Reducing heavy drinking in HIV primary care: a randomized trial of brief intervention, with and without technological enhancement

Electronic interventions in primary care to address substance use: A systematic review

The present systematic review aims to identify electronic interventions for addressing substance use and understand their effectiveness in primary care settings. A systematic search was carried out in the Web of Science, PubMed/MEDLINE, Scopus, and Cochrane Library. The search included the keywords "electronic intervention", "substance use", "primary care" and synonyms. To determine the quality and recommendation of the analyzed interventions, the efficacy results reported by the studies were considered, as well as the Mixed Methods Appraisal Tool (MMAT) assessment and the GRADE Evidence Assessment. Twenty-one electronic interventions in Primary Care were identified: internet, mobile or tablet applications, text messages, emails, automated telephone calls, or electronic self-reports. These interventions had diverse components, incorporating theories that have proven effective in face-to-face interventions as their theoretical frameworks. Some of them were complementary to in-person treatment, while others replaced it. Six interventions (28.5 %) displayed high quality: HealthCall, AB-CASI, Quit Genius, eCHECKUP-TOGO, CBI, and TES. Another nine interventions (42.8 %) were found to have moderate-high quality: Alcohol y Salud, IVR-BI, Program of Wallace et al., Let's Talk About Smoking, SMSalud, ESCAPE, AAC-ASPIRE, iQuit, and Programa VIH. One intervention (4.7 %) had moderate-low quality: Vive sin tabaco ¡Decídete! The remaining five interventions (23.8 %) were found to have very low quality: Connection to health, cSBI, Teen Well Check, the program of Helzer et al. (2008), and Down your drink. The programs with the highest recommendation for addressing alcohol-related issues are HealthCall and AB-CASI; for tobacco use, it is Quit Genius; for cannabis use, it is eCHECKUP-TOGO; for addressing both legal and illegal substances, it is CBI and TES. Finally, for specific illicit drug use, the only recommended program is CBI. This last intervention, CBI, is of the highest quality and, therefore, can be considered a model intervention for dissemination in the primary care setting.

HealthCall: Smartphone Enhancement of Brief Interventions to Improve HIV Medication Adherence Among Patients in HIV Care

Heavy drinking among people living with HIV (PLWH) reduces ART adherence and worsens health outcomes. Lengthy interventions are not feasible in most HIV care settings, and patients infrequently follow referrals to outside treatment. Utilizing visual and video features of smartphone technology, we developed HealthCall as an electronic means of increasing patient involvement in a brief intervention to reduce drinking and improve ART adherence. The objective of the current study is to evaluate the efficacy of HealthCall to improve ART adherence among PLWH who drink heavily when paired with two brief interventions: the National Institute on Alcoholism and Alcohol Abuse (NIAAA) Clinician's Guide (CG) or Motivational Interviewing (MI). Therefore, we conducted a 1:1:1 randomized trial among 114 participants with alcohol dependence at a large urban HIV clinic. Participants were randomized to one of three groups: (1) CG only (n = 37), (2) CG and HealthCall (n = 38), or (3) MI and HealthCall (n = 39). Baseline interventions targeting drinking reduction and ART adherence were ~ 25 min, with brief (10-15 min) booster sessions at 30 and 60 days. The outcome was ART adherence assessed using unannounced phone pill-count method (possible adherence scores: 0-100%) at 30-day, 60-day, 3, 6, and 12 months. Analyses were conducted using generalized linear mixed models with pre-planned contrasts. Of the 114 enrolled patients, 58% were male, 75% identified as Black/African American, 28% were Hispanic, and 62% had less than a high school education. The mean age was 47.5 years (standard deviation [SD]  10 years) and the mean number of years since they were diagnosed with HIV was 18.6 (SD 7.6). Participants assigned to HealthCall to extend the CG had increased levels of ART adherence at 60-day and 6-month follow-up (compared to CG only), although there was no statistically significant difference by 12-month follow-up. Participants who were assigned to HealthCall to extend the MI never had statistically significant higher levels of ART adherence. These results suggest that the use of a smartphone app can be used to initially extend the reach of a brief drinking intervention to improve ART adherence over a short period of time; however, sustained long-term improvements in ART adherence after intervention activity ends remains a challenge.

Barriers and facilitators to implementing evidence-based integrated HIV and behavioral health care: perspectives from seven federal ending the HIV epidemic jurisdictions

The federal Ending the HIV Epidemic (EHE) initiative was created to reduce new US HIV infections, largely through pre-exposure prophylaxis and HIV treatments that reduce HIV transmissibility to zero. Behavioral health disorders (mental health and substance use) remain significant barriers to achieving EHE goals. Addressing behavioral health (BH) disorders within HIV primary care settings has been promoted as a critical EHE strategy. Implementation of efficacious HIV-BH care integration and its impact on HIV-related health outcomes is not well documented. In a federally-funded, exploratory phase implementation science study, we used the Collective Impact Framework to engage partners in seven EHE jurisdictions about the feasibility, acceptability, and sustainability of implementing HIV-BH integration interventions within local HIV settings. Partners concluded that full integration will remain the exception unless health systems invest in collaborative practice, professional training, appropriate health technology, and inter-system communication. Partners supported smaller incremental improvements including transdiagnostic approaches to reinforce each team member's sense of value in the shared endeavor. This early phase implementation science study identified research and implementation gaps that are critical to fill to end the HIV epidemic. Both the Collective Impact Framework and implementation science show promise for guiding future implementation of evidence-based HIV-BH intervention integration.

An Intervention to Reduce Drinking Among Individuals With HIV and Hepatitis C: A Pilot Randomized Controlled Trial

OBJECTIVE

Heavy drinking poses serious risks to individuals with HIV, hepatitis C virus (HCV), and especially HIV/HCV coinfection. We adapted the National Institute on Alcohol Abuse and Alcoholism Clinician's Guide to address HIV/HCV coinfection and paired this with the "HealthCall" smartphone app to create an intervention tailored to HIV/HCV. After formative work and pretesting with HIV/HCV coinfected heavy drinkers, we conducted a pilot trial to determine potential of this new intervention for decreasing drinking.

METHOD

A sample of 31 HIV/HCV coinfected heavy drinkers were randomly assigned to either intervention (n = 16) or control (n = 15; psychoeducation and brief advice) conditions. All participants completed a 60-day program consisting of approximately 25-minute-long baseline sessions and brief 5-10-minute booster sessions at 30 and 60 days, as well as an assessment-only follow-up at 90 days. Outcomes were measured using the Timeline Followback at baseline, 30, 60, and 90 days. Generalized linear models were used for analysis.

RESULTS

Intervention participants drank fewer mean drinks per drinking day at 60 days (incidence rate ratio [IRR] = 0.43, p = .03) and 90 days (IRR = 0.34, p < .01). Intervention participants also reported fewer drinking days at 90 days (mean difference = 34.5%; p < .01). Self-efficacy differed between groups during intervention (p < .05).

CONCLUSIONS

Although our sample was small, our results suggested lower drinking among participants who received a modified Clinician's Guide intervention plus use of the smartphone app HealthCall, in comparison with education and advice alone. A larger study is indicated to further examine this brief, disseminable intervention for HIV/HCV coinfected drinkers.

Couples motivational interviewing with mobile breathalysers to reduce alcohol use in South Africa: a pilot randomised controlled trial of Masibambisane

INTRODUCTION

Heavy alcohol use among people living with HIV in sub-Saharan Africa can hinder the success of HIV treatment programmes, impacting progress towards United Nations Programme on HIV/AIDS goals. Primary partners can provide critical forms of social support to reduce heavy drinking and could be included in motivational interviewing (MI) interventions to address heavy drinking; however, few studies have evaluated MI interventions for couples living with HIV in sub-Saharan Africa. We aim to evaluate the feasibility and acceptability of a couple-based MI intervention with mobile breathalyser technology to reduce heavy alcohol use and improve HIV treatment outcomes among HIV-affected couples in South Africa.

METHODS AND ANALYSIS

We will employ a three-arm randomised controlled trial to assess the efficacy of couple-based MI (MI-only arm) and in conjunction with mobile breathalysers (MI-plus arm) to address alcohol use and HIV outcomes, as compared with enhanced usual care (control arm). We will enrol heterosexual couples aged 18-49 in a primary relationship for at least 6 months who have at least one partner reporting hazardous alcohol use and on antiretroviral therapy for 6 months. Participants in both MI arms will attend three manualised counselling sessions and those in the MI-plus arm will receive real-time feedback on blood alcohol concentration levels using a mobile breathalyser. Couples randomised in the control arm will receive enhanced usual care based on the South African ART Clinical Guidelines. Feasibility and acceptability indicators will be analysed descriptively, and exploratory hypotheses will be examined through regression models considering time points and treatment arms.

ETHICS AND DISSEMINATION

The study was approved by the University of California, San Francisco (HRPP; protocol number 21-35034) and Human Sciences Research Council Research Ethics Committee (REC: protocol number 1/27/20/21). We will disseminate the results at local community meetings, community-level health gatherings and conferences focused on HIV and alcohol use.

TRIAL REGISTRATION NUMBER

NCT05756790.

Screening, brief intervention, and referral to treatment for tobacco consumption, alcohol misuse, and physical inactivity: an equity-informed rapid review

OBJECTIVE

This rapid review systematically synthesizes evidence of the effectiveness of the Screening, Brief Intervention, and Referral (SBIR/T) approach for tobacco use, alcohol misuse, and physical inactivity.

STUDY DESIGN

This was a rapid review.

METHODS

We searched primary studies between 2012 and 2022 in seven electronic databases. The search strategy used concepts related to alcohol-related disorders, intoxication, cigarette, nicotine, physical activity, exercise, sedentary, screening, therapy, and referral. We reviewed both title/abstract and full-text using a priori set inclusion and exclusion criteria to identify the eligible studies. We appraised study quality, extracted data, and summarized the characteristics of the included studies. We applied health equity lenses in the synthesis.

RESULTS

Of the 44 included studies, most focused on alcohol misuse. SBIR/T improved patients' attitudes toward alcohol behavior change, improved readiness and referral initiation for change, and effectively reduced alcohol consumption. Few studies pertained to smoking and physical inactivity. Most studies on smoking demonstrated effectiveness pertaining to patients' acceptance of referral recommendations, improved readiness and attempts to quitting smoking, and reduced or cessation of smoking. Findings were mixed about the effectiveness of SBIR/T in improving physical activity. Minimal studies exist on the impacts of SBIR/T for these three risk factors on healthcare resource use or costs. Studies considering diverse population characteristics in the design and effectiveness assessment of the SBIR/T intervention are lacking.

