Addressing Unhealthy Alcohol Use and the HIV Pre-exposure Prophylaxis Care Continuum in Primary Care: A Scoping Review

Medical chart-reported alcohol consumption, substance use, and mental health issues in association with HIV pre-exposure prophylaxis (PrEP) nonadherence among gay, bisexual, and other men-who-have-sex-with-men

BACKGROUND

Although some evidence suggests that alcohol, substance use, and mental health issues diminish adherence to HIV Pre-Exposure Prophylaxis (PrEP) among gay, bisexual, and other men-who-have-sex-with-men (gbMSM), findings are somewhat inconsistent and have primarily derived from studies involving non-random samples. Medical chart extraction can provide unique insight by in part surmounting sampling-related limitations, as data for entire PrEP clinic populations can be examined. Our investigation entailed comprehensive chart extraction to assess the extent to which chart-reported alcohol, substance use, and mental health issues were associated with chart-reported PrEP nonadherence.

METHODS

Data from medical charts of gbMSM at two PrEP clinics in Toronto, Canada were extracted for a retrospective 12-month period (02/2018-01/2019). Charts were reviewed for all patients who were 1) ≥ 18 years old; 2) gbMSM; 3) prescribed PrEP ≥ 3 months, and 4) not in a PrEP-related drug trial. Information regarding PrEP, alcohol, substance use, mental health, and sexual behavior was extracted. PrEP adherence was classified in terms of (1) any reported nonadherence, and (2) 'suboptimal adherence,' reflecting nonadherence patterns indicative of insufficient pharmacological protection from HIV. Multivariate logistic regression was employed to identify factors associated with adherence outcomes.

RESULTS

Data were extracted from 4,292 clinic visits among 501 eligible patients (age: M = 39.1; duration on PrEP: M = 17.4 months; daily PrEP regimen = 93.8%). Hazardous/harmful drinking, club drug use, and mental health issues were reported among 8.8%, 22.2%, and 26.1% of patients, respectively. Any nonadherence and suboptimal adherence were reported among 37.5% and 12.4% of patients, respectively. Factors significantly associated with any nonadherence included age < 25 (AOR = 3.08, 95%CI = 1.54-6.15, p < .001), club drug use (AOR = 2.71, 95%CI = 1.65-4.47, p < .001), and condomless sex (AOR = 1.83, 95%CI = 1.19-2.83, p = .006). For suboptimal adherence, significant factors included age < 25 (AOR = 4.83, 95%CI = 2.28-10.22, p < .001), non-daily PrEP regimens (AOR = 2.94, 95%CI = 1.19-7.22, p = .019), missing PrEP appointments (AOR = 1.97, 95%CI = 1.09-3.55, p = .025), and club drug use (AOR = 1.97, 95%CI = 1.01-3.68, p = .033). Neither alcohol nor mental health issues were associated with nonadherence outcomes.

CONCLUSIONS

Chart-indicated suboptimal adherence was present among a small subgroup of PrEP-prescribed gbMSM. Adherence-related interventions should target gbMSM who use club drugs, are younger, experience challenges attending PrEP care, and are prescribed non-daily regimens. Offering long-acting injectable PrEP when available and feasible may also improve PrEP's HIV-preventive impact among this population.

A Brief Alcohol Intervention (BAI) to reduce alcohol use and improve PrEP outcomes among men who have sex with men in Vietnam: study protocol for a randomized controlled trial

BACKGROUND

In Vietnam and other global settings, men who have sex with men (MSM) have become the population at greatest risk of HIV infection. Although HIV pre-exposure prophylaxis (PrEP) has been implemented as a prevention strategy, PrEP outcomes may be affected by low persistence and adherence among MSM with unhealthy alcohol use. MSM have a high prevalence of unhealthy alcohol use in Vietnam, which may affect PrEP outcomes.

METHODS

Design: We will conduct a two-arm hybrid type 1 effectiveness-implementation randomized controlled trial of a brief alcohol intervention (BAI) compared to the standard of care (SOC) at the Sexual Health Promotion (SHP) clinic Hanoi, Vietnam.

