HIV / AIDS , tuberculosis , and tobacco in Brazil : a syndemic that calls for integrated interventions VIH / SIDA , tuberculosis

Correspondência T. Novotny San Diego State University 5500 Campanile Drive, San Diego, California 92182, U. S. A. tnovotny@mail.sdsu.edu HIV/AIDS, tuberculose (TB) e tabagismo são três grandes desafios para a saúde global. As três epidemias agem de maneira independente, mas também coletivamente, amplificando os impactos de cada uma na saúde. Esse sinergismo de doenças é chamado de “sindemia” 1. As três epidemias geralmente são abordadas através de programas separados, liderados por infectologistas, pneumologistas e comportamentalistas, respectivamente. Os determinantes sociais das doenças, inclusive pobreza, baixa escolaridade, densidade demográfica alta e normas culturais, são comuns às três. Essa sindemia também desafia os sistemas de saúde, indicando que uma abordagem sistêmica pode melhorar os desfechos e práticas em saúde. Existem evidências para os elos entre o HIV/AIDS, a TB e o tabagismo. A TB, a mortalidade e a TB recorrente estão associadas ao tabagismo 2. Fumar aumenta o risco da infecção latente de TB, a progressão à doença ativa, o atraso na negativação do exame de escarro, falhas de adesão ao tratamento, recaída e multirresistência. Fumaça de segunda mão também pode aumentar o risco de TB intra-domiciliar. A TB é a infecção oportunista mais importante entre pessoas vivendo com HIV/AIDS. HIV/ AIDS é um fator de risco para desfechos terapêuticos negativos em TB e para maior mortalidade por TB 3. Pessoas que vivem com TB têm risco de 1,6 vezes maior de progredir para AIDS e 2 vezes mais probabilidade de morrer em comparação com TB-negativas 4. A TB também aumenta a replicação do HIV, devido à ativação do vírus latente nos macrófagos e linfócitos-T, e está associada à redução nas contagens de células CD4+ 5. Em uma coorte dinamarquesa, mais de 60% dos óbitos por HIV/AIDS estavam associados ao tabaco 6. O tabagismo entre pessoas vivendo com HIV/AIDS aumenta o risco de pneumonia 7 e de doenças da orofaringe 8. O tabagismo também aumenta o risco de doenças cardiovasculares, dislipidemia, resistência insulínica e doença pulmonar obstrutiva crônica em pessoas vivendo com HIV/AIDS 9. A nicotina tem efeitos moduladores sobre o sistema imune 10.

Cad. Saúde Pública 2017; 33 Sup 3:e00124215 Tobacco use is still a concern in Brazil, with 15% current adult smoking in 2013 and higher prevalence among those with lowest education (20.2%) 15 .A recent cohort study found that after controlling for socioeconomic status, smokers had 2.5 greater risk for recurrent TB compared to non-smokers and that smokers were more likely to default on TB treatment 16 .A 2014 Brazilian cohort study of 2,775 persons living with HIV/AIDS found 29.9% current smokers and 23.9% former smokers 10 .Current smokers were more likely to be less educated; to use alcohol, crack, and cocaine; and to be hospitalized for co-existing conditions.

A syndemic approach
Traditional public health approaches usually involve single programs that do not address interactions of risks or diseases.A syndemic approach to HIV/AIDS and TB should integrate tobacco control in the care of patients with these conditions.At a minimum, improved overall health can be expected as a result of smoking cessation.A more comprehensive approach to the social determinants of tobacco use may also reduce combined effects of TB and HIV/AIDS.
New diagnoses of TB or HIV/AIDS are critical events for patients and could be linked to tobacco interventions.Newly diagnosed TB patients receive directly observed treatment short-course (DOTS), a patient-centered case management approach that requires regular provider contact for six months.This represents an opportunity to address tobacco use among patients and families.Similarly, patients diagnosed with HIV/AIDS and taking anti-retroviral treatment (ART) need significant clinical support to adhere to ART; they may be especially receptive to health interventions such as smoking cessation.
There have been multiple pilot studies on TB and cessation, including in Brazil 17 , with randomized trials in Pakistan 18 and South Africa 19 .Brief advice and motivational interviewing were effective in reducing smoking among TB patients.A 2014 review of cessation interventions among persons living with HIV/AIDS indicated that these must take into account social context, mental health, and other risk behaviors.Multiple, varied interventions delivered consistently over time were most successful 20 .

Conclusion
There is sufficient evidence that TB, HIV/AIDS, and tobacco use create synergistic disease burdens.Persons with TB and HIV/AIDS who use tobacco may not access health care or social supports necessary for health behavior change.They may not understand the impacts of tobacco use on their infectious diseases, and social norms may facilitate health risk behaviors.Add to this the impacts of poverty, dietary insufficiency, and crowding, and then the challenges to providing comprehensive care become clear.These factors may be best addressed using a systems-based approach.
Brazil has implemented effective TB and HIV/AIDS programs.These may be able to integrate low-cost tobacco control interventions, including cessation services, community participation, and outreach that can reduce tobacco use.To implement integrated tobacco control within TB and HIV/ AIDS programs, context-specific research and guidelines are needed.Policies that increase the price of cigarettes, reduce access to tobacco products, support smoke-free homes and workplaces, publicize risks of tobacco use for TB and HIV/AIDS, and mandate cessation counseling in DOTS and ART programs could impact the health of affected populations.However, potential barriers and limitations include: gaining political authority to change policy with DOTS and ART programs; engaging infectologists in the relevance of tobacco control; and involving communities and families in a collective approach to tobacco use among affected patients.Nonetheless, the benefits of a syndemic approach to patients suffering from these conditions would likely far outweigh costs of implementation.
Research to test integration of tobacco control within TB and HIV/AIDS programs should involve the Family Health System in Brazil.In this system, geographically-based Family Medicine teams involving physicians, nurses, practical nurses, and agentes (community health workers) provide comprehensive care to targeted communities.These teams can integrate care for multiple diseases and Cad.Saúde Pública 2017; 33 Sup 3:e00124215 address community health.Brazil has prioritized tobacco control as a national objective, with notable success in the reduction of smoking prevalence from approximately 35% among adults in 1989 to 15% in 2013 15 .This bodes well for an integrated approach to tobacco use among populations affected by TB and HIV/AIDS.However, these populations will need more than simple behavioral therapy to become smoke-free (Figure 1).
1. Implementation research is needed to address the syndemic of HIV/AIDS, TB, and tobacco use in Brazil.Such research must take into account the common social determinants of these conditions.

2 .
Behavioral interventions alone are insufficient to reduce smoking prevalence among poor, marginalized, and highly vulnerable populations affected by TB and HIV/AIDS.Comprehensive, policy-based approaches must be implemented in order to reinforce clinical behavioral interventions as well.3.Brazil's priomary care-based health system and established tobacco control efforts provide an appropriate setting to test interventions among highly-vulnerable populations affected by the HIV/AIDS, TB, and tobacco syndemic.

ContributorsT.
Novotny contributed in the original concept and completed final editing.E. Hendrickson contributed in the conducted original research and compiled first draft.E. C. C. Soares contributed to the writing, review and approval of the final version. A. B. Sereno contributed to the revision, edition and approval of the final version.S. M. Kiene contributed in the writing and approval of the final version