This article by Michael Carter first appeared on aidsmap.com here.  Reproduced with permission.

Levels of adherence to modern HIV treatment are unaffected by dosing frequency or number of daily pills, Italian investigators report in HIV Medicine. However, people who were taking larger numbers of pills reported poorer health. The investigators suggest this is because “many of the patients receiving more complex regimens had more advanced disease and/or were harbouring virus with more drug-resistance mutations.”

It has been uncertain if frequency of dosing and daily pill burden affect adherence to antiretroviral therapy. Research conducted soon after combination HIV treatment was first introduced showed that adherence and outcomes were poorer in people taking more complicated regimens with larger numbers of pills.

However, there have been significant advances in HIV therapy in recent years, with treatment becoming simpler, more potent and less toxic.

Italian investigators wanted to gain a better understanding of the relationship between the number of daily doses and pills and HIV treatment outcomes in the era of modern antiretroviral therapy.

They therefore designed a study involving 2114 people who received HIV care in Milan between March and May 2010. Adherence and self-reported health status were assessed using questionnaires.

The study participants had a median age of 46 years and 78% were men. The median duration of antiretroviral therapy was ten years. Median CD4 cell count was 598 cells/mm3 and 85% of participants had an undetectable viral load. Most (57%) were taking a once-daily antiretroviral regimen. The remaining 43% were taking their treatment twice daily. The median number of daily pills taken by each participant was 3.67. The most commonly used combinations of drugs were efavirenz/tenofovir/FTC (Atripla) (14%); ritonavir-boosted atazanavir (Reyataz) with tenofovir/FTC (Truvada) (12%); and lopinavir/ritonavir (Kaletra) with tenofovir/FTC (7%).

Over three-quarters (79%) of study participants  reported taking all their doses.

Adherence levels did not differ according to whether treatment was taken once- or twice-daily. People taking once- and twice-daily therapy were equally likely to have missed at least one dose of their medication in the previous week (17% vs 16%) and to have stopped treatment for two or more days in the previous month (11% vs 10%).

People with an undetectable viral load reported better adherence than those with a detectable viral load (95% vs 88%, p < 0.002). Higher levels of adherence were also associated with better self-rated health status (p < 0.001).

“We observed a direct correlation between self-reported health status and adherence, which suggests that patients experiencing more drug side effects not only experience worse health, but are also more likely to miss doses”, comment the investigators.

CD4 cell counts were highest in people who had the best adherence (p < 0.001).

Taking a greater number of pills each day was associated with poorer self-rated health status (p = 0.019). However, there was no evidence of a relationship between frequency of dosing and health status.

“Better self-reported health status was associated with a lower pill burden,” write the authors. “Neither the number of daily pills not dosing interval was associated with self-reported adherence.”

They believe their findings show that “when a regimen is well tolerated, adherence and health status are very good, regardless of the number of daily pills or the dosing schedule.”

The investigators stress that their study participants were “highly adherent and virologically suppressed” and conclude “self reported adherence was not associated with the number of daily pills or dosing interval.” They believe their findings “may be clinically important when, because of toxicity, a patient is a candidate for a switch from a very simple nucleoside reverse transcriptase inhibitor (NRTI)-based regimen to a more complex NRTI-sparing regimen.”

Reference

Gianotti N et al. Number of daily pills, dosing schedule, self-reported adherence and health status in 2010: a large cross-sectional study of HIV-infected patients on antiretroviral therapy. HIV Med, online edition. DOI: 10.111/j.1468-1293.2012.01046.x, 2012.

This article by Myles Helfand first appeared in TheBody.com here.  

Plenty of scary headlines have made their way across the Internet in recent years, decrying the body-decaying effects of getting older and portraying the sense that HIV (or HIV meds) causes people to suffer these problems at far higher rates far earlier in their lives. And by "far earlier," some experts felt we were talking as many as 20 years earlier, according to some of the first research that explored the issue.

But the problem that often occurs with early research is that it's ... well, a bit premature in its findings. "There certainly is more of a trend for HIV-positive people to be a bit younger" when they develop certain health problems, says Amy Justice, M.D., Ph.D., a professor of medicine and public health at the Yale School of Medicine. "But when I say a bit younger, we're talking about somewhere between one and six years -- we're not talking about 20 or 30 years."

Justice should know: She is one of the world's leading researchers on aging and HIV. As the lead investigator of the massive Veterans Aging Cohort Study (VACS), it's her job to delve into one of the largest troves of information in existence and help us all better understand the ways in which HIV intersects with other health problems that emerge as we get older.

What she and her team have found is rewriting much of we thought we knew about aging and HIV. It's also helping us figure out some concrete steps we can take to prevent or treat health problems we associate with "premature aging."

A Rose by Any Other Name

To begin with, our whole approach to the idea of "early aging" misses the mark, Justice says. "If you talk to anyone who is a geriatrician -- who studies aging -- they will say this concept of 'premature aging' is a misnomer," she explains. "If you look at anyone with chronic disease, they look older than someone without chronic disease."

