Reducing heavy drinking in HIV primary care: a randomized trial of brief intervention, with and without technological enhancement

Time Spent with HIV Viral Load > 1500 Copies/mL Among Persons Engaged in Continuity HIV Care in an Urban Clinic in the United States, 2010-2015

Persons with HIV who have entered care but have viral load > 1500 copies/mL may be the source of the majority of new HIV infections in the United States. We followed patients engaged in continuity care in the Johns Hopkins HIV Clinical Cohort between January 2010 and August 2015. We estimated person-time spent with viral load > 1500 copies/mL while in care after antiretroviral therapy (ART) initiation, while in care, and while alive. Person-time was classified according to the most recent viral load measurement. Of 11,283.1 person-years in care on after ART initiation, 11,954.7 person-years in care and 13,990.0 total person-years of follow-up spent alive, 12.5, 14.8%, and between 12.6 and 27.2%, respectively (depending on assumptions about the viral load of persons lost to clinic) were spent with viral load > 1500 copies/mL. Patients with lower baseline CD4 cell count, younger age, black race, history of injection drug use, or baseline hazardous alcohol use spent more time with viral load > 1500 copies/mL after ART initiation.

Computer-based personalized feedback intervention for cigarette smoking and prescription analgesic misuse among persons living with HIV (PLWH)

Pain, tobacco cigarette smoking, and prescription opioid misuse are all highly prevalent among persons living with HIV (PLWH). Smoking and pain medication misuse can lead to deleterious outcomes, including more severe pain and physical impairment. However, we are not aware of any interventions that have attempted to address these issues in an integrated manner. Participants (N = 68) were recruited from an outpatient infectious disease clinic and randomized to either a computer-based personalized feedback intervention (Integrated PFI) that aimed to increase motivation, confidence, and intention to quit smoking, and decrease intentions to misuse prescription analgesic medications, or a Control PFI. Results indicated that PLWH who received the Integrated PFI (vs. Control PFI) evinced greater post-treatment knowledge of interrelations between pain and tobacco smoking. Moreover, participants who received the Integrated PFI and smoked at least 10 cigarettes per day (but not < 10 CPD) reported greater confidence and readiness/intention to quit smoking. Effects of the Integrated PFI on knowledge of pain and opioid misuse, and attitudes/intentions regarding prescription pain medication misuse were not statistically-significant. Taken together, these results indicate that this novel intervention strategy may offer promise for addressing a critical public health need in a population that is generally underrepresented in clinical research.

Game Plan: Development of a Web App Designed to Help Men Who Have Sex With Men Reduce Their HIV Risk and Alcohol Use

Background

Men who have sex with men (MSM) are at high risk for HIV, and alcohol use is a major risk factor for HIV infection. Internet-facilitated brief interventions have been shown to reduce alcohol use and HIV-risk behavior in other at-risk populations, but have so far incorporated limited content and have not been tested among MSM.

Objective

This manuscript describes Game Plan, an interactive, tablet-optimized web application designed to help heavy drinking, high-risk MSM consider reducing their alcohol use and sexual risk behavior. In this paper, we discuss the rationale, goals, and flow for each of Game Plan’s components, which were modelled after common in-person and web-based brief motivational interventions for these behaviors.

Methods

The development of Game Plan was informed by a thorough user-focused design research process that included (1) audits of existing interventions, (2) focus groups with stakeholders and (3) intended users (high-risk, heavy drinking MSM), and (4) usability testing. The aesthetic, features, and content of the app were designed iteratively throughout this process

Results

The fully-functional Game Plan app provides (1) specific and personal feedback to users about their level of risk, (2) exercises to help prompt users to reflect on whether their current behavior aligns with other important life goals and values, and for those open to change, (3) exercises to help users understand factors that contribute to risk, and (4) a change planning module. In general, this flow was constructed to roughly align with the two phases described in early accounts of motivational interviewing (MI): (1) Content intended to elicit intrinsic motivation for change, and when/if sufficient motivation is present, (2) content intended to translate that motivation into specific goals and plans for change. This sequence first focuses on the user’s HIV risk behavior, followed by their alcohol use and the connection between the two. The app’s overall aesthetic (eg, branding, color palettes, icons/graphics) and its onboarding sequence was also designed to align with the “spirit” of MI by conveying respect for autonomy, open-mindedness (ie, avoiding judgment), and empathy.

Conclusions

Should future research support its efficacy in facilitating behavior change, Game Plan could represent a wide-reaching and scalable tool that is well-suited for use in settings where delivering evidence-based, in-person interventions would be difficult or cost-prohibitive.

A Cross-Sectional Study of Depressive Symptoms and Risky Alcohol Use Behaviors Among HIV Primary Care Patients in New York City

An association between problem drinking and depression among HIV-infected individuals has been previously demonstrated; however, which specific risky drinking behaviors are associated with higher levels of depression has not yet been investigated. Using an adult sample of HIV-infected primary care patients (78% male, 94% Black or Hispanic), we investigated whether depressive symptoms are associated with various risky drinking behaviors. Participants were administered the Beck Depression Inventory-II to assess depressive symptoms, and the Alcohol Use Disorders and Associated Disabilities Interview Schedule-IV to evaluate alcohol involvement. Participants with depressive symptoms (26%) were at higher risk for alcohol dependence [adjusted odds ratio (AOR) 3.8; 95% CI 2.0-7.2], regular binge drinking (AOR 2.0; 95% CI 1.1-3.8), and regular daytime drinking (AOR 2.1; 95% CI 1.2-3.8), in comparison with their non-depressed counterparts. Because both depression and unhealthy drinking negatively affect medication adherence and clinical outcomes, a better understanding of the association between depression and certain risky drinking behaviors among HIV-infected individuals is vital to improving their care and prognoses.

HealthCall delivered via smartphone to reduce co-occurring drug and alcohol use in HIV-infected adults: A randomized pilot trial

AIMS

Co-occurrence of drug and alcohol use among people living with HIV is linked to poor medication adherence and lack of viral suppression. HealthCall, a technological enhancement of brief Motivational Interviewing (MI), involves brief daily self-monitoring, positive reinforcement, and personalized feedback. This randomized pilot study among people living with HIV investigated the feasibility and efficacy of reducing non-injection drug and alcohol use with MI+HealthCall as adapted for smartphone technology.

DESIGN

An urban, largely-minority community sample of adults living with HIV were screened for eligibility: last 30 day use of non-injection drugs (≥4days of crack/cocaine, methamphetamine, or heroin use) and binge drinking (≥1day of 4+ standard drinks). Those eligible were randomized to one of two groups: MI-only (n=21) and MI+HealthCall-S (n=21). Trained counselors delivered the brief MI at baseline. Drug and alcohol use assessments were completed at baseline, 30 and 60days (end of treatment). Primary outcomes derived from a Timeline Follow Back (TLFB) of the past 30 days included (1) total number of days used primary drug (NumDU) (2) total quantity of primary drug used (dollar amount spent per day; QuantU), (3) total number of drinking days (NumDD) and (4) mean number of drinks per day (QuantDD). Feasibility was determined by HealthCall use rates, patient satisfaction questionnaire (1-5 scale, 5 being best), and retention.

FINDINGS

The median daily use rate for HealthCall was 95%, patient satisfaction was excellent (4.5) and retention was high (93%). Both treatment groups reduced drug and alcohol use by end of treatment, with MI+Healthcall-S showing significantly greater reductions than MI-only in QuantU (p=0.01) and NumDU (p=0.046). P-values for reductions in alcohol quantity and frequency in the MI+Healthcall group were 0.09-0.11.

CONCLUSIONS

This proof-of-concept randomized trial indicates that HealthCall on the smartphone is a highly feasible intervention in urban, minority individuals with HIV, and suggests efficacy in reducing co-occurring drug and alcohol use. Results suggest opportunities for brief behavioral intervention that may be enhanced through interactive mobile technology to address complex alcohol and drug use patterns that interfere with HIV care, medication adherence and ultimately, viral suppression. A larger randomized trial is warranted to replicate and extend present results.

Health systems facilitators and barriers to the integration of HIV and chronic disease services: a systematic review

Integration of services for patients with more than one diagnosed condition has intuitive appeal but it has been argued that the empirical evidence to support it is limited. We report the findings of a systematic review that sought to identify health system factors, extrinsic to the integration process, which either facilitated or hindered the integration of services for two common disorders, HIV and chronic non-communicable diseases. Findings were initially extracted and organized around a health system framework, followed by a thematic cross-cutting analysis and validation steps. Of the 150 articles included, 67% (n = 102) were from high-income countries. The articles explored integration with services for one or several chronic disorders, the most studied being alcohol or substance use disorders (47.7%), and mental health issues (29.5%). Four cross-cutting themes related to the health system were identified. The first and most common theme was the requirement for effective collaboration and coordination: formal and informal productive relationships throughout the system between providers and within teams, and between staff and patients. The second was the need for adequate and appropriately skilled and incentivized health workers-with the right expertise, training and operational support for the programme. The third was the need for supportive institutional structures and dedicated resources. The fourth was leadership in terms of political will, effective managerial oversight and organizational culture, indicating that actual implementation is as important as programme design. A fifth theme, outside the health system, but underpinning all aspects of the system operation, was that placing the patient at the centre of service delivery and responding holistically to their diverse needs. This was an important facilitator of integration. These findings confirm that integration processes in service delivery depend substantially for their success on characteristics of the health systems in which they are embedded.