CONCLUSIONS

More research on the impacts of SBIR/T on tobacco use, alcohol misuse, and physical inactivity is required to inform the planning and delivery of SBIR/T for general and disadvantaged populations.

Motivational interviewing for substance use reduction

BACKGROUND

Substance use is a global issue, with around 30 to 35 million individuals estimated to have a substance-use disorder. Motivational interviewing (MI) is a client-centred method that aims to strengthen a person's motivation and commitment to a specific goal by exploring their reasons for change and resolving ambivalence, in an atmosphere of acceptance and compassion. This review updates the 2011 version by Smedslund and colleagues.

OBJECTIVES

To assess the effectiveness of motivational interviewing for substance use on the extent of substance use, readiness to change, and retention in treatment.

SEARCH METHODS

We searched 18 electronic databases, six websites, four mailing lists, and the reference lists of included studies and reviews. The last search dates were in February 2021 and November 2022.

SELECTION CRITERIA

We included randomised controlled trials with individuals using drugs, alcohol, or both. Interventions were MI or motivational enhancement therapy (MET), delivered individually and face to face. Eligible control interventions were no intervention, treatment as usual, assessment and feedback, or other active intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane, and assessed the certainty of evidence with GRADE. We conducted meta-analyses for the three outcomes (extent of substance use, readiness to change, retention in treatment) at four time points (post-intervention, short-, medium-, and long-term follow-up).

MAIN RESULTS

We included 93 studies with 22,776 participants. MI was delivered in one to nine sessions. Session durations varied, from as little as 10 minutes to as long as 148 minutes per session, across included studies. Study settings included inpatient and outpatient clinics, universities, army recruitment centres, veterans' health centres, and prisons. We judged 69 studies to be at high risk of bias in at least one domain and 24 studies to be at low or unclear risk. Comparing MI to no intervention revealed a small to moderate effect of MI in substance use post-intervention (standardised mean difference (SMD) 0.48, 95% confidence interval (CI) 0.07 to 0.89; I2 = 75%; 6 studies, 471 participants; low-certainty evidence). The effect was weaker at short-term follow-up (SMD 0.20, 95% CI 0.12 to 0.28; 19 studies, 3351 participants; very low-certainty evidence). This comparison revealed a difference in favour of MI at medium-term follow-up (SMD 0.12, 95% CI 0.05 to 0.20; 16 studies, 3137 participants; low-certainty evidence) and no difference at long-term follow-up (SMD 0.12, 95% CI -0.00 to 0.25; 9 studies, 1525 participants; very low-certainty evidence). There was no difference in readiness to change (SMD 0.05, 95% CI -0.11 to 0.22; 5 studies, 1495 participants; very low-certainty evidence). Retention in treatment was slightly higher with MI (SMD 0.26, 95% CI -0.00 to 0.52; 2 studies, 427 participants; very low-certainty evidence). Comparing MI to treatment as usual revealed a very small negative effect in substance use post-intervention (SMD -0.14, 95% CI -0.27 to -0.02; 5 studies, 976 participants; very low-certainty evidence). There was no difference at short-term follow-up (SMD 0.07, 95% CI -0.03 to 0.17; 14 studies, 3066 participants), a very small benefit of MI at medium-term follow-up (SMD 0.12, 95% CI 0.02 to 0.22; 9 studies, 1624 participants), and no difference at long-term follow-up (SMD 0.06, 95% CI -0.05 to 0.17; 8 studies, 1449 participants), all with low-certainty evidence. There was no difference in readiness to change (SMD 0.06, 95% CI -0.27 to 0.39; 2 studies, 150 participants) and retention in treatment (SMD -0.09, 95% CI -0.34 to 0.16; 5 studies, 1295 participants), both with very low-certainty evidence. Comparing MI to assessment and feedback revealed no difference in substance use at short-term follow-up (SMD 0.09, 95% CI -0.05 to 0.23; 7 studies, 854 participants; low-certainty evidence). A small benefit for MI was shown at medium-term (SMD 0.24, 95% CI 0.08 to 0.40; 6 studies, 688 participants) and long-term follow-up (SMD 0.24, 95% CI 0.07 to 0.41; 3 studies, 448 participants), both with moderate-certainty evidence. None of the studies in this comparison measured substance use at the post-intervention time point, readiness to change, and retention in treatment. Comparing MI to another active intervention revealed no difference in substance use at any follow-up time point, all with low-certainty evidence: post-intervention (SMD 0.07, 95% CI -0.15 to 0.29; 3 studies, 338 participants); short-term (SMD 0.05, 95% CI -0.03 to 0.13; 18 studies, 2795 participants); medium-term (SMD 0.08, 95% CI -0.01 to 0.17; 15 studies, 2352 participants); and long-term follow-up (SMD 0.03, 95% CI -0.07 to 0.13; 10 studies, 1908 participants). There was no difference in readiness to change (SMD 0.15, 95% CI -0.00 to 0.30; 5 studies, 988 participants; low-certainty evidence) and retention in treatment (SMD -0.04, 95% CI -0.23 to 0.14; 12 studies, 1945 participants; moderate-certainty evidence). We downgraded the certainty of evidence due to inconsistency, study limitations, publication bias, and imprecision.

AUTHORS' CONCLUSIONS

Motivational interviewing may reduce substance use compared with no intervention up to a short follow-up period. MI probably reduces substance use slightly compared with assessment and feedback over medium- and long-term periods. MI may make little to no difference to substance use compared to treatment as usual and another active intervention. It is unclear if MI has an effect on readiness to change and retention in treatment. The studies included in this review were heterogeneous in many respects, including the characteristics of participants, substance(s) used, and interventions. Given the widespread use of MI and the many studies examining MI, it is very important that counsellors adhere to and report quality conditions so that only studies in which the intervention implemented was actually MI are included in evidence syntheses and systematic reviews. Overall, we have moderate to no confidence in the evidence, which forces us to be careful about our conclusions. Consequently, future studies are likely to change the findings and conclusions of this review.

Mapping Studies of Alcohol Use Among People Living with HIV/AIDS During 1990-2019 (GAPRESEARCH)

Alcohol drinking has long been reported to be common in people living with HIV/AIDS, having biological and behavioral impacts on the transmission, progression, and prevention of HIV/AIDS. A total of 7059 eligible articles and reviews published in English from 1990 to 2019 were extracted from the WOS. Results show an increase in publication volume, while citations peak for papers published in 2006. Content analysis reveals a wide-ranging coverage of topics, with the most popular being effects of alcohol consumption on ART adherence and outcomes, alcohol-related sexual behaviors, TB co-infection, and psycho-socio-cultural considerations in examining and designing measures targeting alcohol use and interventions to reduce alcohol dependence in PLWHA. This calls for more active engagement of governments in research and in designing and implementing interventions, as well as collaborations and knowledge transfer from high-income countries to developing counterparts, to effectively address alcohol use-related issues in PLWHA, moving toward the HIV/AIDS eradication target.

Brief interventions for alcohol misuse among people living with HIV: a meta-analysis

Background: One-third of people living with HIV (PLHIV) have alcohol misuse or alcohol use disorders which negatively affect course and outcome of HIV.Objectives: The meta-analysis sought to evaluate the effectiveness of brief interventions (BI) on alcohol and HIV outcomes in PLHIV with alcohol misuse.Methods: We included clinical trials published between 1990 and September 2022 on adults with harmful/hazardous alcohol use; only randomized clinical trials (RCTs) were included in the meta-analysis. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Clinical Trials.Gov, and the World Health Organization's International Clinical Trials Registry Platform databases. Cochrane's risk-of-bias assessment was used.Results: Eighteen studies were included in the narrative synthesis, and a meta-analysis could be performed on 13 studies. Among the included RCTs, seven showed a low risk and two showed a high risk of bias; others showed some concerns. There was no evidence of publication bias. Compared to the control, BI significantly reduces the drinks per drinking day (N = 5, Hedge's g= -0.45, 95%CI = -0.58, -0.32) and the number of heavy drinking days (N = 4, Hedge'sg = -0.81, 95% CI= -0.94, -0.67) between 3-6 months post-intervention. BI also reduces the odds of mortality by 42% (N = 7, OR = 0.58, 95% CI = 0.34, 0.99) in 6-12 months. BI does not change the alcohol risk scores and transition to harmful alcohol use; it does not improve adherence to Anti-Retroviral Therapy and increase viral suppression.Conclusion: Policymakers must introduce and scale up integrated screening and brief intervention services within HIV clinics and primary care.

Economic Cost of the HealthCall Smartphone Intervention to Reduce Heavy Alcohol Drinking in Adults With HIV

OBJECTIVE

Alcohol use among people living with HIV (PLWH) can reduce adherence and worsen health outcomes. We evaluated the economic cost of an effective smartphone application (HealthCall) to reduce drinking and improve antiretroviral adherence among heavy-drinking PLWH participating in a randomized trial.

METHOD

Participants were randomized to receive a brief drinking-reduction intervention, either (a) the National Institute on Alcohol Abuse and Alcoholism (NIAAA) Clinician's Guide (CG-only, n = 37), (b) CG enhanced by HealthCall to monitor daily alcohol consumption (CG+HealthCall, n = 38), or (c) motivational interviewing delivered by a nonclinician enhanced by HealthCall (MI+HealthCall, n = 39). We used micro-costing techniques to evaluate start-up costs and incremental costs per participant incurred from the health care sector perspective in 2018 U.S. dollars. We also investigated potential cost offsets using participant-reported health care utilization.

RESULTS

Participants attended three intervention visits, and each visit cost on average $29 for CG-only, $32 for CG+HealthCall, and $15 for MI+HealthCall. The total intervention cost per participant was $94 for CG-only, $114 for CG+HealthCall, and $57 for MI+HealthCall; the incremental cost of CG+HealthCall compared with CG-only was $20 per participant, and the incremental savings of MI+HealthCall compared with CG-only was $37 per participant. No significant differences in health care utilization occurred among the three groups over 12 months.

CONCLUSIONS

The cost of enhancing CG with the HealthCall application for heavy-drinking PLWH was modestly higher than using the CG alone, whereas MI enhanced with HealthCall delivered by a nonclinician had a lower cost than CG alone. HealthCall may be a low-cost enhancement to brief interventions addressing alcohol use and antiretroviral adherence among PLWH.

