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smoking cessation programme given that behavioural of this pilot trial, high HIV burden LMICs such as Botswana
smoking cessation programmes rarely yield quit rates higher may benefit because the intervention may become standard
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than 10% – 15%. There is no comparable trial that tested the of care in the country, reducing disease burden caused by
intervention developed by the team of the authors with an tobacco use. Being a behavioural intervention without
HIV-negative cohort of smokers. Two comparisons are pharmacological intervention, the cost is expected to be
worth noting, and both indicate a substantial benefit from substantially less with the BAPS-SC compared with
authors’ intervention. Firstly, meta-analyses of behavioural a pharmacological intervention. A formal cost-effective
interventions (without medications) for smoking cessation analysis will be needed to be undertaken following the roll
rooted in classic cognitive-behavioural theory show that they out of the programme.
yield quit rates of generally less than 15% at the end of
treatment. Secondly, MacPherson et al. (2010), in their pilot Results of the exit questionnaires to evaluate the acceptability
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test of BAT for smoking cessation, reported an end-of- of the BAPS-SC trial indicate that HIV-infected smokers in
treatment quit rate of 17%. The authors used a higher Botswana find the programme to be appealing and acceptable.
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threshold of CO to determine smoking cessation as opposed The results indicate a lower-than-expected retention rate
to a more stringent cut-off in the range of 3 ppm – 4 ppm with slightly over half of the participants remaining in the
recently proposed by other researchers. However, 8 ppm is study after a 12-week follow-up period. The retention rates
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the cut-off used in most smoking cessation clinical trials 42
for PLWHA, so the authors chose this cut-off to compare across most smoking cessation trials generally exceed 75%.
their results to the current literature. With regard to past This may be improved by asking participants to provide
behavioural smoking cessation treatments for PLWHA, a cell contact numbers of associates such as friends and family
phone-based intervention was found to be associated with members who can be contacted if the participant is
significantly higher initial quit rates compared with usual unreachable after a number of attempts and increasing
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care. Other studies including a group-based tailored incentives to complete follow-ups. From an evidence-based
intervention, motivational interventions and a web-based medicine perspective, if efficacy of the intervention is
intervention (vs in-person or self-help) have not yielded determined to be high, implementation science methods
significant increases in quit rates. 30,31,32,33,34,35,36 Two pilot would need to be employed in the clinical care setting to
studies of behavioural treatments that address negative incorporate the intervention into HIV programmes. The
affect (depression and anxiety) show promise for PLWHA. 37,38 intervention leverages the existing HIV care infrastructure
and will likely facilitate scale-up in sub-Saharan African
The BAPS-SC trial proved feasible. Firstly, the target sample settings where HIV is common and smoking continues to
size of 40 participants was reached within 8 weeks of emerge as a threat to HIV-positive individuals’ health and
recruitment, a rate of enrolment that would make large trials survival.
feasible. The authors’ findings indicated that a large-scale
clinical trial would be feasible to determine the efficacy of the Limitations
BAPS-SC programme in this setting where HIV prevalence is
relatively high. Furthermore, smoking prevalence in the This pilot study evaluating the feasibility of BAPS-SC
setting of their pilot study was estimated to be as high as amongst HIV-infected smokers in Botswana has notable
51% for male candidates and 6% for female candidates with limitations. This was a single-arm trial, and therefore the
39
HIV infection. There were proportionately fewer female results indicate only preliminary evidence of efficiency of the
candidates enrolled in the present study consistent with data intervention and do not confirm efficacy. However, the
40
from demographic and health surveys in sub-Saharan Africa. authors’ main aim was to evaluate feasibility of implementing
Although these smoking rates appear to be comparatively the intervention. The planned full clinical trial informed by
lower than reports from North America and Europe, these these results will be powered to address efficacy. Additionally,
rates are projected to increase in the African continent the follow-up period was of only 12 weeks as the aim was to
whilst they are falling in other parts of the world. 40,41 Given evaluate feasibility of the novel intervention. Thus, the
the limited behavioural health infrastructure in low middle follow-up period was not long enough to assess long-term
income countries (LMICs) such as Botswana, the authors abstinence. However, this was a pilot study to inform a future
leveraged HIV clinical care sites and telephone-delivered clinical trial.
counselling to extend the reach of skilled practitioners. The
authors found this strategy to be effective and acceptable by Conclusion
the participants in the pilot trial.
The results of this single-arm pilot trial demonstrate the
Smoking is a major cause of morbidity and mortality, yet feasibility of leveraging HIV clinical infrastructure for
smokers find it very difficult to quit. If individuals quit implementing BAPS-SC as a smoking cessation intervention
because of this intervention, they will reduce their risk of programme amongst HIV-infected smokers in a resource-
cardiovascular disease, chronic obstructive pulmonary limited setting with high HIV burden. A full-scale clinical
disease and cancers, particularly lung cancer. This will be of trial comparing BAPS-SC with standard counselling is thus
direct benefit to the individual participant. Further, if the warranted to evaluate the efficacy of this novel intervention
authors are able to mount a full-scale trial based on the results in these settings.

http://www.sajhivmed.org.za 166 Open Access