Addressing the Health Needs of People Living with HIV: Positive Quitting Initiative - A Smoking Cessation Intervention SEAN B. ROURKE, PhD Scientific and

Addressing the Health Needs of People Living with HIV: Positive Quitting Initiative - A Smoking Cessation InterventionSEAN B. ROURKE, PhDScientific and Executive Director, Ontario HIV Treatment NetworkDirector, CIHR Centre for REACH in HIV/AIDS and CBR Collaborative CentreDirector, Universities Without Walls (CIHR-STIHR)Scientist, Li Ka Shing Knowledge Institute of St. Michael's HospitalProfessor of Psychiatry, University of Toronto

ADVISORY COMMITTEEAdrian Betts – AIDS Committee of Durham Region Alice Tseng – Toronto General Hospital Donna Turner – Rainbow Health Ontario James Murray – AIDS Bureau, MOHLTC Jay Koornstra – Bruce HouseJohn McCullagh – Positivelite.com Leonard Moore – Sandy Hill Community Health Centre Louise Balfour – The Ottawa Hospital Lynne Cioppa – Ontario AIDS NetworkMarek Smieja – McMaster UniversityPeter Selby – Centre for Addictions & Mental Health Rita Shahin – Toronto Public Health Shannon Carney – Toronto Public Health Susan Clifford – St. Joseph's Health Care (London) Evan Collins – University of TorontoRandy Jackson – McMaster University Monica Bennett - Smokers' Helpline TorontoJocelyn Watchorn – AIDS Committee of Toronto

STEERING COMMITTEEBob Leahy (Chair) – Positivelite.comSean B. Rourke (Co-Chair) – OHTN, University of TorontoShannon Carney – Toronto Public Health Sergio Rueda – OHTN, University of TorontoDiana Campbell– OHTN Dmitry Rechnov– OHTN Jean Bacon – OHTN Francisco Ibáñez-Carrasco – Universities Without Walls, OHTN

PARTNER AGENCIES

THE ISSUE

SMOKING AND HIV:THE PREVALENCE

GENERAL POPULATION:• Canada 2011 – 17.3%• Ontario 2011 – 16.3%Canadian Tobacco Use Monitoring Survey (CTUMS). (2011).

HIV-POSITIVE POPULATION:• 37% among participants of the OHTN

Cohort Study (overall 2012)Bekele et al. (2012). CAHR Conference

• 43-49% among patients visiting the HIV clinic at The Ottawa HospitalBalfour L, et al. (2010). The OHTN Conference

• 50-70% among PHAs in the US (three times the national average)Chander G, et al. (2012). AIDS & Behavior. Tesoriero JM, et al. (2010). AIDS & Behavior

QUIT INTENTIONS:• Canada 2011 – 66% seriously

considered quitting in the next 6 monthsCanadian Tobacco Use Monitoring Survey (CTUMS). (2011).

Northern Ontario

C & SW Ontario

Eastern Ontario

GTA

0 20 40 60 80 100

81%

45%

35%

29%

Prevalence of smoking among OHTN Cohort Study participants

by region (2012)Smoking prevalence in the

general Ontario population 2011

SMOKING IN PEOPLE WITH HIV IS ASSOCIATED WITH:

• Higher risk of death• Higher risk of cancer• Higher risk of respiratory symptoms• Higher risk of hospitalization• Higher risk of cardiovascular diseases• Higher risk of chronic obstructive pulmonary disease• Higher risk of oral diseases• Reduced lung function• Less CD4-T-lymphocyte improvement over timeVidrine DJ. (2009). AIDS Educ Prev

SMOKING AND HIV: HEALTH IMPLICATIONS

1. To reduce the smoking rates for people living with HIV in Ontario by 5-10%.

2. To provide equitable access to smoking cessation programs throughout Ontario.

3. To reduce smoking-related morbidity (e.g., cardiovascular disease, chronic lung disease, cancer, oral disease) and mortality.

4. To improve health-related quality of life.

FIVE-YEAR OBJECTIVES

WHAT WE KNOW

FINDINGS FROM THE CANADIAN TOBACCO USE MONITORING SURVEY (CTUMS)

SMOKING PREVALENCE BY PROVINCE, 1999-2011

SMOKING PREVALENCE INONTARIO

15% 16%

2010 2011

= 14 CPD

Women:14%

AVERAGE DAILY CIGARETTE CONSUMPTION IN 2011

Men: 19%

Women:13 CPD

Men: 14 CPD

AVERAGE PRICE PER CARTON (200 cig.): $80.16


SMOKING PREVALENCE IN ONTARIO, BY SEX, 1999-2011


SMOKING PREVALENCE IN ONTARIO, BY AGE GROUP, 1999-2011


AVERAGE DAILY CIGARETTE CONSUMPTION IN ONTARIO, BY SEX, 1999-2011

DETERMINANTS OF HEALTH AND CIGARETTE SMOKING: FINDINGS FROM THE OHTN COHORT STUDY (OCS)

*Includes 910 former smokers and 1,353 people who have never smoked.Ω Finding was not significant.

