Alcohol-Antiretroviral Therapy Interactive Toxicity Beliefs and Intentional Medication Nonadherence: Review of Research with Implications for Interventions

Perceived sensitivity to medicines and medication concerns beliefs predict intentional nonadherence to antiretroviral therapy among young people living with HIV

Objective: Among the sources of antiretroviral therapy (ART) nonadherence are patient decisions to skip or stop taking their medications, often stemming from medication beliefs and concerns about side- effects. While individuals who perceive greater sensitivity to medicines may be prone to medication concerns, understanding how these factors contribute to HIV treatment adherence requires further research. The current study tested the direct and indirect effects of perceived sensitivity to medicines on intentional nonadherence to ART, and whether medication concerns mediate this association.

Methods: A sample of 418 younger (< 36 years of age) people living with HIV was recruited through community outreach to complete assessments of perceived sensitivity to medicines, medication concerns beliefs, adherence assessed by unannounced phone- based pill counts and HIV viral load, as well as monthly follow- up assessments of intentional nonadherence over a 15- month period.

Results: Analyses at baseline and prospective Poisson regression models conducted over 15- months converged to show that perceived sensitivity to medicines significantly predicted intentional nonadherence to ART through medication concerns.

Conclusions: These findings suggest that people who perceive greater sensitivity to medicines are prone to greater medication concerns that are related to intentional nonadherence. Cognitive behavioral interventions are needed to resolve medication concerns and reduce intentional nonadherence among people receiving ART.

Daily Associations Between Alcohol Consumption and Antiretroviral Therapy (ART) Adherence Among HIV-Positive Men Who Have Sex With Men

Alcohol consumption is one of the strongest predictors of suboptimal adherence to antiretroviral therapy (ART), however, there is little research that has investigated both within- and between-person associations of alcohol consumption and ART adherence at the event-level. In this secondary data-analysis, (N = 22) HIV-positive MSM prospectively reported daily alcohol consumption and ART adherence for 42-days. Multilevel models demonstrated (1) days in which participants reported consuming any alcohol was associated with 2.48 increased odds of ART non-adherence, compared to days in which participants reported no alcohol consumption, and (2) there was a non-significant trend indicating days in which participants reported consuming greater than their own average levels of alcohol was associated with increased odds of ART non-adherence. Findings highlight the importance of combining intervention efforts that address alcohol consumption and suboptimal ART adherence, and indicate a need for future research to investigate the mechanisms by which alcohol influences ART adherence.

Gender and Context Matter: Behavioral and Structural Interventions for People Who Use Alcohol and Other Drugs in Africa

Heavy alcohol consumption and other drug use are prominent across Africa and increase the risk of exposure to violence, HIV acquisition, and other life-threatening injuries. This review synthesizes evidence on alcohol and other drug (AOD) interventions in Africa; evaluates the differences between interventions that do and do not specifically target populations that use AODs; and highlights the impact of comprehensive vs. brief interventions and those that address syndemic issues from a gender and contextualized lens. Literature searches were conducted to identify research outcomes of randomized interventions published between January 2010 and May 2022 that address AOD use in Africa. Thirty-five full-text articles were included in this review. Most of the identified research studies were concentrated in a few countries. Most studies were conducted in South Africa. Many of the studies comprised brief interventions. However, the most comprehensive interventions were the most effective for AOD outcomes. Several studies indicated the importance of addressing AOD use alongside gender-based violence, mental health needs, gender roles, and other social determinants that affect health outcomes. Intervening on AOD use and addressing social determinants from a gender and contextually relevant perspective is essential to ensuring the long-term health and well-being of people in Africa.

Believing That It Is Hazardous to Mix Alcohol With Medicines Predicts Intentional Nonadherence to Antiretrovirals

BACKGROUND

Drinking alcohol is a robust predictor of medication nonadherence. In addition to the impact of intoxication on adherence, individuals who believe that it is hazardous to mix medications with alcohol (ie, interactive toxicity beliefs) may forgo taking their medications when drinking. Previous research suggests that alcohol-related intentional nonadherence is a direct result of interactive toxicity beliefs. This study prospectively tested the association between alcohol interactive toxicity beliefs and intentional nonadherence to HIV treatment [ie, antiretroviral therapy (ART)].

METHODS

Four hundred eight people living with HIV completed comprehensive baseline assessments and 15-month attributions for ART nonadherence.

RESULTS

One in 5 participants reported foregoing taking their ART when drinking out of concern for hazardous mixing of alcohol and ART. Poisson regression models predicting the number of months that participants were intentionally nonadherent to ART because they were drinking was predicted by alcohol-ART interactive toxicity beliefs.

CONCLUSIONS

Beliefs that it is hazardous to drink alcohol when taking medications explains intentional nonadherence and should be directly addressed in adherence improvement interventions for people living with HIV who drink alcohol.

Substance Use-Related Intentional Nonadherence to Antiretroviral Therapy Among Young Adults Living with HIV

Antiretroviral therapy (ART) reduces HIV disease burden, increases life expectancy, and prevents HIV transmission. Previous research suggests that believing that it is harmful to take ART when using substances (i.e., interactive toxicity beliefs) leads to intentional ART nonadherence; however, these associations have not been investigated among younger adults living with HIV and have not been linked to clinical outcomes. We examined the associations among interactive toxicity beliefs, intentional nonadherence, and HIV clinical outcomes in young adults living with HIV. People living with HIV younger than the age of 36 years who tested positive for at least one substance use biomarker (N = 406) completed a 1-month pretrial run-in study that included computerized interviews, substance use biomarkers, HIV viral load, and unannounced pill counts for ART adherence. Analyses compared three HIV clinical outcome groups: (1) HIV viral unsuppressed, (2) HIV viral suppressed and ART nonadherent, and (3) HIV viral suppressed and ART adherent, on substance use, interactive toxicity beliefs, and substance use-related intentional ART nonadherence. Results showed that a majority of participants reported intentional nonadherence. Participants with unsuppressed HIV reported greater interactive toxicity beliefs and intentional nonadherence. We conclude that intentional nonadherence adds to the detrimental impacts of substance use on ART adherence and interactive toxicity beliefs that foster these behaviors may be amenable to interventions.

Alcohol Use and the Risk of Communicable Diseases

The body of knowledge on alcohol use and communicable diseases has been growing in recent years. Using a narrative review approach, this paper discusses alcohol's role in the acquisition of and treatment outcomes from four different communicable diseases: these include three conditions included in comparative risk assessments to date-Human Immunodeficiency Virus (HIV)/AIDS, tuberculosis (TB), and lower respiratory infections/pneumonia-as well as Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) because of its recent and rapid ascension as a global health concern. Alcohol-attributable TB, HIV, and pneumonia combined were responsible for approximately 360,000 deaths and 13 million disability-adjusted life years lost (DALYs) in 2016, with alcohol-attributable TB deaths and DALYs predominating. There is strong evidence that alcohol is associated with increased incidence of and poorer treatment outcomes from HIV, TB, and pneumonia, via both behavioral and biological mechanisms. Preliminary studies suggest that heavy drinkers and those with alcohol use disorders are at increased risk of COVID-19 infection and severe illness. Aside from HIV research, limited research exists that can guide interventions for addressing alcohol-attributable TB and pneumonia or COVID-19. Implementation of effective individual-level interventions and alcohol control policies as a means of reducing the burden of communicable diseases is recommended.