PARTICIPANTS

Sexually active MSM (n=564) who are newly initiating PrEP or re-initiating PrEP and have unhealthy alcohol use will be recruited and randomized 1:1 to the SOC or BAI arm. A subgroup of participants (n=20) in each arm will be selected for longitudinal qualitative interviews; an additional subset (n=48) in the BAI arm will complete brief quantitative and qualitative interviews after completion of the BAI to assess the acceptability of the intervention. Additional implementation outcomes will be assessed through interviews with clinic staff and stakeholders (n=35).

INTERVENTION

Study participants in both arms will receive standard care for PrEP clients. In the BAI arm, each participant will receive two face-to-face intervention sessions and two brief booster phone sessions, based on cognitive behavioral therapy and delivered in motivational interviewing informed style, to address their unhealthy alcohol use.

OUTCOMES

Effectiveness (PrEP and alcohol use) and cost-effectiveness outcomes will be compared between the two arms. Intervention implementation outcomes (acceptability, feasibility, adoption) will be assessed among MSM participants, clinic staff, and stakeholders.

DISCUSSION

This proposed trial will assess an alcohol intervention for MSM with unhealthy alcohol use who initiate or re-initiate PrEP, while simultaneously preparing for subsequent implementation. The study will measure the effectiveness of the BAI for increasing PrEP persistence through reducing unhealthy alcohol use in a setting where excessive alcohol consumption is a normative behavior. If effective, implementation-focused results will inform future scale-up of the BAI in similar settings.

TRIAL REGISTRATION

NCT06094634 on clinicaltrials.gov. Registered 16 October 2023.

Prevalence of substance and hazardous alcohol use and their association with risky sexual behaviour among youth: findings from a population-based survey in Zimbabwe

OBJECTIVES

Hazardous drinking (HD) and substance use (SU) can lead to disinhibited behaviour and are both growing public health problems among Southern African youths. We investigated the prevalence of SU and HD and their association with risky sexual behaviour among youth in Zimbabwe.

DESIGN

Data analysis from a population-based survey conducted between October 2021 and June 2022 to ascertain the outcomes of a cluster randomised trial (CHIEDZA: Trial registration number:NCT03719521). Trial Stage: Post-results.

SETTING

24 communities in three provinces in Zimbabwe.

PARTICIPANTS

Youth aged 18-24 years living in randomly selected households.

OUTCOME MEASURES

HD was defined as an Alcohol Use Disorders Identification Test score ≥8, SU was defined as ever use of ≥1 commonly used substances in the local setting.

RESULTS

Of 17 585 participants eligible for this analysis, 61% were women and the median age was 20 (IQR: 19-22) years. Overall, 4.5% and 7.0% of participants reported HD and SU, respectively. Men had a substantially higher prevalence than women of HD (8.2% vs 1.9%) and SU (15.1% vs 1.5%). Among men, after adjusting for socio-demographic factors, we found increased odds of having >1 sexual partner in those who engaged in SU (adjusted OR (aOR)=2.67, 95% CI: 2.21 to 3.22), HD (aOR=3.40, 95% CI: 2.71 to 4.26) and concurrent HD and SU (aOR=4.57,95% CI: 3.59 to 5.81) compared with those who did not engage in HD or SU. Similarly, there were increased odds of receiving/providing transactional sex among men who engaged in SU (aOR=2.51, 95% CI: 1.68 to 3.74), HD (aOR=3.60, 95% CI: 2.24 to 5.79), and concurrent HD and SU (aOR=7.74, 95% CI: 5.44 to 11.0). SU was associated with 22% increased odds of inconsistent condom use in men (aOR=1.22, 95% CI: 1.03 to 1.47). In women, the odds of having >1 sexual partner and having transactional sex were also increased among those who engaged in SU and HD.

CONCLUSION

SU and HD are associated with sexual behaviours that increase the risk of HIV acquisition in youth. Sexual and reproductive health interventions must consider HD and SU as potential drivers of risky sexual behaviour in youths.