Behavioral Interventions Targeting Alcohol Use Among People Living with HIV/AIDS: A Systematic Review and Meta-Analysis

Alcohol use is often reported among people living with HIV/AIDS (PLWHA) and is associated with increased sexual risk and poor medication adherence. This meta-analysis evaluated the efficacy of behavioral interventions addressing alcohol use among PLWHA. Twenty-one studies (N = 8461 PLWHA) that evaluated an individual-level intervention addressing alcohol use alone or as part of a more comprehensive alcohol/HIV intervention, included a control condition, and were available through December 2016 were included. Independent raters coded study, sample, and intervention content. Weighted mean effect sizes, using random-effects models, were calculated. Results indicate that interventions reduced alcohol consumption, increased condom use, and improved medication adherence relative to controls (d +s = 0.10-0.24). Plasma viral load was also reduced in intervention versus control participants (d + = 0.14, 95% CI = 0.02, 0.26; k = 7). These findings show that behavioral interventions addressing alcohol use can successfully reduce alcohol consumption and also improve HIV-related outcomes among PLWHA.

Personalised digital interventions for reducing hazardous and harmful alcohol consumption in community-dwelling populations

BACKGROUND

Excessive alcohol use contributes significantly to physical and psychological illness, injury and death, and a wide array of social harm in all age groups. A proven strategy for reducing excessive alcohol consumption levels is to offer a brief conversation-based intervention in primary care settings, but more recent technological innovations have enabled people to interact directly via computer, mobile device or smartphone with digital interventions designed to address problem alcohol consumption.

OBJECTIVES

To assess the effectiveness and cost-effectiveness of digital interventions for reducing hazardous and harmful alcohol consumption, alcohol-related problems, or both, in people living in the community, specifically: (i) Are digital interventions more effective and cost-effective than no intervention (or minimal input) controls? (ii) Are digital interventions at least equally effective as face-to-face brief alcohol interventions? (iii) What are the effective component behaviour change techniques (BCTs) of such interventions and their mechanisms of action? (iv) What theories or models have been used in the development and/or evaluation of the intervention? Secondary objectives were (i) to assess whether outcomes differ between trials where the digital intervention targets participants attending health, social care, education or other community-based settings and those where it is offered remotely via the internet or mobile phone platforms; (ii) to specify interventions according to their mode of delivery (e.g. functionality features) and assess the impact of mode of delivery on outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, PsycINFO, CINAHL, ERIC, HTA and Web of Knowledge databases; ClinicalTrials.com and WHO ICTRP trials registers and relevant websites to April 2017. We also checked the reference lists of included trials and relevant systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated the effectiveness of digital interventions compared with no intervention or with face-to-face interventions for reducing hazardous or harmful alcohol consumption in people living in the community and reported a measure of alcohol consumption.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included 57 studies which randomised a total of 34,390 participants. The main sources of bias were from attrition and participant blinding (36% and 21% of studies respectively, high risk of bias). Forty one studies (42 comparisons, 19,241 participants) provided data for the primary meta-analysis, which demonstrated that participants using a digital intervention drank approximately 23 g alcohol weekly (95% CI 15 to 30) (about 3 UK units) less than participants who received no or minimal interventions at end of follow up (moderate-quality evidence).Fifteen studies (16 comparisons, 10,862 participants) demonstrated that participants who engaged with digital interventions had less than one drinking day per month fewer than no intervention controls (moderate-quality evidence), 15 studies (3587 participants) showed about one binge drinking session less per month in the intervention group compared to no intervention controls (moderate-quality evidence), and in 15 studies (9791 participants) intervention participants drank one unit per occasion less than no intervention control participants (moderate-quality evidence).Only five small studies (390 participants) compared digital and face-to-face interventions. There was no difference in alcohol consumption at end of follow up (MD 0.52 g/week, 95% CI -24.59 to 25.63; low-quality evidence). Thus, digital alcohol interventions produced broadly similar outcomes in these studies. No studies reported whether any adverse effects resulted from the interventions.A median of nine BCTs were used in experimental arms (range = 1 to 22). 'B' is an estimate of effect (MD in quantity of drinking, expressed in g/week) per unit increase in the BCT, and is a way to report whether individual BCTs are linked to the effect of the intervention. The BCTs of goal setting (B -43.94, 95% CI -78.59 to -9.30), problem solving (B -48.03, 95% CI -77.79 to -18.27), information about antecedents (B -74.20, 95% CI -117.72 to -30.68), behaviour substitution (B -123.71, 95% CI -184.63 to -62.80) and credible source (B -39.89, 95% CI -72.66 to -7.11) were significantly associated with reduced alcohol consumption in unadjusted models. In a multivariable model that included BCTs with B > 23 in the unadjusted model, the BCTs of behaviour substitution (B -95.12, 95% CI -162.90 to -27.34), problem solving (B -45.92, 95% CI -90.97 to -0.87), and credible source (B -32.09, 95% CI -60.64 to -3.55) were associated with reduced alcohol consumption.The most frequently mentioned theories or models in the included studies were Motivational Interviewing Theory (7/20), Transtheoretical Model (6/20) and Social Norms Theory (6/20). Over half of the interventions (n = 21, 51%) made no mention of theory. Only two studies used theory to select participants or tailor the intervention. There was no evidence of an association between reporting theory use and intervention effectiveness.

AUTHORS' CONCLUSIONS

There is moderate-quality evidence that digital interventions may lower alcohol consumption, with an average reduction of up to three (UK) standard drinks per week compared to control participants. Substantial heterogeneity and risk of performance and publication bias may mean the reduction was lower. Low-quality evidence from fewer studies suggested there may be little or no difference in impact on alcohol consumption between digital and face-to-face interventions.The BCTs of behaviour substitution, problem solving and credible source were associated with the effectiveness of digital interventions to reduce alcohol consumption and warrant further investigation in an experimental context.Reporting of theory use was very limited and often unclear when present. Over half of the interventions made no reference to any theories. Limited reporting of theory use was unrelated to heterogeneity in intervention effectiveness.

Direct and Indirect Effects of Heavy Alcohol Use on Clinical Outcomes in a Longitudinal Study of HIV Patients on ART

In a cohort of patients receiving care for HIV, we examined longitudinally the impact of past 30-day frequency of heavy drinking (consuming 5+ drinks on one occasion) on HIV-related (detectable viral load and CD4+ T cell count) and non-HIV-related (hemoglobin and biomarkers of kidney function and liver fibrosis) clinical outcomes and the extent to which these effects were due to reduced antiretroviral therapy (ART) adherence. Data came from the Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy. Between March 2004 and June 2006, 533 individuals receiving ART were recruited and followed every 6 months for six years. Using longitudinal mediation analysis, we estimated natural direct effects (NDE) of heavy drinking frequency (never, 1-3 times, or 4+ times in the past 30 days) on clinical outcomes and natural indirect effects (NIE) mediated via ART adherence. A one-level increase in heavy drinking frequency had a significant negative NDE on CD4+ T-cell counts (-10.61 cells/mm³; 95 % CI [-17.10, -4.12]) and a significant NIE through reduced ART adherence of -0.72 cells/mm³ (95 % CI [-1.28, -0.15]), as well as a significant NIE on risk of detectable viral load (risk ratio = 1.03; 95 % CI [1.00, 1.05]). Heavy drinking had a significant detrimental NIE on a combined index of 5-year mortality risk and detrimental NDE and total effect on a biomarker of liver fibrosis. Heavy drinking has deleterious effects on multiple clinical outcomes in people living with HIV, some of which are mediated through reduced ART adherence.

Integrating HIV and substance use services: a systematic review

INTRODUCTION

Substance use is an important risk factor for HIV, with both concentrated in certain vulnerable and marginalized populations. Although their management differs, there may be opportunities to integrate services for substance use and HIV. In this paper we systematically review evidence from studies that sought to integrate care for people living with HIV and substance use problems.

METHODS

Studies were included if they evaluated service integration for substance use and HIV. We searched multiple databases from inception until October 2015. Articles were screened independently by two reviewers and assessed for risk of bias.

RESULTS AND DISCUSSION

11,057 records were identified, with 7616 after removal of duplicates. After screening titles and abstracts, 51 met the inclusion criteria. Integration models were categorized by location (HIV, substance use and other facilities), level of integration from mirco (integrated care delivered to individuals) to macro (system level integrations) and degree of integration from least (screening and counselling only) to most (care for HIV, substance use and/or other illnesses at the same facility). Most reported descriptive or cohort studies; in four randomized control trials integrated activities improved patient outcomes. There is potential for integrating services at all facility types, including mobile health services. While services offering screening only can achieve synergies, there are benefits from delivering integrated treatment for HIV and substance use, including ease of referral to other mental health and social services.

CONCLUSIONS

Our review used a wide range of databases and conference archives to increase representation of papers from low- and middle-income countries. Limitations include the overrepresentation of studies from the United States, and the descriptive nature of the majority of papers. The evidence reviewed shows that greater integration offers important benefits in both patient and service outcomes but further research and outcome reporting is needed to better understand innovative and holistic care models at the complex intersection of substance use and HIV services.

Documented brief intervention not associated with resolution of unhealthy alcohol use one year later among VA patients living with HIV

OBJECTIVE

Unhealthy alcohol use is particularly risky for patients living with HIV (PLWH). Brief interventions reduce drinking among patients with unhealthy alcohol use, but whether its receipt in routine outpatient settings is associated with reduced drinking among PLWH with unhealthy alcohol use is unknown. We assessed whether PLWH who screened positive for unhealthy alcohol use were more likely to resolve unhealthy drinking one year later if they had brief alcohol intervention (BI) documented in their electronic health record in a national sample of PLWH from the Veterans Health Administration.

