Alcohol consumption patterns in HIV-infected adults with alcohol problems

Chronic High Risk Prescription Opioid Use Among Persons With HIV

Persons with HIV (PWH) are a population at risk for adverse sequelae of opioid use. Yet, few studies have examined correlates of chronic high risk opioid use and its impact on HIV outcomes. Trends in prescribing patterns and identification of factors that impact the use of opioid prescriptions among PWH are crucial to determine prevention and treatment interventions. This study examined electronic medical records (EMR) of patients receiving HIV care to characterize prescribing patterns and identify risk factors for chronic high risk prescription opioid use and the impact on HIV outcomes among PWH in primary care from July 1, 2016-December 31, 2017. EMR were analyzed from 8,882 patients who were predominantly male and ethnically and racially diverse with half being 50 years of age or older. The majority of the 8,744 prescriptions (98% oral and 2% transdermal preparations) given to 1,040 (12%) patients were oxycodone (71%), 8% were morphine, 7% tramadol, 4% hydrocodone, 4% codeine, 2% fentanyl, and 4% were other opioids. The number of monthly prescriptions decreased about 14% during the study period. Bivariate analyses indicated that most demographic and clinical variables were associated with receipt of any opioid prescription. After controlling for patient socio-demographic characteristics and clinical factors, the odds of receipt of any prescription were higher among patients with pain diagnoses and opioid use and mental health disorders. In addition, the odds of receipt of high average daily morphine equivalent dose (MED) prescriptions were higher for patients with pain diagnoses. Lastly, patients with substance use disorders (SUD) had an increased likelihood of detectable viral load compared to patients with no SUD, after adjusting for known covariates. Our findings show that despite opioid prescribing guidelines and monitoring systems, additional efforts are needed to prevent chronic high risk prescriptions in patients with comorbid conditions, including pain-related, mental health and substance use disorders. Evidence about the risk for chronic high risk use based on prescribing patterns could better inform pain management and opioid prescribing practices for patients receiving HIV care.

Food insecurity and substance use in people with HIV infection and substance use disorder

BACKGROUND

Food insecurity and substance use are common among people living with HIV (PLWH). Substance use may help people cope with hunger and thus be associated with food insecurity, but the association is uncertain. This study assessed whether, in PLWH and substance dependence, if there was an association between food insecurity and substance use.

Methods: We studied adults with HIV and current substance dependence or ever injection drug use interviewed at 12 and 24 months after enrollment in a prospective cohort study. The presence of food insecurity (insufficient food quantity or quality, or anxiety about its availability) was assessed using the Household Food Insecurity Assessment Scale questionnaire (HFIAS). Unhealthy alcohol use was assessed with the Alcohol Use Disorder Identification Test - Consumption (AUDIT-C) and past 30-day other drug use with the Addiction Severity Index. Associations using repeat cross-sectional data from each of two time-points, 12 months apart, from the same participants were tested using generalized estimating equations logistic regressions.

Results: The 233 participants had a mean age of 50 years and 65% were male. At the first interview, 44% reported food insecurity, 40% unhealthy alcohol use, 25% past 30-day cocaine use, and 17% past 30-day illicit opioid use. In analyses adjusted for demographics, social factors, physical and mental health function, and substance use related variables, there was no significant association between food insecurity and unhealthy alcohol use (adjusted odds ratio (aOR) = 1.06 (95% CI: 0.59, 1.87)). Those with food insecurity had higher odds of illicit opioid use (aOR = 2.5 (95% CI: 1.12, 5.58)) and cocaine use (aOR = 1.95 (CI 95%: 1.00, 3.81)).

Conclusion: Food insecurity was not associated with unhealthy alcohol use but was associated with cocaine and illicit opioid use. Given the prevalence and impact substance use has on PLWH, food insecurity should be identified and addressed.

