The human immunodeficiency virus (HIV) epidemic in sub-Saharan Africa has resulted in a large-scale transformation of healthcare delivery in heavily affected countries such as Botswana.¹ Unfortunately, other health threats such as cardiovascular disease and cancer have emerged amongst people living with HIV/AIDS (PLWHA) partly because of the chronic inflammation of HIV that is compounded by high rates of smoking in this population.² As such, addressing modifiable cardiovascular risk factors amongst those with HIV infection, including tobacco use, has become a critical priority.^3,4

Indeed, continued smoking amongst those with HIV infection can result in serious adverse effects, including reduced effectiveness of antiretroviral (ARV) therapy.⁵ Controlling for medication adherence and comorbid illicit drug use, HIV-infected smokers on ARV have a significantly lower likelihood of achieving a viral response and a greater chance of viral or immunologic failure compared with their non-smoking counterparts.⁶ Persistent smoking amongst HIV-infected individuals may also increase progression to acquired immunodeficiency syndrome (AIDS).⁷ Pulmonary tuberculosis, a major public health crisis in sub-Saharan Africa, occurs at higher rates in smokers compared with non-smokers.⁸ Overall, the mortality gains of ARV treatment and the associated improved quality of life amongst those with HIV infection are being jeopardised by the cardiovascular and neoplastic diseases attributable to tobacco use in this population.⁹

Although interest in quitting smoking is high amongst PLWHA,^10,11,12 particularly when HIV treatment is initiated¹³ and when tobacco use treatment is integrated with HIV care,¹⁴ remarkably little research has focussed on developing and testing smoking cessation interventions for PLWHA.¹¹ Unfortunately, in low-income and developing countries, the costs of pharmacotherapy for nicotine addiction make pharmacological treatments currently inaccessible for PLWHA and further emphasise the importance of novel behavioural strategies.

Depressive symptoms are common in HIV-infected populations, often comorbid with smoking, and associated with poor smoking cessation rates.¹⁵ Behavioural activation therapy (BAT), rooted in a behavioural economic framework, has been effective at treating depression, and preliminary data in the United States of America (USA) suggests that it may also effectively address smoking.¹⁶ Behavioural activation therapy aims to increase engagement in healthy rewarding activities (i.e., alternative reinforcers) by reducing patterns of avoidance, withdrawal and inactivity, and to decrease activities that enhance the rewarding aspects of smoking (i.e., complementary reinforcers). Additionally, problem-solving approaches have been used with PLWHA to improve medication adherence and decrease depressive symptoms.¹⁷ Behavioural activation therapy and problem-solving approach may help smokers select and implement activities that will replace smoking, thereby reducing smoking rates.

The authors developed a novel counselling model incorporating elements of behavioural activation and problem solving to address the unique challenges of tobacco cessation amongst those with HIV infection. They aimed to assess the feasibility and appeal of Behavioural Activation/Problem Solving for Smoking Cessation (BAPS-SC) intervention to determine whether it should be tested in an adequately powered clinical trial.

The authors conducted a single-arm pilot trial of the BAPS-SC intervention programme, a novel behavioural smoking cessation intervention for PLWHA in a high-HIV-burden sub-Saharan country wherein all 40 participants received the intervention. This design is ideal for studies aiming to determine if a novel intervention is appealing and feasible in the setting and warrants a full-scale clinical trial.²⁴ The results of the CO monitoring and exit interviews suggest that BAPS-SC is likely to be efficacious.

