Gender and alcohol use: influences on HIV care continuum in a national cohort of patients with HIV

Prevalence and Correlates of Heavy Alcohol use among People Living with HIV who use Unregulated Drugs in Vancouver, Canada

Among people living with HIV (PLWH), heavy alcohol use is associated with many negative health consequences. However, the impacts of heavy alcohol use are not well described for PLWH who use drugs. Thus, we investigated the prevalence and correlates of heavy alcohol use among a cohort of people who use drugs (PWUD) living with HIV in Vancouver, Canada. We accessed data from an ongoing community-recruited prospective cohort of PLWH who use drugs with linked comprehensive HIV clinical monitoring data. We used generalized linear mixed-effects modeling to identify factors longitudinally associated with periods of heavy alcohol use between December 2005 and December 2019. Of the 896 participants included, 291 (32.5%) reported at least one period with heavy alcohol use. Periods of recent incarceration (Adjusted Odds Ratio [AOR] = 1.48, 95% Confidence Interval [CI]: 1.01-2.17), encounters with police (AOR = 1.87, 95% CI: 1.37-2.56), and older age (AOR = 1.05, 95% CI: 1.02-1.07) were positively associated with heavy alcohol use. Engagement in drug or alcohol treatment (AOR = 0.54, 95% CI: 0.42-0.70) and male gender (AOR = 0.46; 95% CI: 0.27-0.78) were negatively associated with heavy alcohol use. We observed that heavy alcohol use was clearly linked to involvement with the criminal justice system. These findings, together with the protective effects of substance use treatment, suggest the need to expand access for drug and alcohol treatment programs overall, and in particular through the criminal justice system to reduce alcohol-related harms among PLWH who use drugs.

Statistical methods applied for the assessment of the HIV cascade and continuum of care: a systematic scoping review

OBJECTIVES

This scoping review aims to identify and synthesise existing statistical methods used to assess the progress of HIV treatment programmes in terms of the HIV cascade and continuum of care among people living with HIV (PLHIV).

DESIGN

Systematic scoping review.

DATA SOURCES

Published articles were retrieved from PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete and Excerpta Medica dataBASE (EMBASE) databases between April and July 2022. We also strategically search using the Google Scholar search engine and reference lists of published articles.

ELIGIBILITY CRITERIA

This scoping review included original English articles that estimated and described the HIV cascade and continuum of care progress in PLHIV. The review considered quantitative articles that evaluated either HIV care cascade progress in terms of the Joint United Nations Programme on HIV and AIDS targets or the dynamics of engagement in HIV care.

DATA EXTRACTION AND SYNTHESIS

The first author and the librarian developed database search queries and screened the retrieved titles and abstracts. Two independent reviewers and the first author extracted data using a standardised data extraction tool. The data analysis was descriptive and the findings are presented in tables and visuals.

RESULTS

This review included 300 articles. Cross-sectional study design methods were the most commonly used to assess the HIV care cascade (n=279, 93%). In cross-sectional and longitudinal studies, the majority used proportions to describe individuals at each cascade stage (276/279 (99%) and 20/21 (95%), respectively). In longitudinal studies, the time spent in cascade stages, transition probabilities and cumulative incidence functions was estimated. The logistic regression model was common in both cross-sectional (101/279, 36%) and longitudinal studies (7/21, 33%). Of the 21 articles that used a longitudinal design, six articles used multistate models, which included non-parametric, parametric, continuous-time, time-homogeneous and discrete-time multistate Markov models.

CONCLUSIONS

Most literature on the HIV cascade and continuum of care arises from cross-sectional studies. The use of longitudinal study design methods in the HIV cascade is growing because such methods can provide additional information about transition dynamics along the cascade. Therefore, a methodological guide for applying different types of longitudinal design methods to the HIV continuum of care assessments is warranted.

Does treating pain with alcohol affect drinking reduction among women with HIV enrolled in a clinical trial of naltrexone?

BACKGROUND

Many women living with HIV (WLWH) experience pain. Alcohol use with the intent to treat pain could lead to hazardous drinking and difficulty in reducing drinking. Naltrexone acts on opioid receptors important for pain regulation and is an approved treatment for alcohol use disorder. In this secondary analysis of a randomized double-blind placebo-controlled naltrexone clinical trial, the goals were to (1) compare alcohol reduction between women who drank to treat pain and those who did not and (2) examine differences in alcohol reduction by both drinking intention and treatment arm.

