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HIV+ Smokers on Antiretroviral Treatment Lose More Years to Smoking than to Virus


Researchers in Denmark, where antiretroviral therapy (ART) is free and widely used, found that HIVpositive smokers tripled their risk of death, and mortality associated with tobacco use was greater for people with HIV than for the general population, according to a study published in the December 18, 2012, advance edition of Clinical Infectious Diseases.

A growing body of evidence indicates that HIV infection and associated inflammation and metabolic changes contribute to non-AIDS conditions such as cardiovascular disease and cancer. But traditional risk factors also play an important role in development of these diseases.

Marie Hellebergfrom Copenhagen University Hospital and colleagues looked mortality attributable to smoking among people with HIV. They compared mortality rates, mortality rate ratios, life expectancy, number of life-years lost, and population-attributable risk of death among current smokers and people who never smoked in an HIV positive cohort and a general population cohort.

The analysis included 2921 people in a nationwide HIV cohort (14,281 person-years of data) and a control group of 10,642 HIV negative people in the Copenhagen General Population Studymatched for sex and age (45,122 person-years of data). The median follow-up period was approximately 4 years.

The HIV cohort entered care between 1995 and 2010. Denmark provides free antiretroviral treatment, has a well-organized health system, and collects comprehensive data on people with HIV nationwide. Consistent with past studies, people with HIV were more likely to smoke. Nearly half (47.4%) of HIV positive participants were current smokers and 17.7% were ex-smokers, comparedwith 20.6% and 32.8%, respectively, in the control group.


  • Overall, 221 people with HIV and 132 people in the HIV negative control group died during follow-up.
  • Among the HIV positive participants, 26% died due to AIDS-related causes, 64% due to non-AIDS-related conditions, and 10% due to violence.
  • Both all-cause and non-AIDS-related mortality were substantially higher among HIV positive smokers compared with HIV positive non-smokers (mortality rate ratios of 4.4 vs 5.3, respectively).
  • HIV positive smokers had an excess mortality rate of 17.6 extra deaths per 1000 person-years, compared with 4.8 extra deaths for HIV negative smokers.
  • Among 35-year-old HIV positive individuals, smokers had a median life expectancy of 62.6 years, compared with 69.1 years for ex-smokers and 78.4 years for people who never smoked.
  • Among HIV positive people, 12.3 life-years were lost due to smoking, compared with 5.1 years lost due to HIV infection; in the HIV negative group, smokers lost 3.5 years relative to those who never smoked.
  • The risk of death associated with smoking was 61.5% for people with HIV, compared with 34.2% for HIV negative people.

"In a setting where HIV care is well organized and antiretroviral therapy is free of charge, HIV-infected smokers lose more life-years to smoking than to HIV," the study authors concluded. "The excess mortality of smokers is tripled and the population-attributable risk of death associated with smoking is doubled among HIV patients compared to the background population."

"More than 60% of deaths among HIV patients are associated with smoking," rather than HIV, Helleberg said in a press statement.

"Our findings emphasize the importance of counseling HIV patients on smoking cessation as smoking may impact their life expectancy considerably more than the HIV infection itself," the researchers stressed.



M Helleberg, S Afzal, G Kronborg, et al. Mortality Attributable to Smoking among HIV-1-Infected Individuals: A Nationwide, Population-Based Cohort Study. Clinical Infectious Diseases. December 18, 2012 (Epub ahead of print).

Other Source

Infectious Diseases Society of America. HIV patients in care lose more years of life to smoking than to HIV infection. Press release.  December 19, 2012.