by Sharon Nyatsanza (PhD), National Council Against Smoking (NCAS)
The WHO Global Tuberculosis Report 2020 indicates that around 360 000 people fell ill with TB in South Africa in 2019. 62% of the 58,000 people who died, were HIV-positive.
As tobacco use in people living with both TB and HIV increases the risk of death and worsens health outcomes, it is very concerning that over 30% of people living with these diseases use tobacco products, according to a study in the Nicotine and Tobacco Research Journal. The World Health Organisation (WHO) estimates that 24% of HIV-related deaths are attributable to smoking. A comprehensive response to the TB and HIV epidemics must include a strategy to reduce tobacco consumption.
A 2016 South African study found that smoking among people living with HIV tripled their risk of developing TB. Tobacco use is also a risk factor for diabetes, which is again independently associated with increased TB risk. Reducing tobacco use is therefore critical, considering that most HIV-related deaths are as a result of TB. To echo Nelson Mandela, we cannot fight AIDS unless we do much more to fight TB. And it is clear that we cannot end TB and reduce HIV-related mortality, without reducing tobacco use.
With ARVs leading to improved life expectancy, HIV has been transformed into a chronic condition. However, smoking compromises the body’s immunity, limits the effectiveness of ARVs in fighting the virus and threatens the gains achieved in prolonging life for people living with HIV. Other studies have established an association between lower adherence to ARV treatment and tobacco use. When there is low adherence to ARV treatment, the level of HIV in the blood may increase, and this can also make the virus-resistant.
Tobacco use threatens the progress made in the fight against the HIV and TB comorbidity. Smokers who are HIV-positive lose an average of 12.3 years of life compared to HIV-positive non-smokers. HIV/AIDS and TB education programs should highlight the need to stop tobacco use and the health benefits that flow from that.
The WHO has called for the integration of tobacco control in country responses to the HIV and TB twin epidemics, instead of disease-specific responses. Implementing the WHO Framework Convention on Tobacco Control (WHO FCTC), as the Control of Tobacco and Electronic Delivery Systems Bill seeks to do; will help achieve the sustainable development goal to improve good health and well-being, addressing both the non-communicable disease (NCD) problem and the HIV/AIDS and TB epidemics that South Africa faces. The Tobacco Control Bill must be passed urgently to reduce smoking rates in both the general population and within this subpopulation.
Scaling up tobacco cessation support services for smokers in TB and HIV treatment settings and beyond is also essential, especially considering the high smoking rates within this subpopulation. Article 14 of the WHO FCTC recommends country members to take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence. Undoubtedly, smoking cessation will ameliorate multiple diseases and improve overall health outcomes for those living with HIV and TB.
For a country like South Africa which is disproportionately affected by HIV and TB, passing the Tobacco Control Bill is a desirable option. A decrease in tobacco use would improve HIV/AIDS and TB outcomes and this will also raise the much-needed funds for HIV, TB and other public health priorities.