METHODS

Women living with HIV (N = 194, mean age 48.3 years, 83% non-Hispanic Black, 11% Hispanic) with hazardous drinking (>7 drinks/week) were randomized to receive daily treatment with naltrexone 50 mg or placebo for 4 months. Study visits occurred at baseline and 2, 4, and 7 months (posttreatment). The number of drinks/week was measured using the Timeline Follow Back. Use of alcohol to treat pain was self-reported. Participants were categorized as using alcohol to treat pain or not and in the naltrexone or placebo group. Chi-square, t-test, MANOVA, and sequential mixed effects models were used to determine group differences in demographic factors, mean/drinks per week, and percent change in mean drinks/week at baseline and each follow-up visit.

RESULTS

There was a consistent decrease in drinking throughout the study. There was not a significant difference in mean drinks/week at any point in the study between women who used alcohol to treat pain and those who did not. When considering treatment arm, at 2 months only those who did not use alcohol to treat pain in the naltrexone group had a significantly lower mean drinks/week than the other groups (p = 0.007); all groups had similar decreases in drinking from 4 months onward.

CONCLUSION

In the naltrexone group, WLWH who drank to treat pain reduced their alcohol consumption more slowly than WLWH who did not drink to treat pain. Replication of these findings would suggest that alcohol treatment guidelines should address pain as a factor in drinking outcomes.

Syndemic trajectories of heavy drinking, smoking, and depressive symptoms are associated with mortality in women living with HIV in the United States from 1994 to 2017

BACKGROUND

Heavy drinking, smoking, and depression are common among people with HIV. Little is known about the co-occurring, synergistic effect of having two or more of these conditions long-term -a sustained syndemic - on mortality among women with HIV (WWH).

METHODS

Data from 3282 WWH of the Women's Interagency HIV Study from 1994 to 2017 were utilized. National Death Index review identified cause of death (n=616). Sustained syndemic phenotypes were based on membership in high-risk groups defined by group-based trajectory models of repeated self-reported alcohol use, smoking, and depressive symptoms and their co-occurrence. Cox proportional hazard models estimated associations of sustained syndemic phenotypes with all-cause, non-AIDS, and non-overdose mortality, adjusting for age, race/ethnicity, education, enrollment wave, illicit drug use, and time-varying HIV viral load and CD4+ T-cell count.

RESULTS

WWH were 58% Black and 26% Hispanic, with a mean baseline age of 36.7 years. Syndemic phenotypes included zero (45%, n=1463), heavy drinking only (1%, n=35), smoking only (28%, n=928), depressive symptoms only (9%, n=282), and 2+ trajectories (17%, n=574). Compared to zero trajectories, having 2+ trajectories was associated with 3.93 times greater all-cause mortality risk (95% CI 3.07, 5.04) after controlling for confounders and each high-risk trajectory alone. These findings persisted in sensitivity analyses, removing AIDS- and overdose-related mortalities.

CONCLUSIONS

Clustering of 2+ conditions of heavy drinking, smoking, and depression affected nearly one in five WWH and was associated with higher mortality than zero or one condition. Our findings underscore the need for coordinated screening and parsimonious treatment strategies for these co-occurring conditions.

Factors Associated with Bothersome Symptoms in Individuals With and Without HIV Who Report Alcohol Use

Bothersome symptoms potentially related to drinking are commonly reported by people with and without HIV (PWH/PWoH). However, the relationship between bothersome symptoms and level of alcohol use is often not appreciated by patients or providers. Therefore, among persons reporting prior-year alcohol use, we assessed whether alcohol use level (AUDIT-C score), HIV status, and demographic covariates influenced the likelihood of the patient reporting a bothersome symptom. We used the Veterans Aging Cohort Study (VACS) surveys (2002-2018), including a validated symptoms index. Among 3679 PWH and 3830 PWoH currently drinking alcohol, the most commonly reported symptoms were muscle/joint pain (52%), sleep disturbance (51%), and fatigue (50%). Level of alcohol use was independently associated with 18 of 20 bothersome symptoms, including seven symptoms more common among PWH. Results can help inform PWH/PWoH who drink alcohol about the strong relationship between level of alcohol use and bothersome symptoms, potentially motivating reduced use.

