Direct and Indirect Effects of Heavy Alcohol Use on Clinical Outcomes in a Longitudinal Study of HIV Patients on ART

Experimentally Induced Reductions in Alcohol Consumption and Brain, Cognitive, and Clinical Outcomes in Older Persons With and Those Without HIV Infection (30-Day Challenge Study): Protocol for a Nonrandomized Clinical Trial

BACKGROUND

Both alcohol consumption and HIV infection are associated with worse brain, cognitive, and clinical outcomes in older adults. However, the extent to which brain and cognitive dysfunction is reversible with reduction or cessation of drinking is unknown.

OBJECTIVE

The 30-Day Challenge study was designed to determine whether reduction or cessation of drinking would be associated with improvements in cognition, reduction of systemic and brain inflammation, and improvement in HIV-related outcomes in adults with heavy drinking.

METHODS

The study design was a mechanistic experimental trial, in which all participants received an alcohol reduction intervention followed by repeated assessments of behavioral and clinical outcomes. Persons were eligible if they were 45 years of age or older, had weekly alcohol consumption of 21 or more drinks (men) or 14 or more drinks (women), and were not at high risk of alcohol withdrawal. After a baseline assessment, participants received an intervention consisting of contingency management (money for nondrinking days) for at least 30 days followed by a brief motivational interview. After this, participants could either resume drinking or not. Study questionnaires, neurocognitive assessments, neuroimaging, and blood, urine, and stool samples were collected at baseline, 30 days, 90 days, and 1 year after enrollment.

RESULTS

We enrolled 57 persons with heavy drinking who initiated the contingency management protocol (mean age 56 years, SD 4.6 years; 63%, n=36 male, 77%, n=44 Black, and 58%, n=33 people with HIV) of whom 50 completed 30-day follow-up and 43 the 90-day follow-up. The planned study procedures were interrupted and modified due to the COVID-19 pandemic of 2020-2021.

CONCLUSIONS

This was the first study seeking to assess changes in brain (neuroimaging) and cognition after alcohol intervention in nontreatment-seeking people with HIV together with people without HIV as controls. Study design strengths, limitations, and lessons for future study design considerations are discussed. Planned analyses are in progress, after which deidentified study data will be available for sharing.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03353701; https://clinicaltrials.gov/study/NCT03353701.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/53684.

Healthcare Utilization Among Persons with HIV and Unhealthy Alcohol Use in St. Petersburg, Russia

Few studies have examined the association between healthcare utilization and heavy alcohol use in Russia among persons with HIV (PWH), a group with high healthcare needs. This study analyzed the association between unhealthy alcohol use (defined as AUDIT score ≥ 8) and healthcare utilization among PWH with heavy alcohol use and daily smoking in St. Petersburg, Russia. This secondary analysis used data from a randomized controlled trial addressing alcohol use. The primary outcome was seeing an infectionist for HIV care in the past year. Outcomes were measured at baseline, 6 months, and 12 months. We assessed the association between unhealthy alcohol use and healthcare utilization outcomes with a repeated measures logistic regression model, controlling for relevant covariates. Nearly all (96.0%) participants had unhealthy alcohol use at baseline, and 90.0% had seen an infectionist for HIV care in the past year. In adjusted analyses, unhealthy alcohol use was associated with a 36% decrease in seeing an infectionist for HIV care (aOR = 0.64, 95% CI 0.43-0.95). Participants reported low levels of emergency department visits and hospitalizations. Understanding how to engage this population in alcohol use disorder treatment and HIV care is an important next step for improving health outcomes for this population.

Association of Alcohol Consumption With CD4 Recovery After Antiretroviral Therapy Initiation in St. Petersburg, Russia

BACKGROUND

Delayed CD4 recovery after initiating antiretroviral therapy (ART) is a novel potential mechanism by which alcohol consumption leads to increased morbidity and mortality in people with HIV. We hypothesized that alcohol consumption at ART initiation is associated with slower CD4 recovery.

METHODS

We retrospectively analyzed 2 pooled longitudinal alcohol/HIV cohorts (2014-2019) in St. Petersburg, Russia. Eligible participants initiated the first ART during parent studies; had alcohol consumption assessed by the blood biomarker, phosphatidylethanol (PEth), at the last research visit before ART initiation; and had ≥1 CD4 count measurement before and after initiating ART. Participants were stratified by low, moderate, and high PEth (<8, 8-80, and >80 ng/mL, respectively). We used random-effects piecewise linear regression models to estimate CD4 recovery, defined as CD4 count change per 30 days after ART initiation, by the alcohol group.