Longitudinal analysis of social and behavioral determinants of health in the EHR: exploring the impact of patient trajectories and documentation practices

Social and behavioral determinants of health (SBDH) are environmental and behavioral factors that impede disease self-management and can exacerbate clinical conditions. While recent research in the informatics community has focused on building systems that can automatically infer SBDH from the patient record, it is unclear how such determinants change overtime. This study analyzes the longitudinal characteristics of 4 common SBDH as expressed in the patient record and compares the rates of change among distinct SBDH. In addition, manual review of patient notes was undertaken to establish whether changes in patient SBDH status reflected legitimate changes in patient status or rather potential data quality issues. Our findings suggest that a patient's SBDH status is liable to change over time and that some changes reflect poor social history taking by clinicians.

Barriers and facilitators to recruitment and enrollment of HIV-infected individuals with opioid use disorder in a clinical trial

BACKGROUND

The CTN-0067 CHOICES trial tests implementation of extended-release naltrexone (XR-NTX) versus treatment-as-usual (TAU) for opioid use disorders (OUD) in HIV clinics to improve HIV viral suppression. The study team investigated recruitment strategies to elucidate the barriers and facilitators to recruitment and enrollment in the study.

MAIN TEXT

Methods: Semi-structured, in-depth, digitally recorded interviews were completed with study recruitment-related staff and medical providers (n = 26) from six participating HIV clinics in the fall of 2018. Interviews probed 1) factors that might prevent prospective participants from engaging in study recruitment and enrollment procedures and 2) strategies used by study staff that encourage eligible patient participation. Interviews were transcribed and thematically analyzed using a content analysis approach.

RESULTS

All respondents reported that barriers to recruitment and enrollment included challenging patient social and structural factors (e.g., homelessness or living environments with high substance use, criminal justice involvement), difficulty locating patients with unsuppressed HIV viral load and OUD within the HIV clinic, time-consuming study enrollment processes, and stigma around HIV and OUD which inhibited treatment seeking. Some respondents observed that distrust of research and researchers impeded recruitment activities in the community. A specific medication-related barrier was patient fear of opioid abstinence required prior to XR-NTX induction. Facilitators of recruitment included use of trusted peer outreach/recruitment workers in the community, hospitalizations that offered windows of opportunities for screening and XR-NTX induction, providing participant transportation, and partnerships with harm reduction organizations for referrals.

CONCLUSIONS

Though study personnel encountered barriers to recruitment in the CHOICES study, persons with untreated HIV and OUD can be enrolled in multisite clinical trials by using enhanced recruitment strategies that extend outside of the HIV clinic. Employing peer outreach workers and collaborating with syringe service programs may be especially helpful in facilitating recruitment and merit inclusion in similar study protocols.

Transitions To and From At-Risk Alcohol Use in Adults in the United States

Introduction

The objective of this research was to study transitions to and from at-risk alcohol use.

Methods

Logistic regression analyses (done 2015-2016) assessed transitions to and from past-year at-risk drinking in a representative sample of U.S. adults surveyed twice (in 2001-2 and 2004-5).

Results

Among 34,653 adults, 28% reported at-risk use at time 1. Of those, 73% had at-risk use at time 2. Of those without at-risk use at time 1, 15% reported at-risk use at time 2. Positive high-risk drinking transition predictors were, at time 1, being young, male, white, childless, in good to excellent health, ever smoking, using drugs, military membership (time 1 but not 2), and becoming divorced or separated by time 2. Positive low-risk drinking transition predictors were being elderly (age ≥65), female, non-white, never smoking or using drugs, no alcohol use disorder, alcohol treatment, and, after time 1, having children.

Conclusions

Many adults transition to and from at-risk alcohol use; youth is the strongest positive predictor of transition to at-risk and not transitioning to low-risk drinking. Persons transitioning to legal drinking age are most likely to transition to high-risk and least likely to low-risk drinking.