Perspectives on unhealthy alcohol use among men who have sex with men prescribed HIV pre-exposure prophylaxis: A qualitative study

Unhealthy alcohol use is a common, often unaddressed behavior associated with increased risk for acquisition of HIV and may also be associated with decreased adherence to oral pre-exposure prophylaxis (PrEP) among gay, bisexual, and other men who have sex with men (MSM) living in the United States. To inform future alcohol-reduction interventions among individuals engaging in PrEP care, we sought to explore perspectives on alcohol use, PrEP adherence, and the acceptability of alcohol use treatment options for MSM prescribed oral formulations of PrEP in the Northeastern United States. Between February 2019 and July 2020, we conducted semi-structured interviews with 15 MSM without HIV who were prescribed PrEP and screened positive for unhealthy alcohol use with AUDIT-C ≥ 4 and were receiving care in Providence, Rhode Island or New Haven, Connecticut. Interviews were coded and analyzed using thematic analysis. Three themes emerged: 1) Consequences of fluctuations in drinking 2) Alcohol use negatively impacts health and relationships; and 3) Desire for a multimodal approach to treatment of unhealthy alcohol use. Our findings support the need to raise awareness of potential alcohol-related harms, address the spectrum of unhealthy alcohol use among MSM prescribed PrEP, and the acceptability and preferences for alcohol reduction interventions within PrEP programs.

Interventions to Reduce Alcohol Use and HIV Risk among Sexual and Gender Minority Populations: a Systematic Review

PURPOSE OF REVIEW

Sexual and gender minority (SGM) individuals are diagnosed with HIV at disproportionate rates, and hazardous alcohol use can increase their HIV risk. This review assessed the state of the literature examining interventions for addressing alcohol use and sexual HIV risk behaviors among SGM individuals.

RECENT FINDINGS

Fourteen manuscripts from 2012 to 2022 tested interventions that address both alcohol use and HIV risk behaviors among SGM populations, with only 7 randomized controlled trials (RCTs). Virtually all the interventions targeted men who have sex with men, with none focused on transgender populations or cisgender women. While they demonstrated some evidence of effectiveness in reducing alcohol use and/or sexual risk, the outcomes varied widely between studies. More research is needed that tests interventions in this area, particularly for transgender individuals. The use of larger-scale RCTs with diverse populations and standardized outcome measures are needed to strengthen the evidence base.

Sexual Risk among Pregnant Women at Risk of HIV Infection in Cape Town, South Africa: What Does Alcohol Have to Do with It?

This study examines baseline associations between alcohol use and HIV sexual risk among a cohort of HIV-uninfected pregnant women (n = 1201) residing in a high HIV burdened community in Cape Town, South Africa. Alcohol use was measured using a modified version of the Alcohol Use Disorder Identification Test (AUDIT). HIV sexual risk was measured through a composite variable of four risk factors: diagnosis with a STI, self-report of > 1 recent sex partners, partner HIV serostatus (unknown or HIV+) and condomless sex at last sex. Any past year alcohol use prior to pregnancy was reported by half of participants (50%); 6.0% reported alcohol use during pregnancy. Alcohol use prior to pregnancy was associated with increased odds of being at high risk of HIV (aOR = 1.33, 95% CI 1.05-1.68, for 2 risks and aOR = 1.47, 95% CI 0.95-2.27 for 3 risks). In addition to reducing alcohol use, several other strategies to address HIV sexual risk were identified. Evidence-based interventions to address alcohol use and other HIV sexual risk behaviors during pregnancy in South Africa are desperately needed. Qualitative work exploring individual and community level drivers of alcohol use among pregnant and breastfeeding women in this setting could support development of a culturally tailored intervention to address these issues in this population.