Sexually Transmitted Infection Screening in Key Populations of Persons Living with HIV

Annual screening for bacterial sexually transmitted infections (STI), including gonorrhea/chlamydia (GC/CT) and syphilis, is recommended for persons with HIV (PWH). We used the prevention index to quantify the extent to which STI screening was completed at guideline-recommended frequency in African American and Latinx persons, women, persons with alcohol (AUD) and substance (SUD) use disorders. Data from PWH at Kaiser Permanente Northern California were collected from electronic health records. We defined receipt of GC/CT and syphilis screening consistent with recommendations as a prevention index score ≥ 75%. Among 9655 PWH (17.7% Latinx; 16.2% African American; 9.6% female; 12.4% AUD; 22.1% SUD), prevention index scores for GC/CT and syphilis increased from 2015 to 2019. African American PWH had lower odds of receiving an annual syphilis screen (aOR 0.87 [95% CI 0.79-0.97]). Female sex was associated with lower odds of GC/CT (aOR 0.30 [95% CI 0.27-0.34]) and syphilis (aOR 0.27 [95% CI 0.24-0.310) screening. AUD and SUD were not associated with differences in annual GC/CT or syphilis screening. Key PWH subgroups experience ongoing challenges to annual STI screening despite comparable healthcare access.

Substance Use and Adherence to Antiretroviral Therapy among People Living with HIV in the United States

People with HIV (PWH) report substance use at higher rates than HIV-uninfected individuals. The potential negative impact of single and polysubstance use on HIV treatment among diverse samples of PWH is underexplored. PWH were recruited from the Center for Positive Living at the Montefiore Medical Center (Bronx, NY, USA) from May 2017-April 2018 and completed a cross-sectional survey with measures of substance use, antiretroviral therapy (ART) use, and ART adherence. The overall sample included 237 PWH (54.1% Black, 42.2% female, median age 53 years). Approximately half of the sample reported any current substance use with 23.1% reporting single substance use and 21.4% reporting polysubstance use. Polysubstance use was more prevalent among those with current cigarette smoking relative to those with no current smoking and among females relative to males. Alcohol and cannabis were the most commonly reported polysubstance combination; however, a sizeable proportion of PWH reported other two, three, and four-substance groupings. Single and polysubstance use were associated with lower ART adherence. A thorough understanding of substance use patterns and related adherence challenges may aid with targeted public health interventions to improve HIV care cascade goals, including the integration of substance use prevention into HIV treatment and care settings.

Longitudinal HIV care outcomes by gender identity in the United States

OBJECTIVE

Describe engagement in HIV care over time after initial engagement in HIV care, by gender identity.

DESIGN

Observational, clinical cohort study of people with HIV engaged in routine HIV care across the United States.

METHODS

We followed people with HIV who linked to and engaged in clinical care (attending ≥2 visits in 12 months) in cohorts in the North American Transgender Cohort Collaboration, 2000-2018. Within strata of gender identity, we estimated the 7-year (84-month) restricted mean time spent: lost-to-clinic (stratified by pre/postantiretroviral therapy (ART) initiation); in care prior to ART initiation; on ART but not virally suppressed; virally suppressed (≤200 copies/ml); or dead (pre/post-ART initiation).

RESULTS

Transgender women ( N  = 482/101 841) spent an average of 35.5 out of 84 months virally suppressed (this was 30.5 months for cisgender women and 34.4 months for cisgender men). After adjustment for age, race, ethnicity, history of injection drug use, cohort, and calendar year, transgender women were significantly less likely to die than cisgender people. Cisgender women spent more time in care not yet on ART, and less time on ART and virally suppressed, but were less likely to die compared with cisgender men. Other differences were not clinically meaningful.

CONCLUSIONS

In this sample, transgender women and cisgender people spent similar amounts of time in care and virally suppressed. Additional efforts to improve retention in care and viral suppression are needed for all people with HIV, regardless of gender identity.

Associations between female birth sex and risk of chronic kidney disease development among people with HIV in the USA: A longitudinal, multicentre, cohort study

Background

Women represent a meaningful proportion of new HIV diagnoses, with Black women comprising 58% of new diagnoses among women. As HIV infection also increases risk of chronic kidney disease (CKD), understanding CKD risk among women with HIV (WWH), particularly Black women, is critical.

Methods

In this longitudinal cohort study of people with HIV (PWH) enrolled in CFAR Network of Integrated Clinical Systems (CNICS), a multicentre study comprised of eight academic medical centres across the United States from Jan 01, 1996 and Nov 01, 2019, adult PWH were excluded if they had ≤2 serum creatinine measurements, developed CKD prior to enrollment, or identified as intersex or transgendered, leaving a final cohort of 33,998 PWH. The outcome was CKD development, defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1·73 m2 calculated using the CKD-EPI equation, for ≥90 days with no intervening higher values.

