HIV Australia | Vol. 11 No. 2 | July 2013
By Karalyn McDonald and Julian Elliott for the HealthMap Project Team
Cardiovascular disease and HIV
Since the advent of HAART (highly active antiretroviral therapy) in 1996, HIV has progressively transitioned from a life-threatening to a chronic disease.
The average age of people living with HIV in Australia is now over 45 years and modelling estimates that the number of people aged over 60 has been increasing at 12% per year since 1995.1 2 3
However, despite the majority of people who take antiretroviral therapy (ART) having fully suppressed HIV viraemia and high CD4+ T-cell counts,4 the life expectancy for people who are receiving effective ART is only two thirds that of the general population.5
One of the main reasons for this is the onset of cardiovascular disease (CVD). Furthermore, ‘serious non- AIDS events’, such as CVD, are now more frequent than AIDS events, have a higher risk of death and occur with increased frequency compared with age matched general population cohorts.6
ART toxicity, health behaviours and HIV infection itself, possibly due to ongoing immune activation associated with HIV infection7are all believed to contribute towards the increased risk of CVD in people with HIV.
Yet, importantly, one of the major risk factors for CVD in HIV-positive people is smoking. More than one third of people with HIV in Australia are smokers, with one estimate indicating that 42% are smokers,8 which is more than twice the rate of the general Australian population.
Method
The aim of this study was to help inform the design of HealthMap, a complex health, self-management intervention for people with HIV. The focus of HealthMap is the reduction of the risk of CVD, which will be assessed using a cluster randomised control trial in 2014.
Semi-structured, face-to-face interviews were used to explore practices and motivations of participants to maintain and manage their health.
In addition to exploring the role of HIV in people’s lives and how they thought about ageing or growing older, we also asked them to detail their current practices aimed at maintaining their health and who supported them in these practices.
We asked participants if there was anything they would like to be doing differently in relation to their health, what they thought could help them achieve any changes they identified and where their main sources of health information came from.
Current smokers were asked to detail their thoughts about smoking, desires to quit and any quit attempts – which for the sake of brevity, will be the focus of this article.
Thirty-three interviews were conducted in Victoria and NSW in 2012, including in regional and rural areas.
Recruitment included participants who are non-community identified and socially isolated, men and women, gay and straight. Interviews lasted approximately one hour and were transcribed verbatim and thematically analysed.
Ethics approval was received from Monash University, Alfred and Prince of Wales Hospitals, Victorian AIDS Council/Gay Men’s Health Centre and ACON.
Results
Thirteen participants in our sample were currently smokers. A further six men said they did not smoke. Of these six men, two men had quit in the weeks prior to the interview and one had quit two years ago.
A further two participants said they only used tobacco when they smoked marijuana and another said he was an occasional social smoker.
During the interviews we explored their smoking practices and motivations, if any, to quit. All of the smokers were men, aged between 20 and 69.
Fourteen identified as gay, three as straight, one as ‘mostly straight’ and another as ‘confused’. Nine men were diagnosed before HAART and 17 were taking antiretroviral medication.
Eleven men were taking other medication for co-morbidities, including emphysema, high blood pressure, high cholesterol, lupus and depression.
Two men had been diagnosed with emphysema and another two men had already experienced myocardial infarction (heart attacks).
Only one of these men had quit smoking and he had had two heart attacks in the previous two years. He had only just ceased smoking three weeks prior to his interview and he said this was largely driven by feeling unwell or vomiting whenever he smoked.
The second man who had experienced a heart attack said whilst he did not smoke while he was in hospital, he starting smoking again as soon as he was discharged, finding quitting smoking more challenging than giving up heroin and methadone.
The two men with emphysema acknowledged that they should quit and one man said he had considered hypnotherapy, however, he also acknowledged that he did not feel an urgent need to quit or to create expectations for himself that he believed he could not meet.
It is important to note that when talking about quitting, most of the men raised other concerns that did not pertain to their health. For example, the amount of money spent on smoking tended to be a bigger issue for most smokers in this study.
This is not surprising when considered in the context of living on pensions and/or reduced income.
Most smokers said they wanted or hoped to quit in the future and quite a few had already identified rewards, as a motivation, that they would buy themselves when they got around to quitting; usually in the form of technology such as computers, tablets or smart phones.
It was often recognised that the money saved from quitting or reducing their smoking would free up funds for other pursuits:
I’ve promised myself that when I give up I’ll get an iPhone or an iPad.
— Int 3
There are things that I want to buy … I am going to have to give up cigarettes to get them. I want to get a new computer.
— Int 4
Most smokers also identified the social context of smoking such as meeting with friends, smoking when drinking or smoking during daily routines such as with a morning coffee or using the computer.
It was often described as a pleasurable activity, one that was associated with social connectedness and was often entrenched in one’s identity.
One smoker described his habit as an ‘insidious friend’ and another described his sexual identity and sexual pleasure as being explicitly linked to smoking:
But I have actually got a fairly unusual sexual fetish which is watching people smoke. I have had this since I was 12 years old.
It’s … somehow my sexuality developed that way. The first person that ever, or first guy that ever turned me on was blowing a smoke ring at the time, instead of being attracted to the guy I became attracted to the smoke rings and just sort of went down that road.
— Int 2
When talking about quitting, some said they would have to go ‘cold turkey’ but that they needed to be completely mentally prepared for this.