Prevalence and Factors Associated with Hazardous Alcohol Use Among Persons Living with HIV Across the US in the Current Era of Antiretroviral Treatment

Hazardous alcohol use is associated with detrimental health outcomes among persons living with HIV (PLWH). We examined the prevalence and factors associated with hazardous alcohol use in the current era using several hazardous drinking definitions and binge drinking defined as ≥5 drinks for men versus ≥4 for women. We included 8567 PLWH from 7 U.S. sites from 2013 to 2015. Current hazardous alcohol use was reported by 27% and 34% reported binge drinking. In adjusted analyses, current and past cocaine/crack (odd ratio [OR] 4.1:3.3-5.1, p < 0.001 and OR 1.3:1.1-1.5, p < 0.001 respectively), marijuana (OR 2.5:2.2-2.9, p < 0.001 and OR 1.4:1.2-1.6, p < 0.001), and cigarette use (OR 1.4:1.2-1.6, p < 0.001 and OR 1.3:1.2-1.5, p < 0.001) were associated with increased hazardous alcohol use. The prevalence of hazardous alcohol use remains high in the current era, particularly among younger men. Routine screening and targeted interventions for hazardous alcohol use, potentially bundled with interventions for other drugs, remain a key aspect of HIV care.

Feasibility and safety of extended-release naltrexone treatment of opioid and alcohol use disorder in HIV clinics: a pilot/feasibility randomized trial

BACKGROUND AND AIMS

HIV-infected people with substance use disorders are least likely to benefit from advances in HIV treatment. Integration of extended-release naltrexone (XR-NTX) into HIV clinics may increase engagement in the HIV care continuum by decreasing substance use. We aimed to compare (1) XR-NTX treatment initiation, (2) retention and (3) safety of XR-NTX versus treatment as usual (TAU) for treating opioid use disorder (OUD) and/or alcohol use disorder (AUD) in HIV clinics.

DESIGN

Non-blinded randomized trial of XR-NTX versus pharmacotherapy TAU.

SETTING

HIV primary care clinics in Vancouver, BC, Canada and Chicago, IL, USA.

PARTICIPANTS

Fifty-one HIV-infected patients seeking treatment for OUD (n = 16), AUD (n = 27) or both OUD and AUD (n = 8).

MEASUREMENTS

Primary outcomes were XR-NTX initiation (receipt of first injection within 4 weeks of randomization) and retention at 16 weeks. Secondary outcomes generated point estimates for change in substance use, HIV viral suppression [HIV RNA polymerase chain reaction (pcr) < 200 copies/ml] and safety.

FINDINGS

Two-thirds (68%) of participants assigned to XR-NTX initiated treatment, and 88% of these were retained on XR-NTX at 16 weeks. In comparison, 96% of TAU participants initiated treatment, but only 50% were retained on medication at 16 weeks. Mean days of opioid use in past 30 days decreased from 17.3 to 4.1 for TAU and from 20.3 to 7.7 for XR-NTX. Mean heavy drinking days decreased from 15.6 to 5.7 for TAU and 12.5 to 2.8 for XR-NTX. Among those with OUD, HIV suppression improved from 67 to 80% for XR-NTX and 58 to 75% for TAU. XR-NTX was well tolerated, with no precipitated withdrawals and one serious injection-site reaction.

CONCLUSIONS

Extended-release naltrexone (XR-NTX) is feasible and safe for treatment of opioid use disorder and alcohol use disorder in HIV clinics. Treatment initiation appears to be lower and retention greater for XR-NTX compared with treatment as usual (clinicaltrials.gov NCT01908062).

Toward Development of Enhanced Preventive Interventions for HIV Sexual Risk among Alcohol-Using Populations: Confronting the 'Mere Pause from Thinking'

The papers in this issue detail state-of-the science knowledge regarding the role of alcohol use in HIV/AIDS risk, as well as offer suggestions for ways forward for behavioral HIV prevention for at-risk alcohol-using populations. In light of recent evidence suggesting that the anticipated uptake of the newer biomedical HIV prevention approaches, prominently including pre-exposure prophylaxis, has been stalled owing to a host of barriers, it has become ever more clear that behavioral prevention avenues must continue to receive due consideration as a viable HIV/AIDS prevention approach. The papers collected here make a valuable contribution to "combination prevention" efforts to curb HIV spread.

