Each December for World Aids Day and Aids Awareness Month, the spotlight is cast on the tremendous progress which has been made in addressing the challenges posed by the HIV/AIDS epidemic. Of the estimated 7.6 million people living with HIV in South Africa, over 5 million are on antiretroviral (ARV) programs. In 2018, 71,000 South Africans died from AIDS-related illnesses. Whilst these are still huge numbers, there has been a dramatic reduction in AIDS-related deaths in South Africa which have dropped by 50% from 30.6% in 2002 to 15% in 2020. 

With ARVs leading to improved life expectancy, HIV has been transformed into a chronic condition. South Africa has one of the largest ARV programs in the world, and in 2017 more than $1.54 billion was invested to run these ARV programs. ARVs highly suppress the HI virus replication and boost the body’s immune system to recover and improve its capacity to fight infections. 

Smoking does the complete opposite: it compromises the body’s immunity, it 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.

HIV magnifies the health hazards of tobacco use, increasing the risk of developing non-communicable diseases (NCDs) like heart disease, cancer and lung diseases. Tobacco use also increases vulnerability to infections like thrush, pneumonia and most commonly tuberculosis (TB).

An estimated 20% of adult TB cases are attributable to smoking. A 2016 South African study found that smoking among people living with HIV tripled the 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. 

In 2019, 66% of the people who died from TB in South Africa were HIV positive. It is clear that we cannot end TB and reduce HIV-related mortality, without reducing tobacco use.

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.

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 derive from that. The Tobacco Control Bill must also be finalised 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.

The WHO FCTC also recommends tobacco tax increases, which remain one of the most effective means of reducing smoking, “quicker than any other single measure”. For a country like South Africa which is disproportionately affected by HIV and TB, higher tax rates on tobacco products are 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.

A comprehensive response to the HIV/AIDS and TB epidemics must include a strategy to reduce tobacco consumption so that people living with HIV are not excluded from the many health gains that a smoke-free lifestyle provides. 

For help to stop smoking, call the National Council Against Smoking (NCAS) Quitline on 011 720 3145.