Promoting alcohol treatment engagement post-hospitalization with brief intervention, medications and CBT4CBT: protocol for a randomized clinical trial in a diverse patient population

BACKGROUND

Alcohol use disorder (AUD) commonly causes hospitalization, particularly for individuals disproportionately impacted by structural racism and other forms of marginalization. The optimal approach for engaging hospitalized patients with AUD in treatment post-hospital discharge is unknown. We describe the rationale, aims, and protocol for Project ENHANCE (ENhancing Hospital-initiated Alcohol TreatmeNt to InCrease Engagement), a clinical trial testing increasingly intensive approaches using a hybrid type 1 effectiveness-implementation approach.

METHODS

We are randomizing English and/or Spanish-speaking individuals with untreated AUD (n = 450) from a large, urban, academic hospital in New Haven, CT to: (1) Brief Negotiation Interview (with referral and telephone booster) alone (BNI), (2) BNI plus facilitated initiation of medications for alcohol use disorder (BNI + MAUD), or (3) BNI + MAUD + initiation of computer-based training for cognitive behavioral therapy (CBT4CBT, BNI + MAUD + CBT4CBT). Interventions are delivered by Health Promotion Advocates. The primary outcome is AUD treatment engagement 34 days post-hospital discharge. Secondary outcomes include AUD treatment engagement 90 days post-discharge and changes in self-reported alcohol use and phosphatidylethanol. Exploratory outcomes include health care utilization. We will explore whether the effectiveness of the interventions on AUD treatment engagement and alcohol use outcomes differ across and within racialized and ethnic groups, consistent with disproportionate impacts of AUD. Lastly, we will conduct an implementation-focused process evaluation, including individual-level collection and statistical comparisons between the three conditions of costs to providers and to patients, cost-effectiveness indices (effectiveness/cost ratios), and cost-benefit indices (benefit/cost ratios, net benefit [benefits minus costs). Graphs of individual- and group-level effectiveness x cost, and benefits x costs, will portray relationships between costs and effectiveness and between costs and benefits for the three conditions, in a manner that community representatives also should be able to understand and use.

CONCLUSIONS

Project ENHANCE is expected to generate novel findings to inform future hospital-based efforts to promote AUD treatment engagement among diverse patient populations, including those most impacted by AUD.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT05338151.

Pilot Trial of a Smartphone-Based Intervention to Reduce Alcohol Consumption among Veterans with HIV

Veterans engage in disproportionate levels of alcohol use, which can impact treatment outcomes among veterans with HIV. The TRAC (Tracking and Reducing Alcohol Consumption) intervention, which combines smartphones, mobile breathalyzers, and motivational interviewing (MI), was developed to help reduce alcohol use among this population. This study reports results of an 8-week pilot trial of TRAC among veterans with HIV (N = 10). Participants attended weekly MI sessions conducted via videoconferencing or phone and completed twice-daily self-monitoring of alcohol consumption using breathalyzers and surveys. They also completed pre- and post-intervention questionnaires and a qualitative interview. Analyses explored adherence to self-monitoring tasks, perceptions of the intervention, and preliminary effects of TRAC on alcohol use and readiness to change drinking behavior. Participants completed 76% of breathalyzer readings and 73% of surveys and completed more daytime than evening monitoring tasks. AUDIT hazardous drinking scores significantly decreased between baseline and post-test. Qualitative interviews revealed positive attitudes toward the technologies and MI sessions. Overall, this pilot demonstrated that the TRAC intervention has potential to reduce alcohol use among veterans with HIV, though additional effort is needed to improve adherence to mobile monitoring. Results were used to refine the intervention in preparation for a randomized controlled trial.

A Causal Analysis of Young Adults' Binge Drinking Reduction and Cessation

BACKGROUND

This study, using the multiple disadvantage model (MDM), sought to identify factors (disadvantaging social disorganization, social structural, social integration, health/mental health, co-occurring substance use, and substance treatment access factors) in young adults' binge drinking reduction and cessation in the United States.

METHODS

We extracted data on 942 young adult binge drinkers (25-34 years, 47.8% female) from the National Longitudinal Study of Adolescent to Adult Health (Add Health), carrying out a temporal-ordered causal analysis, meaning the evaluation of select variables' impacts on an outcome at a subsequent time.

RESULTS

MDM found a relatively high reduction likelihood for non-Hispanic African Americans and respondents with relatively more education. MDM found a relatively low reduction likelihood accompanying an alcohol-related arrest, higher income, and greater number of close friends. Change to nondrinking was found more likely for non-Hispanic African Americans, other non-Hispanic participants having minority ethnicity, older respondents, those with more occupational skills, and healthier respondents. Such change became less likely with an alcohol-related arrest, higher income, relatively more education, greater number of close friends, close friends' disapproval of drinking, and co-occurring drug use.

CONCLUSIONS

Interventions incorporating a motivational-interviewing style can effectively promote health awareness, assessment of co-occurring disorders, friendships with nondrinkers, and attainment of occupational skills.

Characterizing Unhealthy Alcohol Use Patterns and Their Association with Alcohol Use Reduction and Alcohol Use Disorder During Follow-Up in HIV Care

Outcomes of PWH with unhealthy alcohol use, such as alcohol use reduction or progression to AUD, are not well-known and may differ by baseline patterns of unhealthy alcohol use. Among 1299 PWH screening positive for NIAAA-defined unhealthy alcohol use in Kaiser Permanente Northern California, 2013-2017, we compared 2-year probabilities of reduction to low-risk/no alcohol use and rates of new AUD diagnoses by baseline use patterns, categorized as exceeding: only daily limits (72% of included PWH), only weekly limits (17%), or both (11%), based on NIAAA recommendations. Overall, 73.2% (95% CI 70.5-75.9%) of re-screened PWH reduced to low-risk/no alcohol use over 2 years, and there were 3.1 (95% CI 2.5-3.8%) new AUD diagnoses per 100 person-years. Compared with PWH only exceeding daily limits at baseline, those only exceeding weekly limits and those exceeding both limits were less likely to reduce and likelier to be diagnosed with AUD during follow-up. PWH exceeding weekly drinking limits, with or without exceeding daily limits, may have a potential need for targeted interventions to address unhealthy alcohol use.

Smartphone intervention to optimize medication-assisted treatment outcomes for opioid use disorder: study protocol for a randomized controlled trial

BACKGROUND

Opioids accounted for 75% of drug overdoses in the USA in 2020, with rural states particularly impacted by the opioid crisis. While medication-assisted treatment (MAT) with Suboxone remains one of the more efficacious treatments for opioid use disorder (OUD), approximately 40% of people receiving Suboxone for outpatient MAT for OUD (MOUD) relapse within the first 6 months of treatment. We developed the smartphone app-based intervention OptiMAT as an adjunctive intervention to improve MOUD outcomes. The aims of this study are to (1) evaluate the efficacy of adjunctive OptiMAT use in reducing opioid misuse among people receiving MOUD and (2) evaluate the role of specific OptiMAT features in reducing opioid misuse, including the use of GPS-driven just-in-time intervention.

METHODS

We will conduct a two-arm, single-blind, randomized controlled trial of adults receiving outpatient MOUD in the greater Little Rock AR area. Participants are English-speaking adults ages 18 or older recently enrolled in outpatient MOUD at one of our participating study clinics. Participants will be allocated via 1:1 randomized block design to (1) MOUD with adjunctive use of OptiMAT (MOUD+OptiMAT) or (2) MOUD without OptiMAT (MOUD-only). Our blinded research statistician will evaluate differences between the two groups in opioid misuse (as determined by quantitative urinalysis conducted by clinical lab staff blinded to group membership) during the 6-months following study enrolment. Secondary analyses will evaluate if OptiMAT-usage patterns within the MOUD+OptiMAT group predict opioid misuse or continued abstinence.

DISCUSSION

This study will test if adjunctive use of OptiMAT improve MOUD outcomes. Study findings could lead to expansion of OptiMAT into rural clinical settings, and the identification of OptiMAT features which best predict positive clinical outcome could lead to refinement of this and similar smartphone app-based interventions.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT05336188 , registered March 21, 2022.

Smartphone intervention to optimize medication assisted treatment outcomes for opioid use disorder: study protocol for a randomized controlled trial

Background: Opioids accounted for 75% of drug overdoses in the United States in 2020, with rural states particularly impacted by the opioid crisis. While medication assisted treatment (MAT) with Suboxone remains one of the more efficacious treatments for opioid use disorder (OUD), approximately 40% of people receiving Suboxone for outpatient MAT for OUD (MOUD) relapse within the first 6 months of treatment. We developed the smartphone app-based intervention OptiMAT as an adjunctive intervention to improve MOUD outcomes. The aims of this study are to (1) evaluate the efficacy of adjunctive OptiMAT use in reducing opioid misuse among people receiving MOUD; and (2) evaluate the role of specific OpitMAT features in reducing opioid misuse, including the use of GPS-driven just-in-time intervention. Methods: We will conduct a two-arm, single-blind, randomized controlled trial of adults receiving outpatient MOUD in the greater Little Rock AR area. Participants are English-speaking adults ages 18 or older recently enrolled in outpatient MOUD at one of our participating study clinics. Participants will be allocated via 1:1 randomized block design to (1) MOUD with adjunctive use of OptiMAT (MOUD+OptiMAT) or (2) MOUD without OptiMAT (MOUD-only). Our blinded research statistician will evaluate differences between the two groups in opioid misuse (as determined by quantitative urinalysis conducted by clinical lab staff blinded to group membership) during the 6-months following study enrolment. Secondary analyses will evaluate if OptiMAT-usage patterns within the MOUD+OptiMAT group predict opioid misuse or continued abstinence. Discussion: This study will test if adjunctive use of OptiMAT improve MOUD outcomes. Study findings could lead to expansion of OptiMAT into rural clinical settings, and the identification of OptiMAT features which best predict positive clinical outcome could lead to refinement of this and similar smartphone appbased interventions. Trial registration: ClinicalTrials.gov identifier: NCT05336188, registered March 21, 2022, https://clinicaltrials.gov/ct2/show/NCT05336188.

HealthCall: A randomized trial assessing a smartphone enhancement of brief interventions to reduce heavy drinking in HIV care

INTRODUCTION

Heavy drinking among people living with HIV (PLWH) worsens their health outcomes and disrupts their HIV care. Although brief interventions to reduce heavy drinking in primary care are effective, more extensive intervention may be needed in PLWH with moderate-to-severe alcohol use disorder. Lengthy interventions are not feasible in most HIV primary care settings, and patients seldom follow referrals to outside treatment. Utilizing visual and video features of smartphone technology, we developed the "HealthCall" app to provide continued engagement after brief intervention, reduce drinking, and improve other aspects of HIV care with minimal demands on providers. We conducted a randomized trial of its efficacy.