RESULTS

Of 60 eligible participants, median age was 34 years and 28% were female. The median pre-ART PEth in the low, moderate, and high PEth groups were <8, 23, and 232 ng/mL, respectively. After starting ART, the CD4 count increased by 13.60 cells/mm3/mo (95% CI: 0.33 to 26.87) with low PEth, 0.93 cells/mm3/mo (95% CI: -6.18 to 8.04) with moderate PEth, and 2.33 cells/mm3/mo (95% CI: -3.44 to 8.09) with high PEth.

CONCLUSIONS

Among Russians with HIV, we observed faster CD4 recovery after ART initiation in those with low alcohol consumption compared with those with moderate and high alcohol consumption, as assessed by PEth. This analysis provides further evidence for the possible value of alcohol reduction interventions for people with HIV who are initiating ART.

Rural Veterans with HIV and Alcohol Use Disorder receive less video telehealth than urban Veterans

PURPOSE

Alcohol use disorder (AUD) is highly prevalent among Veterans with HIV. Rural Veterans with HIV are at especially high risk for not receiving appropriate treatment. This retrospective cohort cross-sectional study aimed to investigate patterns of mental health treatment utilization across delivery modality among Veterans diagnosed with HIV and AUD. It was hypothesized that rural Veterans with HIV and AUD would receive a lower rate of mental health treatment delivered via video telehealth than urban Veterans with HIV and AUD.

METHODS

A national Veterans Health Association administrative database was used to identify a cohort of Veterans diagnosed with HIV and AUD (N = 2,075). Geocoding was used to categorize rural Veterans (n = 246) and urban Veterans (n = 1,829). Negative binomial regression models tested associations between rurality and mental health treatment delivered via face-to-face, audio-only, and video telehealth modalities.

FINDINGS

Results demonstrated that rural Veterans with HIV and AUD received fewer mental health treatment sessions delivered via telehealth than urban Veterans with HIV and AUD (incidence rate ratio = 0.62; 95% confidence intervals [0.44, 0.87]; P < .01). No differences were found in terms of treatment delivered face-to-face or by audio-only.

CONCLUSIONS

Rural Veterans with HIV and AUD represent a vulnerable subpopulation of Veterans who may most benefit from video telehealth. Efforts to increase access and improve the uptake of evidence-based mental health treatment delivered via video telehealth are needed.

Changes in frequency of cannabis use among people with HIV during the COVID-19 pandemic: a multi-methods study to explore the underlying reasons for change

Background: People with HIV (PWH) report higher rates of cannabis use than the general population. It is unclear how cannabis use among PWH has been impacted by the COVID-19 pandemic and the implications for the health and wellbeing of PWH.Objectives: To describe changes in frequency of cannabis use among a sample of PWH during the pandemic, reasons for those changes, and implications of the findings.Methods: The data are cross-sectional and come from questions asked in a follow-up phone survey administered to a prospective cohort of PWH in Florida between May 2020 and March 2021. Participants who used cannabis were asked about changes in their frequency of cannabis use in a quantitative survey and reasons for changes in a qualitative open-ended question. Qualitative data were analyzed using thematic analysis.Results: Among 227 PWH (mean age 50, 50% men, 69% Black/African American, 14% Hispanic/Latino), 13% decreased frequency of cannabis, 11% increased frequency, and 76% reported no change. The most common reasons for increasing frequency of cannabis use were reducing anxiety/stress, trying to relax, coping with grief or reducing symptoms of depression, and reducing boredom during the pandemic. Supply or access issues, health concerns, and having already wanted to reduce cannabis use were common reasons for decreased frequency.Conclusion: Nearly 25% of the sample changed their cannabis use frequency during the pandemic. These findings shed light on the behaviors and motivations of PWH who use cannabis and can inform clinical practice and interventions during public health emergencies and beyond.

Effects of drug and hazardous alcohol use on having a detectable HIV viral load: An adherence mediation analysis

Objectives

People living with HIV (PWH) with substance or alcohol use often have unsuppressed plasma HIV viral loads (pVL). The degree to which substance and alcohol use effects on HIV viral suppression are mediated through medication nonadherence is incompletely understood.

