Alcohol use and immune reconstitution among HIV-infected patients on antiretroviral therapy in Nairobi, Kenya

A systematic review of substance use and substance use disorder research in Kenya

Objectives

The burden of substance use in Kenya is significant. The objective of this study was to systematically summarize existing literature on substance use in Kenya, identify research gaps, and provide directions for future research.

Methods

This systematic review was conducted in line with the PRISMA guidelines. We conducted a search of 5 bibliographic databases (PubMed, PsychINFO, Web of Science, Cumulative Index of Nursing and Allied Professionals (CINAHL) and Cochrane Library) from inception until 20 August 2020. In addition, we searched all the volumes of the official journal of the National Authority for the Campaign Against Alcohol & Drug Abuse (the African Journal of Alcohol and Drug Abuse). The results of eligible studies have been summarized descriptively and organized by three broad categories including: studies evaluating the epidemiology of substance use, studies evaluating interventions and programs, and qualitative studies exploring various themes on substance use other than interventions. The quality of the included studies was assessed with the Quality Assessment Tool for Studies with Diverse Designs.

Results

Of the 185 studies that were eligible for inclusion, 144 investigated the epidemiology of substance use, 23 qualitatively explored various substance use related themes, and 18 evaluated substance use interventions and programs. Key evidence gaps emerged. Few studies had explored the epidemiology of hallucinogen, prescription medication, ecstasy, injecting drug use, and emerging substance use. Vulnerable populations such as pregnant women, and persons with physical disability had been under-represented within the epidemiological and qualitative work. No intervention study had been conducted among children and adolescents. Most interventions had focused on alcohol to the exclusion of other prevalent substances such as tobacco and cannabis. Little had been done to evaluate digital and population-level interventions.

Conclusion

The results of this systematic review provide important directions for future substance use research in Kenya.

Systematic review registration

PROSPERO: CRD42020203717.

Integration of Alcohol Use Disorder Interventions in General Health Care Settings in Sub-Saharan Africa: A Scoping Review

Introduction

Alcohol use disorder (AUD) is among the leading cause of morbidity and mortality in sub-Saharan Africa. Despite this, AUD is often not detected in health care settings, which contributes to a wide treatment gap. Integrating services for mental, neurological, and substance use disorders in general health care settings is among the recommended strategies to narrow this treatment gap. This scoping review aimed to map the available evidence on integration of AUD interventions in general health care settings in sub-Saharan Africa.

Methods

We searched four databases (PubMed, PsycINFO, CINAHL, and Africa Wide Information) for publications up to December 2020. The search strategy focused on terms for alcohol use, alcohol interventions, and sub-Saharan African countries. Studies that reported AUD interventions in general health care settings in sub-Saharan Africa were eligible for inclusion. Over 3,817 potentially eligible articles were identified. After the removal of duplicates and screening of abstracts, 56 articles were included for full article review. Of these, 24 papers reporting on 22 studies were eligible and included in a narrative review.

Results

Of the 24 eligible articles, 19 (80%) described AUD interventions that were being delivered in general health care settings, 3 (12%) described plans or programs for integrating AUD interventions at different levels of care, including in health facilities, and 2 (8%) studies reported on AUD interventions integrated into general health care settings.

Conclusions

This review shows that there is limited evidence on the integration of AUD interventions in health care settings in sub-Saharan Africa. There is an urgent need for studies that report systematically on the development, adaptation, implementation, and evaluation of integrated AUD interventions in health care settings in sub-Saharan Africa.

Heavy Alcohol Use is Associated with Lower CD4 Counts among Russian Women Living with HIV: A Multilevel Analysis

Alcohol use remains prevalent among Russian women with HIV infection. Multilevel mixed effects models were used to estimate the association of heavy drinking and HIV outcomes among women (N = 250 at baseline; N = 207 at follow-up), aged 18-35, engaged in HIV care in Saint Petersburg. Alcohol use was assessed at baseline and 3 months by self-report and by the biomarker phosphatidylethanol (PEth). Overall, 35% of women were heavy drinkers, defined as women reporting ≥ 1 past-30-day heavy drinking episode (≥ 4 standard drinks on one occasion) or with PEth blood levels ≥ 80 ng/mL. Women who engaged in heavy drinking had an average 41 CD4 cells/mm³ (95% CI = - 81, - 2; z = - 2.04; P = 0.042) fewer than those who did not. Heavy drinking was associated with higher HIV symptom burden (IRR = 1.20; 95% CI = 1.05, 1.36; z = 2.73; P = 0.006) and suboptimal antiretroviral adherence (OR = 3.04; 95% CI = 1.27, 7.28; χ² = 2.50; P = 0.013), but not with viral load. Findings support the integration of alcohol treatment interventions as part of routine HIV care in Russia.