Findings

Adjusting for demographic and clinical characteristics, WWH were 61% more likely to develop CKD than men (adjusted hazard ratio [aHR]: 1·61, 95% CI: 1·46-1·78, p<0·001). This difference persisted after further adjustment for APOL1 risk variants (aHR female sex: 1·92, 95% CI: 1·63-2·26, p<0·001) and substance abuse (aHR female sex: 1·70, 95% CI: 1·54-1·87, p<0·001).

Interpretation

WWH experienced increased risk of CKD. Given disparities in care among patients with end-stage kidney disease, efforts to engage WWH in nephrology care to improve chronic disease management are critical.

Funding

US National Institutes of Health.

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.

HIV care using differentiated service delivery during the COVID-19 pandemic: a nationwide cohort study in the US Department of Veterans Affairs

Introduction

The Department of Veterans Affairs (VA) is the largest provider of HIV care in the United States. Changes in healthcare delivery became necessary with the COVID‐19 pandemic. We compared HIV healthcare delivery during the first year of the COVID‐19 pandemic to a prior similar calendar period.

Methods

We included 27,674 people with HIV (PWH) enrolled in the Veterans Aging Cohort Study prior to 1 March 2019, with ≥1 healthcare encounter from 1 March 2019 to 29 February 2020 (2019) and/or 1 March 2020 to 28 February 2021 (2020). We counted monthly general medicine/infectious disease (GM/ID) clinic visits and HIV‐1 RNA viral load (VL) tests. We determined the percentage with ≥1 clinic visit (in‐person vs. telephone/video [virtual]) and ≥1 VL test (detectable vs. suppressed) for 2019 and 2020. Using pharmacy records, we summarized antiretroviral (ARV) medication refill length (<90 vs. ≥90 days) and monthly ARV coverage.

Results

Most patients had ≥1 GM/ID visit in 2019 (96%) and 2020 (95%). For 2019, 27% of visits were virtual compared to 64% in 2020. In 2019, 82% had VL measured compared to 74% in 2020. Of those with VL measured, 92% and 91% had suppressed VL in 2019 and 2020. ARV refills for ≥90 days increased from 39% in 2019 to 51% in 2020. ARV coverage was similar for all months of 2019 and 2020 ranging from 76% to 80% except for March 2019 (72%). Women were less likely than men to be on ARVs or to have a VL test in both years.

Conclusions

During the COVID‐19 pandemic, the VA increased the use of virtual visits and longer ARV refills, while maintaining a high percentage of patients with suppressed VL among those with VL measured. Despite decreased in‐person services during the pandemic, access to ARVs was not disrupted. More follow‐up time is needed to determine whether overall health was impacted by the use of differentiated service delivery and to evaluate whether a long‐term shift to increased virtual healthcare could be beneficial, particularly for PWH in rural areas or with transportation barriers. Programmes to increase ARV use and VL testing for women are needed.

Factors Associated with Viral Suppression Among Racial/Ethnic Minority Women in the Miami-Dade County Ryan White Program, 2017

The study's objective was to identify factors associated with differences in the rate of viral suppression among minority women with HIV/AIDS in care in the Miami-Dade County Ryan White Program (RWP). A retrospective cohort study was conducted using social characteristics and laboratory data of minority women enrolled in the Miami-Dade County RWP in 2017. Viral suppression was defined as <200 copies/mL using the last viral load test of 2017. Multilevel logistic regression models were used to estimate adjusted odds ratio (aOR) and 95% confidence intervals (CIs). Of the 1,550 racial/ethnic minority women in the study population, 43.1% were African American, 31.3% were Hispanic, and 25.6% were Haitian. The proportion of women virally suppressed was lower among African Americans (80.8%) than among Hispanics (86.4%) and Haitians (85.1%). Viral suppression rates were significantly lower among women aged 18-34 years (aOR: 0.41, CI: 0.27-0.64) and 35-49 years (0.63, 0.45-0.90) vs. ≥50 years, born in the United States (0.48, 0.30-0.78), having a household income of <100% the federal poverty level (0.54, 0.30-0.95), previously diagnosed with AIDS (0.60, 0.44-0.81), reporting problematic drug use (0.23, 0.08-0.69), and living in a residentially unstable neighborhood (0.77, 0.64-0.93). Race/ethnicity was not associated with viral suppression after adjusting for other factors. Factors associated with lack of viral suppression were similar among minority racial/ethnic groups. Interventions at the individual level focusing on young, U.S. born individuals, and those who report drug use, and at the neighborhood level for those living in residentially unstable neighborhoods are needed to improve viral suppression outcomes.