Methods

We included PWH prescribed antiretroviral therapy and receiving care at an academic HIV clinic between 2014 and 2018 who completed both patient-reported outcomes (PRO) questionnaires and had subsequent pVL measurements. Measures included assessments of alcohol use (AUDIT-C), drug use (NIDA-ASSIST), and self-reported adherence measured using four different methods. Substances found in bivariate analysis to predict detectable pVL were modeled separately for mediation effects through adherence. We report natural direct (NDE) and indirect effect (NIE), marginal total effect (MTE), and percentage mediated.

Results

Among 3125 PWH who met eligibility criteria, 25.8% reported hazardous alcohol use, 27.1% cannabis, 13.1% amphetamines, 1.9% inhalants, 5.3% cocaine, 4.5% sedative-hypnotics, 2.9% opioids, and 2.3% hallucinogens. Excellent adherence was reported by 58% of PWH, and 10% had detectable pVL. Except for sedatives, using other substances was significantly associated with worse adherence. Bivariate predictors of detectable pVL were [OR (95% CI)]: amphetamine use 2.4 (1.8-3.2) and opioid use 2.3 (1.3-4.0). The percent of marginal total effect mediated by nonadherence varied by substance: 36% for amphetamine use, 27% for opioid use, and 39% for polysubstance use.

Conclusion

Use of amphetamines, opioids, and multiple substances predicted detectable pVL. Up to 40% of their effects were mediated by self-reported nonadherence. Confirmation using longitudinal measurement models will strengthen causal inference from this cross-sectional analysis.

Resting state connectivity in people living with HIV before and after stopping heavy drinking

Background

Heavy alcohol use in people living with HIV (PLWH) has widespread negative effects on neural functioning. It remains unclear whether experimentally-induced reduction in alcohol use could reverse these effects. We sought to determine the effects of 30-days drinking cessation/reduction on resting state functional connectivity in people with and without HIV.

Methods

Thirty-five participants (48.6% PLWH) demonstrating heavy alcohol use attempted to stop drinking for 30 days via contingency management (CM). MRI was acquired at baseline and after thirty days, and functional connectivity across five resting-state fMRI (rsfMRI) networks was calculated with the Conn toolbox for Matlab and examined in relation to transdermal alcohol concentration (TAC) recorded by the ankle-worn secure continuous remote alcohol monitor (SCRAM) and self-reported alcohol use (timeline follow-back; TLFB). Associations between alcohol use and reduction, HIV status, functional connectivity, and change in functional connectivity across five major rsfMRI networks were determined relative to the pre- and post-CM timepoints.

Results

Baseline resting-state functional connectivity was not significantly associated with average TAC-AUC during the pre-CM period, though higher self-reported alcohol use over the preceding 30 days was significantly associated with higher baseline connectivity within the Dorsal Attention Network (DAN; p-FDR < 0.05). Baseline connectivity within the Salience network was significantly negatively related to objective drinking reduction after intervention (DAN; p-FDR < 0.05), whereas baseline connectivity within the Limbic network was positively associated with self-reported drinking reduction (p-FDR < 0.05). Change in between-networks functional connectivity after intervention was significantly positively associated with biosensor-confirmed drinking reduction such that higher reduction was associated with stronger connectivity between the limbic and fronto-parietal control networks (p-FDR < 0.05). PLWH with lower DAN connectivity at baseline demonstrated poorer alcohol reduction than those with higher DAN connectivity at baseline.

Discussion

Lower resting-state functional connectivity of the Salience network significantly predicted stronger drinking reduction across all participants, suggesting a potential biomarker for reduced susceptibility to the environmental and social cues that often make alcohol use reduction attempts unsuccessful. Increased between-networks connectivity was observed in participants with higher alcohol reduction after CM, suggesting a positive benefit to brain connectivity associated with reduced drinking. PLWH with lower baseline DAN connectivity may not benefit as greatly from CM for alcohol reduction.

Discrimination and alcohol problems among heavy drinking HIV-positive men who have sex with men: The buffering effect of a brief Motivational Intervention to reduce alcohol use

INTRODUCTION

Heavy alcohol use negatively impacts health outcomes among people with HIV and is especially prevalent among men who have sex with men (MSM). Alcohol problems among MSM with HIV may occur, in part, due to increased stress caused by experiences of identity-based discrimination, such as heterosexism, HIV stigma, and racism. The current study examined (a) whether MSM with HIV who experience greater identity-based discrimination reported higher levels of alcohol problems over time in the absence of alcohol intervention, and (b) whether motivational interviewing (MI) to reduce alcohol use would attenuate the effects of discrimination on alcohol problems.

