An Emerging Syndemic of Smoking and Cardiopulmonary Diseases in People Living with HIV in Africa

Abstract

Background: African countries have the highest number of people living with HIV (PWH). The continent is home to 12% of the global population, but accounts for 71% of PWH globally. Antiretroviral therapy has played an important role in the reduction of the morbidity and mortality rates for HIV, which necessitates increased surveillance of the threats from pernicious risks to which PWH who live longer remain exposed. This includes cardiopulmonary comorbidities, which pose significant public health and economic challenges. A significant contributor to the cardiopulmonary comorbidities is tobacco smoking. Indeed, globally, PWH have a 2–4-fold higher utilization of tobacco compared to the general population, leading to endothelial dysfunction and atherogenesis that result in cardiopulmonary diseases, such as chronic obstructive pulmonary disease and coronary artery disease. In the context of PWH, we discuss (1) the current trends in cigarette smoking and (2) the lack of geographically relevant data on the cardiopulmonary conditions associated with smoking; we then review (3) the current evidence on chronic inflammation induced by smoking and the potential pathways for cardiopulmonary disease and (4) the multifactorial nature of the syndemic of smoking, HIV, and cardiopulmonary diseases. This commentary calls for a major, multi-setting cohort study using a syndemics framework to assess cardiopulmonary disease outcomes among PWH who smoke. Conclusion: We call for a parallel program of implementation research to promote the adoption of evidence-based interventions, which could improve health outcomes for PWH with cardiopulmonary diseases and address the health inequities experienced by PWH in African countries.

Mapping of global, regional and national incidence, mortality and mortality-to-incidence ratio of lung cancer in 2020 and 2050

“…These patterns also follow the low smoking prevalence rates in Africa, barring a few countries in Northern Africa (e.g., Algeria 15.6%) and Southern Africa (e.g., Lesotho 27.2%; South Africa 20.7%; Botswana: 20.1%). However, in persons living with HIV/AIDS, smoking rates are 2–4 times higher than the general population in Africa [ 31 ]. The lung cancer burden in Africa is expected to double or more by 2050 based on demographic changes alone.…”

Using a Syndemics Framework to Understand How Substance Use Contributes to Morbidity and Mortality among People Living with HIV in Africa: A Call to Action

“…For example, in a LMIC where TB and food insecurity are significant risks for PWH, those issues will play a much more significant role in intersectional stigma [77] of PWH, compared to sexual minority males living in a HIC, where food insecurity could be an issue but from a different contextual framework [81]. In both situations, SU may be a significant issue; however, to address the health outcomes of SU/SUD among PWH in LMICs, the customs, societal norms, general support structures of each group must be examined using an equity-based syndemics framework [82]. Essentially, this framework illustrates that various causal relationships cannot be disentangled from one another.…”

Tobacco Use among HIV-Positive and HIV-Negative Women and Men in Zambia—Demographic and Health Survey, 2018

“…Where antiretroviral therapy (ART) for HIV is available, tobacco smoking results in a greater loss of life years than the HIV infection itself among PLWH who smoke [ 10 ]. The co-occurrence of HIV alongside noncommunicable diseases (NCDs) and their risk factors, such as tobacco use, has been described as a joint or synergistic epidemic [ 11 , 12 ].…”

“…The global and multicountry estimates described here clearly indicate an urgent need to better characterize country-specific estimates for tobacco use, NCDs, and related risk factors among PLWH. Unfortunately, these country-specific estimates are lacking for much of SSA, and for LMICs in particular [ 11 , 14 , 15 ].…”