Correlates of personal health record registration and utilization among veterans with HIV

Objective

We examined correlates of registration and utilization of the Veteran Health Administration's (VHA) personal health record (PHR), My HealtheVet (MHV), among a national cohort of veterans living with HIV.

Materials and Methods

Using VHA administrative data, we matched veterans with HIV who registered for MHV in fiscal year 2012-2018 (n = 8589) to 8589 veterans with HIV who did not register for MHV. We compared demographic and geographic characteristics, housing status, comorbidities, and non-VHA care between MHV registrants and nonregistrants to identify correlates of MHV registration. Among registrants, we examined the association between these characteristics and MHV tool use (prescription refill, record download, secure messaging, view labs, and view appointments).

Results

MHV registrants were more likely to be younger, women, White, and to have bipolar disorder, depression, or post-traumatic stress disorder diagnosis than nonregistrants. Having a substance use disorder (SUD) diagnosis or a higher Elixhauser score was associated with lower odds of MHV registration. Among registrants, women were less likely to use prescription refill. Patients who were at risk of homelessness in the past year were less likely to use secure messaging and, along with those who were homeless, were less likely to use view labs and prescription refill. Bipolar disorder and depression were associated with increased secure messaging use. Diagnoses of SUD and alcohol use disorder were both associated with lower rates of prescription refill.

Discussion

Among veterans living with HIV, we identified significant differences in PHR registration and utilization by race, sex, age, housing status, and diagnosis.

The Contributions of Clinical Pharmacology to HIV Cure Research

Combination antiretroviral therapy (ART) can suppress plasma HIV-RNA to < 50 copies/mL, decrease HIV transmission, reduce mortality, and improve quality of life for people living with HIV. ART cannot, however, eliminate HIV from an infected individual. The primary barrier to cure HIV infection is the multiple reservoir sites, including adipose tissue, bone marrow, central nervous system, liver, lungs, male and female reproductive system, secondary lymph nodes, and gut-associated lymphoid tissue, established 1 to 2 weeks after acquisition of HIV. Additional challenges include understanding the mechanism(s) by which HIV is maintained at low or undetectable levels and developing treatments that will eradicate or produce a sustained suppression of virus without ART. To date, the most extensive clinical investigations of cure strategies have been the shock-and-kill approach using histone deacetylase inhibitors (HDACis) to induce reactivation of latent HIV. Despite evidence for HIV latency reversal, HDACis alone have not decreased the size of the latent reservoir. Clinical pharmacologic explanations for these results include a low inhibitory quotient (i.e., low potency) within the reservoir sites and intrinsic (e.g., sex differences and reservoir size) and extrinsic (physiochemical and pharmacokinetic drug characteristics) factors. We offer an outline of desired clinical pharmacologic attributes for therapeutics intended for clinical HIV cure research and call for research teams to have early and ongoing involvement of clinical pharmacologists. We believe such a collective effort will provide a solid scientific basis and hope for reaching the goal of a cure for HIV infection.

Changing Patterns of Alcohol Use and Probability of Unsuppressed Viral Load Among Treated Patients with HIV Engaged in Routine Care in the United States

We examined HIV viral load non-suppression ([Formula: see text] 200 copies/mL) subsequent to person-periods (3-18 months) bookended by two self-reports of alcohol use on a standardized patient reported outcome assessment among adults in routine HIV care. We examined the relative risk (RR) of non-suppression associated with increases and decreases in alcohol use (relative to stable use), stratified by use at the start of the person-period. Increases in drinking from abstinence were associated with higher risk of viral non-suppression (low-risk without binge: RR 1.16, 95% CI 1.03, 1.32; low-risk with binge: RR 1.35, 95% CI 1.11, 1.63; high-risk: RR 1.89, 95% CI 1.16, 3.08). Decreases in drinking from high-risk drinking were weakly, and not statistically significantly associated with lower risk of viral non-suppression. Other changes in alcohol use were not associated with viral load non-suppression. Most changes in alcohol consumption among people using alcohol at baseline were not strongly associated with viral non-suppression.