METHODS

Data came from a clinical trial in which MSM with HIV were randomized into brief MI for alcohol harm reduction [n = 89] or an HIV treatment as usual assessment only control [TAU; n = 91]. Alcohol use and problems were assessed at baseline, 3, 6, and 12 months.

RESULTS

Generalized Estimating Equations found a significant interaction between MI and baseline identity-based discrimination, such that in those not receiving MI, discrimination prospectively predicted alcohol problems over time (B = 0.065, SE = 0.018, p < .001, 95% Wald CI [.030- 0.100]). In those receiving MI, discrimination did not have an effect (B = - 0.002, SE = 0.131, p = .987, 95% Wald CI [- 0.258 to 0.254]).

CONCLUSIONS

Even without explicitly targeting experiences of identity-based discrimination, a person-centered intervention, like MI, appears to mitigate the negative impact of identity-based discrimination on alcohol-related problems.

Chronic Alcohol Exposure Among People Living with HIV Is Associated with Innate Immune Activation and Alterations in Monocyte Phenotype and Plasma Cytokine Profile

Despite advances in antiretroviral therapy, chronic immune activation continues to be observed among individuals with well-controlled HIV viral loads, and is associated with non-AIDS defining morbidities among people living with HIV. Alcohol use disorder impacts a significant proportion of individuals living with HIV, and alcohol exposure is known to damage the intestinal epithelium which may increase translocation of pathogens and their molecular products, driving systemic immune activation and dysregulation. The aim of this study was to determine if adults living with HIV with well-controlled viral loads, who also suffer from alcohol use disorder with and without hepatitis C virus co-infection (n=23), exhibit evidence of advanced systemic immune activation, intestinal damage, and microbial translocation, as compared to adults living with HIV who are not exposed to chronic alcohol or other substances of abuse (n=29). The impact of a 1-month intervention to treat alcohol-use disorder was also examined. Alcohol-use disorder was associated with evidence of advanced innate immune activation, alterations in monocyte phenotype including increased expression of Toll-like receptor 4, increased burden of stimulatory ligands for Toll-like receptor 4, and alterations in plasma cytokine signature, most notably elevations in soluble CD40 ligand and transforming growth factor beta. Alcohol-associated immune activation was more pronounced among individuals with hepatitis C virus co-infection. Although the 1-month intervention to treat alcohol use disorder did not result in significant reductions in the interrogated indicators of immune activation, our findings suggest that chronic alcohol exposure is a major modifiable risk factor for chronic immune activation and dysregulation among people-living with HIV.

High-Dimensional Mediation Analysis Based on Additive Hazards Model for Survival Data

Mediation analysis has been extensively used to identify potential pathways between exposure and outcome. However, the analytical methods of high-dimensional mediation analysis for survival data are still yet to be promoted, especially for non-Cox model approaches. We propose a procedure including "two-step" variable selection and indirect effect estimation for the additive hazards model with high-dimensional mediators. We first apply sure independence screening and smoothly clipped absolute deviation regularization to select mediators. Then we use the Sobel test and the BH method for indirect effect hypothesis testing. Simulation results demonstrate its good performance with a higher true-positive rate and accuracy, as well as a lower false-positive rate. We apply the proposed procedure to analyze DNA methylation markers mediating smoking and survival time of lung cancer patients in a TCGA (The Cancer Genome Atlas) cohort study. The real data application identifies four mediate CpGs, three of which are newly found.

Alcohol use and alcohol-related consequences are associated with not being virally suppressed among persons living with HIV in the Rakai region of Uganda

BACKGROUND

Alcohol use is common among persons living with HIV (PWH) in Uganda and associated with poor HIV care outcomes; findings regarding the relationship between alcohol use and viral suppression (VS) have been inconclusive.

METHODS

Data from two rounds (2017-2020) of the Rakai Community Cohort Study, an open population-based cohort study in the Rakai region, Uganda, were analyzed. Two alcohol exposures were explored: past year alcohol use and alcohol-related consequences. Multivariable models (GEE) were used to estimate associations between alcohol exposures and VS for the overall sample and stratified by sex, adjusting for repeated measurement. Causal mediation by ART use was explored.