METHODS

Secondary VA clinical and administrative data from the electronic medical record (EMR) were used to identify all positive alcohol screens (AUDIT-C score≥5) documented among PLWH (10/01/09-5/30/13) followed by another alcohol screen documented 9-15months later. Unadjusted and adjusted Poisson regression models assessed the association between brief intervention (advice to reduce drinking or abstain documented in EMR) and resolution of unhealthy alcohol use (follow-up AUDIT-C<5 with ≥2 point reduction).

RESULTS

Overall 2101 PLWH with unhealthy drinking (10/01/09-5/30/13) had repeat alcohol screens 9-15months later. Of those, 77% had brief intervention documented after their first screen, and 61% resolved unhealthy alcohol use at follow-up. Documented brief intervention was not associated with resolution [Adjusted incidence rate ratio 0.96, (95% CI 0.90-1.02)].

CONCLUSIONS

Documented brief intervention was not associated with resolving unhealthy alcohol use at follow-up screening among VA PLWH with unhealthy alcohol use. Effective methods of resolving unhealthy alcohol use in this vulnerable population are needed.

An integrative review of the efficacy of motivational interviewing in HIV management

OBJECTIVE

The purpose of this integrative review is to examine the use of motivational interviewing (MI) to improve health outcomes in persons living with HIV (PLWH).

METHODS

We reviewed the existing literature, using the PRISMA model. The PubMed, Web of Science, Embase, and CINAHL databases were searched for all relevant studies, using the terms HIV, AIDS, and motivational interviewing.

RESULTS

Of 239 articles identified initially, 19 met our criteria for synthesis. These studies were conducted throughout the world, including the U.S., Thailand, and South Africa. In general, studies that used MI, either alone or in conjunction with other interventions, reported improved adherence, decreased depression, and decreased risky sexual behaviors.

CONCLUSION

This review demonstrates a positive relationship between MI-based interventions and behavioral change, which may lead to improved health outcomes in PLWH.

PRACTICE IMPLICATIONS

Motivational interviewing can be an effective method of therapeutic communication for PLWH, who struggle with adherence, depression, and risky sexual behaviors.

Reducing non-injection drug use in HIV primary care: A randomized trial of brief motivational interviewing, with and without HealthCall, a technology-based enhancement

AIMS

In HIV-infected individuals, non-injection drug use (NIDU) compromises many health outcomes. In HIV primary care, the efficacy of brief motivational interviewing (MI) to reduce NIDU is unknown, and drug users may need greater intervention. We designed an enhancement to MI, HealthCall (HC), for daily patient self-monitoring calls to an interactive voice response (IVR) phone system, and provided participants with periodic personalized feedback. To reduce NIDU among HIV primary care patients, we compared the efficacy of MI+HealthCall to MI-only and an educational control condition.

DESIGN

Participants age >18 with >4days of NIDU during the prior 30days were recruited from large urban HIV primary care clinics. Of the 240 participants, 83 were randomly assigned to control, 77 to MI-only, and 80 to MI+HC. Counselors provided educational control, MI-only or MI+HC at baseline. At 30 and 60days (end-of-treatment), counselors briefly discussed drug use, moods and health behaviors, using HealthCall-generated graphs with MI+HC patients. Primary outcomes (last 30days) were number of days used primary drug (NumDU), and total quantity of primary drug used (dollar amount spent; QuantU), derived from the Time-Line Follow-Back.

FINDINGS

Across all groups, at end-of-treatment, frequency and quantity of NIDU decreased, with significantly greater reductions in the MI-Only group. A twelve-month post-treatment follow-up indicated sustained benefits of MI+HC and MI-only relative to control.

CONCLUSIONS

Brief interventions can be successfully used to reduce non-injection drug use in HIV primary care. IVR-based technology may not be sufficiently engaging to be effective. Future studies should investigate mobile technology to deliver a more engaging version of HealthCall to diverse substance abusing populations.

Clinical Validation of Reduced Alcohol Consumption After Treatment for Alcohol Dependence Using the World Health Organization Risk Drinking Levels

Background

Alcohol use disorder (AUD) is a highly prevalent public health problem associated with considerable individual and societal costs. Abstinence from alcohol is the most widely accepted target of treatment for AUD, but it severely limits treatment options and could deter individuals who prefer to reduce their drinking from seeking treatment. Clinical validation of reduced alcohol consumption as the primary outcome of alcohol clinical trials is critical for expanding treatment options. One potentially useful measure of alcohol treatment outcome is a reduction in the World Health Organization (WHO, International Guide for Monitoring Alcohol Consumption and Related Harm. Geneva, Switzerland, 2000) risk levels of alcohol use (very high risk, high risk, moderate risk, and low risk). For example, a 2‐shift reduction in WHO risk levels (e.g., high risk to low risk) has been used by the European Medicines Agency (2010, Guideline on the Development of Medicinal Products for the Treatment of Alcohol Dependence. UK) to evaluate nalmefene as a treatment for alcohol dependence (AD; Mann et al. 2013, Biol Psychiatry 73, 706–13).

Methods

The current study was a secondary data analysis of the COMBINE study (n = 1,383; Anton et al., 2006) to examine the association between reductions in WHO risk levels and reductions in alcohol‐related consequences and mental health symptoms during and following treatment in patients with AD.

Results

Any reduction in WHO risk drinking level during treatment was associated with significantly fewer alcohol‐related consequences and improved mental health at the end of treatment and for up to 1 year posttreatment. A greater reduction in WHO risk drinking level predicted a greater reduction in consequences and greater improvements in mental health.

Conclusions

Changes in WHO risk levels appear to be a valid end point for alcohol clinical trials. Based on the current findings, reductions in WHO risk drinking levels during treatment reflect meaningful reductions in alcohol‐related consequences and improved functioning.

Automated telephone communication systems for preventive healthcare and management of long-term conditions

BACKGROUND

Automated telephone communication systems (ATCS) can deliver voice messages and collect health-related information from patients using either their telephone's touch-tone keypad or voice recognition software. ATCS can supplement or replace telephone contact between health professionals and patients. There are four different types of ATCS: unidirectional (one-way, non-interactive voice communication), interactive voice response (IVR) systems, ATCS with additional functions such as access to an expert to request advice (ATCS Plus) and multimodal ATCS, where the calls are delivered as part of a multicomponent intervention.

OBJECTIVES

To assess the effects of ATCS for preventing disease and managing long-term conditions on behavioural change, clinical, process, cognitive, patient-centred and adverse outcomes.

SEARCH METHODS

We searched 10 electronic databases (the Cochrane Central Register of Controlled Trials; MEDLINE; Embase; PsycINFO; CINAHL; Global Health; WHOLIS; LILACS; Web of Science; and ASSIA); three grey literature sources (Dissertation Abstracts, Index to Theses, Australasian Digital Theses); and two trial registries (www.controlled-trials.com; www.clinicaltrials.gov) for papers published between 1980 and June 2015.

SELECTION CRITERIA

Randomised, cluster- and quasi-randomised trials, interrupted time series and controlled before-and-after studies comparing ATCS interventions, with any control or another ATCS type were eligible for inclusion. Studies in all settings, for all consumers/carers, in any preventive healthcare or long term condition management role were eligible.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods to select and extract data and to appraise eligible studies.

MAIN RESULTS

We included 132 trials (N = 4,669,689). Studies spanned across several clinical areas, assessing many comparisons based on evaluation of different ATCS types and variable comparison groups. Forty-one studies evaluated ATCS for delivering preventive healthcare, 84 for managing long-term conditions, and seven studies for appointment reminders. We downgraded our certainty in the evidence primarily because of the risk of bias for many outcomes. We judged the risk of bias arising from allocation processes to be low for just over half the studies and unclear for the remainder. We considered most studies to be at unclear risk of performance or detection bias due to blinding, while only 16% of studies were at low risk. We generally judged the risk of bias due to missing data and selective outcome reporting to be unclear.For preventive healthcare, ATCS (ATCS Plus, IVR, unidirectional) probably increase immunisation uptake in children (risk ratio (RR) 1.25, 95% confidence interval (CI) 1.18 to 1.32; 5 studies, N = 10,454; moderate certainty) and to a lesser extent in adolescents (RR 1.06, 95% CI 1.02 to 1.11; 2 studies, N = 5725; moderate certainty). The effects of ATCS in adults are unclear (RR 2.18, 95% CI 0.53 to 9.02; 2 studies, N = 1743; very low certainty).For screening, multimodal ATCS increase uptake of screening for breast cancer (RR 2.17, 95% CI 1.55 to 3.04; 2 studies, N = 462; high certainty) and colorectal cancer (CRC) (RR 2.19, 95% CI 1.88 to 2.55; 3 studies, N = 1013; high certainty) versus usual care. It may also increase osteoporosis screening. ATCS Plus interventions probably slightly increase cervical cancer screening (moderate certainty), but effects on osteoporosis screening are uncertain. IVR systems probably increase CRC screening at 6 months (RR 1.36, 95% CI 1.25 to 1.48; 2 studies, N = 16,915; moderate certainty) but not at 9 to 12 months, with probably little or no effect of IVR (RR 1.05, 95% CI 0.99, 1.11; 2 studies, 2599 participants; moderate certainty) or unidirectional ATCS on breast cancer screening.Appointment reminders delivered through IVR or unidirectional ATCS may improve attendance rates compared with no calls (low certainty). For long-term management, medication or laboratory test adherence provided the most general evidence across conditions (25 studies, data not combined). Multimodal ATCS versus usual care showed conflicting effects (positive and uncertain) on medication adherence. ATCS Plus probably slightly (versus control; moderate certainty) or probably (versus usual care; moderate certainty) improves medication adherence but may have little effect on adherence to tests (versus control). IVR probably slightly improves medication adherence versus control (moderate certainty). Compared with usual care, IVR probably improves test adherence and slightly increases medication adherence up to six months but has little or no effect at longer time points (moderate certainty). Unidirectional ATCS, compared with control, may have little effect or slightly improve medication adherence (low certainty). The evidence suggested little or no consistent effect of any ATCS type on clinical outcomes (blood pressure control, blood lipids, asthma control, therapeutic coverage) related to adherence, but only a small number of studies contributed clinical outcome data.The above results focus on areas with the most general findings across conditions. In condition-specific areas, the effects of ATCS varied, including by the type of ATCS intervention in use.Multimodal ATCS probably decrease both cancer pain and chronic pain as well as depression (moderate certainty), but other ATCS types were less effective. Depending on the type of intervention, ATCS may have small effects on outcomes for physical activity, weight management, alcohol consumption, and diabetes mellitus. ATCS have little or no effect on outcomes related to heart failure, hypertension, mental health or smoking cessation, and there is insufficient evidence to determine their effects for preventing alcohol/substance misuse or managing illicit drug addiction, asthma, chronic obstructive pulmonary disease, HIV/AIDS, hypercholesterolaemia, obstructive sleep apnoea, spinal cord dysfunction or psychological stress in carers.Only four trials (3%) reported adverse events, and it was unclear whether these were related to the interventions.