CharacteristicsSmokers(n=1,527)

Non-smokers* (n=2,263)

Age 44.3 (9.3) 46.3 (10.8)

Man 1,275 (84%) 1814 (80%)

Gay, lesbian, or bisexual 979 (64)Ω 1484 (66%)

Caucasian 1,152 (75%) 1,460 (65%)

Born in Canada (yes) 1,239 (81%) 1372 (61%)Married/common-law/in a committed relationship 529 (35%) 973 (43%)

Study site (Toronto/Ottawa/Hamilton) 1,072 (70%) 1,916 (85%)

Have a high school diploma or higher 1,182 (77%) 2049 (91%)Currently working 550 (36%) 1217 (54%)Annual income is <$30K 1,023 (69%) 1058 (48%)

Used non-medicinal drugs (past 6 months) 458 (30%) 310 (14%)Drink alcohol frequently (≥ 2 times /month) 850 (56%) 1126 (50%)Drink heavily (≥ 5 drinks/episode) 309 (20%) 145 (6%)

DEMOGRAPHIC AND SUBSTANCE USE CHARACTERISTICS SIGNIFICANTLY ASSOCIATED WITH CIGARETTE SMOKING


CharacteristicsSmokers (n=1,527)

Non-smokers (n=2,263)

Low CD4 (<200 cells ) 183 (12%) 186 (8%)Detectable viral load (≥50 copies/mL) 516 (34%) 541 (24%)Diagnosed with Hepatitis C (ever) 415 (27%) 208 (9%)

Health-related quality of life (SF-12 survey)Physical Component Summary (mean, SD) 46.8 (11.2) 50.2 (9.7)Mental Component Summary (mean, SD) 44.1 (12.1) 47.2 (11.3)

HEALTH CHARACTERISTICS SIGNIFICANTLY ASSOCIATED WITH CIGARETTE SMOKING


Predictor variable OR (95% CI)

Age 0.98 (0.97, 0.99)

Gender 1.33 (1.08, 1.65)

Caucasian 1.61 (1.35, 1.91)Married/common-law/committed relationship 1.28 (1.10, 1.49)Study site (Toronto/Ottawa/Hamilton) 0.48 (0.40, 0.57)

Have at least a high school diploma 0.48 (0.38, 0.59)Currently working 0.56 (0.48, 0.66)

Used non-medicinal drugs 1.77 (1.46, 2.13)Quantity of alcohol consumed 1.47 (1.38, 1.59)

Years since HIV diagnosis 1.02 (1.01, 1.03)Diagnosed with Hepatitis C (ever) 2.50 (2.03, 3.07)

OR, Odds Ratio; CI,Confidence Interval

FACTORS SIGNIFICANTLY ASSOCIATED WITH CIGARETTE SMOKING MULTIVARIATE LOGISTIC REGRESSION MODEL (N=3,716)

OUR PLANS

IMPLEMENTATION SCIENCEImplementation science is the scientific study of methods to promote the integration of research findings and evidence-based interventions into health policy and practice and hence to improve the quality and effectiveness of health services and care.National Institutes of Health. (2013). grants.nih.gov/grants/guide/pa-files/PAR-10-038.htmlEccles MP, Mittman BS. (2006). Implementation Science

WELLNESS APPROACHOur work will be framed in the larger context of a broader wellness/health promotion approach that takes into account other modifiable risk factors that lead to poor health, such as substance use, nutrition, exercise, oral health, stress management and sleep.

IMPLEMENTATION SCIENCE AND WELLNESS APPROACH

USING AN IMPLEMENTATION SCIENCE APPROACH, THE PROJECT WILL: Synthesize evidence on smoking cessation. Connect groups working on smoking cessation and service provision. Develop interventions to help Ontarians with HIV who wish to quit. Assess interventions for their effectiveness and sustainability. Integrate research findings into service delivery and practice.

TARGET AUDIENCES: People living with HIV. Clinicians (primary care physicians, HIV specialists and pharmacists). AIDS Service Organizations (Executive Directors and front line staff).

OUR PLANS

1. ENGAGE PEOPLE WITH HIV AND BUILD CAPACITIES.

Project driven by people with HIV. Network of Peer Research

Associates (PRAs) will provide ongoing support to its research activities.