The problem, Justice says, is not that people with HIV are "getting older" more quickly. Instead, what happens is that HIV, like many other chronic illnesses (such as diabetes), sometimes triggers or worsens other health issues -- many of which we're naturally at greater risk for as we get older. "Are people who are sick and have HIV more frail, more likely to have problems with their health, than someone who's not? Of course they are," Justice says. "Why do we have to invoke 'premature aging' when we talk about that?"

Defining the Risk

Through her work with VACS, Justice and her colleagues have uncovered some of the most reliable information we've learned to date about the timing of various health problems in people with HIV.

Here's how the study works: More than 7,400 people living in or near eight U.S. cities are enrolled in VACS. The HIV-positive people are "matched" against HIV-negative people who otherwise have extremely similar characteristics (such as age, location and race). The study then follows these people over time and records when they develop various health complications.

A slide from a presentation given by Amy Justice at an HIV/AIDS conference in 2012. (Click the image to enlarge it.) It compares the average age at which HIV-positive people and HIV-negative people enrolled in VACS were first diagnosed with certain key health problems. ("MI" is short for "myocardial infarction" -- i.e., a heart attack.)

When comparing the HIV-positive people to the HIV-negative people, VACS has found that HIV-positive people:

• Develop kidney failure about four years earlier.
• Develop lung cancer about two years earlier.
• Develop cardiovascular disease as much as six years earlier -- but do not begin to experience heart attacks earlier at all.
• Develop liver cirrhosis about one year earlier.
• Fracture a bone due to bone weakness one year later.

This isn't the only research being done to make more accurate estimates of how much "earlier" people with HIV develop health problems. Less than two years ago, a major study funded by the National Cancer Institute found that previous estimates drastically overestimated how much earlier people with HIV develop certain cancers, because it didn't properly take people's ages into account.

But why is it that studies such as VACS manage to find such a smaller age difference than earlier studies had found? Which findings should you believe more?

Making Sense of the Research

To determine whether HIV-positive people have a "greater" risk of developing certain health problems as they get older, researchers have to compare those HIV-positive people to a group of HIV-negative people. Who those HIV-negative people are, and what measurements researchers use to examine them, makes all the difference. 

People with HIV who are visiting a Veterans Affairs hospital in Los Angeles are likely to be very different from your average HIV-negative people living in a Massachusetts suburb. For instance, they're more likely to be people of color; they're more likely to be from an inner city; and they're also just more likely to be sick in the first place, since they're the ones visiting a hospital.

Another slide from a presentation given by Amy Justice at an HIV/AIDS conference in 2012. (Click the image to enlarge it.) It shows some of the key results from a study published in the Annals of Internal Medicine that corrected earlier research which drastically overestimated how much earlier people with HIV develop certain cancers, because it didn't properly take people's ages into account.

All of these kinds of factors -- race, location, gender, income, access to health care, average age, you name it -- can impact the risk a person has of developing a health problem. Sure, an HIV-positive black man working a low-wage job and living in an unsafe neighborhood in Los Angeles may develop heart disease many, many years earlier than an HIV-negative white man living in a million-dollar home in Weston, Mass. But is it the HIV that's to blame?

Studies like VACS try to level the playing field by comparing groups of people who are as similar as possible in every measurable way -- except that one group has HIV and the other does not. Very few studies like this exist, because finding enough HIV-positive and HIV-negative people to match in this way is extremely difficult (not to mention extremely expensive).

VACS is not the be-all, end-all of studies on aging and HIV. Researchers are constantly looking for ways to refine their studies, enroll more volunteers and make their results more reliable. But as you saw in the list above, what we've learned so far is enough to dispel some widely held myths about HIV and aging. It's also enough to give researchers some insight into how people with HIV can reduce the risk that they'll develop various health problems as they get older.

The Power to Change

"'Premature aging' -- I think it frightens the living daylights out of people," Justice says. "It suggests there's nothing you can do: You'll be 70 when you're 50, and when you're 70, you'll be 90. I don't think that's useful in clinical care."

In hopes of helping HIV-positive people and their health care providers combat this feeling of helplessness in the face of the relentless passage of time, Justice and her colleagues have developed a tool called the VACS Index Calculator. The tool, which is available online -- and even has a mobile-friendly version -- pulls together all of the research VACS has done to date and attempts to answer the question: "What are my odds of dying?"  

OK, yes, it's a terrifying concept: You check off a bunch of boxes -- age, sex, race, CD4 count, HIV viral load, liver enzymes and so forth -- and the calculator spits out a single number called your "five-year mortality risk." In other words, your risk of dying within the next five years.

But here's why the tool isn't remotely as terrifying as it seems: It's not a prediction. It's just VACS telling you, "Among the people in our study who are similar to you, this many passed away within five years." Which means you and your health care provider have the power to change those odds.