AUTHORS' CONCLUSIONS

ATCS interventions can change patients' health behaviours, improve clinical outcomes and increase healthcare uptake with positive effects in several important areas including immunisation, screening, appointment attendance, and adherence to medications or tests. The decision to integrate ATCS interventions in routine healthcare delivery should reflect variations in the certainty of the evidence available and the size of effects across different conditions, together with the varied nature of ATCS interventions assessed. Future research should investigate both the content of ATCS interventions and the mode of delivery; users' experiences, particularly with regard to acceptability; and clarify which ATCS types are most effective and cost-effective.

Reasons for drinking as predictors of alcohol involvement one year later among HIV-infected individuals with and without hepatitis C

INTRODUCTION

Heavy drinking can be harmful for individuals with HIV, particularly those coinfected with hepatitis C virus (HCV). HIV patients' reasons for drinking predict short-term alcohol involvement, but whether they predict longer-term involvement is unknown. Also, it remains unknown whether these motives are differentially predictive for HIV monoinfected and HIV/HCV coinfected patients.

METHOD

HIV-infected heavy drinkers (n = 254) participated in a randomized trial of brief alcohol interventions, 236 (92.9%) of whom reported on baseline motives and alcohol involvement 12 months later (77.1% male, 94.9% minority, 30.6% with HCV).

RESULTS

Greater endorsement of baseline drinking to cope with negative affect predicted greater alcohol dependence symptoms at 12 months (incident rate ratio [IRR] = 1.80, p < 0.05), while greater endorsement of baseline drinking due to social pressure predicted fewer drinks consumed at 12 months (IRR = 0.67, p < 0.05). Coping and social reasons were both predictive for HIV monoinfected patients, whereas only coping reasons were predictive for HIV/HCV coinfected patients.

DISCUSSION

Drinking for coping and social reasons predict alcohol involvement 12 months later; however, social reasons may only be important for HIV monoinfected patients. Understanding patient reasons for drinking may help predict patient risk up to a year later. KEY MESSAGES Among HIV patients, drinking motives predict alcohol involvement 12 months later. For HIV monoinfected patients, drinking to cope and drinking for social reasons predict 12-month alcohol involvement. For HIV/Hepatitis C coinfected patients, coping (but not social) motives predict 12-month alcohol involvement.

Alcohol use disorder and its impact on chronic hepatitis C virus and human immunodeficiency virus infections

Alcohol use disorder (AUD) and hepatitis C virus (HCV) infection frequently co-occur. AUD is associated with greater exposure to HCV infection, increased HCV infection persistence, and more extensive liver damage due to interactions between AUD and HCV on immune responses, cytotoxicity, and oxidative stress. Although AUD and HCV infection are associated with increased morbidity and mortality, HCV antiviral therapy is less commonly prescribed in individuals with both conditions. AUD is also common in human immunodeficiency virus (HIV) infection, which negatively impacts proper HIV care and adherence to antiretroviral therapy, and liver disease. In addition, AUD and HCV infection are also frequent within a proportion of patients with HIV infection, which negatively impacts liver disease. This review summarizes the current knowledge regarding pathological interactions of AUD with hepatitis C infection, HIV infection, and HCV/HIV co-infection, as well as relating to AUD treatment interventions in these individuals.

Comparison of AUDIT-C collected via electronic medical record and self-administered research survey in HIV infected and uninfected patients

BACKGROUND

Using electronic medical record (EMR) data for clinical decisions, quality improvement, and research is common. While unhealthy alcohol use is particularly risky among HIV infected individuals (HIV+), the validity of EMR data for identifying unhealthy alcohol use among HIV+ is unclear. Among HIV+ and uninfected, we: (1) assess agreement of EMR and research AUDIT-C at validated cutoffs for unhealthy alcohol use; (2) explore EMR cutoffs that maximize agreement; and (3) assess subpopulation variation in agreement.

METHODS

Using data from the Veterans Aging Cohort Study (VACS), EMR AUDIT-C cutoffs of 2+, 3+, and 4+ for men (2+ and 3+ for women) were compared to research AUDIT-C 4+ for men (3+ for women). Agreement was compared by demographics, HIV, hepatitis C infection, and alcohol related diagnosis.

RESULTS

Among 1082 HIV+ and 1160 uninfected men, 14% and 22% had an EMR and research AUDIT-C 4+, respectively. Among 32 HIV+ and 115 uninfected women, 9% and 14% had an EMR and research AUDIT-C 3+. For men, EMR agreement with the research AUDIT-C 4+ was highest at a cutoff of 3+ (kappa=0.49). For women, EMR agreement with AUDIT-C 3+ was highest at a cutoff of 2+ (kappa=0.46). Moderate agreement was consistent across subgroups.

CONCLUSIONS

EMR AUDIT-C underestimates unhealthy alcohol use compared to research AUDIT-C in both HIV+ and uninfected individuals. Methods for improving quality of clinical screening may be in need of investigation. Researchers and clinicians may consider alternative EMR cutoffs that maximize agreement given limitations of clinical screening.

Alcohol Use and Human Immunodeficiency Virus (HIV) Infection: Current Knowledge, Implications, and Future Directions

Alcohol use is common among people living with human immunodeficiency virus (HIV). In this narrative review, we describe literature regarding alcohol's impact on transmission, care, coinfections, and comorbidities that are common among people living with HIV (PLWH), as well as literature regarding interventions to address alcohol use and its influences among PLWH. This narrative review identifies alcohol use as a risk factor for HIV transmission, as well as a factor impacting the clinical manifestations and management of HIV. Alcohol use appears to have additive and potentially synergistic effects on common HIV-related comorbidities. We find that interventions to modify drinking and improve HIV-related risks and outcomes have had limited success to date, and we recommend research in several areas. Consistent with Office of AIDS Research/National Institutes of Health priorities, we suggest research to better understand how and at what levels alcohol influences comorbid conditions among PLWH, to elucidate the mechanisms by which alcohol use is impacting comorbidities, and to understand whether decreases in alcohol use improve HIV-relevant outcomes. This should include studies regarding whether state-of-the-art medications used to treat common coinfections are safe for PLWH who drink alcohol. We recommend that future research among PLWH include validated self-report measures of alcohol use and/or biological measurements, ideally both. Additionally, subgroup variation in associations should be identified to ensure that the risks of particularly vulnerable populations are understood. This body of research should serve as a foundation for a next generation of intervention studies to address alcohol use from transmission to treatment of HIV. Intervention studies should inform implementation efforts to improve provision of alcohol-related interventions and treatments for PLWH in healthcare settings. By making further progress on understanding how alcohol use affects PLWH in the era of HIV as a chronic condition, this research should inform how we can mitigate transmission, achieve viral suppression, and avoid exacerbating common comorbidities of HIV and alcohol use and make progress toward the 90-90-90 goals for engagement in the HIV treatment cascade.

Association between change in self-efficacy to resist drinking and drinking behaviors among an HIV-infected sample: Results from a large randomized controlled trial

Heavy drinking among HIV-infected individuals is associated with health complications. Health-behavior self-efficacy may be characteristically low among this population or negatively affected by HIV-infected status. We assessed whether self-efficacy to resist drinking increased during brief educational and motivational drinking-reduction interventions within HIV primary care and whether increases in self-efficacy predicted drinking among HIV-infected heavy drinkers. Results indicate that increases in self-efficacy from baseline to end-of-intervention inversely predicted drinking at end-of-intervention and at follow-up. Findings suggest that brief treatment interventions within HIV primary care may promote self-efficacy and that increases in self-efficacy predict initiation and maintenance of drinking reductions among HIV patients.