METHODS

The study recruited alcohol-dependent PLWH (n = 114) from a large urban HIV clinic. Using a 1:1:1 randomized design, the study assigned patients to: Motivational Interviewing (MI) plus HealthCall (n = 39); NIAAA Clinician's Guide (CG) plus HealthCall (n = 38); or CG-only (n = 37). Baseline MI and CG interventions took ~25 min, with brief (10-15 min) 30- and 60-day booster sessions. HealthCall involved daily use of the smartphone app (3-5 min/day) to report drinking and health in the prior 24 h. Outcomes assessed at 30 and 60 days and at 3, 6 and 12 months included drinks per drinking day (DpDD; primary outcome) and number of drinking days, analyzed with generalized linear mixed models and pre-planned contrasts.

RESULTS

Study retention was excellent (85%-94% across timepoints). At 30 days, DpDD among patients in MI + HealthCall, CG + HealthCall, and CG-only was 3.80, 5.28, and 5.67, respectively; patients in MI + HealthCall drank less than CG-only and CG + HealthCall (IRRs = 0.62, 95% CI = 0.46, 0.84, and 0.64, 95% CI = 0.48, 0.87, respectively). At 6 months (end-of-treatment), DpDD was lower in CG + HealthCall (DpDD = 4.88) than MI + HealthCall (DpDD = 5.88) or CG-only (DpDD = 6.91), although these differences were not significant. At 12 months, DpDD was 5.73, 5.31, and 6.79 in MI + HealthCall, CG + HealthCall, and CG-only, respectively; DpDD was significantly lower in CG + HealthCall than CG-only (IRR = 0.71, 95% CI = 0.51, 0.98).

CONCLUSIONS

During treatment, patients in MI + HealthCall had lower DpDD than patients in other conditions; however, at 12 months, drinking was lowest among patients in CG + HealthCall. Given the importance of drinking reduction and the low costs/time required for HealthCall, pairing HealthCall with brief interventions merits widespread consideration.

A conceptual model of alcohol use and adherence to antiretroviral therapy: systematic review and theoretical implications for mechanisms of action

Alcohol consumption is one of the most prevalent correlates of antiretroviral therapy (ART) adherence, yet causal processes underlying this association remain largely unexplored. The goal of this systematic review was to develop a conceptual model that describes the causal effect of alcohol consumption on ART nonadherence. We reviewed 230 studies that examined the association between alcohol consumption and ART adherence with three primary aims: (1) to replicate and extend previous reviews of the literature, (2) to summarize and critique study designs capable of answering questions about temporal overlap and (3) to summarize potential mechanisms of action. A model of alcohol-associated ART nonadherence was proposed to guide future work, integrating general theories of ART adherence and theory on the psychological and behavioral effects of alcohol intoxication. The conceptual model describes two mechanistic processes-prospective memory impairment and interactive toxicity beliefs/avoidance behaviors-involved in alcohol-associated intentional and unintentional nonadherence, respectively. This model can be used to guide future research on the causal processes involved in the frequently observed correlation between alcohol consumption and adherence.

Computer delivered intervention for alcohol and sexual risk reduction among women attending an urban sexually transmitted infection clinic: A randomized controlled trial

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Unhealthy alcohol use is prevalent among women attending STI clinics.

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We tested whether CBI or CBI-IVR-TM, reduced alcohol use among women in this setting.

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Neither CBI nor CBI-IVR-TM reduced alcohol use more than control.

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2/3 of women had an alcohol use disorder, 65% substance use, 28% depressive symptoms.

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CBI is insufficient for alcohol reduction in this high severity, high comorbidity setting.

Objective

We sought to determine if a computer delivered brief alcohol intervention (CBI) with or without interactive voice response counseling and text messages (CBI-IVR-TM), reduced alcohol use and sexual risk behaviors compared to attention control.

Methods

We conducted a 3-arm RCT among women (n = 439) recruited from Baltimore City Sexually Transmitted Infection (STI) Clinics. Eligibility included: 1) consumption of >7 drinks per week or 2) ≥2 episodes of heavy episodic drinking or ≥2 episodes of sex under the influence of alcohol in the prior three months. Research assessments conducted at baseline, 3, 6 and 12 months included a 30-day Timeline Followback querying daily alcohol use, drug use, and sexual activity. We used the MINI International Neuropsychiatric Interview-DSM-IV to ascertain drinking severity. Primary alcohol outcomes included: drinking days, heavy drinking days, drinks per drinking day. Secondary sexual risk outcomes included number of sexual partners, days of condomless sex, and days of condomless sex under the influence of drugs and alcohol.

Results

Median age was 31 (IQR 25–44 years), 88% were African American, 65% reported current recreational drug use, and 26% endorsed depressive symptoms. On the MINI 66% met criteria for alcohol use disorder (49% alcohol dependence, 18% abuse). At follow-up, all three groups reduced drinking days, heavy drinking days, drinks per drinking day and drinks per week with no significant differences between study arms. There was no difference in sexual risk outcomes among the groups.

Conclusions

 Among women attending an urban STI clinic single session CBI with or without IVR and text message boosters was insufficient to reduce unhealthy alcohol use or sexual risk behaviors beyond control. The high severity of alcohol use and the prevalence of mental health symptoms and other substance use comorbidity underscores the importance of developing programs that address not only alcohol use but other determinants of STI risk among women.

Decreased Alcohol Consumption in an Implementation Study of Computerized Brief Intervention among HIV Patients in Clinical Care

This prospective, nonrandomized implementation study evaluated a computerized brief intervention (CBI) for persons with HIV (PWH) and heavy/hazardous alcohol use. CBI was integrated into two HIV primary care clinics. Eligible patients were engaged in care, ≥ 18 years old, English speaking, endorsed heavy/hazardous alcohol use on the Alcohol Use Disorders Identification Test-C (AUDIT-C). Two 20-min computerized sessions using cognitive behavioral techniques were delivered by a 3-D avatar on touch screen tablets. Of 816 eligible AUDIT-C scores, 537 (66%) resulted in CBI invitation, 226 (42%) of invited patients enrolled, and 176 (78%) of enrolled patients watched at least one session. CBI enrollment was associated with a significant average reduction of 9.1 drinks/week (95% CI - 14.5, - 3.6) 4-12 months post-enrollment. Among those who participated in one or both sessions, average reduction in drinks/week was 11.7 drinks/week (95% CI - 18.8, - 4.6). There was corresponding improvement in AUDIT-C scores. Overall patients reported high levels of intervention satisfaction, particularly among older and Black patients. These promising results point to a practical intervention for alcohol reduction in this vulnerable patient population with elevated rates of heavy/hazardous drinking. Future research should examine strategies to increase initial engagement, strengthen intervention effects to increase the number of patients who achieve non-hazardous drinking, and examine the duration of therapeutic effects.

Cultural Adaptation of an Intervention to Reduce Hazardous Alcohol Use Among People Living with HIV in Southwestern Uganda

Hazardous drinking by persons living with HIV (PLHIV) is a well-established determinant of sub-optimal HIV care and treatment outcomes. Despite this, to date, few interventions have sought to reduce hazardous drinking among PLHIV in sub-Saharan Africa (SSA). We describe an iterative cultural adaptation of an evidence-based multi-session alcohol reduction intervention for PLHIV in southwestern Uganda. The adaptation process included identifying core, theoretically informed, intervention elements, and conducting focus group discussions and cognitive interviews with community members, HIV clinic staff and patients to modify key intervention characteristics for cultural relevance and saliency. Adaptation of evidence-based alcohol reduction interventions can be strengthened by the inclusion of the target population and key stakeholders in shaping the content, while retaining fidelity to core intervention elements.

A Randomized Trial Comparing Brief Advice and Motivational Interviewing for Persons with HIV-HCV Co-infection Who Drink Alcohol

Alcohol use contributes to the progression of liver disease in HIV-HCV co-infected persons, but alcohol interventions have never addressed low levels of alcohol use in this population. We enrolled 110 persons consuming at least 4 alcoholic drinks weekly in a clinical trial comparing two active 18-month long interventions, delivered every 3 months by phone, brief advice about drinking versus a motivational intervention. Final assessment was at 24 months. MI had larger reductions in alcohol use days than the BA arm at all follow-up assessments. The treatment by time effect was not significant for days of drinking (p = 0.470), mean drinks per day (p = 0.155), or for the continuous FIB-4 index (p = 0.175). Drinking declined in both conditions from baseline, but given the small sample, we do not have sufficient data to make any conclusion that one treatment is superior to the other.Trial Registry Trial registered at clinicaltrials.gov; Clinical Trial NCT02316184.

The use and impact of self-monitoring on substance use outcomes: A descriptive systematic review

BACKGROUND

Self-Monitoring (SM), the act of observing ones' own behavior, has been used in substance use treatment because SM may bring conscious awareness to automatized substance use behaviors. Empirical findings regarding SM's effectiveness are mixed. The aim of this study was to synthesize the literature for the efficacy of SM on substance use. Method: A literature search was conducted using MEDLINE/PubMed. Results: Out of 2,659 citations, 41 studies with 126 analyses were included. Among analyses from studies rated Moderate (n = 24) or Strong (n = 3) quality, SM was shown to have a helpful effect (e.g., reducing substance use) 29% of the time; to have no effect 63.0% of the time; and to be detrimental in 8.0% of analyses. SM's helpful effects were associated with methodological characteristics including longer monitoring and Phone/IVR and EMA/Computer methodologies compared to Paper/Pencil. SM was more helpful in non-treatment-seekers (35.0% of analyses showed SM to be helpful compared to 25.0% of analyses with treatment-seekers). Conclusions: Results of this study suggest that SM, under certain circumstances, as the potential to be a low-cost, low-risk research and early intervention strategy for substance users.

Emerging prevalence of fatty liver disease in HIV

Fatty liver disease is a growing concern in people living with HIV, the main drivers are alcoholic liver disease and nonalcoholic fatty liver disease. It has shown to negatively impact HIV care continuum and result in notable non-HIV related morbidity and mortality. With the advancement in antiretroviral therapy and effective direct acting antivirals, fatty liver disease is surfacing as the next big challenge in this population like that observed in the general population. This review article summarizes the gravity of these two common diseases in HIV-infected people and aims to sheds light on an unmet need to develop effective methods to identify, screen and manage fatty liver disease in this unique population.

Effectiveness of a psychological intervention delivered by general nurses for alcohol use disorders in people living with HIV in Zimbabwe: a cluster randomized controlled trial

INTRODUCTION

There have been very few randomized clinical trials of interventions for alcohol use disorders (AUD) in people living with HIV (PLWH) in African countries. This is despite the fact that alcohol use is one of the modifiable risk factors for poor virological control in PLWH on antiretroviral therapy.