Barriers and Facilitators to HIV Pre-Exposure Prophylaxis Uptake Among Men Who have Sex with Men Who Use Stimulants: A Qualitative Study

The HIV epidemic disproportionately impacts men who have sex with men (MSM), particularly those who use stimulants. We explored barriers and facilitators to pre-exposure prophylaxis (PrEP) uptake among this population. From June 2018 through February 2019, we conducted semi-structured interviews in Providence, Rhode Island, and New Haven, Connecticut, with 21 MSM who reported recent (past six months) stimulant use. We identified individual, interpersonal, and structural barriers to PrEP, including: (1) high awareness but mixed knowledge of PrEP, resulting in concerns about side effects and drug interactions; (2) interest that was partly determined by substance use and perceived HIV risk; (3) fragmented and constrained social networks not conducive to disseminating PrEP information; and (4) PrEP access, such as insurance coverage and cost. Our findings suggest potential approaches to increase PrEP uptake in this group, including promotion through mainstream and social media, clarifying misinformation, and facilitating increased access through structural interventions.

Substance Use and Healthcare Utilization Across the Pre-Exposure Prophylaxis (PrEP) Care Cascade among Black and Latino Men Who Have Sex with Men

Background: Despite the documented efficacy of pre-exposure prophylaxis (PrEP) for HIV prevention, large disparities in uptake and adherence exist among Black and Latino/Hispanic men who have sex with men (BLMSM). Limited data exists among BLMSM on the impact of substance use at different stages of the PrEP Care Cascade. We examined the ways substance (alcohol, cannabis, other drug) use is related to PrEP experiences across the PrEP Care Cascade (PrEP aware/no use; PrEP use/discontinuation; PrEP use/adherent).Methods: We utilized data from a national sample of 908 BLMSM (Mage = 25.17, range: 18-29), collected between February and October 2020.Results: We found that heavier alcohol use, more other drug (e.g., cocaine) use, more participant healthcare utilization, and higher number of partners across all measures of substance use were separately associated with a lower likelihood of being aware of PrEP. These same factors were also associated with a higher likelihood of PrEP adherence. Conversely, only cannabis use was associated with discontinuation of PrEP use.Conclusions: While we confirm some earlier findings (i.e., alcohol use is associated with both PrEP discontinuation and PrEP use), we newly identify cannabis as a barrier to the adherence of PrEP. Our findings highlight the need for improved PrEP interventions to increase awareness among BLMSM with substance use who are among the most at-risk for HIV infection.

Determinants of Implementation for HIV Pre-exposure Prophylaxis Based on an Updated Consolidated Framework for Implementation Research: A Systematic Review

BACKGROUND

Delivery and use of HIV pre-exposure prophylaxis (PrEP) are suboptimal in the United States. Previous reviews of barriers and facilitators have not used an implementation science lens, limiting comprehensiveness and the link to implementation strategies. To summarize the state of the science, we systematically reviewed determinants of PrEP implementation using the updated Consolidated Framework for Implementation Research (CFIR 2.0).

SETTING

PrEP-eligible communities and delivery settings in the United States.

METHODS

In January 2021, we searched Ovid MEDLINE, PsycINFO, and Web of Science for peer-reviewed articles related to HIV/AIDS, interventions, implementation, and determinants or strategies. We identified 286 primary research articles published after 1999 about US-based PrEP implementation. Team members extracted discrete "mentioned" and "measured" determinants, coding each by setting, population, valence, measurement, and CFIR 2.0 construct.

RESULTS

We identified 1776 mentioned and 1952 measured determinants from 254 to 239 articles, respectively. Two-thirds of measured determinants were of PrEP use by patients as opposed to delivery by providers. Articles contained few determinants in the inner setting or process domains (ie, related to the delivery context), even among studies of specific settings. Determinants across priority populations also focused on individual patients and providers rather than structural or logistical factors.

CONCLUSION

Our findings suggest substantial knowledge in the literature about general patient-level barriers to PrEP use and thus limited need for additional universal studies. Instead, future research should prioritize identifying determinants, especially facilitators, unique to understudied populations and focus on structural and logistical features within current and promising settings (eg, pharmacies) that support integration of PrEP into clinical practice.