Alcohol Use and Antiretroviral Adherence Among Patients Living with HIV: Is Change in Alcohol Use Associated with Change in Adherence?

Alcohol use increases non-adherence to antiretroviral therapy (ART) among persons living with HIV (PLWH). Dynamic longitudinal associations are understudied. Veterans Aging Cohort Study (VACS) data 2/1/2008-7/31/16 were used to fit linear regression models estimating changes in adherence (% days with ART medication fill) associated with changes in alcohol use based on annual clinically-ascertained AUDIT-C screening scores (range - 12 to + 12, 0 = no change) adjusting for demographics and initial adherence. Among 21,275 PLWH (67,330 observations), most reported no (48%) or low-level (39%) alcohol use initially, with no (55%) or small (39% ≤ 3 points) annual change. Mean initial adherence was 86% (SD 21%), mean annual change was - 3.1% (SD 21%). An inverted V-shaped association was observed: both increases and decreases in AUDIT-C were associated with greater adherence decreases relative to stable scores [p < 0.001, F (4, 21,274)]. PLWH with dynamic alcohol use (potentially indicative of alcohol use disorder) should be considered for adherence interventions.

Health System-Based Unhealthy Alcohol Use Screening and Treatment Comparing Demographically Matched Participants With and Without HIV

BACKGROUND

Unhealthy alcohol use among persons living with HIV (PLWH) is linked to significant morbidity, and use of alcohol services may differ by HIV status. Our objective was to compare unhealthy alcohol use screening and treatment by HIV status in primary care.

METHODS

Cohort study of adult (≥18 years) PLWH and HIV-uninfected participants frequency matched 20:1 to PLWH by age, sex, and race/ethnicity who were enrolled in a large integrated healthcare system in the United States, with information ascertained from an electronic health record. Outcomes included unhealthy alcohol screening, prevalence, provider-delivered brief interventions, and addiction specialty care visits. Other predictors included age, sex, race/ethnicity, neighborhood deprivation index, depression, smoking, substance use disorders, Charlson comorbidity index, prior outpatient visits, insurance type, and medical facility. Cox proportional hazards models were used to compute hazard ratios (HR) for the outcomes of time to unhealthy alcohol use screening and time to first addiction specialty visit. Poisson regression with robust standard errors was used to compute prevalence ratios (PR) for other outcomes.

RESULTS

11,235 PLWH and 227,320 HIV-uninfected participants were included. By 4.5 years after baseline, most participants were screened for unhealthy alcohol use (85% of PLWH and 93% of HIV-uninfected), but with a lower rate among PLWH (adjusted HR 0.84, 95% CI 0.82 to 0.85). PLWH were less likely, compared with HIV-uninfected participants, to report unhealthy drinking among those screened (adjusted PR 0.74, 95% CI 0.69 to 0.79), and among those who screened positive, less likely to receive brief interventions (adjusted PR 0.82, 95% CI 0.75 to 0.90), but more likely (adjusted HR 1.7, 95% CI 1.2 to 2.4) to have an addiction specialty visit within 1 year.

CONCLUSIONS

Unhealthy alcohol use was lower in PLWH, but the treatment approach by HIV status differed. PLWH reporting unhealthy alcohol use received less brief interventions and more addiction specialty care than HIV-uninfected participants.

Health care utilization and HIV clinical outcomes among newly enrolled patients following Affordable Care Act implementation in a California integrated health system: a longitudinal study

BACKGROUND

The Affordable Care Act (ACA) has increased insurance coverage for people with HIV (PWH) in the United States. To inform health policy, it is useful to investigate how enrollment through ACA Exchanges, deductible levels, and demographic factors are associated with health care utilization and HIV clinical outcomes among individuals newly enrolled in insurance coverage following implementation of the ACA.

METHODS

Among PWH newly enrolled in an integrated health care system (Kaiser Permanente Northern California) in 2014 (N = 880), we examined use of health care and modeled associations between enrollment mechanisms (enrolled in a Qualified Health Plan through the California Exchange vs. other sources), deductibles (none, $1-$999 and > = $1000), receipt of benefits from the California AIDS Drug Assistance Program (ADAP), demographic factors, and three-year patterns of health service utilization (primary care, psychiatry, substance treatment, emergency, inpatient) and HIV outcomes (CD4 counts; viral suppression at HIV RNA < 75 copies/mL).

