Page 172 - HIVMED_v21_i1.indb

Page 2 of 6 Original Research

Pulmonary tuberculosis, a major public health crisis in sub- untreated and unstable alcohol dependence; current use or
Saharan Africa, occurs at higher rates in smokers compared discontinuation within last 14 days of smoking cessation
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with non-smokers. Overall, the mortality gains of ARV medications; current diagnosis of unstable and untreated
treatment and the associated improved quality of life major depression or current or past diagnosis of psychotic
amongst those with HIV infection are being jeopardised by disorder; use of chewing tobacco, snuff or snus; current
the cardiovascular and neoplastic diseases attributable to participation in a smoking cessation programme; or plans to
tobacco use in this population. 9 use nicotine substitutes or smoking cessation treatments in
the next 7 months. The restriction to 7 months was based on
Although interest in quitting smoking is high amongst the anticipated period to conduct the trial so as to avoid
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PLWHA, 10,11,12 particularly when HIV treatment is initiated contamination of the intervention with other smoking
and when tobacco use treatment is integrated with HIV cessation modalities not under investigation.
care, remarkably little research has focussed on developing
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and testing smoking cessation interventions for PLWHA. A trained recruiter approached each patient in clinic to
11
Unfortunately, in low-income and developing countries, ascertain smoking status. Those acknowledging smoking
the costs of pharmacotherapy for nicotine addiction make were asked to participate in a questionnaire related to their
pharmacological treatments currently inaccessible for smoking and offered participation in the pilot trial. Those
PLWHA and further emphasise the importance of novel who agreed were referred to the research assistant who
behavioural strategies. arranged to meet with them to determine eligibility and
administer informed consent.
Depressive symptoms are common in HIV-infected
populations, often comorbid with smoking, and associated Design of intervention
with poor smoking cessation rates. Behavioural activation
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therapy (BAT), rooted in a behavioural economic framework, The authors merged BAT with the principles of problem-
has been effective at treating depression, and preliminary solving therapy to create a novel five-session counselling
data in the United States of America (USA) suggests that model to address the unique challenges of tobacco cessation
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it may also effectively address smoking. Behavioural amongst PLWHA (BAPS-SC). Members of the team created a
activation therapy aims to increase engagement in healthy formal treatment manual, which was evaluated for cultural
rewarding activities (i.e., alternative reinforcers) by reducing appropriateness by Botswana co-investigators, including
patterns of avoidance, withdrawal and inactivity, and to assessment of translation and back translation and pre-pilot
decrease activities that enhance the rewarding aspects of testing using videoconferencing to role play. Key components
smoking (i.e., complementary reinforcers). Additionally, of BAPS-SC include activity monitoring and rewarding
problem-solving approaches have been used with PLWHA activity scheduling, assessment of personal goals and values,
to improve medication adherence and decrease depressive assessment and altering of avoidance behaviour and other
symptoms. Behavioural activation therapy and problem- maladaptive coping strategies, and contingency management.
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solving approach may help smokers select and implement Behavioural Activation/Problem Solving for Smoking
activities that will replace smoking, thereby reducing Cessation focuses on reducing stress pile-up and loss of
smoking rates. pleasure that accompanies the cessation process and on
identifying and establishing environmental/social changes
The authors developed a novel counselling model to promote abstinence. Behavioural Activation/Problem
incorporating elements of behavioural activation and Solving for Smoking Cessation addresses smoking as a
problem solving to address the unique challenges of tobacco behaviour that prevents and restricts opportunities for
cessation amongst those with HIV infection. They aimed to contact with healthy rewarding behaviours. These changes
assess the feasibility and appeal of Behavioural Activation/ are achieved through altering daily routines previously
Problem Solving for Smoking Cessation (BAPS-SC) associated with smoking in ways that increase pleasure and
intervention to determine whether it should be tested in an mastery across life domains, reducing rumination and
adequately powered clinical trial. increasing behavioural skills to prevent return to smoking as
a means of avoiding stressors.
Methods
Participant enrolment A pre-quit session (session 1) introduces participants to:
(1) self-monitoring of mood and behaviour; (2) assessment
The authors conducted a single-arm pilot trial of the of personal values to refine the treatment plan; and
BAPS-SC intervention in Botswana amongst HIV-infected (3) scheduling of substitute rewarding activities that align
individuals aged 18–65 years who smoked ≥ 5 cigarettes/day, with their abstinence goal. At the target quit date (TQD)
on average, at four outpatient HIV clinics. The target accrual session (session 2), participants’ experiences with abstinence
goal was 40 participants. This was based on the assumption are reviewed and functional analysis of behaviour is
that at least five participants would be enrolled per week, introduced, especially as it relates to smoking and avoidance
thus ensuring that the recruitment of human subjects into the patterns. Information obtained is used to help generate a
trial is timely as this is vital to the success of the trial. The tailored behavioural activation plan by using the problem-
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authors excluded participants if they reported current solving framework to increase rewarding activities and

http://www.sajhivmed.org.za 164 Open Access