Alcohol-related beliefs and non-adherence to antiretroviral therapy in Cape Town, South Africa

Applying a mutual capacity building model to inform peer provider programs in South Africa and the United States: A combined qualitative analysis

BACKGROUND

Globally, there is a treatment gap for substance use treatment and harm reduction services. As peer-delivered interventions expand to address this gap in both high-income countries (HICs) and low and middle-income countries (LMICs), they provide an opportunity to examine mutual capacity building, the bidirectional exchange of ideas between distinct settings to address common challenges.

METHODS

The aim of this study was to explore the perspectives of patients in Cape Town and Baltimore about the acceptability and feasibility of a peer-delivered intervention using a combined qualitative analysis across a HIC and LMIC. Semi-structured qualitative interviews were conducted with participants in pilot trials in Cape Town, South Africa and Baltimore, USA (n=55). Across both trials, participants received a peer-delivered behavioral intervention focused on problem solving strategies for medication adherence, behavioral activation, and other cognitive-behavioral skills. The datasets from each location were merged and analyzed jointly using thematic analysis to develop codes and themes. Transcripts were coded to theoretical saturation (n=21 from Baltimore, n=16 from Cape Town).

RESULTS

Participants highlighted what they valued about the peer-delivered intervention: 1) behavioral skills learned, 2) relationship with the peer, 3) ability to help others based on what they learned, 4) improved adherence to HIV or substance use medications, and 5) changes in substance use behaviors. In Baltimore, participants were typically more focused on their supportive relationship with the peer, which contrasted with many other relationships in their lives. In Cape Town, many participants highlighted the value of the skills they learned, such as mindfulness and activity scheduling.

CONCLUSIONS

Across sites, participants valued that the peer could support them to accomplish meaningful life goals beyond substance use recovery, such as building relationships or health. Differences between settings may highlight the importance of tailoring peer interventions to fill context-specific gaps in available services.

Gender Moderates Results of a Randomized Clinical Trial for the Khanya Intervention for Substance Use and ART Adherence in HIV Care in South Africa

Little is known about gender effects of alcohol and drug use (AOD) among people living with HIV (PLWH) in resource-limited settings. Using multilevel models, we tested whether gender moderated the effect of Khanya, a cognitive-behavioral therapy-based intervention addressing antiretroviral (ART) adherence and AOD reduction. We enrolled 61 participants from HIV care and examined outcomes at 3- and 6-months compared to enhanced treatment as usual (ETAU). Gender significantly moderated the effect of Khanya on ART adherence (measured using electronically-monitored and biomarker-confirmed adherence), such that women in Khanya had significantly lower ART adherence compared to men in Khanya; no gender differences were found for AOD outcomes. Exploratory trajectory analyses showed men in Khanya and both genders in ETAU had significant reductions in at least one AOD outcome; women in Khanya did not. More research is needed to understand whether a gender lens can support behavioral interventions for PLWH with AOD.

Trial registry ClinicalTrials.gov identifier: NCT03529409. Trial registered on May 18, 2018.

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.

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

The successful treatment of HIV infection relies on adherence to antiretroviral therapy (ART). Alcohol use remains a threat to ART adherence, including the beliefs held by people who drink alcohol that it is harmful to take ART when consuming alcohol (i.e., alcohol-ART interactive toxicity beliefs, AA-ITB). We reviewed the current research that has investigated AA-ITB and their relationship to intentional ART nonadherence. The review of 17 published studies found that AA-ITB are prevalent among people receiving ART and that AA-ITB are directly associated with ART nonadherence and incomplete HIV suppression. Family, friends and healthcare providers are common sources and reinforcers of AA-ITB. Studies suggest that AA-ITB may best be explained by the Medication Necessity and Concerns Beliefs Model, treating AA-ITB as a specific circumstance of medication concerns. Interventions are needed to communicate the realities of potential medication interactions and dispel myths that it is harmful to mix alcohol with ART, while not inadvertently suggesting that it is safe to drink with all medications, which could undermine adherence to ART by increasing alcohol use.