Neighborhood-Level Drinking Norms and Alcohol Intervention Outcomes in HIV Patients Who Are Heavy Drinkers

BACKGROUND

Heavy alcohol consumption can be harmful, particularly for individuals with HIV. There is substantial variability in response to interventions that aim to reduce drinking. Neighborhood drinking norms may explain some of this variability among HIV-infected patients. Therefore, we investigated whether neighborhood-level drinking norms modified response to alcohol intervention among HIV-infected heavy drinkers.

METHODS

Heavily-drinking HIV comprehensive care patients (n = 230) completed 1 of 3 brief alcohol interventions (an educational intervention, a motivational interviewing [MI] intervention, or an MI intervention with a technological enhancement called HealthCall). Drinking was reported at baseline and end of treatment (60 days). Neighborhood-level drinking norms were obtained from a separate general population study.

RESULTS

Patients' reductions in drinks per drinking day in response to MI (as compared with the educational control) were more pronounced in neighborhoods with more permissive drinking norms. In contrast, patients' reductions in drinks per drinking day in response to MI plus HealthCall did not significantly vary between neighborhoods with different drinking norms. Norms did not evidence significant interactions with intervention condition for 3 other exploratory drinking outcomes (drinking frequency, binge frequency, and maximum quantity).

CONCLUSIONS

Neighborhood-level drinking norms help explain differential response to an alcohol MI intervention among HIV-infected patients. This study suggests the utility of considering neighborhood context as an effect modifier of alcohol interventions.

HIV Care Providers' Attitudes regarding Mobile Phone Applications and Web-Based Dashboards to support Patient Self-Management and Care Coordination: Results from a Qualitative Feasibility Study

In-depth qualitative interviews were conducted with healthcare providers (HCPs) from five HIV medical care coordination teams in a large Los Angeles County HIV clinic, including physicians, nurses, and psychosocial services providers. HCPs reported on the potential utility, acceptability, and barriers for patient self-monitoring and notifications via mobile phones, and web-based dashboards for HCPs. Potential benefits included: 1) enhancing patient engagement, motivation, adherence, and self-management; and 2) improving provider-patient relationships and HCP care coordination. Newly diagnosed and patients with co-morbidities were highest priorities for mobile application support. Facilitators included universal mobile phone ownership and use of smartphones or text messaging. Patient-level barriers included concerns about low motivation and financial instability for consistent use by some patients. Organizational barriers, cited primarily by physicians, included concerns about privacy protections, easy dashboard access, non-integrated electronic records, and competing burdens in limited appointment times. Psychosocial services providers were most supportive of the proposed mobile tools.

Efficacy of a Single, Brief Alcohol Reduction Intervention among Men and Women Living with HIV/AIDS and Using Alcohol in Kampala, Uganda: A Randomized Trial

We evaluated the efficacy of a brief motivational intervention (MI) counseling in reducing alcohol consumption among persons living with HIV/AIDS in Kampala, Uganda. Persons living with HIV/AIDS with Alcohol Use Disorders Identification Tool (AUDIT) score ≥3 points were randomized to either standardized positive prevention counseling alone or in combination with alcohol brief MI counseling. The mean change in AUDIT-C scores over 6 months was compared by treatment arm. The mean (standard deviation [SD]) AUDIT-C scores were 6.3 (2.3) and 6.8 (2.3) for control and MI arms ( P = .1) at baseline, respectively, and change in mean AUDIT-C score was not statistically different between arms over the 6 months ( P = .8). However, there was a statistically significant decrease in mean AUDIT-C score (-1.10; 95% confidence interval: -2.19 to -0.02, P = .046) among women in the MI arm. There was a nondifferential reduction in alcohol consumption overall, but MI appeared effective among women only. Studies with more than 1 counseling session and evaluation of gender differences in treatment response are needed.

HIV primary care providers--Screening, knowledge, attitudes and behaviors related to alcohol interventions

BACKGROUND

Alcohol has particularly harmful health effects in HIV-infected patients; therefore, HIV clinics are an important setting for integration of brief alcohol intervention and alcohol pharmacotherapy to improve patient outcomes. Current practices of alcohol screening, counseling, and prescription of pharmacotherapy by HIV providers are unknown.

METHODS

We conducted a cross-sectional survey of HIV providers from 8 HIV clinical sites across the United States. Surveys queried knowledge and use of alcohol screening, brief advice, counseling and pharmacotherapy, confidence and willingness to prescribe pharmacotherapy and barriers to their use of alcohol pharmacotherapy. We used multivariable logistic regression to examine provider factors associated with confidence and willingness to prescribe pharmacotherapy.

RESULTS

Providers (N=158) were predominantly female (58%) and Caucasian (73%); almost half were infectious disease physicians and 31% had been in practice 10-20 years. Most providers (95%) reported always or usually screening for alcohol use, although only 10% reported using a formal screening tool. Over two-thirds never or rarely treated alcohol-dependent patients with pharmacotherapy themselves. Most (71%) referred alcohol-dependent patients for treatment. Knowledge regarding alcohol pharmacotherapy was low. The major barrier to prescribing pharmacotherapy was insufficient training on use of pharmacotherapy. Provider confidence ratings were positively correlated with their practice patterns.

CONCLUSIONS

HIV providers reported high rates of screening for alcohol use, though few used a formal screening tool. Most providers referred alcohol dependent patients to outside resources for treatment. Few reported prescribing alcohol pharmacotherapy. Increased training on alcohol pharmacotherapy may increase confidence in prescribing and use of these medications in HIV care settings.

Utilization of Alcohol Treatment Among HIV-Positive Women with Hazardous Drinking

Hazardous alcohol consumption has been frequently reported among women with HIV infection and is associated with a variety of negative health consequences. Treatments to reduce alcohol use may bring in health benefits. However, little is known regarding the utilization of alcohol treatment services among HIV+ women with hazardous drinking. Using data from the Women's Interagency HIV Study (WIHS), this study assessed utilization of any alcohol treatment in the past 6 months and performed multivariable logistic regression to determine correlates of receipt of any alcohol treatment. Among 474 HIV+ women reporting recent hazardous drinking, less than one in five (19%) reported recent utilization of any alcohol treatment. Alcoholics Anonymous (AA) was the most commonly reported (12.9%), followed by inpatient detoxification (9.9%) and outpatient alcohol treatment program (7.0%). Half (51%) receiving any alcohol treatment reported utilization of multiple treatments. Multivariable analyses found alcohol treatment was more often utilized by those who had social support (odds ratio [OR]=1.68, 95% confidence interval [CI]=1.00 to 2.83), fewer economic resources (income ≤$12,000 vs. >$12,000, OR=3.10, 95% CI=1.53 to 6.27), higher levels of drinking (16-35 drinks/week vs. 12-15 drinks/week, OR=3.02, 95% CI=1.47 to 6.21; 36+ drinks/week vs. 12-15 drinks/week, OR=4.41, 95% CI=2.03 to 9.59), and those who reported any illicit drug use (OR=2.77, 95% CI=1.44 to 5.34). More efforts are needed to enhance the utilization of alcohol treatment. Our findings highlight the unique profile of those who utilized alcohol treatment. Such information is vital to improve treatment delivery to address unmet need in this particular population.

Declining and rebounding unhealthy alcohol consumption during the first year of HIV care in rural Uganda, using phosphatidylethanol to augment self-report

AIMS

We examined whether unhealthy alcohol consumption, which negatively impacts HIV outcomes, changes after HIV care entry overall and by several factors. We also compared using phosphatidylethanol (PEth, an alcohol biomarker) to augment self-report to using self-report alone.

DESIGN

A prospective 1-year observational cohort study with quarterly visits.

SETTING

Large rural HIV clinic in Mbarara, Uganda.

PARTICIPANTS

A total of 208 adults (89 women and 119 men) entering HIV care, reporting any prior year alcohol consumption.

MEASUREMENTS

Unhealthy drinking was PEth+ (≥ 50 ng/ml) or Alcohol Use Disorders Identification Test-Consumption+ (AUDIT-C+, over 3 months, women ≥ 3; men ≥ 4). We calculated adjusted odds ratios (AOR) for unhealthy drinking per month since baseline, and interactions of month since baseline with perceived health, number of HIV symptoms, antiretroviral therapy (ART), gender and self-reported prior unhealthy alcohol use.

FINDINGS

The majority of participants (64%) were unhealthy drinkers (PEth+ or AUDIT-C+) at baseline. There was no significant trend in unhealthy drinking overall [per-month AOR: 1.01; 95% confidence interval (CI) = 0.94-1.07], while the per-month AORs were 0.91 (95% CI = 0.83-1.00) and 1.11 (95% CI = 1.01-1.22) when participants were not yet on ART and on ART, respectively (interaction P-value < 0.01). In contrast, 44% were AUDIT-C+; the per-month AORs for being AUDIT-C+ were 0.89 (95% CI = 0.85-0.95) overall, and 0.84 (95% CI = 0.78-0.91) and 0.97 (95% CI = 0.89-1.05) when participants were not on and were on ART, respectively.

CONCLUSIONS

Unhealthy alcohol use among Ugandan adults entering HIV care declines prior to the start of anti-retroviral therapy but rebounds with time. Augmenting self-reported alcohol use with biomarkers increases the ability of current alcohol use measurements to detect unhealthy alcohol use.

