Tobacco use and cessation in the context of ART adherence: Insights from a qualitative study in HIV clinics in Uganda.

Frances Thirlway,Joseph K.B Matovu,Andrew Kibuuka Miti,Kellen Namusisi Nyamurungi,Noreen Dadirai Mdege

doi:10.1016/j.socscimed.2021.113759

Frances Thirlway, Joseph K.B Matovu + Show 3 more

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https://doi.org/10.1016/j.socscimed.2021.113759

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Abstract

Sub-Saharan Africa carries a disproportionate burden of human immunodeficiency virus (HIV). Tobacco use amongst people living with HIV is higher than in the general population even though it increases the risk of life-threatening opportunistic infections including tuberculosis (TB). Research on tobacco use and cessation amongst people living with HIV in Africa is sparse and it is not clear what interventions might achieve lasting cessation. We carried out qualitative interviews in Uganda in 2019 with 12 current and 13 former tobacco users (19 men and 6 women) receiving antiretroviral therapy (ART) in four contrasting locations. We also interviewed 13 HIV clinic staff. We found that tobacco use and cessation were tied into the wider moral framework of ART adherence, but that the therapeutic citizenship fashioned by ART regimes was experienced more as social control than empowerment. Patients were advised to stop using tobacco; those who did not concealed this from health workers, who associated both tobacco and alcohol use with ART adherence failure. Most of those who quit tobacco did so following the biographical disruption of serious TB rather than HIV diagnosis or ART treatment, but social support from family and friends was key to sustained cessation. We put forward a model of barriers and facilitators to smoking cessation and ART adherence based on engagement with either ‘reputation’ or ‘respectability’. Reputation involved pressure to enjoy tobacco with friends whereas family-oriented respectability demanded cessation, but those excluded by isolation or precarity escaped anxiety and depression by smoking and drinking with their peers.

Highlights

Sub-Saharan Africa carries a disproportionate burden of human immunodeficiency virus (HIV), accounting for more than 70% of the global burden of infection (Kharsany and Karim, 2016)
In Sub-Saharan Africa, the most significant of these is tuberculosis (TB), which has seen a strong resurgence in a population weakened by HIV (Glaziou et al, 2018) and is the leading killer of people living with HIV (WHO, 2019)
Socioeconomic factors are of increasing importance in the lives of people living with HIV in Sub-Saharan Africa; concerns about immediate death have been overtaken by financial problems arising from chronic illness i.e. financial precarity, caring for children etc. (Whyte, 2015)

Summary

Introduction

Sub-Saharan Africa carries a disproportionate burden of human immunodeficiency virus (HIV), accounting for more than 70% of the global burden of infection (Kharsany and Karim, 2016). Tobacco use by people living with HIV is higher than in the general population (Mdege et al, 2017; Murphy et al, 2018), including in Uganda, which is the location for this study (Kruse et al, 2014; GATS, 2013). This is a particular concern because tobacco use makes people living with HIV more vulnerable to opportunistic infections (Siddiqi and Mdege, 2016; van Zyl Smit et al, 2010). Whilst the ‘biographical disruption’ (Bury, 1982; Carricaburu and Pierret, 1995) of receiving a HIV diagnosis and starting ART can itself be a trigger to quit (Edwards et al, 2019, Mitton et al, 2018), the factors which might support a lasting departure from tobacco use are not well understood

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