METHODS

Sixteen clinic clusters in Zimbabwe were selected through stratified randomization and randomized 1: 1 to Intervention and Control arms. Inclusion criteria for individual participants were being adult, living with HIV and a probable alcohol use disorder as defined by a score of 6 (women) or 7 (men) on the Alcohol Use Disorders Identification Test (AUDIT). In the Intervention clusters, participants received 8 to 10 sessions of Motivational Interviewing blended with brief Cognitive Behavioural Therapy (MI-CBT). In the control clusters, participants received four Enhanced Usual Care (EUC) sessions based on the alcohol treatment module from the World Health Organisation mhGAP intervention guide. General Nurses from the clinics were trained to deliver both treatments. The primary outcome was a change in AUDIT score at six-month post-randomization. Viral load, functioning and quality of life were secondary outcomes. A random-effects analysis-of-covariance model was used to account for the cluster design.

RESULTS

Two hundred and thirty-four participants (n = 108 intervention and n = 126 control) were enrolled across 16 clinics. Participants were recruited from November 2016 to November 2017 and followed through to May 2018. Their mean age was 43.3 years (SD = 9.1) and 78.6% (n = 184) were male. At six months, the mean AUDIT score fell by -6.15 (95% CI -6.32; -6.00) in the MI-CBT arm, compared to a fall of - 3.09 95 % CI - 3.21; -2.93) in the EUC arm (mean difference -3.09 (95% CI -4.53 to -1.23) (p = 0.05). Viral load reduced and quality of life and functioning improved in both arms but the difference between arms was non-significant.

CONCLUSIONS

Interventions for hazardous drinking and AUD comprising brief, multiple alcohol treatment sessions delivered by nurses in public HIV facilities in low-income African countries can reduce problematic drinking among PLWH. Such interventions should be integrated into the primary care management of AUD and HIV and delivered by non-specialist providers. Research is needed on cost-effectiveness and implementation of such interventions, and on validation of cut-points for alcohol use scales in low resource settings, in partnership with those with lived experience of HIV and AUD.

Smartphone application plus brief motivational intervention reduces substance use and sexual risk behaviors among homeless young adults: Results from a randomized controlled trial

Homeless young adults are more likely than their never-homeless counterparts to abuse substances and engage in sexual risk behaviors. This study evaluated the feasibility and preliminary effectiveness of OnTrack, a smartphone application to self-monitor substance use and sexual risk behaviors, plus a brief motivational intervention (BMI), in reducing substance use and sexual risk among homeless young adults. A randomized controlled pilot trial (N = 60) compared OnTrack + BMI to treatment as usual (TAU) at an inner-city crisis shelter for homeless young adults (aged 18-21 years). Participants were assessed at baseline and 2 weeks, 4 weeks, and 6 weeks after baseline to evaluate substance use and sexual risk behaviors. Kruskal-Wallis tests determined differences between baseline and postintervention assessments. Logistic regression models examined treatment effect on change in outcomes between baseline and postintervention follow-up assessment, controlling for baseline levels. Participants in OnTrack + BMI significantly reduced past 2-week number of drinks (p = .023), times used marijuana (p = .046), times engaged in unprotected sex (p = .012), and times used drugs before sexual activity (p = .019). No reductions of substance use or sexual risk behaviors were found among participants in TAU (all ps > .05). After adjusting for baseline levels of substance use and sexual risk, participants in OnTrack + BMI had significantly lower odds than those in TAU for drinking alcohol (adjusted OR = 0.14; p = .01) and having unprotected sex (adjusted OR = 0.151; p = .032). OnTrack + BMI is feasible and effective in reducing past 2-week alcohol use and unprotected sex among homeless young adults. A larger randomized trial is warranted to replicate and extend present results. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Substance use service availability in HIV treatment programs: Data from the global IeDEA consortium, 2014-2015 and 2017

BACKGROUND

Substance use is common among people living with HIV and has been associated with suboptimal HIV treatment outcomes. Integrating substance use services into HIV care is a promising strategy to improve patient outcomes.

METHODS

We report on substance use education, screening, and referral practices from two surveys of HIV care and treatment sites participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. HIV care and treatment sites participating in IeDEA are primarily public-sector health facilities and include both academic and community-based hospitals and health facilities. A total of 286 sites in 45 countries participated in the 2014-2015 survey and 237 sites in 44 countries participated in the 2017 survey. We compared changes over time for 147 sites that participated in both surveys.

RESULTS

In 2014-2015, most sites (75%) reported providing substance use-related education on-site (i.e., at the HIV clinic or the same health facility). Approximately half reported on-site screening for substance use (52%) or referrals for substance use treatment (51%). In 2017, the proportion of sites providing on-site substance use-related education, screening, or referrals increased by 9%, 16%, and 8%, respectively. In 2017, on-site substance use screening and referral were most commonly reported at sites serving only adults (compared to only children/adolescents or adults and children/adolescents; screening: 86%, 37%, and 59%, respectively; referral: 76%, 47%, and 46%, respectively) and at sites in high-income countries (compared to upper middle income, lower middle income or low-income countries; screening: 89%, 76%, 68%, and 45%, respectively; referral: 82%, 71%, 57%, and 34%, respectively).

CONCLUSION

Although there have been increases in the proportion of sites reporting substance use education, screening, and referral services across IeDEA sites, gaps persist in the integration of substance use services into HIV care, particularly in relation to screening and referral practices, with reduced availability for children/adolescents and those receiving care within resource-constrained settings.

A descriptive analysis of concurrent alcohol and substance use among patients living with HIV/HCV co-infection

The objectives of this study were to estimate the prevalence of concurrent alcohol and substance use among patients living with HIV/HCV co-infection and to compare demographic and clinical characteristics of those with concurrent alcohol and substance to those with alcohol or substance use, and to those who were abstinent. We conducted an analysis of patient reported outcomes data of patients living with HIV/HCV co-infection (n = 327) who transitioned from primary care to sub-specialty care for evaluation of candidacy for HCV treatment at a university-affiliated HIV Clinic. The prevalence of self-reported concurrent alcohol and substance use was 33%. A higher proportion of those with concurrent alcohol and substance use were currently smoking tobacco, and those who were abstinent had higher ratings of health-related quality of life compared to those with alcohol or substance use. To reduce patients' risk for progression to advanced stages of HIV, HCV, and liver-related disease due to continued alcohol and substance and tobacco use, social workers and other health care professionals are encouraged to develop and implement intervention strategies to assist patients living with HIV/HCV co-infection in efforts to achieve behavioral change.

Integrated stepped alcohol treatment for patients with HIV and at-risk alcohol use: a randomized trial

BACKGROUND

At-risk levels of alcohol use threaten the health of patients with HIV (PWH), yet evidence-based strategies to decrease alcohol use and improve HIV-related outcomes in this population are lacking. We examined the effectiveness of integrated stepped alcohol treatment (ISAT) on alcohol use and HIV outcomes among PWH and at-risk alcohol use.

METHODS

In this multi-site, randomized trial conducted between January 28, 2013 through July 14, 2017, we enrolled PWH and at-risk alcohol use [defined as alcohol consumption of ≥ 14 drinks per week or ≥ 4 drinks per occasion in men ≤ 65 years old or ≥ 7 drinks per week or ≥ 3 drinks per occasion in women or men > 65 years old]. ISAT (n = 46) involved: Step 1- Brief Negotiated Interview with telephone booster, Step 2- Motivational Enhancement Therapy, and Step 3- Addiction Physician Management. Treatment as usual (TAU) (n = 47) involved receipt of a health handout plus routine care. Analyses were conducted based on intention to treat principles.

RESULTS

Despite a multi-pronged approach, we only recruited 37% of the target population (n = 93/254). Among ISAT participants, 50% advanced to Step 2, among whom 57% advanced to Step 3. Participants randomized to ISAT and TAU had no observed difference in drinks per week over the past 30 days at week 24 (primary outcome) [least square means (Ls mean) (95% CI) = 8.8 vs. 10.6; adjusted mean difference (AMD) (95% CI) =  - 0.4 (- 3.9, 3.0)].

CONCLUSION

An insufficient number of patients were interested in participating in the trial. Efforts to enhance motivation of PWH with at-risk alcohol use to engage in alcohol-related research and build upon ISAT are needed. Trial registration Clinicaltrials.gov: NCT01410123, First posted August 4, 2011.

A randomized clinical trial of mobile phone motivational interviewing for alcohol use problems in Kenya

AIM

To test the effectiveness of a motivational interviewing (MI) intervention using the mobile phone among adults with alcohol use problems.

DESIGN

A randomized clinical trial of mobile MI and standard in-person MI with 1- and 6-month follow-up, including a 1-month waitlist control followed by mobile MI.

SETTING

A primary health center in rural Kenya.

PARTICIPANTS

Three hundred adults screening positive for alcohol use problems were randomized and received immediate mobile MI (n = 89), in-person MI (n = 65) or delayed mobile MI (n = 76) for waiting-list controls 1 month after no treatment, with 70 unable to be reached for intervention.

INTERVENTION AND COMPARATOR

One MI session was provided either immediately by mobile phone, in-person at the health center or delayed by 1 month and then provided by mobile phone.

MEASUREMENTS

Alcohol use problems were repeatedly assessed using the Alcohol Use Disorder Identification Test (AUDIT) and the shorter AUDIT-C. The primary outcome was difference in alcohol score 1 month after no intervention for waiting-list control versus 1 month after MI for mobile MI. The secondary outcomes were difference in alcohol score for in-person MI versus mobile MI one and 6 months after MI.

FINDINGS

For our primary outcome, average AUDIT-C scores were nearly three points higher (difference = 2.88, 95% confidence interval = 2.11, 3.66) for waiting-list controls after 1 month of no intervention versus mobile MI 1 month after intervention. Results for secondary outcomes supported the null hypothesis of no difference between in-person and mobile MI at 1 month (Bayes factor = 0.22), but were inconclusive at 6 months (Bayes factor = 0.41).

CONCLUSION

Mobile phone-based motivational interviewing may be an effective treatment for alcohol use problems among adults visiting primary care in Kenya. Providing mobile motivational interviewing may help clinicians in rural areas to reach patients needing treatment for alcohol use problems.

Social Determinants of Potential eHealth Engagement Among People Living with HIV Receiving Ryan White Case Management: Health Equity Implications from Project TECH

OBJECTIVES

Evaluate the relationships between social characteristics of Floridian persons living with HIV (PLWH) and both use of digital technologies and willingness to use eHealth for HIV-related information.

