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

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.

Perspectives on contingency management for alcohol use and alcohol-associated conditions among people in care with HIV

BACKGROUND

Contingency management (CM) is an evidence-based approach for reducing alcohol use; however, its implementation into routine HIV primary care-based settings has been limited. We evaluated perspectives on implementing CM to address unhealthy alcohol use and associated conditions for people with HIV in primary care settings.

METHODS

From May 2021 to August 2021, we conducted two focus groups with staff involved in delivering the intervention (n = 5 Social Workers and n = 4 Research Coordinators) and individual interviews (n = 13) with a subset of participants involved in the multi-site Financial Incentives, Randomization, and Stepped Treatment (FIRST) trial. Qualitative data collection and analyses were informed by the Promoting Action on Research Implementation in Health Service (PARIHS) implementation science framework, including evidence (perception of CM), context (HIV primary care clinic and CM procedures), and facilitation (feasibility outside the research setting).

RESULTS

Several major themes were identified. Regarding the evidence, participants lacked prior experience with CM, but the intervention was well received and, by some, perceived to lead to lasting behavior change. Regarding the clinical context for the reward schedule, the use of biochemical testing, specifically fingerstick phosphatidylethanol testing, and the reward process were perceived to be engaging and gratifying for both staff and patients. Participants indicated that the intervention was enhanced by its co-location within the HIV clinic. Regarding facilitation, participants suggested addressing the intervention's feasibility for non-research use, simplifying the reward structure, and rewarding non-abstinence in alcohol use.

CONCLUSIONS

Among patients and staff involved in a clinical trial, CM was viewed as a helpful, positive, and feasible approach to addressing unhealthy alcohol use and related conditions. To enhance implementation, future efforts may consider simplified approaches to the reward structure and expanding rewards to non-abstinent reductions in alcohol consumption.

Contingency management with stepped care for unhealthy alcohol use among individuals with HIV: Protocol for a randomized controlled trial

BACKGROUND

Although unhealthy alcohol use is associated with increased morbidity and mortality among people with HIV (PWH), many are ambivalent about engaging in treatment and experience variable responses to treatment. We describe the rationale, aims, and study design for the Financial Incentives, Randomization, with Stepped Treatment (FIRST) Trial, a multi-site randomized controlled efficacy trial.

METHODS

PWH in care recruited from clinics across the United States who reported unhealthy alcohol use, had a phosphatidylethanol (PEth) >20 ng/mL, and were not engaged in formal alcohol treatment were randomized to integrated contingency management with stepped care versus treatment as usual. The intervention involved two steps; Step 1: Contingency management (n = 5 sessions) with potential rewards based on 1) short-term abstinence; 2) longer-term abstinence; and 3) completion of healthy activities to promote progress in addressing alcohol consumption or conditions potentially impacted by alcohol; Step 2: Addiction physician management (n = 6 sessions) plus motivational enhancement therapy (n = 4 sessions). Participants' treatment was stepped up at week 12 if they lacked evidence of longer-term abstinence. Primary outcome was abstinence at week 24. Secondary outcomes included alcohol consumption (assessed by TLFB and PEth) and the Veterans Aging Cohort Study (VACS) Index 2.0 scores; exploratory outcomes included progress in addressing medical conditions potentially impacted by alcohol. Protocol adaptations due to the COVID-19 pandemic are described.

CONCLUSIONS

The FIRST Trial is anticipated to yield insights on the feasibility and preliminary efficacy of integrated contingency management with stepped care to address unhealthy alcohol use among PWH.

CLINICALTRIALS

gov identifier: NCT03089320.

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

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

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.

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.

Systematic review of the efficacy, effectiveness, and cost-effectiveness of stepped-care interventions for the prevention and treatment of problematic substance use

BACKGROUND

Stepped-care is a commonly recommended and implemented care model across health care domains, including substance use. Despite their presumed efficient allocation of treatment resources, a current and robust evidence synthesis is needed on the efficacy, effectiveness and cost-effectiveness of stepped-care for substance use.

METHODS

This systematic review analyzed articles describing evaluations of stepped-care models that measured the use of acutely psychoactive substances (i.e., alcohol, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics, anxiolytics, and stimulants) as a primary or secondary outcome, in participants over 18 years old. The analysis investigated model and participant characteristics associated with treatment outcomes.

RESULTS

The study team conducted a search of five databases of literature (PsychINFO, MEDLINE, Embase, Cochrane Library and Scopus) published between January 1, 2010, and November 1, 2020. The search yielded 1051 unique articles, 19 of which were included in the analysis. The studies had considerable variability in sample sizes (n = 18-2310), time to follow-up (4.5 months to 3 years), and retention rates (35.1-100 %). Studies examined outcomes for either alcohol alone (n = 9), alcohol and other drug use (n = 9), or drug use alone (n = 1). Most studies (n = 13;) were rated as good quality. Three (15.8 %) were rated as fair and three (15.8 %) were rated as poor quality. The evidence regarding the efficacy, effectiveness and cost-effectiveness of stepped-care approaches is limited, but four of seven studies found that adaptive-care interventions delivered in the context of other systemic interventions produced greater benefit than control conditions in relation to at least one alcohol-related outcome. We have insufficient evidence to determine whether the modes or intensity of interventions included in the models, or decision rules used to step people up or down to differing levels of care, have an impact on outcome.