Training program to teach PRAs to deliver workshops aimed at improving a host of modifiable risk factors (e.g., nutrition, exercise) to empower people with HIV both as clients and as providers.

OUR PLANS (cont’d)

2. TRACK AND MONITOR SMOKING RATES FOR ONTARIANS LIVING WITH HIV.

Establish innovative ways to monitor prevalence and intensity of smoking in Ontarians living with HIV.

Expand OHTN Cohort Study (OCS) smoking questionnaire module to better evaluate and document individuals’ smoking and smoking cessation history, and willingness to quit.

Use observational studies to better understand risks and health consequences associated with smoking and resilience factors associated with smoking reduction/cessation.


3. ENGAGE HIV CLINICIANS AND AIDS SERVICE ORGANIZATIONS TO DOCUMENT CURRENT PRACTICES, NEEDS, GAPS AND BARRIERS TO HELPING ONTARIANS LIVING WITH HIV QUIT SMOKING.

Design a questionnaire to assess and document cessation program practices, support delivery methods, beliefs and attitudes, barriers and facilitators, and monitoring and referral practices.


?

4. IMPLEMENT AND SCALE UP INTERVENTIONS: TAKING ADVANTAGE OF AVAILABLE RESOURCES IN THE COMMUNITY.

Mobilize the HIV sector and smoking cessation programs.

Establish connections with existing programs and services, using our networks to connect people with HIV who are interested in quitting.


4A. IMPLEMENT AND SCALE UP INTERVENTIONS: DEVELOPING A HUB OF PEER-LED INTERVENTIONS ADDRESSING SMOKING CESSATION.

Adapt and tailor effective interventions to the needs of people living with HIV

Reduce the prevalence of tobacco use by increasing identification and treatment capacity among service providers

Smoking Treatment for Ontario Patients (STOP) workshops

Training Enhancement in Applied Cessation Counselling and Health (TEACH Project - www.teachproject.ca)


4B. IMPLEMENT AND SCALE UP INTERVENTIONS: PEER-LED INTERVENTIONS WILL ADDRESS OTHER MODIFIABLE RISK FACTORS.

Adapt available guidelines to have greatest impact for people living with HIV in the following areas:

Tobacco and alcohol use (Canadaptt Guidelines, CCSA/CAMH Low Risk Drinking Guidelines)

Nutrition (Canada’s Food Guide) Exercise (Canada Physical Activity Guide) Stress management (CANMAT Guidelines) Sleep (CDC Recommendations)

Help people identify risk factors in their environment that contribute to poorer health support them by improving their health and well-being


4C. IMPLEMENT AND SCALE UP INTERVENTIONS: DEVELOPING COLLABORATIONS WITH HEALTH PROFESSIONALS.

Support research aimed at smoking cessation strategies in the context of HIV.

ie. The CanQuit study: counselling, nicotine replacement, and varenicline (Champix) to assess efficacy, safety, and immune improvements.

Advocate for more research on the effects of smoking on HIV infection, including better screening and mitigation of smoking-related health conditions such as cardiovascular disease, cancer, chronic lung disease


4D. IMPLEMENT AND SCALE UP INTERVENTIONS:DEVELOPING INNOVATIVE INTERVENTIONS TO EMPOWER PEOPLE LIVING WITH HIV.

Promote increased utilization through empowerment by using e-health and information technology (e.g. internet-based patient engagement models that trigger clinician engagement to prioritize smoking cessation).


SMOKING REDUCTION VS. SMOKING CESSATION

Most evidence related to improved health outcomes is limited to smoking cessation programs.

Observational studies show reducing smoking may improve health outcomes for those who are not ready or willing to quit smoking.

Harm reduction approaches should be made available – there is strong evidence that reducing the number of cigarettes smoked can play an important role as a precursor to cessation.


/

5. DEVELOP A COMMUNICATIONS STRATEGY TO SYNTHESIZE EXISTING AND EVOLVING KNOWLEDGE

Develop rapid responses that summarize literature findings on the health effects of smoking and the effectiveness of smoking interventions.

Leverage knowledge synthesis approaches to better understand what drives smoking rate disparities between people living with HIV and the general public.

Identify equity issues that can inform the development of interventions for people living with HIV who smoke.