METHODS

Ryan White case managers (N = 155) from 55 agencies in 47 Florida counties administered a survey to PLWH (N = 1268) from June 2016-April 2017. Multilevel logistic regression models were used to identify correlates of technology use and willingness.

RESULTS

Use of mobile phones with text messaging was high (89%). Older (vs. younger) adults and non-Hispanic blacks (vs. whites) were less likely to use most technologies. These groups, along with Hispanics (vs. whites) were less likely to express willingness to use technologies for HIV-related information in models adjusting for use.

CONCLUSIONS

Among PLWH in Florida, eHealth-related inequities exist. Willingness to engage in HIV-related eHealth is affected by social determinants, even when considering technology access. Although eHealth may reduce some healthcare inequities, it may exacerbate others.

Alcohol Use and Ethnicity Independently Predict Antiretroviral Therapy Nonadherence Among Patients Living with HIV/HCV Coinfection

BACKGROUND

Adherence to antiretroviral therapy (ART) is important to counter synergistic effects of HIV and hepatitis C (HCV) in patients living with coinfection. Predictors of ART nonadherence among patients living with HIV/HCV coinfection are not well established. This knowledge would be advantageous for clinicians and behavioral health specialists who provide care to patients living with HIV/HCV coinfection.

OBJECTIVES

The purpose of this study was to assess prevalence and predictors of ART nonadherence in a sample of patients living with HIV/HCV coinfection who were actively in HIV clinical care.

METHOD

A sample of patients living with HIV/HCV coinfection who received care at a university-affiliated HIV clinic (n = 137) between January 2013 and July 2017 were included in the study. Computerized patient-reported data or outcomes (PROs) and electronic medical record data of these respective patients were collected and analyzed. Binomial logistic regression was used to examine predictors of ART nonadherence.

RESULTS

The prevalence of ART nonadherence was 31%. In multivariate analysis, African American ethnicity (OR = 3.28, CI 1.241-8.653, p = 0.017) and a higher number of alcoholic drinks per drinking day (OR = 1.31, CI 1.054-1.639, p = 0.015) were positively associated with ART nonadherence.

CONCLUSIONS

Behavioral health providers are encouraged to incorporate alcohol use reduce interventions in HIV clinical settings to reduce ART nonadherence among patients living with HIV/HCV coinfection. Additionally, public health professionals and researchers, and clinicians are encouraged to use inductive methods to discover why ART nonadherence disproportionately impacts African American patients living with HIV/HCV coinfection and to develop approaches that are sensitive to those respective barriers.

Substance Use Screening in HIV Care Settings: a Review and Critique of the Literature

PURPOSE OF REVIEW

People living with human immunodeficiency virus/AIDS (PLWHA) experience high prevalence of substance use disorders (SUD). HIV care settings represent a unique opportunity to identify possible SUD, to provide SUD interventions, and to improve linkage to SUD treatment. The aims of this paper are to (a) review and critique the extant literature examining substance use screening approaches among PLWHA in HIV care settings and (b) provide recommendations for future clinical practice.

RECENT FINDINGS

Twenty-one peer-reviewed articles that examined substance screening approaches employed in HIV and other primary care settings were included in the review. There was limited literature reporting on the implementation and evaluation of substance use screening practices within HIV care settings, and methodological rigor varied across studies. Further, the use of validated substance use screening measures or incorporation of other substance use screening approaches (e.g., use of urine drug testing) within routine HIV care practice is limited. Strategies to implement routine substance use screening within HIV care and incorporate additional substance use assessment, brief interventions, and referral to specialty substance use treatment are discussed. Use of self-report substance use screening measures using web- or computer-delivered approaches that can be integrated within electronic health record systems is particularly promising. HIV care practices should consider potential models to optimally screen and treat SUD. Co-location of HIV and SUD treatment services may be optimal; when co-located services are not possible, strategies to consistently provide brief intervention approaches and referrals to specialty SUD treatment are needed.

Prevention, screening, and treatment for heavy drinking and alcohol use disorder

Heavy drinking and alcohol use disorder are major public health problems. Practitioners not specialising in alcohol treatment are often unaware of the guidelines for preventing, identifying, and treating heavy drinking and alcohol use disorder. However, a consensus exists that clinically useful and valuable tools are available to address these issues. Here, we review existing information and developments from the past 5 years in these areas. We also include information on heavy drinking and alcohol use disorder among individuals with co-occurring psychiatric disorders, including drug use disorders. Areas covered include prevention; screening, brief intervention, and referral for treatment; evidence-based behavioural interventions; medication-assisted treatment; technology-based interventions (eHealth and mHealth); and population-level interventions. We also discuss the key topics for future research.

Telehealth interventions to reduce alcohol use in men with HIV who have sex with men: Protocol for a factorial randomized controlled trial

BACKGROUND

Heavy alcohol use is prevalent among men who have sex with men (MSM) living with HIV and is associated with reduced antiretroviral therapy adherence, reduced HIV viral suppression, and reduced survival. We recently found that compared to HIV treatment as usual, three sessions of in-person motivational interviewing (MI) substantially reduced drinking in MSM with HIV. In an effort to enhance the effectiveness and efficiency of this intervention, the present study will test whether MI is more effective than brief intervention when delivered by videoconferencing, whether interactive text messaging (ITM) can enhance the effects of alcohol intervention, and whether extended duration of intervention is more effective than brief duration.

METHODS

Using a 2 × 2 × 2 factorial design, we will randomly assign 224 heavy-drinking MSM with HIV to: MI or brief intervention (BI); ITM or no ITM; Standard or Extended intervention (EI). All participants will receive intervention immediately after baseline assessment via videoconferencing and at 1-month post baseline via telephone. Participants randomized to EI will receive additional intervention sessions at 3, 6, and 9 months. Participants randomized to ITM will receive daily interactive texts about alcohol use for 1 month, with those randomized to EI receiving weekly interactive texts through 9 months. Alcohol and HIV-related outcomes will be assessed at 6 and 12 months post baseline.

CONCLUSION

By testing the combinations of interventions that can most effectively reduce alcohol use among MSM with HIV, this study will set the stage for wider-scale implementation of an optimized intervention combination.

The feasibility of using smartphones and mobile breathalyzers to monitor alcohol consumption among people living with HIV/AIDS

Background

For people living with HIV/AIDS (PLWHA), alcohol consumption is associated with poor treatment outcomes and medication adherence. This pilot study examined the feasibility of using smartphones and mobile Bluetooth breathalyzers for monitoring alcohol consumption among PLWHA (N = 17).

Methods

For 2 weeks, participants responded to twice-daily text message prompts by completing a breathalyzer reading and a mobile survey about their alcohol use. They also completed baseline questionnaires assessing alcohol consumption and hazardous drinking behaviors.

Results

Participants completed an average of 22 of 28 breathalyzer readings and 17 of 28 mobile surveys, and were more likely to complete daytime (vs. evening) monitoring tasks. Results suggested that self-reported frequency of binge drinking at baseline was related to an increased number of days with alcohol consumption according to breathalyzer and mobile surveys, as well as a higher average blood alcohol content. Qualitative interviews found generally positive attitudes toward the technologies, but some participants reported experiencing technical difficulties.

Conclusions

Overall, this preliminary research suggests that smartphone monitoring of alcohol consumption among PLWHA may reflect cross-sectional self-reported alcohol consumption behaviors, but could use improvements to increase adherence to monitoring tasks.

Psychological interventions for alcohol use disorders in people living with HIV/AIDS: a systematic review

BACKGROUND

Alcohol use disorders (AUDs) in people living with HIV/AIDS (PLWH) are a significant impediment to achieving virological control. HIV non-suppression in PLWH with AUDs is mainly attributable to sub-optimal antiretroviral therapy adherence. Sub-optimal adherence makes control of the epidemic elusive, considering that effective antiretroviral treatment and viral suppression are the two key pillars in reducing new infections. Psychological interventions have been proposed as effective treatments for the management of AUDs in PLWH. Evidence for their effectiveness has been inconsistent, with two reviews (2010 and 2013) concluding a lack of effectiveness. However, a 2017 review that examined multiple HIV prevention and treatment outcomes suggested that behavioural interventions were effective in reducing alcohol use. Since then, several studies have been published necessitating a re-examination of this evidence. This review provides an updated synthesis of the effectiveness of psychological interventions for AUDs in PLWH.

METHODS

A search was conducted in the following databases: PubMed, Cochrane Central Register of Trials (CENTRAL), MEDLINE (Ovid), EMBASE, PsychInfo (Ovid) and Clinical trials.gov (clinicaltrials.gov) for eligible studies until August 2018 for psychotherapy and psychosocial interventions for PLWH with AUDs. Two reviewers independently screened titles, abstracts and full texts to select studies that met the inclusion criteria. Two reviewers independently performed data extraction with any differences resolved through discussion. Risk of bias was assessed by two independent reviewers using the Cochrane risk of bias tool, and the concordance between the first and second reviewers was 0.63 and between the first and third reviewers 0.71. Inclusion criteria were randomised controlled trials using psychological interventions in people aged 16 and above, with comparisons being usual care, enhanced usual care, other active treatments or waitlist controls.

RESULTS

A total of 21 studies (6954 participants) were included in this review. Studies had diverse populations including men alone, men and women and men who had sex with men (MSM). Use of motivational interviewing alone or blended with cognitive behavioural therapy (CBT) and technology/computer-assisted platforms were common as individual-level interventions, while a few studies investigated group motivational interviewing or CBT. Alcohol use outcomes were all self-report and included assessment of the quantity and the frequency of alcohol use. Measured secondary outcomes included viral load, CD4 count or other self-reported outcomes. There was a lack of evidence for significant intervention effects in the included studies. Isolated effects of motivational interviewing, cognitive behavioural therapy and group therapy were noted. However for some of the studies that found significant effects, the effect sizes were small and not sustained over time. Owing to the variation in outcome measures employed across studies, no meta-analysis could be carried out.

CONCLUSION

This systematic review did not reveal large or sustained intervention effects of psychological interventions for either primary alcohol use or secondary HIV-related outcomes. Due to the methodological heterogeneity, we were unable to undertake a meta-analysis. Effectiveness trials of psychological interventions for AUDs in PLWH that include disaggregation of data by level of alcohol consumption, gender and age are needed. There is a need to standardise alcohol use outcome measures across studies and include objective biomarkers that provide a more accurate measure of alcohol consumption and are relatively free from social desirability bias.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD  42017063856 .