CONCLUSION

Heterogeneity between studies with regard to model and evaluation design limited the degree to which the analysis could draw robust conclusions. Sample recruitment and statistical power are particular challenges, and the field needs more innovative evaluation designs to assess the efficacy, effectiveness, and cost-effectiveness of stepped-care models.

Integrating HIV and substance misuse services: a person-centred approach grounded in human rights

Integrating HIV-related care with treatment for substance use disorder provides an opportunity to better meet the needs of people living with these conditions. People with substance use disorder are rendered especially vulnerable by prevailing policies, structural inequalities, and stigmatisation. In this Series paper we analyse existing literature and empirical evidence from scoping reviews on integration designs for the treatment of HIV and substance use disorder, to understand barriers to and facilitators of care integration and to map ways forward. We discuss how approaches to integration address two core gaps in current models: a failure to consider human rights when incorporating the perspectives of people living with HIV and people who use drugs, and a failure to reflect critically on structural factors that determine risk, vulnerability, health-care seeking, and health equity. We argue that successful integration requires a person-centred approach, which is grounded in human rights, treats both concerns holistically, and reconnects with underlying social, economic, and political inequalities.

The Relationship Between Drinking Behavior and Conversational Processes During a Brief Alcohol Reduction Intervention for People with HIV

People with HIV (PWH) frequently engage in unhealthy alcohol use, which can adversely affect antiretroviral adherence and HIV disease progression. Brief interventions based on Motivational Interviewing (MI), including the Brief Negotiated Interview (BNI), can help to reduce drinking. This study examines MI processes observed during a single 15-20 min BNI session delivered by social workers to PWH with unhealthy alcohol use (N = 59) in the context of a stepped care intervention to reduce alcohol consumption. BNI sessions were coded for technical and relational processes encouraged in MI, such as autonomy support, instructive language, and self-exploration. Multiple regression analyses explored the relationship between: (1) Participants' pre-intervention drinking behaviors (weekly drinks and heavy drinking days) and these MI processes, and (2) MI processes and intervention outcomes. Results indicated that PWH who reported more weekly drinks at baseline engaged in less self-exploration, while social workers delivering the BNI used less instructive language for those who reported more heavy drinking days. PWH who engaged in more self-exploration and received more autonomy support had fewer heavy drinking days 6 months after the intervention. These findings suggest the value of providing more opportunities within BNIs to encourage self-exploration, as it may help to enhance intervention efficacy.

Patient-Reported Bothersome Symptoms Attributed to Alcohol Use Among People With and Without HIV

Helping people with HIV (PWH) and without HIV (PWoH) understand the relationship between physical symptoms and alcohol use might help motivate them to decrease use. In surveys collected in the Veterans Aging Cohort Study from 2002 to 2018, PWH and PWoH were asked about 20 common symptoms and whether they thought any were caused by alcohol use. Analyses were restricted to current alcohol users (AUDIT-C > 0). We applied generalized estimating equations. The outcome was having any Symptoms Attributed to Alcohol use (SxAA). Primary independent variables were each of the 20 symptoms and HIV status. Compared to PWoH, PWH had increased odds of SxAA (OR 1.54; 95% CI 1.27, 1.88). Increased AUDIT-C score was also associated with SxAA (OR 1.32; 95% CI 1.28, 1.36), as were trouble remembering, anxiety, and weight loss/wasting. Evidence that specific symptoms are attributed to alcohol use may help motive people with and without HIV decrease their alcohol use.

Current Interventions for People Living with HIV Who Use Alcohol: Why Gender Matters

PURPOSE OF REVIEW

Alcohol is the most misused substance in the world. For people living with HIV (PLWH), alcohol misuse may impact ART adherence and viral suppression. This review of the most recently published alcohol intervention studies with PLWH examines how these studies considered gender in the samples, design, and analyses.

RECENT FINDINGS

Three searches were conducted initially, and 13 intervention studies fit our criteria with alcohol outcomes. In general, most studies did not consider gender and had used small samples, and few demonstrated significant efficacy/effectiveness outcomes. Five studies considered gender in their samples or analyses and/or were woman-focused with larger samples and demonstrated significant outcomes. It is essential for women who misuse alcohol to not only be well represented in alcohol and HIV research but also for studies to consider the barriers to reaching them and their contextual demands and/or co-occurring issues that may affect participation and outcomes in intervention research.