Alcohol and associated characteristics among older persons living with human immunodeficiency virus on antiretroviral therapy

BACKGROUND

Alcohol use, and particularly unhealthy alcohol use, is associated with poor human immunodeficiency virus (HIV)-related outcomes among persons living with HIV (PLWH). Despite a rapidly growing proportion of PLWH ≥50 years, alcohol use and its associated characteristics are underdescribed in this population. The authors describe alcohol use, severity, and associated characteristics using data from a sample of PLWH ≥50 years who participated in a trial of a telephone-based intervention to improve adherence to antiretroviral therapy (ART).

METHODS

Participants were recruited from acquired immunodeficiency syndrome (AIDS) service organizations in 9 states and included PLWH ≥50 years who were prescribed ART, reported suboptimal adherence at screening (missing >1.5 days of medication or taking medications 2 hours early or late on >3 days in the 30 days prior to screening), and consented to participate. The AUDIT-C (Alcohol Use Disorders Identification Test-Consumption) alcohol screen, sociodemographic characteristics, substance use, and mental health comorbidity were assessed at baseline. AUDIT-C scores were categorized into nondrinking, low-level drinking, and mild-moderate unhealthy, and severe unhealthy drinking (0, 1-3, 4-6, and 7-12, respectively). Analyses described and compared characteristics across drinking status (any/none) and across AUDIT-C categories among drinkers.

RESULTS

Among 447 participants, 57% reported drinking in the past year (35%, 15%, and 7% reported low-level drinking, mild-moderate unhealthy drinking, and severe unhealthy drinking, respectively). Any drinking was most common among men and those who were lesbian, gay, bisexual, or transgender (LGBT), married/partnered, had received past-year alcohol treatment, and never used injection drugs (P values all <.05). Differences in race, employment status, past-year alcohol treatment, and positive depression screening (P values all <.05) were observed across AUDIT-C categories, with African American race, less than full-time employment, past-year alcohol treatment, and positive depression screening being most common among those with the most severe unhealthy drinking.

CONCLUSIONS

In this sample of older PLWH with suboptimal ART adherence, a majority reported past-year alcohol use and 22% screened positive for unhealthy alcohol use. Any and unhealthy alcohol use were associated with demographics, depression, and substance use history. Further research is needed regarding alcohol use among older PLWH.

International collaboration in HIV prevention research: evidence from a research seminar in Russia

HIV transmission is a major health concern. Global efforts are necessary to control the spread of infection. International collaborative studies in countries with high rates of new infections are essential for increasing knowledge on the behavioral, social, and biomedical aspects of HIV/AIDS and HIV transmission. Statistics indicate a growing HIV epidemic in Russia. There are alarming proportions of new cases attributed to heterosexual contact, and HIV is increasingly affecting people in the general population who are not part of any traditional high-risk group. Despite recent advances in HIV prevention, data on effective behavioral prevention approaches are limited. There is minimal evidence to suggest which types of prevention will be effective in reducing the risk for HIV transmission among people at risk in the general population. This article presents a review and discussion of an international research seminar, HIV Prevention Research: Evidence-Based Behavioral Approaches. Local and international interdisciplinary researchers gathered for the purposes of exchanging research results and information about ongoing studies, identifying gaps in knowledge, and discussing promising prevention strategies. The overarching goal was to advance HIV prevention research through scientific integration. The seminar provided an excellent platform for building research capacity in interdisciplinary HIV research in Russia and integrating research efforts with the international research community to contribute to HIV prevention research throughout the world.

Alcohol dependence and CD4 cell count: is there a relationship?

Alcohol and other drugs use seem to be common among people infected with HIV on antiretroviral treatment (ART). Their effects on HIV progression is still in debate. This study aimed to assess the association between alcohol and drug use and an HIV disease progression biomarker (CD4 cell count) among patients on ART. A cross-sectional study was carried out at an HIV treatment center affiliated with Medical School of the University of São Paulo, Brazil. Four hundred and thirty-eight HIV-positive patients on ART were interviewed by trained psychiatrists and psychologists using the following instruments: Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), Alcohol Use Disorders Identification Test (AUDIT), 17-item Hamilton Rating Scale for Depression, and the Simplified Medication Adherence Questionnaire (SMAQ). In the previous month, 219 (50%) and 41 (9.3%) patients reported use of alcohol and illicit drugs, respectively. Fifty patients (12.6%) were classified as having harmful alcohol use by AUDIT. According to SCID-I, 80 patients (18.3%) were alcohol abusers, 24 (5.5%) alcohol dependents, and 21 (4.2%) had a current depressive disorder. Almost 73% (n = 319-72.8%) of the patients were adherent to ART. Alcohol dependents were nine times (p < 0.01) more likely to have CD4 cell count ≤200/mm(3), and this association was independent of ART adherence. In conclusion, alcohol dependence seems to be associated with low CD4 cell count in HIV-positive patients. Based on these data, HIV health care workers should always assess alcohol consumption in the treatment setting, and patients should be advised that alcohol dependence may be linked to low CD4.