Motivational interviewing with personalized feedback to reduce alcohol use in HIV-infected men who have sex with men: A randomized controlled trial

OBJECTIVE

This randomized controlled trial tested the efficacy of motivational interviewing (MI) to reduce alcohol use among heavy drinking men who have sex with men (MSM) who are engaged in HIV care but not currently receiving addictions treatment.

METHOD

One hundred eighty MSM living with HIV-recruited regardless of interest in changing drinking-were randomly assigned to MI or an assessment-only treatment as usual (TAU) control. MI comprised one in-person session followed by two brief phone calls and in-person booster sessions at 3 and 6 months. The Timeline Follow-Back Interview assessed past 30-day alcohol use and sexual behavior at 3, 6, and 12 months postbaseline, and serum samples and medical records assessed viral load, CD4 cell count, and liver function.

RESULTS

At 6 and 12 months, MI compared to TAU resulted in significantly fewer drinks per week (6 months: b = -8.72, 95% confidence interval (CI) [-12.69, -4.76]; 12 months: b = -5.98, 95% CI [-9.77, -2.19]) and lower number of heavy drinking days (6 months: incidence rate ratio = 0.55, 95% CI [0.38, 0.79]; 12 months: incidence rate ratio = 0.50, 95% CI [0.33, 0.78]). Effects on viral load, CD4 cell count, and liver function were nonsignificant. Among those reporting condomless sex with nonsteady partners at baseline, MI resulted in significantly lower rates of this behavior at 3 and 12 months compared to TAU.

CONCLUSIONS

In MSM living with HIV, MI shows substantial promise for reducing heavy drinking and for reducing condomless sex among those at risk. (PsycINFO Database Record

Development of a tailored, telehealth intervention to address chronic pain and heavy drinking among people with HIV infection: integrating perspectives of patients in HIV care

BACKGROUND

Chronic pain and heavy drinking commonly co-occur and can influence the course of HIV. There have been no interventions designed to address both of these conditions among people living with HIV (PLWH), and none that have used telehealth methods. The purpose of this study was to better understand pain symptoms, patterns of alcohol use, treatment experiences, and technology use among PLWH in order to tailor a telehealth intervention that addresses these conditions.

SUBJECTS

Ten participants with moderate or greater chronic pain and heavy drinking were recruited from a cohort of patients engaged in HIV-care (Boston Alcohol Research Collaborative on HIV/AIDS Cohort) and from an integrated HIV/primary care clinic at a large urban hospital.

METHODS

One-on-one interviews were conducted with participants to understand experiences and treatment of HIV, chronic pain, and alcohol use. Participants' perceptions of the influence of alcohol on HIV and chronic pain were explored as was motivation to change drinking. Technology use and treatment preferences were examined in the final section of the interview. Interviews were recorded, transcribed and uploaded into NVivo^® v12 software for analysis. A codebook was developed based on interviews followed by thematic analysis in which specific meanings were assigned to codes. Interviews were supplemented with Likert-response items to evaluate components of the proposed intervention.

RESULTS

A number of themes were identified that had implications for intervention tailoring including: resilience in coping with HIV; autonomy in health care decision-making; coping with pain, stress, and emotion; understanding treatment rationale; depression and social withdrawal; motives to drink and refrain from drinking; technology use and capacity; and preference for intervention structure and style. Ratings of intervention components indicated that participants viewed each of the proposed intervention content areas as "helpful" to "very helpful". Videoconferencing was viewed as an acceptable modality for intervention delivery.

CONCLUSIONS

Results helped specify treatment targets and provided information about how to enhance intervention delivery. The interviews supported the view that videoconferencing is an acceptable telehealth method of addressing chronic pain and heavy drinking among PLWH.

Integrated stepped alcohol treatment for patients with HIV and liver disease: A randomized trial

BACKGROUND

There is no known safe level of alcohol use among patients with HIV and liver disease. We examined the effectiveness of integrated stepped alcohol treatment (ISAT) on alcohol use, HIV, and liver outcomes among patients with HIV and liver disease.

METHODS

In this multi-site, randomized trial conducted between January 28, 2013 through July 15, 2016, we enrolled 95 patients with HIV and liver disease [defined as having active hepatitis C infection or FIB-4 score > 1.45]. ISAT (n = 49) involved: Step 1- Brief Negotiated Interview with telephone booster, Step 2- Motivational Enhancement Therapy, and Step 3- Addiction Physician Management. Treatment as usual (TAU) (n = 46) involved receipt of a health handout plus routine care. Analyses were conducted based on intention to treat.

RESULTS

Among ISAT participants, 55% advanced to Step 2, among whom 70% advanced to Step 3. Participants randomized to ISAT and TAU increased abstinence (primary outcome) over time. Abstinence rates were non-significantly higher by self-report (38% vs. 23%, adjusted odds ratio [AOR] [95% CI] = 2.6 [0.8, 9.0]) and phosphatidylethanol (43% vs. 32%, AOR [95% CI] = 1.8 [0.5, 6.3] among those randomized to ISAT vs. TAU at week 24. VACS Index scores (AMD [95% CI] = 1.1 [-3.2, 5.5]) and the proportion with an undetectable HIV viral load (AOR [95% CI] = 0.3 [0.1, 1.3]) did not differ by group at week 24 (p values >0.05). ISAT had non-significantly lower FIB-4 scores (adjusted mean difference [AMD] [95% CI] = -0.2 [-0.9, 0.5]), ALT (AMD [95% CI] = -7 [-20, 7]) and AST (AMD [95% CI] = -4 [-15, 7]) at week 24 compared to TAU.

CONCLUSION

ISAT is feasible and potentially effective at enhancing delivery of evidence-based alcohol treatment to promote alcohol abstinence and improve liver biomarkers among patients with HIV and liver disease.

Text-Messaging, Online Peer Support Group, and Coaching Strategies to Optimize the HIV Prevention Continuum for Youth: Protocol for a Randomized Controlled Trial

Background

America’s increasing HIV epidemic among youth suggests the need to identify novel strategies to leverage services and settings where youth at high risk (YAHR) for HIV can be engaged in prevention. Scalable, efficacious, and cost-effective strategies are needed, which support youth during developmental transitions when risks arise. Evidence-based behavioral interventions (EBIs) have typically relied on time-limited, scripted, and manualized protocols that were often delivered with low fidelity and lacked evidence for effectiveness.

Objective

This study aims to examine efficacy, implementation, and cost-effectiveness of easily mountable and adaptable, technology-based behavioral interventions in the context of an enhanced standard of care and study assessments that implement the guidelines of Centers for Disease Control and Prevention (CDC) for routine, repeat HIV, and sexually transmitted infection (STI) testing for high-risk youth.

Methods

Youth aged between 12 and 24 years (n=1500) are being recruited from community-based organizations and clinics serving gay, bisexual, and transgender youth, homeless youth, and postincarcerated youth, with eligibility algorithms weighting African American and Latino youth to reflect disparities in HIV incidence. At baseline and 4-month intervals over 24 months (12 months for lower-risk youth), interviewers monitor uptake of HIV prevention continuum steps (linkage to health care, use of pre- or postexposure prophylaxis, condoms, and prevention services) and secondary outcomes of substance use, mental health, and housing security. Assessments include rapid diagnostic tests for HIV, STIs, drugs, and alcohol. The study is powered to detect modest intervention effects among gay or bisexual male and transgender youth with 70% retention.

Youth are randomized to 4 conditions: (1) enhanced standard of care of automated text-messaging and monitoring (AMM) and repeat HIV/STI testing assessment procedures (n=690); (2) online group peer support via private social media plus AMM (n=270); (3) coaching that is strengths-based, youth-centered, unscripted, based on common practice elements of EBI, available over 24 months, and delivered by near-peer paraprofessionals via text, phone, and in-person, plus AMM (n=270); and (4) online group peer support plus coaching and AMM (n=270).

Results

The project was funded in September 2016 and enrollment began in May 2017. Enrollment will be completed between June and August 2019. Data analysis is currently underway, and the first results are expected to be submitted for publication in 2019.

Conclusions

This hybrid implementation-effectiveness study examines alternative models for implementing the CDC guidelines for routine HIV/STI testing for YAHR of acquiring HIV and for delivering evidence-based behavioral intervention content in modular elements instead of scripted manuals and available over 24 months of follow-up, while also monitoring implementation, costs, and effectiveness. The greatest impacts are expected for coaching, whereas online group peer support is expected to have lower impact but may be more cost-effective.

Trial Registration

ClinicalTrials.gov NCT03134833; https://clinicaltrials.gov/ct2/show/NCT03134833 (Archived by WebCite at http://www.webcitation.org/76el0Viw9)

International Registered Report Identifier (IRRID)

DERR1-10.2196/11165

The roles of heavy drinking and drug use in engagement in HIV care among hospitalized substance using individuals with poorly controlled HIV infection

BACKGROUND

Substance use can reduce care engagement for individuals with HIV. However, little is known as to whether heavy drinkers differ from drug users. This study compares heavy drinkers, drug users, and those drinking heavily and using drugs on their HIV care engagement.

METHODS

HIV-infected adult inpatients (n = 801; 67% male; 78% Black) from 11 urban hospitals across the United States participated in a multisite clinical trial to improve patient engagement in HIV care and virologic outcomes. All participants drank heavily and/or used drugs, and had poorly controlled HIV. Participants reported care history at baseline. We compared heavy drinkers, drug users, and those both drinking heavily and using drugs (reference group) on their engagement in care.

RESULTS

Heavy drinkers reported lowest rates of lifetime HIV care, AOR = 0.59 (95% CI = 0.36, 0.97). Groups did not differ in recent care, prescription of HIV medication, medical mistrust, or patient-provider relationship. Drug users evidenced the best medication adherence, AOR = 2.38 (95% CI = 1.33, 4.23). Exploratory analyses indicated that drinkers had lower initial care engagement, but that it increased more rapidly with duration of known HIV infection, with similar rates of recent care. Drinkers had the lowest CD4 counts (B=-0.28, p < 0.0001), but no difference in viral load.

CONCLUSIONS

Heavy drinkers were least likely to have ever been in HIV care. More research is needed to determine why heavy drinkers evidence the lowest initial care engagement and current CD4 counts, and whether drinking intervention early in infection may increase HIV care engagement.

Addressing unhealthy alcohol use among people living with HIV: recent advances and research directions

PURPOSE OF REVIEW

Unhealthy alcohol use is prevalent among people living with HIV (PLWH). We sought to identify the most current literature examining the impact of unhealthy alcohol on health outcomes and latest developments on how to best intervene.

RECENT FINDINGS

New research shows that PLWH have heightened morbidity and mortality at lower levels of alcohol consumption compared with HIV-uninfected persons. Studies published since 2016 have further elucidated the effects of persistent unhealthy alcohol use on HIV treatment outcomes over time. Screening and brief interventions, as well as pharmacologic treatment, can reduce unhealthy alcohol use among PLWH.