RESULTS

Health care use was greatest immediately after enrollment and decreased over 3 years. Those with high deductibles were less likely to use primary care (OR = 0.64, 95% CI = 0.49-0.84, p < 0.01) or psychiatry OR = 0.59, 95% CI = 0.37, 0.94, p = 0.03) than those with no deductible. Enrollment via the Exchange was associated with fewer psychiatry visits (rate ratio [RR] = 0.40, 95% CI = 0.18-0.86; p = 0.02), but ADAP was associated with more psychiatry visits (RR = 2.22, 95% CI = 1.24-4.71; p = 0.01). Those with high deductibles were less likely to have viral suppression (OR = 0.65, 95% CI = 0.42-1.00; p = 0.05), but ADAP enrollment was associated with viral suppression (OR = 2.20, 95% CI = 1.32-3.66, p < 0.01). Black (OR = 0.35, 95% CI = 0.21-0.58, p < 0.01) and Hispanic (OR = 0.50, 95% CI = 0.29-0.85, p = 0.01) PWH were less likely to be virally suppressed.

CONCLUSIONS

In this sample of PWH newly enrolled in an integrated health care system in California, findings suggest that enrollment via the Exchange and higher deductibles were negatively associated with some aspects of service utilization, high deductibles were associated with worse HIV outcomes, but support from ADAP appeared to help patients achieve viral suppression. Race/ethnic disparities remain important to address even among those with access to insurance coverage.

Racial/ethnic and gender differences in receipt of brief intervention among patients with unhealthy alcohol use in the U.S. Veterans Health Administration

OBJECTIVE

Brief intervention (BI) for unhealthy alcohol use is a top prevention priority for adults in the U.S, but rates of BI receipt vary across patients. We examine BI receipt across race/ethnicity and gender in a national cohort of patients from the Department of Veterans Affairs (VA)-the largest U.S. integrated healthcare system and a leader in implementing preventive care for unhealthy alcohol use.

METHODS

Among 779,041 VA patients with documented race/ethnicity and gender who screened positive for unhealthy alcohol use (AUDIT-C score ≥ 5) between 10/1/09 and 5/30/13, we fit Poisson regression models to estimate the predicted prevalence of BI (EHR-documented advice to reduce or abstain from drinking) across race/ethnicity and gender.

RESULTS

Rates of BI were lowest among Black women (67%), Black men (68%), and Asian/Pacific Islander women (68%), and highest among white men (75%), Hispanic men (75%), and Asian/Pacific Islander men (75%). A significant race/ethnicity by gender interaction indicated that the associations between race/ethnicity and gender with BI depended on the other factor. Gender differences were largest among Asian/Pacific Islander patients and were nonsignificant among American Indian/Alaska Native patients. Adjustment for covariates not expected to be on the causal pathway (e.g., age, year of AUDIT-C screen) slightly attenuated but did not change the direction of results.

CONCLUSIONS

Receipt of BI for unhealthy alcohol use varied by race/ethnicity and gender, and the impact of one factor depended on the other. Black women, Black men, and Asian/Pacific Islander women had the lowest rates of receiving recommended alcohol-related care. We found these disparities in a healthcare system that has implemented universal alcohol screening and incentivized BI for all patients with unhealthy alcohol use, suggesting that reducing disparities in alcohol-related care may require targeted interventions.

Patterns of alcohol use and associated characteristics and HIV-related outcomes among a sample of African-American women living with HIV

BACKGROUND

Alcohol use is common among people living with HIV and negatively impacts care and outcomes. African-American women living with HIV are subject to vulnerabilities that may increase risk for alcohol use and associated HIV-related outcomes.

METHODS

We used baseline data from a randomized controlled trial of an HIV-related stigma-reduction intervention among African-American women living with HIV in Chicago and Birmingham (2013-2015). Patterns of alcohol use [any use, unhealthy alcohol use (UAU), heavy episodic drinking (HED)] were measured using the AUDIT-C. We assessed demographic, social, and clinical characteristics which may influence alcohol use and HIV-related outcomes which may be influenced by patterns of alcohol use in bivariate and multivariable analyses.