Psychosocial and demographic correlates of drug use in a sample of HIV-positive adults ages 50 and older

The prevalence of HIV among adults 50 and older in the USA is increasing as a result of improvements in treatment and detection of HIV infection. Substance use by this population has implications for physical and mental health outcomes. We examined patterns of demographics, mental health, and recent substance use in a diverse sample of heterosexual, bisexual, and gay adults 50 and older living with HIV/AIDS (PLWHA) in New York City. The most commonly used substances were cigarettes or alcohol; however, the majority of the sample did not report recent use of marijuana, poppers, or hard drugs (crystal methamphetamine, cocaine, crack, heroin, ecstasy, GHB, ketamine, and LSD or PCP). Statistically significant associations between substance use and psychological states (well-being and loneliness) were generally weak, and depression scores were not significantly related to use; instead, drug use was associated with gender/sexual orientation. The study observations support addressing substance use specific to subpopulations within PLWHA.

Measuring alcohol consumption using Timeline Followback in non-treatment-seeking medical clinic patients with and without HIV infection: 7-, 14-, or 30-day recall

OBJECTIVE

The measurement of alcohol consumption is an essential component of research in patients at risk for or infected with HIV. Daily estimation measures such as the Timeline Followback (TLFB) have been validated, yet the optimal time window and its performance in non-treatment-seeking medical clinic subjects and among those with HIV are not known.

METHOD

In 1,519 HIV-infected and 1,612 uninfected men receiving medical care in general medical or infectious disease clinics, we compared the association between 7-, 14-, and 30-day TLFB reports, obtained via telephone, of alcohol consumption using Spearman's correlation coefficients. To evaluate agreement between 7-, 14-, and 30-day reports of heavy episodic drinking, we evaluated percent agreement, sensitivity, and kappa statistics, considering 30-day report as the gold standard.

RESULTS

The estimated prevalence of heavy episodic drinking was progressively higher for longer TLFB intervals (7 days: 6.3%; 14 days: 8.0%; 30 days: 9.5%). Correlation coefficients with 30- day TLFB were higher for 14 days (.94) than for 7 days (.86) overall (p < .001) and among HIV-infected (.94 vs. .86, p < .001) and uninfected (.95 vs. .87, p < 001). Correlations were similar by HIV status. When considered overall and by HIV status, the sensitivity, percent agreement, and kappa statistics are better for heavy episodic drinking based on 14 days compared with 7 days.

CONCLUSIONS

A TLFB for alcohol consumption of 14 days is preferable to 7 days for non-treatment-seeking patients in medical clinics with and without HIV infection when compared with 30 days.

Liver injury in HIV monoinfected patients: should we turn a blind eye to it?

With the advent of combined antiretroviral therapies, liver diseases have emerged as a key issue in the management of HIV infection. In addition to hepatitis co-infection, a large spectrum of liver diseases can affect the prognosis of HIV infection. Acute or progressive hepatic injuries require an accurate diagnosis for a better clinical management. Here, we provide an overview of the main liver diseases associated with HIV infection, which are not covered by the widely documented field of viral hepatitis co-infection.