SUMMARY

Unhealthy alcohol use is an important and modifiable risk factor for poor health and HIV treatment outcomes among PLWH. More research is needed to encourage and maintain engagement in alcohol-related interventions and improve implementation.

A Preliminary Randomized Controlled Trial of Game Plan, A Web Application to Help Men Who Have Sex with Men Reduce Their HIV Risk and Alcohol Use

Alcohol use is a key risk factor for HIV infection among men who have sex with men (MSM). Past studies show that brief motivational interventions (BMI) can increase the use of prevention methods (e.g., condoms), reduce alcohol use, and can be adapted for web-based delivery. However, few studies have explored these interventions' effects in MSM. Forty high-risk, heavy drinking MSM who sought rapid HIV testing were randomly assigned to receive either (1) standard post-test counseling (SPC) alone, or (2) SPC plus Game Plan (GP), a tablet tablet-based BMI for alcohol use and HIV risk. Over three months of follow-up, GP participants reported 24% fewer heavy drinking days, 17% fewer alcohol problems, and 50% fewer new anal sex partners than controls. GP participants also reported fewer high-risk condomless anal sex events than controls, but these differences were not significant. These initial results suggest that web-based BMIs may be promising tools to help MSM reduce health risk behaviors.

Technology-Based Alcohol Interventions in Primary Care: Systematic Review

Background

Primary care settings are uniquely positioned to reach individuals at risk of alcohol use disorder through technology-delivered behavioral health interventions. Despite emerging effectiveness data, few efforts have been made to summarize the collective findings from these delivery approaches.

Objective

The aim of this study was to review recent literature on the use of technology to deliver, enhance, or support the implementation of alcohol-related interventions in primary care. We focused on addressing questions related to (1) categorization or target of the intervention, (2) descriptive characteristics and context of delivery, (3) reported efficacy, and (4) factors influencing efficacy.

Methods

We conducted a comprehensive search and systematic review of completed studies at the intersection of primary care, technology, and alcohol-related problems published from January 2000 to December 2018 within EBSCO databases, ProQuest Dissertations, and Cochrane Reviews. Of 2307 initial records, 42 were included and coded independently by 2 investigators.

Results

Compared with the years of 2000 to 2009, published studies on technology-based alcohol interventions in primary care nearly tripled during the years of 2010 to 2018. Of the 42 included studies, 28 (64%) were randomized controlled trials. Furthermore, studies were rated on risk of bias and found to be predominantly low risk (n=18), followed by moderate risk (n=16), and high risk (n=8). Of the 24 studies with primary or secondary efficacy outcomes related to drinking and drinking-related harms, 17 (71%) reported reduced drinking or harm in all primary and secondary efficacy outcomes. Furthermore, of the 31 studies with direct comparisons with treatment as usual (TAU), 13 (42%) reported that at least half of the primary and secondary efficacy outcomes of the technology-based interventions were superior to TAU. High efficacy was associated with provider involvement and the reported use of an implementation strategy to deliver the technology-based intervention.

Conclusions

Our systematic review has highlighted a pattern of growth in the number of studies evaluating technology-based alcohol interventions in primary care. Although these interventions appear to be largely beneficial in primary care, outcomes may be enhanced by provider involvement and implementation strategy use. This review enables better understanding of the typologies and efficacy of these interventions and informs recommendations for those developing and implementing technology-based alcohol interventions in primary care settings.

Mobile Health Interventions for Self-Control of Unhealthy Alcohol Use: Systematic Review

Background

Unhealthy alcohol use (UAU) is one of the major causes of preventable morbidity, mortality, and associated behavioral risks worldwide. Although mobile health (mHealth) interventions can provide consumers with an effective means for self-control of UAU in a timely, ubiquitous, and cost-effective manner, to date, there is a lack of understanding about different health outcomes brought by such interventions. The core components of these interventions are also unclear.

Objective

This study aimed to systematically review and synthesize the research evidence about the efficacy of mHealth interventions on various health outcomes for consumer self-control of UAU and to identify the core components to achieve these outcomes.

Methods

We systematically searched 7 electronic interdisciplinary databases: Scopus, PubMed, PubMed Central, CINAHL Plus with full text, MEDLINE with full text, PsycINFO, and PsycARTICLES. Search terms and Medical Subject Headings “mHealth,” “text message,” “SMS,” “App,” “IVR,” “self-control,” “self-regulation,” “alcohol*,” and “intervention” were used individually or in combination to identify peer-reviewed publications in English from 2008 to 2017. We screened titles and abstracts and assessed full-text papers as per inclusion and exclusion criteria. Data were extracted from the included papers according to the Consolidated Standards of Reporting Trials-EHEALTH checklist (V 1.6.1) by 2 authors independently. Data quality was assessed by the Mixed Methods Appraisal Tool. Data synthesis and analyses were conducted following the procedures for qualitative content analysis. Statistical testing was also conducted to test differences among groups of studies.

Results

In total, 19 studies were included in the review. Of these 19 studies, 12 (63%) mHealth interventions brought significant positive outcomes in improving participants’ health as measured by behavioral (n=11), physiological (n=1), and cognitive indicators (n=1). No significant health outcome was reported in 6 studies (6/19, 32%). Surprisingly, a significant negative outcome was reported for the male participants in the intervention arm in 1 study (1/19, 5%), but no change was found for the female participants. In total, 5 core components reported in the mHealth interventions for consumer self-control of UAU were context, theoretical base, delivery mode, content, and implementation procedure. However, sound evidence is yet to be generated about the role of each component for mHealth success. The health outcomes were similar regardless of types of UAU, deployment setting, with or without nonmobile cointervention, and with or without theory.

Conclusions

Most studies reported mHealth interventions for self-control of UAU appeared to be improving behavior, especially the ones delivered by short message service and interactive voice response systems. Further studies are needed to gather sound evidence about the effects of mHealth interventions on improving physiological and cognitive outcomes as well as the optimal design of these interventions, their implementation, and effects in supporting self-control of UAU.

Efficacy of Extended-Release Naltrexone on HIV-Related and Drinking Outcomes Among HIV-Positive Patients: A Randomized-Controlled Trial

We sought to test the efficacy of extended-release naltrexone (XR-NTX) on HIV-related and drinking outcomes. From April 2011-February 2015, we conducted a 4-site randomized double-blind placebo controlled clinical trial involving 51 HIV-positive patients with heavy drinking and < 95% antiretroviral (ART) adherence. All participants received counseling. The primary outcome was proportion with ≥ 95% ART adherence. Secondary outcomes included HIV biomarkers, VACS Index score, and past 30-day heavy drinking days. Based on receipt of ≥ 5 injections, 23 participants were retained at 24 weeks. We did not detect an effect of XR-NTX on ART adherence (p = 0.38); undetectable HIV viral load (p = 0.26); CD4 cell count (p = 0.75) or VACS Index score (p = 0.70). XR-NTX was associated with fewer heavy drinking days (p = 0.03). While XR-NTX decreases heavy drinking days, we did not detect improvements in ART adherence or HIV outcomes. Strategies to improve retention in alcohol treatment and HIV-related outcomes among heavy drinking HIV-positive patients are needed.

Medical Reasons for Limiting Drinking: Data from a Sexual Health Clinic

BACKGROUND

Heavy drinking poses health risks for individuals with HIV, and some individuals with HIV attempt to reduce drinking. Little is known about whether medical reasons motivate HIV-infected individuals to reduce drinking.

OBJECTIVES

We evaluated medical reasons for limiting drinking among patients in a sexual health clinic, and explored whether these reasons could be operationalized as a new scale for research and clinical use in sexual health clinics.

METHODS

A sample of 70 patients in a sexual health clinic who reported efforts to limit drinking in the past month (84% with self-reported HIV; 81% male; 50% Black) completed a nine-item medical reasons for limiting drinking scale on a tablet while waiting for their appointment. Exploratory factor analysis was performed to evaluate psychometric properties of the scale.

RESULTS

Patients most commonly endorsed general concerns about health, and concerns about alcohol's effect on the liver. Support was found for a unidimensional (one-factor) eight-item scale, which evidenced good internal consistency (α = 0.84). Results were identical when analyses were restricted to the subset of 59 individuals who self-reported HIV infection. Conclusions/Importance: This study suggests that individuals in a sexual health clinic most commonly endorse broad nonspecific concerns about drinking and health, as well as concerns about their liver. This study yields an 8-item scale to measure medical reasons for limiting drinking in sexual health clinics and among individuals with HIV. This scale should enhance researchers' ability to study this important construct and may facilitate discussion of drinking reduction with HIV-infected heavy drinkers, requiring future study.

Acceptance and Commitment Therapy (ACT) for HIV-infected Hazardous Drinkers: A Qualitative Study of Acceptability

Alcohol use is a significant problem in HIV care, and clinical trials of alcohol interventions for people living with HIV infection (PLWH) have produced mixed results. The purpose of this qualitative study was to collect preliminary data on the practical feasibility and acceptability of Acceptance and Commitment Therapy (ACT) as a treatment for PLWH who are hazardous drinkers. A total of 25 PLWH participated in individual interviews. Four major themes emerged from the thematic analysis: (I) Perceived Appropriateness for PLWH and People who use Alcohol and/or other Substances, (II) General Satisfaction and Dissatisfaction, (III) Positive and Negative Effects on Participants and (IV) Facilitators and Barriers to Implementing ACT Intervention Strategies.

Time Spent with HIV Viral Load > 1500 Copies/mL Among Persons Engaged in Continuity HIV Care in an Urban Clinic in the United States, 2010-2015

Persons with HIV who have entered care but have viral load > 1500 copies/mL may be the source of the majority of new HIV infections in the United States. We followed patients engaged in continuity care in the Johns Hopkins HIV Clinical Cohort between January 2010 and August 2015. We estimated person-time spent with viral load > 1500 copies/mL while in care after antiretroviral therapy (ART) initiation, while in care, and while alive. Person-time was classified according to the most recent viral load measurement. Of 11,283.1 person-years in care on after ART initiation, 11,954.7 person-years in care and 13,990.0 total person-years of follow-up spent alive, 12.5, 14.8%, and between 12.6 and 27.2%, respectively (depending on assumptions about the viral load of persons lost to clinic) were spent with viral load > 1500 copies/mL. Patients with lower baseline CD4 cell count, younger age, black race, history of injection drug use, or baseline hazardous alcohol use spent more time with viral load > 1500 copies/mL after ART initiation.