Background:
Dry nasal snuff is a fine powdered smokeless tobacco product inhaled through the nose. People living with HIV (PLWH) in South Africa have a higher prevalence of smoking than their sero-negative peers, however little is known about the prevalence of snuff use or its health effects.

Methods:
A cross-sectional survey was conducted among randomly selected adults with HIV infection attending 3 HIV treatment clinics in Klerksdorp, South Africa from April 2012 to August 2013. A questionnaire was administered to participants to assess snuff use and current smoking status, and urine for cotinine analysis was collected from each participant.

Results:
We enrolled 1,130 HIV-infected adults, of whom 705 (62%) were women. At the time of interview, 304 (43%) women and 11 (3%) men self-reported snuff use. Only 10 (3%) women who used snuff also smoked cigarettes, thus we limited our analysis to the n = 606 non-smoking women. Nearly all participants were receiving ART, and their median (IQR) CD4 count and BMI were 390 cells/mL (236 - 564 cells/mL) and 25 kg/m² (21 - 30 kg/m²), respectively. Adjusted analysis showed odds of snuff use were lower among women completing grade 12 or higher (OR 0.3; 95% CI: 0.2, 0.6). Odds of snuff use were higher among women who had ever had tuberculosis (TB) (OR 1.4; 95% CI 1.0 - 2.1). A subset of participants was asked about alcohol use, which was positively associated with snuff use (OR 2.8; 95% CI: 1.3 - 6.0). In the model including alcohol, association with TB lost statistical significance.

Conclusions:
An extremely high proportion of women with HIV use snuff. Snuff prevention and cessation strategies are needed and should not be overlooked by tobacco control efforts, especially for women, in this population. Drivers of snuff use and the health consequences, particularly regarding TB, need further elucidation.