RESULTS

Over half (55 %) of participants (n = 3823 PWH) reported alcohol use at baseline; 37.8 % of those reporting alcohol use reported alcohol-related consequences. ART use and VS at baseline significantly differed by alcohol use with person reporting alcohol use being less likely to be on ART or VS. Alcohol use was significantly associated with decreased odds of VS among women but not men (adj. OR 0.72 95 % CI 0.58-0.89, p = 0.0031). However, among males who use alcohol, experiencing alcohol-related consequences was significantly associated with decreased odds of VS (adj. OR 0.69 95 % CI 0.54-0.88, p = 0.0034). The relationships between both alcohol exposures and VS were not significant in models restricted to persons on ART.

CONCLUSIONS

We provide sex-stratified estimates of associations between two alcohol measures and VS in the context of current HIV treatment guidelines. This study confirms that alcohol use is adversely associated with VS but ART use mediates this pathway, suggesting that initiation and retention on ART are critical steps to addressing alcohol-related disparities in VS.

Cannabis and Alcohol Co-Use and Condomless Anal Sex Among Men Who have Sex with Men Living with HIV: An Event-Level Analysis

Men who have sex with men (MSM) account for more than two thirds of new HIV diagnoses annually. Sexual behavior that increases risk for onward transmission of HIV is associated with both alcohol and cannabis use. However, little is known about the influence of cannabis and alcohol co-use on engagement in condomless anal sex (CAS). The current study explored daily associations between substance use and CAS among HIV-positive MSM using a 42-day timeline followback interview (N = 101). Generalized estimating equation (GEE) logistic regression models were used to examine the association between cannabis and alcohol co-use and CAS at the sexual event while controlling for study site, condition, adherence to antiretroviral therapy, sex-related alcohol expectancies, and partner type. Participants provided data for 1052 sexual activity days, 60.7% of which involved CAS. Of 638 CAS days, 9.1% involved no substances, 72.0% involved either cannabis or alcohol use, and 18.9% involved cannabis and alcohol co-use. Results indicated that the odds of engaging in CAS were higher for sexual events in which cannabis and alcohol co-use occurred (aOR 2.98; 95% CI 1.27, 6.97) compared to events in which no substance use occurred (p = 0.012), but this relationship was no longer significant when cannabis and alcohol co-use was compared to single substance use (aOR 1.57; 95% CI 0.85, 2.90; p = 0.15). Future research should identify specific substance use (e.g., quantity) and partner characteristics (e.g., level of intoxication) that may uniquely influence the relationship between cannabis and alcohol co-use and condomless sex.

A Preliminary Test of an mHealth Facilitated Health Coaching Intervention to Improve Medication Adherence among Persons Living with HIV

This study examined feasibility, acceptability, and preliminary efficacy of an mHealth facilitated health coaching antiretroviral therapy (ART) adherence intervention. Persons living with HIV (n = 53) were randomized to an in-person adherence session and 12 months of app access and health coaching via the app (Fitbit Plus) versus single adherence session (SOC). At baseline and 1, 3, 6, and 12 months, we measured ART adherence, substance use, and depressive symptoms. We also conducted individual qualitative interviews. The intervention was found to be largely feasible and highly acceptable, with the health coach spending an average of 2.4 min per month with a participant and 76.5% of Fitbit Plus participants using the app regularly at 12 months. While most comparisons were not significant, the pattern of results was consistent with better adherence in the Fitbit Plus compared to SOC condition. Substance use was significantly associated with poorer ART adherence while depressive symptoms were not.ClinicalTrials.gov Identifier: NCT02676128; Registered: 2/8/2016.

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

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

Associations Between Patterns of Alcohol Use and Viral Load Suppression Amongst Women Living with HIV in South Africa

This study aimed to identify alcohol use patterns associated with viral non-suppression among women living with HIV (WLWH) and the extent to which adherence mediated these relationships. Baseline data on covariates, alcohol consumption, ART adherence, and viral load were collected from 608 WLWH on ART living in the Western Cape, South Africa. We defined three consumption patterns: no/light drinking (drinking ≤ 1/week and ≤ 4 drinks/occasion), occasional heavy episodic drinking (HED) (drinking > 1 and ≤ 2/week and ≥ 5 drinks/occasion) and frequent HED (drinking ≥ 3 times/week and ≥ 5 drinks/occasion). In multivariable analyses, occasional HED (OR 3.07, 95% CI 1.78–5.30) and frequent HED (OR 7.11, 95% CI 4.24–11.92) were associated with suboptimal adherence. Frequent HED was associated with viral non-suppression (OR 2.08, 95% CI 1.30–3.28). Suboptimal adherence partially mediated the relationship between frequent HED and viral non-suppression. Findings suggest a direct relationship between frequency of HED and viral suppression. Given the mediating effects of adherence on this relationship, alcohol interventions should be tailored to frequency of HED while also addressing adherence.