ANTICIPATED OUTCOMES

PREVALENCE OF SMOKING AMONG PEOPLE LIVING WITH HIVIN ONTARIO BY REGION (2008-2012)

2008 2009 2010 2011 201220

40

60

80

100

Northern Ontario C & SW Ontario Eastern OntarioGreater Toronto Area Ontario average

Prev

alen

ce o

f sm

okin

g (%

)

Source: The Ontario HIV Treatment Network Cohort Study

2012 2013 2014 2015 2016 20170

500

1000

1500

2000

2500

3000

3500

20

22

24

26

28

30

32

34

36

38

35.8%

35.1%34.4%

33.7%33%

35.5%

34.5%

33.5%

32.5%31.5%

36.5%

34.5%

32.5%

30.5%

28.5%

26.5%

Without intervention (3.5% decline)

With intervention (5% decline)

With intervention (10% decline)

Cu

mu

lati

ve

nu

mb

er

of

pe

op

le q

uit

tin

g s

mo

kin

g

Pre

va

len

ce

of

sm

ok

ing

(%

)

with 10% reduction

with 5% reduction

with 3.5% reduction

PROJECTED SMOKING PREVALENCE AND NUMBER OF PEOPLE QUITTING SMOKING WITH & WITHOUT INTERVENTION (2013-2017)

HOW CAN WE WORK TOGETHER TO ADDRESS

THE SMOKING CESSATION NEEDS OF PEOPLE LIVING

WITH HIV IN ONTARIO?

Positive Quitting Initiative – Where We Are NowProgress Update

Positive Quitting Advisory Committee developed a project implementation strategy addressing each of the specific project objectives:

1. ENGAGE PEOPLE WITH HIV AND BUILD CAPACITIES2. TRACK AND MONITOR SMOKING RATES FOR ONTARIANS

LIVING WITH HIV3. ENGAGE HIV CLINICIANS AND AIDS SERVICE ORGANIZATIONS

TO DOCUMENT CURRENT PRACTICES, NEEDS, GAPS AND BARRIERS TO HELPING ONTARIANS LIVING WITH HIV QUIT SMOKING

4. IMPLEMENT AND SCALE UP INTERVENTIONS: TAKING ADVANTAGE OF AVAILABLE RESOURCES IN THE COMMUNITY

IMPLEMENTATION STRATEGY

36

ENGAGE PEOPLE WITH HIV AND BUILD CAPACITIES

In partnership with the AIDS Committee of Toronto Positive Quitting Initiative started piloting a Direct Referral intervention. All clients of ACT are screened for smoking and offered a referral to the Smokers Helpline

Positive Quitting is has identified a peer driven evidence based intervention to pilot among HIV positive and HIV negative gay men who wants to quit smoking

We are seeking for an advice form community members, helping us to shape up information materials, web resources and images to promote the initiative.

WHERE WE ARE

37

TRACK AND MONITOR SMOKING RATES FOR ONTARIANS LIVING WITH HIV

Two smoking questionnaires have been developed to expand the Ontario cohort study. These questionnaires will be routinely used to monitor smoking rate among PWA in Ontario

AIDS service organizations started piloting a new section in OCASE to document support services and referrals they provide to their clients who are interested in addressing their smoking. This section will also allow documenting smoking cessation events.

WHERE WE ARE

38

ENGAGE HIV CLINICIANS AND AIDS SERVICE ORGANIZATIONS TO DOCUMENT CURRENT PRACTICES, NEEDS, GAPS AND BARRIERS TO HELPING ONTARIANS LIVING WITH HIV QUIT SMOKING

PQ team conducted a series of interviews with staff of 14 HIV clinics to document their existing practices and analyze needs and barriers to scale up smoking cessation interventions

Best practices identified through the interviews will be incorporated into HIV Standards of Care. Once implemented, nurses and HIV specialists will be addressing smoking as a routine part of the service provision

WHERE WE ARE

39

IMPLEMENT AND SCALE UP INTERVENTIONS: TAKING ADVANTAGE OF AVAILABLE RESOURCES IN THE COMMUNITY

Following a series of pilot projects Positive Quitting will develop program manuals and guidelines allowing to scale up successful evidence based interventions

PQ will be promoting the intervention offering a vide range of information materials, visual images and videos

Positive Quitting will be officially launched in Ontario on September 15, 2014

WHERE WE ARE

THANK YOU…

SEAN B. ROURKE, PhDScientific and Executive Director, Ontario HIV Treatment NetworkDirector, CIHR Centre for REACH in HIV/AIDS and CBR Collaborative CentreDirector, Universities Without Walls (CIHR-STIHR)Scientist, Li Ka Shing Knowledge Institute of St. Michael's HospitalProfessor of Psychiatry, University of Toronto

[email protected]

Documents

Addressing the Health Needs of People Living with HIV: Positive Quitting Initiative - A Smoking Cessation Intervention SEAN B. ROURKE, PhD Scientific and