Implementation of integrated stepped care for unhealthy alcohol use in HIV clinics

Background

Effective counseling and pharmacotherapy for unhealthy alcohol use are rarely provided in HIV treatment settings to patients. Our goal was to describe factors influencing implementation of a stepped care model to address unhealthy alcohol use in HIV clinics from the perspectives of social workers, psychologists and addiction psychiatrists.

Methods

We conducted two focus groups with Social Workers (n = 4), Psychologists (n = 2), and Addiction Psychiatrists (n = 4) involved in an ongoing randomized controlled trial evaluating the effectiveness of integrated stepped care for unhealthy alcohol use in HIV-infected patients at five Veterans Health Administration (VA) HIV clinics. Data collection and analyses were guided by the Consolidated Framework for Implementation Research (CFIR) domains, with a focus on the three domains which we considered to be most relevant: intervention characteristics (i.e. motivational interviewing, pharmacotherapy), the inner setting (i.e. HIV clinics), and characteristics of individuals (i.e. the providers). A multidisciplinary team used directed content analysis to identify major themes.

Results

From the providers’ perspective, the major implementation themes that emerged by CFIR domain included: (1) Intervention characteristics: providers valued tools and processes for facilitating patient motivation for treatment of unhealthy alcohol use given their perceived lack of motivation, but expressed a desire for greater flexibility; (2) Inner setting: treating unhealthy alcohol use in HIV clinics was perceived by providers to be consistent with VA priorities; and (3) Characteristics of individuals: there was high self-efficacy to conduct the intervention, an expressed need for more consistent utilization to maintain skills, and consideration of alternative models for delivering the components of the intervention.

Conclusions

Use of the CFIR framework reveals that implementation of integrated stepped care for unhealthy alcohol use in HIV clinics is facilitated by tools to help providers enhance patient motivation or address unhealthy alcohol use among patients perceived to be unmotivated. Implementation may be facilitated by its consistency with organizational values and existing models of care and attention to optimizing provider self-efficacy and roles (i.e. approaches to treatment integration).

Brief Intervention Decreases Drinking Frequency in HIV-Infected, Heavy Drinking Women: Results of a Randomized Controlled Trial

OBJECTIVE

Hazardous alcohol use by HIV-infected women is associated with poor HIV outcomes and HIV transmission risk behaviors. We examined the effectiveness of brief alcohol intervention (BI) among hazardous drinking women receiving care in an urban HIV clinic.

METHODS

Women were randomized to a 2-session BI or usual care. Outcomes assessed at baseline, 3, 6, and 12 months included 90-day frequency of any alcohol use and heavy/binge drinking (≥4 drinks per occasion), and average drinks per drinking episode. Secondary outcomes included HIV medication and appointment adherence, HIV-1 RNA suppression, and days of unprotected vaginal sex. We examined intervention effectiveness using generalized mixed-effect models and quantile regression.

RESULTS

Of 148 eligible women, 74 were randomized to each arm. In mixed-effects models, 90-day drinking frequency decreased among intervention group compared with control, with women in the intervention condition less likely to have a drinking day (odds ratio: 0.42; 95% confidence interval: 0.23 to 0.75). Heavy/binge drinking days and drinks per drinking day did not differ significantly between groups. Quantile regression demonstrated a decrease in drinking frequency in the middle to upper ranges of the distribution of drinking days and heavy/binge drinking days that differed significantly between intervention and control conditions. At follow-up, the intervention group had significantly fewer episodes of unprotected vaginal sex. No intervention effects were observed for other outcomes.

CONCLUSIONS

BI reduces frequency of alcohol use and unprotected vaginal sex among HIV-infected women. More intensive services may be needed to lower drinks per drinking day and enhance care for more severely affected drinkers.

Smartphone applications to reduce alcohol consumption and help patients with alcohol use disorder: a state-of-the-art review

Hazardous drinking and alcohol use disorder (AUD) are substantial contributors to USA and global morbidity and mortality. Patient self-management and continuing care are needed to combat these public health threats. However, services are rarely provided to patients outside of clinic settings or following brief intervention. Smartphone applications (“apps”) may help narrow the divide between traditional health care and patient needs. The purpose of this review is to identify and summarize smartphone apps to reduce alcohol consumption or treat AUD that have been evaluated for feasibility, acceptability, and/or efficacy. We searched two research databases for peer-reviewed journal articles published in English that evaluated smartphone apps to decrease alcohol consumption or treat AUD. We identified six apps. Two of these apps (A-CHESS and LBMI-A) promoted self-reported reductions in alcohol use, two (Promillekoll and PartyPlanner) failed to promote self-reported reductions in alcohol use, and two (HealthCall-S and Chimpshop) require further evaluation and testing before any conclusions regarding efficacy can be made. In summary, few evaluations of smartphone apps to reduce alcohol consumption or treat AUD have been reported in the scientific literature. Although advances in smartphone technology hold promise for disseminating interventions among hazardous drinkers and individuals with AUD, more systematic evaluations are necessary to ensure that smartphone apps are clinically useful.

Use of Technology to Address Substance Use in the Context of HIV: A Systematic Review

Substance users are at elevated risk for HIV. HIV researchers, particularly at the intersection of HIV and substance use, have requested new methods to better understand and address this important area. New technologies, such as social media and mobile applications, are increasingly being used as research tools in studies on HIV and substance use. These technologies have the potential to build on existing recruitment methods, provide new and improved intervention methods, and introduce novel ways of monitoring and predicting new HIV cases. However, little work has been done to review and broadly explore the types of studies being conducted on the use of technologies to address HIV and substance use. This systematic literature review identified studies on this topic between 2005 and 2015. We identified 33 studies on this topic after excluding studies that did not fit inclusion criteria. Studies were either observational (n = 24) or interventional (n = 9), with the majority being pilot studies exploring the feasibility of using these new technologies to study HIV and substance use. We discuss the implications of this work along with limitations and recommendations for future research on this topic.

Using e-technologies in clinical trials

Clinical trials have been slow to incorporate e-technology (digital and electronic technology that utilizes mobile devices or the Internet) into the design and execution of studies. In the meantime, individuals and corporations are relying more on electronic platforms and most have incorporated such technology into their daily lives. This paper provides a general overview of the use of e-technologies in clinical trials research, specifically within the last decade, marked by rapid growth of mobile and Internet-based tools. Benefits of and challenges to the use of e-technologies in data collection, recruitment and retention, delivery of interventions, and dissemination are provided, as well as a description of the current status of regulatory oversight of e-technologies in clinical trials research. As an example of ways in which e-technologies can be used for intervention delivery, a summary of e-technologies for treatment of substance use disorders is presented. Using e-technologies to design and implement clinical trials has the potential to reach a wide audience, making trials more efficient while also reducing costs; however, researchers should be cautious when adopting these tools given the many challenges in using new technologies, as well as threats to participant privacy/confidentiality. Challenges of using e-technologies can be overcome with careful planning, useful partnerships, and forethought. The role of web- and smartphone-based applications is expanding, and the increasing use of those platforms by scientists and the public alike make them tools that cannot be ignored.

Perceived medical risks of drinking, alcohol consumption, and hepatitis C status among heavily drinking HIV primary care patients

BACKGROUND

Heavy drinking poses significant risks to the health and survival of individuals infected with HIV, particularly those coinfected with hepatitis C virus (HCV). However, little is known about patients' perceptions of these risks, and whether these perceptions relate to their alcohol consumption.

METHODS

A sample of 254 heavily drinking HIV primary care patients (78% male; 94.5% minority; 31.8% with HCV) reported on their perceptions of the medical risks of drinking and on their alcohol consumption prior to participation in a drinking-reduction intervention trial.

RESULTS

In the HIV-infected sample as a whole, 62.9% reported that they had a medical problem made worse by drinking, and 64.3% reported restricting drinking to avoid future medical problems. Although patients coinfected with HIV/HCV reported greater efforts to restrict drinking to avoid future medical problems (adjusted odds ratio = 1.94), their reported drinking quantity and frequency did not differ from that of HIV mono-infected patients. Awareness of medical risk was not associated with drinking level. Effort to restrict drinking to avoid medical risk was associated with lower drinking quantity, frequency, and binge frequency (ps < 0.05), but the association with binge frequency was specific to patients without HCV.

CONCLUSIONS

Over one-third of HIV patients are unaware of the medical risks of drinking, and do not restrict use, suggesting the need for intervention in this group. Patients coinfected with HIV/HCV may report more effort to restrict drinking, but their reported drinking quantity and frequency suggest that they are actually drinking just as heavily as HIV mono-infected patients. Awareness of medical risk was unrelated to drinking, which suggests the need for interventions consisting of more than simple education. However, reported effort to restrict drinking did predict less drinking, suggesting the importance of patient commitment and initiative in change.

Electronic Interventions for Alcohol Misuse and Alcohol Use Disorders: A Systematic Review

BACKGROUND

The use of electronic interventions (e-interventions) may improve treatment of alcohol misuse.

PURPOSE

To characterize treatment intensity and systematically review the evidence for efficacy of e-interventions, relative to controls, for reducing alcohol consumption and alcohol-related impairment in adults and college students.

DATA SOURCES

MEDLINE (via PubMed) from January 2000 to March 2015 and the Cochrane Library, EMBASE, and PsycINFO from January 2000 to August 2014.

STUDY SELECTION

English-language, randomized, controlled trials that involved at least 50 adults who misused alcohol; compared an e-intervention group with a control group; and reported outcomes at 6 months or longer.

DATA EXTRACTION

Two reviewers abstracted data and independently rated trial quality and strength of evidence.