However, most said they preferred the idea of reducing the amount they smoked in small steps and, in fact, many had already done this, saying they cut habits as many as 60 cigarettes a day down to 10 or 15.
Many identified the problem of being in social gatherings with other smokers, noting it would be easier if their friends did not smoke:
But the trouble is when you go out, and if all my friends decided to give up cigarettes it would make it a lot, lot easier.
— Int 4
Only two smokers said they would not quit. These men said they had already experienced too many losses (including having given up drugs/ heroin) and that this was one last pleasure that was not negotiable.
These men said things like,‘I have to die from something’ or, ‘I have lived longer than I should have anyway’:
That’s the only habit I’ve got. You know, and cigarettes keep me …, it’s my last refuge … So what’s worse? Cigarettes or Hammer or Done?
— Int 15
In thinking about supporting people with HIV to quit smoking, we asked participants to detail where they received most of their health-related support from.
Nearly all participants said their HIV clinician was their most significant health support, however, most did not discuss desired health-related changes with their clinicians.
Generally it was perceived that there was insufficient time to deal with additional health concerns. Whilst most smokers said their clinician had told them to stop, many said it did not come up very regularly and they did not view their clinician as someone who would be able to support them in achieving smoking cessation.
Most participants believed they would be better equipped to cease smoking if they were well supported, to help them maintain their resolve or focus on their goals:
Sometimes I think that smoking should be treated just like any other addiction. I’d be quite happy to go to like an Odyssey House for smokers, be brilliant if something like that was available, but it’s not unfortunately.
Yeah I’ve been in touch with Quit Line a couple of times for advice, information, but I haven’t managed to get past the receptionist who’s said we’ll post you out some info, which is pretty much what you read on the cigarette pack these days, just a bit lengthier, and things you already know.
Also I’d have to find something to replace it with, and I’m having trouble working out just what that would be.
The only thing I could think of is lollies, but I just would end up eating two packs of Fantails a day!
— Int 3
Conclusion
Health practices or behaviours, such as smoking were not always influenced by HIV. For example, wanting to quit or reduce smoking was often linked to freeing up money for other pursuits.
Health is often considered in the context of doctors’ appointments, which leaves few opportunities to engage people in discussions about health-related behaviours and goals.
Also, although participants were aware that their clinicians wanted them to cease smoking, many did not perceive that they would receive the support they would require to sustain their non-smoking behaviour.
Most smokers indicated they believed they would benefit it they were to receive additional support to help maintain their resolve while quitting.
Having strategies while out with other smokers and speaking with a peer who had successfully quit smoking were identified as important.
As has been identified by the participants in this qualitative study, there are challenges in designing an intervention for the self-management of strategies for people with HIV to reduce the risk of CVD in that the design needs to acknowledge the social context of people’s lives.
The complexities of people’s lives need to be considered as we develop an intervention that not only reduces the risk of cardiovascular disease but also adds value to the day-to-day lives of people living with HIV.
Acknowledgements
We would like to acknowledge our 33 participants who generously shared their experiences; our funders: the National Health and Medical Research Council; our recruiters: Julie Silvers, Kit Fairley, Richard Moore, Jeffrey Post, David Baker, Neil McKellar-Stewart, Janine Roney, Norm Roth, Kristine Millar, Anna Avoledo, VAC/GMHC, ACON Northern Rivers; and HealthMap partners: Monash, Alfred, ASHM, NAPWHA, Deakin, Flinders, La Trobe and Melbourne Universities and the Victorian Department of Health.
References
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2 Grierson J., Power, J., Pitts, M., Croy, S., Clement, T., Thorpe, R., et al. (2009). HIV Futures Six: Making Positive Lives Count. Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne.
3 Grierson, J., Bartos, M., deVisser, R., McDonald, K. (2000). HIV Futures II: The Health and Well-being of People with HIV/ AIDS in Australia. The Australian Research Centre in Sex, Health and Society, Latrobe University, Melbourne.
4 Falster, K., Gelgor, L., Shaik, A., Zablotska, I., Prestage, G., Grierson, J., et al. (2008). Trends in antiretroviral treatment use and treatment response in three Australian states in the first decade of combination antiretroviral treatment. Sexual Health, 5(2),141–54.
5 Collaboration. A, Therapy, Cohort. (2008). Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. Lancet, 372(9635), 293.
6 Neuhaus, J., Angus, B., Kowalska, J., La Rosa, A., Sampson, J., Wentworth, D., et al. (2010). Risk of all-cause mortality associated with non-fatal AIDS and serious non-AIDS events among adults infected with HIV. AIDS, 24(5), 697.
7 Hunt, P., Martin, J., Sinclair, E., Bredt, B., Hagos, E., Lampiris, H., et al. T cell activation is associated with lower CD4+ T cell gains in human immunodeficiency virus-infected patients with sustained viral suppression during antiretroviral therapy. Journal of Infectious Diseases, 187(10), 1534–43.
8 Grierson, J., et al., (2009), op. cit.
Dr Karalyn McDonald is a Research Fellow at the Department of Infectious Diseases, Monash University and an Honorary Fellow at the Australian Research Centre for Sex, Health and Society, La Trobe University.
Dr Julian Elliott is Head of the Clinical Research at the Department of Infectious Diseases, Monash University, Head of Clinical Research at the Alfred Hospital Infectious Diseases Unit and HIV Clinical Advisor, Centre for Population Health, Burnet Institute.