Game Plan-a Brief Web-Based Intervention to Improve Uptake and Use of HIV Pre-exposure Prophylaxis (PrEP) and Reduce Alcohol Use Among Gay and Bisexual Men: Content Analysis

Background

HIV pre-exposure prophylaxis (PrEP) has considerable potential for reducing incidence among high-risk groups, such as gay, bisexual, and other men who have sex with men (GBM). However, PrEP’s effectiveness is closely linked with consistent use, and a variety of individual-level barriers, including alcohol use, could impede optimal uptake and use. Web-based interventions can encourage medication adherence, HIV prevention behaviors, and responsible drinking and may help support PrEP care, particularly in resource-limited settings.

Objective

We previously developed a web application called Game Plan that was designed to encourage heavy drinking GBM to use HIV prevention methods and reduce their alcohol use and was inspired by brief motivational interventions. This paper aims to describe the web-based content we designed for integration into Game Plan to help encourage PrEP uptake and consistent use among GBM. In this paper, we also aim to describe this content and its rationale.

Methods

Similar to the original site, these components were developed iteratively, guided by a thorough user-centered design process involving consultation with subject-matter experts, usability interviews and surveys, and user experience surveys.

Results

In addition to Game Plan’s pre-existing content, the additional PrEP components provide specific, personal, and digestible feedback to users about their level of risk for HIV without PrEP and illustrate how much consistent PrEP use could reduce it; personal feedback about their risk for common sexually transmitted infections to address low-risk perceptions; content challenging common beliefs and misconceptions about PrEP to reduce stigma; content confronting familiar PrEP and alcohol beliefs; and a change planning module that allows users to select specific goals for starting and strategies for consistent PrEP use. Users can opt into a weekly 2-way SMS text messaging program that provides similar feedback over a 12-week period after using Game Plan and follows up on the goals they set.

Conclusions

Research preliminarily testing the efficacy of these components in improving PrEP outcomes, including uptake, adherence, sexually transmitted infection rates, and alcohol use, is currently ongoing. If supported, these components could provide a scalable tool that can be used in resource-limited settings in which face-to-face intervention is difficult.

Game Plan, a Web-Based Intervention to Improve Adherence and Persistence to HIV Pre-exposure Prophylaxis and Reduce Heavy Drinking in Gay, Bisexual, and Other Men Who Have Sex With Men: Usability and User Experience Testing

Background

Encouraging consistent use of pre-exposure prophylaxis (PrEP) is essential for reducing HIV incidence, particularly among gay, bisexual, and other men who have sex with men (GBM), and especially those who engage in heavy drinking. Although practice guidelines recommend providing adherence counseling to PrEP patients, clinics and providers may not have the resources or expertise to provide it. Internet-facilitated interventions have been shown to improve HIV prevention outcomes, including medication and care adherence. Game Plan is a website we created to help users make a tangible plan for reducing their HIV risk. We designed additional components of Game Plan to address key individual level barriers to PrEP use.

Objective

The aim of this mixed methods research is to test the usability and user experience of these components with intended users: GBM who drink heavily and are on PrEP.

Methods

In study 1 (usability), we completed a detailed individual interview in which participants (n=10) walked through a prototype of the website, thinking aloud as they did, and completed a follow-up interview and web-based survey afterward. Study 2 (user experience) involved providing participants (n=40) with a link to the prototype website to explore on their own and asking them to complete the same follow-up survey afterward. Qualitative data were analyzed using thematic analysis, and descriptive statistics were used to analyze quantitative data.

Results

Users in both studies gave the website excellent ratings for usability, overall satisfaction, and quality, and most often described the site as informative, helpful, and supportive. Users also rated the site’s content and feel as respectful of them and their autonomy, empathetic, and they stated that it conveyed confidence in their ability to change. The study 1 interviews highlighted the importance of the website’s esthetics to the participants’ engagement with it and its credibility in prompting genuine reflection.

Conclusions

GBM who reported heavy drinking and used PrEP generally found a website focused on helping them to create a plan to use PrEP consistently to be helpful. Adopting user-centered design methods and attending to the esthetics of mobile health interventions are important steps toward encouraging engagement and reducing at-risk behaviors.