DATA SYNTHESIS

In 28 unique trials, the modal e-intervention was brief feedback on alcohol consumption. Available data suggested a small reduction in consumption (approximately 1 drink per week) in adults and college students at 6 months but not at 12 months. There was no statistically significant effect on meeting drinking limit guidelines in adults or on binge-drinking episodes or social consequences of alcohol in college students.

LIMITATIONS

E-interventions that ranged in intensity were combined in analyses. Quantitative results do not apply to short-term outcomes or alcohol use disorders.

CONCLUSION

Evidence suggests that low-intensity e-inter ventions produce small reductions in alcohol consumption at 6 months, but there is little evidence for longer-term, clinically significant effects, such as meeting drinking limits. Future e-interventions could provide more intensive treatment and possibly human support to assist persons in meeting recommended drinking limits.

PRIMARY FUNDING SOURCE

U.S. Department of Veterans Affairs.

Smartphone self-monitoring to support self-management among people living with HIV: perceived benefits and theory of change from a mixed-methods randomized pilot study

BACKGROUND

Self-monitoring by mobile phone applications offers new opportunities to engage patients in self-management. Self-monitoring has not been examined thoroughly as a self-directed intervention strategy for self-management of multiple behaviors and states by people living with HIV (PLH).

METHODS

PLH (n = 50), primarily African American and Latino, were recruited from 2 AIDS services organizations and randomly assigned to daily smartphone (n = 34) or biweekly Web-survey only (n = 16) self-monitoring for 6 weeks. Smartphone self-monitoring included responding to brief surveys on medication adherence, mental health, substance use, and sexual risk behaviors, and brief text diaries on stressful events. Qualitative analyses examine biweekly open-ended user-experience interviews regarding perceived benefits and barriers of self-monitoring, and to elaborate a theoretical model for potential efficacy of self-monitoring to support self-management for multiple domains.

RESULTS

Self-monitoring functions include reflection for self-awareness, cues to action (reminders), reinforcements from self-tracking, and their potential effects on risk perceptions, motivations, skills, and behavioral activation states. Participants also reported therapeutic benefits related to self-expression for catharsis, nonjudgmental disclosure, and in-the-moment support. About one-third of participants reported that surveys were too long, frequent, or tedious. Some smartphone group participants suggested that daily self-monitoring was more beneficial than biweekly due to frequency and in-the-moment availability. About twice as many daily self-monitoring group participants reported increased awareness and behavior change support from self-monitoring compared with biweekly Web-survey only participants.

CONCLUSIONS

Self-monitoring is a potentially efficacious disruptive innovation for supporting self-management by PLH and for complementing other interventions, but more research is needed to confirm efficacy, adoption, and sustainability.

Post-treatment drinking among HIV patients: Relationship to pre-treatment marijuana and cocaine use

BACKGROUND

For individuals with HIV, heavy drinking can pose serious threats to health. Some interventions are effective at reducing drinking in this population, but many HIV-infected heavy drinkers also use marijuana or cocaine. Although these drugs have predicted poor alcohol outcomes in other treatment studies, whether this occurs among HIV patients who drink heavily is unknown.

METHODS

Participants were binge-drinking HIV primary care patients (N=254) enrolled in a randomized trial of three brief drinking interventions over 60 days that varied in intensity. We investigated the relationship of baseline past-year drug use (marijuana-only, cocaine-only, both, neither) to end-of-treatment drinking quantity and frequency. We also evaluated whether the relationship between intervention type and end-of-treatment drinking varied by baseline drug use. Final models incorporated control for patients' demographic and HIV characteristics.

RESULTS

In final models, drinking frequency at the end of treatment did not vary by baseline drug use, but drinking quantity did (X(2)[3] = 13.87, p < 0.01), with individuals using cocaine-only drinking significantly more per occasion (B = 0.32, p < 0.01). Baseline drug use also interacted with intervention condition in predicting end-of-treatment drinking quantity (X(2)[6] = 13.98, p < 0.05), but not frequency, with the largest discrepancies in end-of-treatment drinks per drinking day by intervention intensity among cocaine-only patients.

CONCLUSIONS

In general, HIV patients using cocaine evidenced the highest levels of drinking after alcohol intervention. However, these individuals also evidenced the most pronounced differences in end-of-treatment drinking by intervention intensity. These results suggest the importance of more intensive intervention for individuals using alcohol and cocaine.

The Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 (AUDADIS-5): procedural validity of substance use disorders modules through clinical re-appraisal in a general population sample

BACKGROUND

The purpose of this study was to assess the procedural validity of the substance disorder modules of the lay-administered Alcohol Use Disorder and Associated Disabilities Interview Schedule, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Version (AUDADIS-5) through clinician re-appraisal re-interviews.

METHODS

The study employed a test-retest design among 712 respondents from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III). A clinician-administered, semi-structured interview, the Psychiatric Research Interview for Substance and Mental Disorders, DSM-5 version (PRISM-5) was used as the re-appraisal. Kappa coeffients indicated concordance of the AUDADIS-5 and PRISM-5 for DSM-5 substance use disorder diagnoses, while intraclass correlation coefficients (ICC) indicated concordance on dimensional scales indicating the DSM-5 criteria count for each disorder.

RESULTS

With few exceptions, concordance of the AUDADIS-5 and the PRISM-5 for DSM-5 diagnoses of substance use disorders ranged from fair to good (κ=0.40-0.72). Concordance on dimensional scales was excellent (ICC≥0.75) for the majority of DSM-5 SUD diagnoses, and fair to good (ICC=0.43-0.72) for most of the rest.

CONCLUSIONS

As indicated by concordance with a semi-structured clinician-administered re-appraisal, the procedural validity of the AUDADIS-5 DSM-5 substance use disorder diagnoses found in this study indicates that these AUDADIS-5 diagnoses are useful tools in epidemiologic studies. The considerably stronger concordance of the AUDADIS-5 and PRISM-5 dimensional DSM-5 SUD measures supports a current movement to place more emphasis on dimensional measures of psychopathology, and suggests that such measures may be more informative than binary diagnoses for research, and possibly for clinical purposes as well.

The Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 (AUDADIS-5): reliability of substance use and psychiatric disorder modules in a general population sample

BACKGROUND

The purpose of this study was to assess the test-retest reliability of substance use disorder and psychiatric modules in the Alcohol Use Disorder and Associated Disabilities Interview Schedule, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Version (AUDADIS-5).

METHODS

Kappa and intraclass correlation coefficients were calculated for DSM-5 substance use and psychiatric disorder diagnoses and dimensional criteria scales using a test-retest design among 1006 respondents drawn from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III).

RESULTS

Reliabilities of substance use disorder diagnoses and associated criteria scales were generally good to excellent, while reliabilities for mood, anxiety and trauma and stress-related disorders and associated scales were generally in the fair to good range.

CONCLUSIONS

The observed reliability of the DSM-5 diagnoses and dimensional scales for the substance use and psychiatric disorders found in this study indicates that the AUDADIS-5 can be a useful tool in various research settings, particularly in studies of the general population, the target population for which it was designed.

Efficacy of automated telephone continuing care following outpatient therapy for alcohol dependence

BACKGROUND

Relapse rates following cognitive behavioral therapy (CBT) for alcohol dependence are high. Continuing care programs can prolong therapeutic effects but are underutilized. Thus, there is need to explore options having greater accessibility.

METHODS

This randomized controlled trial tested the efficacy of a novel, fully automated continuing care program, Alcohol Therapeutic Interactive Voice Response (ATIVR). ATIVR enables daily monitoring of alcohol consumption and associated variables, offers targeted feedback, and facilitates use of coping skills. Upon completing 12weeks of group CBT for alcohol dependence, participants were randomly assigned to either four months of ATIVR (n=81) or usual care (n=77). Drinking behavior was assessed pre- and post-CBT, then at 2weeks, 2months, 4months, and 12months post-randomization.

RESULTS

Drinking days per week increased over time for the control group but not the intervention group. There were no significant differences between groups on the other alcohol-related outcome measures. Comparisons on the subset of participants abstinent at the end of CBT (n=72) showed higher rates of continuous abstinence in the experimental group. Effect sizes for the other outcome variables were moderate but not significant in this subgroup.

CONCLUSIONS

For continuing care, ATIVR shows some promise as a tool that may help clients maintain gains achieved during outpatient treatment. However, ATIVR may not be adequate for clients who have not achieved treatment goals at the time of discharge.

Efficacy of an alcohol-focused intervention for improving adherence to antiretroviral therapy (ART) and HIV treatment outcomes - a randomised controlled trial protocol

Background

Little research has examined whether alcohol reduction interventions improve antiretroviral therapy (ART) adherence and HIV treatment outcomes. This study assesses the efficacy of an intervention for reducing alcohol use among HIV patients on ART who are hazardous/harmful drinkers. Specific aims include adapting a blended Motivational Interviewing (MI) and Problem Solving Therapy (PST) intervention for use with HIV patients; evaluating the efficacy of the intervention for reducing alcohol consumption; and assessing counsellors’ and participants’ perceptions of the intervention.

