?

Researchers reviewed clinical data and administered surveys which collected a wide range of social, behavioural and demographic data from OCS participants. A total of 779 participants completed detailed (90 minute long) questionnaires (administered by researchers) between October 2007 and May 2009.

Researchers defined non-adherence as missing one dose (or more) of ART during the four days before the interview. Questions from a number of standardized surveys were included in the questionnaire, including the MOS Support Survey, the Brief COPE instrument, the Centre for Epidemiological Studies Depression Scale, the Pearlin Mastery Scale, a modified version of the Berger Stigma Scale and the National Population Health Survey Stress Questionnaire. 

What were the main results of the study?

Study investigators found that participants were more than twice as likely to be adherent (i.e., report no missed doses) if they were on ART drug regimens that required once-daily dosing (compared to regimens that required more frequent dosing). This finding is consistent with other studies and analyses which have found that once-daily dosing improves adherence. While only 15% of study participants reported suboptimal adherence in the four days before the questionnaire was administered, 70% reported ever missing a dose and 54% reported missing a dose within the last four weeks. Researchers also found that younger participants (under 30 years of age) and those who consumed more than six drinks on one occasion more than once a month (defined as ‘binge drinking’) were also more likely to miss a dose. 

What do the study results mean for the treatment and care of people living with HIV?

The study results were consistent with previous studies indicating a relationship between once-daily dosing and improved adherence, as well as correlations between youth and binge drinking and suboptimal adherence. One of the more interesting findings of the study is that younger participants were more likely to be on once-daily regimens. 

 Where can I find the full-length publication of this study?

This study was published in AIDS and Behavior in 2010. The full text version is available here. Raboud J, Li M, Walmsley S, Cooper C, Blitz S, Bayoumi AM, Rourke S, Rueda S, Rachlis A, Mittman N, Smieja M, Collins E, Loutfy MR (2010). Once Daily Dosing Improves Adherence to Antiretroviral Therapy. AIDS and Behaviour. DOI 10.1007/s10461-010-9818-5. Published online: September 28 2010.

Postscript from Bob Leahy:

Subsequently, I was able to talk to researcher Janet Raboud to ask her further questions about this research. 

Bob: Your research was specific to once-a-day dosing but how might you anticipate it's conclusions relate to more simplified treatments generally? In other words how well have we established the relationship between simplified treatments and adherence generally.

Janet: There is evidence of improved adherence with more simplified regimens.  I have attached a paper showing that many factors affect adherence – pill burden, dosing frequency, dietary restrictions, etc.   I think every step towards a more simplified regimen increases the chances that people can adhere to the regimen as it was intended.

Bob: How would you like to see research findings like this used?

Janet:  I would hope that physicians treating patients that they might anticipate will have difficulties with adherence would prescribe once a day regimens, if clinically suitable, to improve the chances of better adherence.

Bob: Do you see the need for additional research like this?  Or. . . in what specific areas relating to treatment adherence/treatment simplification are there gaps in our knowledge? For instance, do we know how well people on salvage therapy - a four or five drug regime taken twice  a day  - compare in adherence to those, say, taking one pill once a day?

Janet: I would love to pursue further research in this area, particularly among older patients with HIV who are often taking medications for other issues such as hypertension or diabetes.  It would be great to know what sorts of strategies could facilitate adherence in this context. 

I was asked to submit a piece of writing to www.projectremember.ca reflecting on my wife Kim and her contribution to the AIDS movement.

Just recently the 19^th anniversary of her passing was upon me and the children and I found myself as I often do remembering her with great love and admiration.  She passed away the day before Mothers day and a week before our 5^th wedding anniversary.  She is the very heart of my AIDS activism and my own personal hero; she taught me to be brave and most importantly she taught me by example the greatest gift of all; unconditional love. 

I went by the cemetery last weekend which is something I rarely do … it’s just a little much for me … but at the same time I feel it’s somewhat cathartic to sit in the grass by her headstone and talk to this wonderful woman and update her on life and the children she loved so much.  

I checked out the www.projectremember.ca website and certainly encourage others to do the same.  There is a who’s who list of an incredible group of people who in one way or another contributed to the HIV/AIDS movement in Canada. I read every biography, and mourned the passing of many friends on this time travelled list.  I am honoured that my wife would be included in this tribute to strength, courage and resiliency.  

Below is an excerpt from that submission that I am happy to share.

*********************************

Kim Newman was diagnosed with HIV December 10, 1990. Kim was married with 3 young children and was told at the time of diagnosis that her husband and all of her children needed to be tested as well.  On January 15, 1991 Kim’s world came crashing down around her when her husband and the two youngest children also tested positive for HIV; only her oldest child, a daughter, had tested negative.

From the beginning of Kim’s life with AIDS was an inner strength that persevered.  Her love for her children would not allow her to be silent and she felt she needed to do whatever she could to protect and help them.  In the autumn of 1991 after much collaboration and work with the AIDS Committee of London and the HIV clinic in their city; Kim, her husband and their 3 children went public with their story nationwide to bring attention to AIDS awareness and in particular children living with HIV/AIDS.  Kim and her husband began a fund named after their oldest son; The Robby Care Fund.  This fund, under the umbrella of the AIDS Committee of London was established to assist families with children living with HIV/AIDS.

Over the course of the next 2 years Kim, her husband and family was, for lack of a better term, the “poster family” living with AIDS; she was OK with that, in fact it made her very proud.  Kim’s work over this time shed great light on women and children and HIV/AIDS.  She was an outspoken public speaker, a fiery activist and a great Mom to her children; it was the job she cherished the most.

Kim passed away May 15 1993, just 2½ years after her world had changed forever.  The legacy that she left behind empowered the rest of the family to continue to work in the AIDS movement.

Sadly, Robby her oldest son passed away in 1995 at the tender age of 7 but Kim’s daughter went on to win many provincial and federal awards for her own AIDS awareness work, her youngest son worked at an HIV/ AIDS orphanage in South Africa and her husband works as a peer support worker at the Regional HIV/AIDS Connection in London Ontario.