Mechanisms of alcohol-induced endoplasmic reticulum stress and organ injuries

Alcohol is readily distributed throughout the body in the blood stream and crosses biological membranes, which affect virtually all biological processes inside the cell. Excessive alcohol consumption induces numerous pathological stress responses, part of which is endoplasmic reticulum (ER) stress response. ER stress, a condition under which unfolded/misfolded protein accumulates in the ER, contributes to alcoholic disorders of major organs such as liver, pancreas, heart, and brain. Potential mechanisms that trigger the alcoholic ER stress response are directly or indirectly related to alcohol metabolism, which includes toxic acetaldehyde and homocysteine, oxidative stress, perturbations of calcium or iron homeostasis, alterations of S-adenosylmethionine to S-adenosylhomocysteine ratio, and abnormal epigenetic modifications. Interruption of the ER stress triggers is anticipated to have therapeutic benefits for alcoholic disorders.

Substance abuse treatment utilization among adults living with HIV/AIDS and alcohol or drug problems

This is a prospective cohort study to identify factors associated with receipt of substance abuse treatment (SAT) among adults with alcohol problems and HIV/AIDS. Data from the HIV Longitudinal Interrelationships of Viruses and Ethanol study were analyzed. Generalized estimating equation logistic regression models were fit to identify factors associated with any service utilization. An alcohol dependence diagnosis had a negative association with SAT (adjusted odds ratio [AOR] = 0.36, 95% confidence interval [95% CI] = 0.19-0.67), as did identifying sexual orientation other than heterosexual (AOR = 0.46, CI = 0.29-0.72) and having social supports that use alcohol/drugs (AOR = 0.62, CI = 0.45-0.83). Positive associations with SAT include presence of hepatitis C antibody (AOR = 3.37, CI = 2.24-5.06), physical or sexual abuse (AOR = 2.12, CI = 1.22-3.69), social supports that help with sobriety (AOR = 1.92, CI = 1.28-2.87), homelessness (AOR = 2.40, CI = 1.60-3.62), drug dependence diagnosis (AOR = 2.64, CI = 1.88-3.70), and clinically important depressive symptoms (AOR = 1.52, CI = 1.08-2.15). While reassuring that factors indicating need for SAT among people with HIV and alcohol problems (e.g., drug dependence) are associated with receipt, nonneed factors (e.g., sexual orientation, age) that should not decrease likelihood of receipt of treatment were identified.

Mechanisms of alcohol-mediated hepatotoxicity in human-immunodeficiency-virus-infected patients

Clinical observations have demonstrated that excessive chronic alcohol use negatively affects human immunodeficiency virus (HIV) infection and contributes to the liver manifestations of the disease, even in HIV mono-infection. HIV/hepatitis C virus (HCV) co-infection is associated with increased progression of HVC liver disease compared to HCV infection alone, and both of these are negatively affected by alcohol use. Recent data suggest that alcohol use and HIV infection have common targets that contribute to progression of liver disease. Both HIV infection and chronic alcohol use are associated with increased gut permeability and elevated plasma levels of lipopolysaccharide; a central activator of inflammatory responses. Both alcoholic liver disease and HIV infection result in non-specific activation of innate immunity, proinflammatory cytokine cascade upregulation, as well as impaired antigen presenting cell and dendritic cell functions. Finally, alcohol, HIV and antiretroviral therapy affect hepatocyte functions, which contributes to liver damage. The common targets of alcohol and HIV infection in liver disease are discussed in this mini-review.

Alcohol and HIV disease progression: weighing the evidence

Heavy alcohol use is commonplace among HIV-infected individuals; however, the extent that alcohol use adversely impacts HIV disease progression has not been fully elucidated. Fairly strong evidence suggests that heavy alcohol consumption results in behavioral and biological processes that likely increase HIV disease progression, and experimental evidence of the biological effect of heavy alcohol on simian immunodeficiency virus in macaques is quite suggestive. However, several observational studies of the effect of heavy alcohol consumption on HIV progression conducted in the 1990s found no association of heavy alcohol consumption with time to AIDS diagnosis, while some more recent studies showed associations of heavy alcohol consumption with declines of CD4 cell counts and nonsuppression of HIV viral load. We discuss several plausible biological and behavioral mechanisms by which alcohol may cause HIV disease progression, evidence from prospective observational human studies, and suggest future research to further illuminate this important issue.