Methods/Design

A randomised controlled trial will evaluate the intervention among ART patients in public hospital-based HIV clinics in Tshwane, South Africa. We will recruit patients who are HIV-positive, on ART for at least 3 months, and classified as harmful/hazardous drinkers using the AUDIT-3. Eligible patients will be randomly assigned to one of three conditions. Patients in the experimental group will receive the MI-PST intervention to reduce harmful/hazardous alcohol use. Patients in the equal-attention wellness intervention group will receive an intervention focused on addressing health risk behaviours. Patients in the control condition will receive treatment as usual. Participants will complete an interviewer-administered questionnaire at baseline and 3, 6 and 12 months post-randomisation to assess alcohol consumption, ART adherence, physical and mental health. We will also collect biological specimens to test for recent alcohol consumption, CD4 counts and HIV RNA viral loads. The primary outcome will be reduction in the volume of alcohol consumed. Secondary outcomes include reduction in harmful/hazardous use of alcohol, reduction in biological markers of drinking, increase in adherence rates, reductions in viral loads, and increases in CD4 T-cell counts. A process evaluation will ascertain counsellors’ and participants’ perceptions of the acceptability and effectiveness of the interventions.

Discussion

We have obtained ethical approval and approval from the study sites and regional and provincial health departments. The study has implications for clinicians, researchers and policy makers as it will provide efficacy data on how to reduce harmful/hazardous alcohol consumption among HIV patients and will shed light on whether reducing alcohol consumption impacts on HIV treatment adherence and other outcomes.

Trial registration

Pan African Clinical Trials Register Number: PACTR201405000815100.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2334-14-500) contains supplementary material, which is available to authorized users.

Drinking motives among HIV primary care patients

Heavy drinking among individuals with HIV is associated with poor medication adherence and other health problems. Understanding reasons for drinking (drinking motives) in this population is therefore important and could inform intervention. Using concepts of drinking motives from previous alcohol research, we assessed these motives and drinking in 254 HIV-positive primary care patients (78.0 % male; 94.5 % African American or Hispanic) prior to their participation in an alcohol intervention trial. Three motives had good factor structure and internal consistency: "drinking to cope with negative affect", "drinking for social facilitation" (both associated with heavier drinking), and "drinking due to social pressure" (associated with less drinking). Drinking motives may provide important content for alcohol intervention; clinical trials could indicate whether inclusion of such content improves intervention efficacy. Discussing motives in session could help providers assist clients in better managing psychological and social aspects of their lives without reliance on alcohol.

The Use of New Communications Technologies to Evaluate and Intervene in Substance Use Disorders

The widespread availability of high speed, mobile cellular telephones and other advances in communication technology have the potential to change the way that interventions for substance use disorders (SUD) are delivered and how progress is monitored. This article reviews recent research on the use of new technology to monitor progress and deliver interventions for SUD. Several studies of telephone-based interventions show positive effects, but sometimes only in certain subgroups. However, other studies produced negative results. Studies support the use of interactive voice response (IVR) and personal digital assistants (PDAs) to conduct assessments, but there is little data on whether IVR- or PDA-based interventions improve outcomes. Text messaging has received comparatively little research, but appears promising as a means to conduct assessments and deliver automated interventions. Finally, smartphone technology provides the widest range of features and interventions and the greatest flexibility, but few intervention studies that use them have been conducted.

Reasons for limiting drinking in an HIV primary care sample

BACKGROUND

Heavy drinking among individuals with HIV is associated with major health concerns (liver disease, medication nonadherence, immune functioning), but little is known about cognitive-motivational factors involved in alcohol consumption in this population, particularly reasons for limiting drinking.

METHODS

Urban HIV primary care patients (N = 254; 78.0% male; 94.5% African American or Hispanic) in a randomized trial of brief drinking-reduction interventions reported on reasons for limiting drinking, alcohol consumption, and alcohol dependence symptoms prior to intervention.

RESULTS

Exploratory factor analysis indicated 3 main domains of reasons for limiting drinking: social reasons (e.g., responsibility to family), lifestyle reasons (e.g., religious/moral reasons), and impairment concerns (e.g., hangovers). These factors evidenced good internal consistency (αs = 0.76 to 0.86). Higher scores on social reasons for limiting drinking were associated with lower typical quantity, maximum quantity, and binge frequency (ps < 0.01), and higher scores on lifestyle reasons were associated with lower maximum quantity, binge frequency, and intoxication frequency (ps < 0.01). In contrast, higher scores on impairment concerns were associated with more frequent drinking and intoxication, and higher risk of alcohol dependence (ps < 0.05), likely because dependent drinkers are more familiar with alcohol-induced impairment.

CONCLUSIONS

The current study is the first to explore reasons for limiting drinking among individuals with HIV and how these reasons relate to alcohol involvement. This study yields a scale that can be used to assess reasons for limiting drinking among HIV-positive drinkers and provides information that can be used to enhance interventions with this population. Discussing social and lifestyle reasons for limiting drinking among less extreme drinkers may support and validate these patients' efforts to limit engagement in heavy drinking; discussion of impairment reasons for limiting drinking may be a way to engage dependent drinkers in efforts to decrease their alcohol consumption.

HealthCall for the smartphone: technology enhancement of brief intervention in HIV alcohol dependent patients

Background

Heavy drinking jeopardizes the health of patients in HIV primary care. In alcohol dependent patients in HIV primary care, a technological enhancement of brief intervention, HealthCall administered via interactive voice response (HealthCall-IVR) was effective at reducing heavy drinking. The smartphone offered a technology platform to improve HealthCall.

Methods

Working with input from patients, technology experts, and HIV clinic personnel, we further developed HealthCall, harnessing smartphone technological capacities (HealthCall-S). In a pilot study, we compared rates of HealthCall-S daily use and drinking outcomes in 41 alcohol dependent HIV-infected patients with the 43 alcohol dependent HIV-infected patients who used HealthCall-IVR in our previous efficacy study. Procedures, clinic, personnel, and measures were largely the same in the two studies, and the two groups of patients were demographically similar (~90% minority).

Results

Pilot patients used HealthCall-S a median of 85.0% of the 60 days of treatment, significantly greater than the corresponding rate (63.8%) among comparison patients using HealthCall-IVR (p < .001). Mean end-of-treatment drinks per drinking day was similar in the two groups. Patients were highly satisfied with HealthCall-S (i.e., 92% reported that they liked using HealthCall-S).

Conclusions

Among alcohol dependent patients in HIV primary care, HealthCall delivered via smartphone is feasible, obtains better patient engagement than HealthCall-IVR, and is associated with decreased drinking. In HIV primary care settings, HealthCall-S may offer a way to improve drinking outcomes after brief intervention by extending patient engagement with little additional demands on staff time.

Commitment strength, alcohol dependence and HealthCall participation: effects on drinking reduction in HIV patients

BACKGROUND

The role of three factors in drinking outcome after brief intervention among heavily drinking HIV patients were investigated: strength of commitment to change drinking, alcohol dependence, and treatment type: brief Motivational Interview (MI) only, or MI plus HealthCall, a technological extension of brief intervention.

METHODS

HIV primary care patients (N=139) who drank ≥4 drinks at least once in the 30 days before study entry participated in MI-only or MI+HealthCall in a randomized trial to reduce drinking. Patients were 95.0% minority; 23.0% female; 46.8% alcohol dependent; mean age 46.3. Outcome at end of treatment (60 days) was drinks per drinking day (Timeline Follow-Back). Commitment strength (CS) was rated from MI session recordings.

RESULTS

Overall, stronger CS predicted end-of-treatment drinking (p<.001). After finding an interaction of treatment, CS and alcohol dependence (p=.01), we examined treatment×CS interactions in alcohol dependent and non-dependent patients. In alcohol dependent patients, the treatment×commitment strength interaction was significant (p=.006); patients with low commitment strength had better outcomes in MI+HealthCall than in MI-only (lower mean drinks per drinking day; 3.5 and 4.6 drinks, respectively). In non-dependent patients, neither treatment nor CS predicted outcome.

CONCLUSIONS

Among alcohol dependent HIV patients, HealthCall was most beneficial in drinking reduction when MI ended with low commitment strength. HealthCall may not merely extend MI effects, but add effects of its own that compensate for low commitment strength. Thus, HealthCall may also be effective when paired with briefer interventions requiring less skill, training and supervision than MI. Replication is warranted.

Drinking motives as prospective predictors of outcome in an intervention trial with heavily drinking HIV patients

BACKGROUND

Heavy alcohol consumption in HIV patients is an increasing health concern. Applying the drinking motivational model to HIV primary care patients, drinking motives (drinking to cope with negative affect, for social facilitation, and in response to social pressure) were associated with alcohol consumption at a baseline interview. However, whether these motives predict continued heavy drinking or alcohol dependence in this population is unknown.

METHODS

Participants were 254 heavy-drinking urban HIV primary care patients (78.0% male; 94.5% African American or Hispanic) participating in a randomized trial of brief drinking-reduction interventions. Drinking motive scales, as well as measures of alcohol consumption and alcohol dependence, were administered at baseline. Consumption and dependence measures were re-administered at the end of treatment two months later. Regression analyses tested whether baseline drinking motive scale scores predicted continued heavy drinking and alcohol dependence status at the end of treatment, and whether motives interacted with treatment condition.

RESULTS

Baseline drinking to cope with negative affect predicted continued heavy drinking (p<0.05) and alcohol dependence, the latter in both in the full sample (adjusted odds ratio [AOR]=2.14) and among those with baseline dependence (AOR=2.52). Motives did not interact with treatment condition in predicting alcohol outcomes.

CONCLUSIONS

Drinking to cope with negative affect may identify HIV patients needing targeted intervention to reduce drinking, and may inform development of more effective interventions addressing ways other than heavy drinking to cope with negative affect.