Alcohol Use and Antiretroviral Therapy Non-Adherence Among Adults Living with HIV/AIDS in Sub-Saharan Africa: A Systematic Review and Meta-Analysis

Antiretroviral therapy (ART) is efficacious in improving clinical outcomes among people living with HIV (PLWH) and reducing HIV transmission when taken regularly. Research examining modifiable factors associated with ART non-adherence is critical for informing novel intervention development in settings with high HIV prevalence. Alcohol use has been linked with ART non-adherence in studies in sub-Saharan Africa; however, no review has pooled estimates across studies. We reviewed studies of alcohol use and ART non-adherence conducted in sub-Saharan Africa. We searched PubMed, CINAHL, EMBASE, and PsycINFO through August 2019 with terms related to ART non-adherence, alcohol use, and sub-Saharan Africa. One author reviewed titles/abstracts (n = 754) and two authors reviewed full texts (n = 308) for inclusion. Discrepancies were resolved by group consensus. Studies were retained if they quantitatively measured associations between alcohol use and ART non-adherence or viral non-suppression. We defined ART non-adherence using the definitions from each parent study (e.g., patients with > 5% missed ART doses during the previous four, seven or 30 days were considered non-adherent). A random effects meta-analysis was conducted to pool associations and we conducted additional analyses to assess between-study heterogeneity and publication bias and sensitivity analyses to determine robustness of our results when considering only certain study designs, alcohol use or ART scales, or studies that used viral non-suppression as their primary outcome. Of 56 articles meeting our inclusion criteria, 32 articles were included in the meta-analysis. All studies measured alcohol use via self-report. ART non-adherence was assessed using self-report, pill counts, or pharmacy records and definition of non-adherence varied depending on the measure used. Individuals who used alcohol had twice the odds of ART non-adherence compared with those who did not use alcohol (34% non-adherence among alcohol users vs. 18% among non-users; pooled odds ratio: 2.25; 95% confidence interval: 1.87-2.69; p < 0.001). We found evidence of a high degree of heterogeneity between studies (Cochrane Q statistic: 382.84, p< 0.001; I² proportion: 91.9%) and evidence of publication bias. However, the magnitude of our pooled odds ratio was consistent across a number of sensitivity analyses to account for heterogeneity and publication bias. In a secondary analysis with studies using viral non-suppression as their primary outcome, we also estimated a statistically significant pooled effect of alcohol use on viral non-suppression (pooled odds ratio: 2.47; 95% confidence interval: 1.58-3.87). Evidence suggests alcohol use is associated with ART non-adherence in Sub-Saharan Africa, potentially hindering achievement of the UNAIDS 90-90-90 HIV treatment targets.

Factors Associated with Improved HIV/AIDS Treatment Outcomes: Comparing two Major ART Service Delivery Models in Vietnam

A mixed design approach was performed to assess the CD4 count levels over time and their associated factors among 362 HIV patients on ART from clinics with HIV testing and counseling (ART-HTC) services and those with general healthcare (ART-GH) services. Longitudinal CD4 count data were retrospectively collected from medical records. Sociodemographic, clinical, alcohol use and smoking characteristics were obtained via face-to-face interviews. Multivariate mixed effect linear regression was utilized to determine the association. We found that HIV patients at ART-GH clinics were more likely to achieve higher CD4 counts over time compared to patients at ART-HTC clinics. Additionally, having an increase in CD4 counts was found to be associated with having longer duration of ART and higher baseline CD4 levels. Cigarette smoking and hazardous alcohol use, however, were not associated with CD4 count improvement. Our findings suggest that combining HTC and GH services might provide a synergistic benefit in ART treatment outcomes through an improved access to comprehensive HIV healthcare services for HIV patients on therapy.

Alcohol Use and HIV Disease Progression in an Antiretroviral Naive Cohort

BACKGROUND

Alcohol use has been shown to accelerate disease progression in experimental studies of simian immunodeficiency virus in macaques, but the results in observational studies of HIV have been conflicting.

METHODS

We conducted a prospective cohort study of the impact of unhealthy alcohol use on CD4 cell count among HIV-infected persons in southwestern Uganda not yet eligible for antiretroviral treatment (ART). Unhealthy alcohol consumption was 3-month Alcohol Use Disorders Identification Test-Consumption positive (≥3 for women, ≥4 for men) and/or phosphatidylethanol (PEth-an alcohol biomarker) ≥50 ng/mL, modeled as a time-dependent variable in a linear mixed effects model of CD4 count.

RESULTS

At baseline, 43% of the 446 participants were drinking at unhealthy levels and the median CD4 cell count was 550 cells/mm (interquartile range 416-685). The estimated CD4 cell count decline per year was -14.5 cells/mm (95% confidence interval: -38.6 to 9.5) for unhealthy drinking vs. -24.0 cells/mm (95% confidence interval: -43.6 to -4.5) for refraining from unhealthy drinking, with no significant difference in decline by unhealthy alcohol use (P value 0.54), adjusting for age, sex, religion, time since HIV diagnosis, and HIV viral load. Additional analyses exploring alternative alcohol measures, participant subgroups, and time-dependent confounding yielded similar findings.

CONCLUSION

Unhealthy alcohol use had no apparent impact on the short-term rate of CD4 count decline among HIV-infected ART naive individuals in Uganda, using biological markers to augment self-report and examining disease progression before ART initiation to avoid unmeasured confounding because of misclassification of ART adherence.