RESULTS

Among 220 African-American women living with HIV, 54 % reported any alcohol use, 24 % reported UAU, and 27 % reported HED. In bivariate analysis, greater depressive symptoms, lower religiosity, lower social support, marijuana, and crack/cocaine use were associated with patterns of alcohol use (p < 0.05). Marijuana and cocaine/crack use were associated with patterns of alcohol use in adjusted analysis (p < 0.05). In adjusted analysis, any alcohol use and HED were associated with lower likelihood of ART adherence (ARR = 0.72, 95 % CI: 0.53-0.97 and ARR = 0.65, 95 % CI: 0.44-0.96, respectively), and UAU was associated with lack of viral suppression (ARR = 0.78, 95 % CI: 0.63-0.96).

CONCLUSIONS

Findings suggest any and unhealthy alcohol use is common and associated with poor HIV-related outcomes in this population. Regular alcohol screening and intervention should be offered, potentially targeted to subgroups (e.g., those with other substance use).

HIV Disease Severity Is Sensitive to Temporal Changes in Alcohol Use: A National Study of VA Patients With HIV

BACKGROUND

Alcohol use influences HIV disease severity through multiple mechanisms. Whether HIV disease severity is sensitive to changes in alcohol use among people with HIV (PWH) is understudied.

SETTING

National Veterans Health Administration.

METHODS

Pairs of AUDIT-C screens within 9-15 months (February 1, 2008-September 30, 2014) were identified among PWH from the Veterans Aging Cohort Study (VACS). Initial and follow-up VACS Index 2.0 pairs obtained 0-270 days after initial and follow-up AUDIT-Cs, respectively, determined change in VACS Index 2.0, a composite HIV severity measure. Change in VACS Index 2.0 was regressed on AUDIT-C change scores (-12 to +12) adjusted for demographics, initial VACS Index 2.0, and days between VACS Index measures.

RESULTS

Among 23,297 PWH (76,202 observations), most had no (51%) or low-level (38%) alcohol use initially. Most (54%) had no subsequent change; 21% increased and 24% decreased drinking. Initial VACS Index 2.0 scores ranged from 0 to 134, change scores ranged from -65 to +73, with average improvement of 0.76 points (SD 9.48). AUDIT-C change was associated with VACS Index 2.0 change (P < 0.001). Among those with stable alcohol use (AUDIT-C change ≤ │1│ point), VACS Index 2.0 improvements ranged 0.36-0.60 points. For those with maximum AUDIT-C increase (change from 0 to 12), VACS Index 2.0 worsened 3.74 points (95% CI: -4.71 to -2.78); for those with maximum AUDIT-C decrease (change from 12 to 0), VACS Index 2.0 changed minimally [-0.60 (95% CI: -1.43 to 0.23)].

CONCLUSIONS

In this national sample, improvement in HIV severity was generally greatest among those with stable alcohol use (primarily those with no use).

Differences in Receipt of Alcohol-Related Care Across Rurality Among VA Patients Living With HIV With Unhealthy Alcohol Use

PURPOSE

It is unknown whether receipt of evidence-based alcohol-related care varies by rurality among people living with HIV (PLWH) with unhealthy alcohol use-a population for whom such care is particularly important.

METHODS

All positive screens for unhealthy alcohol use (AUDIT-C ≥ 5) among PLWH were identified using Veterans Health Administration electronic health record data (10/1/09-5/30/13). Three domains of alcohol-related care were assessed: brief intervention (BI) within 14 days, and specialty addictions treatment or alcohol use disorder (AUD) medications (filled prescription for naltrexone, disulfiram, acamprosate, or topiramate) within 1 year of positive screen. Adjusted Poisson models and recycled predictions were used to estimate predicted prevalence of outcomes across rurality (urban, large rural, small rural), clustered on facility. Secondary analyses assessed outcomes in the subsample with documented AUD.

FINDINGS

4,581 positive screens representing 3,458 PLWH (3,112 urban, 130 large rural, and 216 small rural) were included; 49.1% had diagnosed AUD. PLWH in large rural areas had highest receipt of BI (urban 56.6%, 95% CI: 55.0-58.2; large rural 66.0%, CI: 58.6-73.5; small rural 60.7%, CI: 54.6-67.0). PLWH in urban areas had highest receipt of specialty addictions treatment (urban 28.2%, CI: 26.7-29.8; large rural 19.7%, CI: 13.1-26.2; small rural 19.6%, CI: 14.1-25.0). There was no difference in receipt of AUD medications, although overall receipt was low (3%-4%). Results were similar in the subsample with AUD.

CONCLUSION

Among PLWH with unhealthy alcohol use, those in rural areas may be vulnerable to under-receipt of specialty addictions treatment. Targeted interventions may help ensure PLWH receive recommended care regardless of rurality.