"It's a way of gauging your overall burden of disease, your overall susceptibility to further injury," Justice explains. "Whether the [cause] is treatment toxicity, HIV disease progression, diabetes, smoking, alcohol -- it reflects all of those things, in terms of looking at their injury on your major organ systems. And, by determining what else is going on in your situation, helping you pinpoint what things you might be able to do to improve it."

The VACS Index Calculator is still in development; Justice hopes over time to add features that may delve more deeply into people's behaviors and life habits, and offer some suggestions about changes they can make to reduce their mortality risk and stay as healthy as possible. She encourages people to use the tool, offer comments on how it can be made even more useful for them (there's a survey link within the tool), and discuss the calculator's results with their health care provider.

"I think the more information you can give patients directly and the more time they have to think about what questions they may have for their providers when they go to see them, the better, the higher quality, the more meaningful the interaction is, and the more likely the behaviors [that increase their health risks] will really change," Justice says.

In the meantime, Justice and her VACS colleagues -- as well as a number of other research teams around the country -- will continue their efforts to more reliably explore the real risks of HIV-positive people developing various health problems as they age.

This article by Michael Carter was first published in aidsmap.com here. 

The provision of smoking cessation counselling and therapy during routine HIV care increases the chances that patients will stop smoking and stay stopped, according to Swiss research published in HIV Medicine.

Physicians at the Zurich HIV clinic received training about smoking cessation counselling and the use of medication to help those wanting to quit.

Compared to other patients in the Swiss HIV Cohort, people who received their care in Zurich were more likely to stop smoking and also less likely to restart smoking after they had quit.

The Zurich doctors were able to successfully integrate smoking cessation support into routine clinic appointments.

Cardiovascular disease is an increasingly important cause of illness and death in patients with HIV. The largest modifiable risk factor for cardiovascular disease is smoking. Compared to individuals in the general population, patients with HIV are significantly more likely to smoke.

Although a significant majority of all smokers wish to stop, only a minority succeed. Approximately a fifth of those trying to stop smoking receive specialist support in the form of counselling or supportive drug therapy. Doctors who have been trained how to support patients who wish to stop smoking are more likely to offer referrals to counsellors or prescribe supportive drug therapy.

Little information is  available on how smoking cessation is handled in HIV care.

Therefore, between 2007 and 2009, all doctors at the HIV treatment centre in Zurich were provided with specialist training about the role of counselling and drug support in smoking cessation. The investigators hypothesised that the patients of these doctors would be more likely to stop smoking than patients at other HIV treatment centres in Switzerland.

The training lasted half a day and was provided by the Swiss Lung Foundation. It provided information on the identification of smokers, nicotine dependence, nicotine withdrawal, motivation stages, methods of counselling and pharmacological support.

A total of 1,689 patients received care at the Zurich treatment centre and 11,056 in the Swiss Cohort during the study.

No centre other than the Zurich clinic offered structured smoking cessation support.

Physicians at the Zurich clinic included smoking cessation in 80% of consultations for current smokers.  

Prevalence of smoking in the entire Swiss Cohort fell from 60% in 2000 to 43% in 2010.

In 2000, 64% of patients in Zurich smoked. This had fallen by 23% by 2010, somewhat greater than the 16% decline recorded in the Swiss Cohort overall.

Just before the start of the study in 2007, the incidence of smoking cessation among the Zurich patients was 6.1 per 100 person years. This had increased to 10.8 per 100 person years in 2010. The corresponding figures for the Swiss Cohort were 4.4 and 6.2 per 100 person years respectively.

Incidence of relapse among former smokers at the Zurich clinic fell dramatically over the period of the study from 8.7 per 100 person years in 2007 to 2.9 per 100 person years in 2010. Incidence at other treatment centres were largely unchanged at 10.9 and 9.2 per 100 person years in 2007 and 2010.

The investigators calculated that patients at the Zurich clinic were approximately 25% more likely to stop smoking than patients receiving care at other Swiss centres (OR = 1.23; 95% CI, 1.07-1.42, p = 0.004). Patients in Zurich who managed to quit were also significantly less likely to start smoking again than patients at other centres (OR = 0.75; 95% CI, 0.61-0.92, p = 0.007).

The effect of the intervention remained significant even after controlling for calendar year.

Injecting drug users and heavy drinkers were significantly less likely to stop smoking (p < 0.001). So too were patients who were either undergoing psychiatric treatment or who had depression (p = 0.03). The same factors were associated with relapse after smoking cessation. In contrast, patients with a history of cardiovascular disease were less likely to relapse after quitting (p = 0.005).

“Smoking cessation should be a topic of discussion in any physician-patient contact,” conclude the investigators. “Our approach of an institution-wide training programme for infectious diseases physicians to improve smoking cessation counselling can be well integrated into routine HIV care, was well accepted by patients and physicians, and can support patients’ efforts to stop smoking.”

Reference

Huber B. Outcomes of smoking cessation counselling of HIV-positive persons by HIV care physicians. HIV Med, doi: 10.1111/j.1468-1293.2011.00984.x, 2012 (click here for the free abstract).

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.