This study’s results of a high degree of smoking cessation success with BAPS-SC suggest a potentially highly impactful smoking cessation programme given that behavioural smoking cessation programmes rarely yield quit rates higher than 10% – 15%.²⁵ There is no comparable trial that tested the intervention developed by the team of the authors with an HIV-negative cohort of smokers. Two comparisons are worth noting, and both indicate a substantial benefit from authors’ intervention. Firstly, meta-analyses of behavioural interventions (without medications) for smoking cessation rooted in classic cognitive-behavioural theory show that they yield quit rates of generally less than 15% at the end of treatment.²⁶ Secondly, MacPherson et al. (2010), in their pilot test of BAT for smoking cessation, reported an end-of-treatment quit rate of 17%.²⁷ The authors used a higher threshold of CO to determine smoking cessation as opposed to a more stringent cut-off in the range of 3 ppm – 4 ppm recently proposed by other researchers.²⁸ However, 8 ppm is the cut-off used in most smoking cessation clinical trials for PLWHA, so the authors chose this cut-off to compare their results to the current literature. With regard to past behavioural smoking cessation treatments for PLWHA, a cell phone-based intervention was found to be associated with significantly higher initial quit rates compared with usual care.²⁹ Other studies including a group-based tailored intervention, motivational interventions and a web-based intervention (vs in-person or self-help) have not yielded significant increases in quit rates.^{30,31,32,33,34,35,36} Two pilot studies of behavioural treatments that address negative affect (depression and anxiety) show promise for PLWHA.^37,38

The BAPS-SC trial proved feasible. Firstly, the target sample size of 40 participants was reached within 8 weeks of recruitment, a rate of enrolment that would make large trials feasible. The authors’ findings indicated that a large-scale clinical trial would be feasible to determine the efficacy of the BAPS-SC programme in this setting where HIV prevalence is relatively high. Furthermore, smoking prevalence in the setting of their pilot study was estimated to be as high as 51% for male candidates and 6% for female candidates with HIV infection.³⁹ There were proportionately fewer female candidates enrolled in the present study consistent with data from demographic and health surveys in sub-Saharan Africa.⁴⁰ Although these smoking rates appear to be comparatively lower than reports from North America and Europe, these rates are projected to increase in the African continent whilst they are falling in other parts of the world.^40,41 Given the limited behavioural health infrastructure in low middle income countries (LMICs) such as Botswana, the authors leveraged HIV clinical care sites and telephone-delivered counselling to extend the reach of skilled practitioners. The authors found this strategy to be effective and acceptable by the participants in the pilot trial.

Smoking is a major cause of morbidity and mortality, yet smokers find it very difficult to quit. If individuals quit because of this intervention, they will reduce their risk of cardiovascular disease, chronic obstructive pulmonary disease and cancers, particularly lung cancer. This will be of direct benefit to the individual participant. Further, if the authors are able to mount a full-scale trial based on the results of this pilot trial, high HIV burden LMICs such as Botswana may benefit because the intervention may become standard of care in the country, reducing disease burden caused by tobacco use. Being a behavioural intervention without pharmacological intervention, the cost is expected to be substantially less with the BAPS-SC compared with a pharmacological intervention. A formal cost-effective analysis will be needed to be undertaken following the roll out of the programme.

Results of the exit questionnaires to evaluate the acceptability of the BAPS-SC trial indicate that HIV-infected smokers in Botswana find the programme to be appealing and acceptable. The results indicate a lower-than-expected retention rate with slightly over half of the participants remaining in the study after a 12-week follow-up period. The retention rates across most smoking cessation trials generally exceed 75%.⁴² This may be improved by asking participants to provide contact numbers of associates such as friends and family members who can be contacted if the participant is unreachable after a number of attempts and increasing incentives to complete follow-ups. From an evidence-based medicine perspective, if efficacy of the intervention is determined to be high, implementation science methods would need to be employed in the clinical care setting to incorporate the intervention into HIV programmes. The intervention leverages the existing HIV care infrastructure and will likely facilitate scale-up in sub-Saharan African settings where HIV is common and smoking continues to emerge as a threat to HIV-positive individuals’ health and survival.

The results of this single-arm pilot trial demonstrate the feasibility of leveraging HIV clinical infrastructure for implementing BAPS-SC as a smoking cessation intervention programme amongst HIV-infected smokers in a resource-limited setting with high HIV burden. A full-scale clinical trial comparing BAPS-SC with standard counselling is thus warranted to evaluate the efficacy of this novel intervention in these settings.