Integrated stepped alcohol treatment for patients with HIV and at-risk alcohol use: a randomized trial

Abstract

Background: At-risk levels of alcohol use threaten the health of patients with HIV (PWH), yet evidence-based strategies to decrease alcohol use and improve HIV-related outcomes in this population are lacking. We examined the effectiveness of integrated stepped alcohol treatment (ISAT) on alcohol use and HIV outcomes among PWH and at-risk alcohol use. Methods: In this multi-site, randomized trial conducted between January 28, 2013 through July 14, 2017, we enrolled PWH and at-risk alcohol use [defined as alcohol consumption of ≥ 14 drinks per week or ≥ 4 drinks per occasion in men ≤ 65 years old or ≥ 7 drinks per week or ≥ 3 drinks per occasion in women or men > 65 years old]. ISAT (n = 46) involved: Step 1-Brief Negotiated Interview with telephone booster, Step 2-Motivational Enhancement Therapy, and Step 3-Addiction Physician Management. Treatment as usual (TAU) (n = 47) involved receipt of a health handout plus routine care. Analyses were conducted based on intention to treat principles. Results: Despite a multi-pronged approach, we only recruited 37% of the target population (n = 93/254). Among ISAT participants, 50% advanced to Step 2, among whom 57% advanced to Step 3. Participants randomized to ISAT and TAU had no observed difference in drinks per week over the past 30 days at week 24 (primary outcome) [least square means (Ls mean) (95% CI) = 8.8 vs. 10.6; adjusted mean difference (AMD) (95% CI) = − 0.4 (− 3.9, 3.0)]. Conclusion: An insufficient number of patients were interested in participating in the trial. Efforts to enhance motivation of PWH with at-risk alcohol use to engage in alcohol-related research and build upon ISAT are needed.

Current Interventions for People Living with HIV Who Use Alcohol: Why Gender Matters

“…So why is gender important in research? Women are the face of HIV globally because of gender norms and inequities [74]. Women face multiple contextual and structural barriers that may interfere with their ability to seek treatment for alcohol misuse and HIV care [55,75,76], let alone participate in research.…”

“…Eight of the identified studies evaluated the efficacy or effectiveness of interventions to reduce alcohol use among PLWH but did not use a gender lens in the design or analyses [21,[61][62][63][64][65][66][67]. The sample sizes of these studies ranged from 93 to 614, with 75% reporting sample sizes of fewer than 250.…”

“…All the interventions evaluated incorporated motivational interviewing. Two interventions included cognitive behavioral therapy (CBT) components [63,67] and 3 interventions included medication-assisted treatment for alcohol use [21,61,62]. All interventions were delivered individually, with one intervention reporting additional optional group intervention components [63].…”

“…All studies used self-report alcohol assessments, such as the Alcohol Use Disorders Identification Test (AUDIT) or the Alcohol Smoking and Substance Involvement Screening Test (ASSIST). Six studies used the Timeline Followback (TLFB) to assess outcomes such as days of drinking, drinks per drinking day, and number of heavy drinking days in the past month [21,[61][62][63][64]66]. Other self-report measures to assess alcohol-related outcomes included AUDIT and ASSIST.…”

“…Other self-report measures to assess alcohol-related outcomes included AUDIT and ASSIST. Also, 3 of the non-gender studies used phosphatidylethanol (PEth) biomarkers to assess alcohol abstinence [21,61,62]. Some studies included in this review also measured viral load using HIV RNA and the cut-off for viral suppression ranged from <20 to <50 copies/ml.…”