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.

Apoptosis of Hepatocytes: Relevance for HIV-Infected Patients under Treatment

Due to medical advances over the past few decades, human immunodeficiency virus (HIV) infection, once a devastatingly mortal pandemic, has become a manageable chronic condition. However, available antiretroviral treatments (cART) cannot fully restore immune health and, consequently, a number of inflammation-associated and/or immunodeficiency complications have manifested themselves in treated HIV-infected patients. Among these chronic, non-AIDS (acquired immune deficiency syndrome)-related conditions, liver disease is one of the deadliest, proving to be fatal for 15–17% of these individuals. Aside from the presence of liver-related comorbidities, including metabolic disturbances and co-infections, HIV itself and the adverse effects of cART are the main factors that contribute to hepatic cell injury, inflammation, and fibrosis. Among the molecular mechanisms that are activated in the liver during HIV infection, apoptotic cell death of hepatocytes stands out as a key pathogenic player. In this review, we will discuss the evidence and potential mechanisms involved in the apoptosis of hepatocytes induced by HIV, HIV-encoded proteins, or cART. Some antiretroviral drugs, especially the older generation, can induce apoptosis of hepatic cells, which occurs through a variety of mechanisms, such as mitochondrial dysfunction, increased production of reactive oxygen species (ROS), and induction of endoplasmic reticulum (ER) stress and unfolded protein response (UPR), all of which ultimately lead to caspase activation and cell death.

Viral load outcomes in a cohort of alcohol-consuming people living with HIV receiving antiretroviral therapy in Mumbai, India

We examined the association between alcohol consumption, adherence and viral load (VL) in a cohort of 940 alcohol-consuming, human immunodeficiency virus (HIV)-positive men receiving antiretroviral therapy in Mumbai. Some of the participants (16.7%) had missed >1 doses in the last four days and 17.6% reported >1 treatment interruptions in the last 12 months; 60.8% of the participants consumed alcohol >2 times/month, 62.8% consumed >3 drinks/typical day and 11.5% reported binge drinking >1 times/month; 76.4% of the participants had VL<200 copies/mL. Higher alcohol consumption was associated with nonadherence (odds ratio [OR]: 1.21; 95% confidence interval [CI]: 1.11-1.31) and treatment interruptions (OR: 1.20; 95% CI: 1.11-1.31). We found no association between alcohol use and VL. There was, however, a significant interaction effect of alcohol use and nonadherence on virological failure (Adjusted Odds Ratio [AOR]: 1.23; 95% CI: 1.03-1.47) implying that alcohol negatively impacts VL outcomes but mediated through adherence. Alcohol use was associated with poor adherence, which in turn was a strong predictor of virological failure.

Changes in Days of Unhealthy Alcohol Use and Antiretroviral Therapy Adherence, HIV RNA Levels, and Condomless Sex: A Secondary Analysis of Clinical Trial Data

In a sample of people with HIV (PWH) enrolled in an alcohol intervention trial and followed for 12 months, we examined the association of changes in days (i.e., decrease, increase, no change [reference]) of unhealthy drinking (consuming ≥ 4/≥ 5 drinks for women/men) with antiretroviral therapy adherence (≥ 95% adherent), viral suppression (HIV RNA < 75 copies/mL), condomless sex with HIV-negative/unknown status partners, and dual-risk outcome (HIV RNA ≥ 75 copies/mL plus condomless sex). The sample included 566 PWH (96.8% male; 63.1% White; 93.9% HIV RNA < 75 copies/mL) who completed baseline, 6-, and 12-month assessments. Decrease in days of unhealthy drinking was associated with increased likelihood of viral suppression (odds ratio [OR] 3.78; 95% confidence interval [CI] 1.06, 13.51, P = .04) versus no change. Increase in days of unhealthy drinking was associated with increased likelihood of condomless sex (OR 3.13; 95% CI 1.60, 6.12, P < .001). Neither increase nor decrease were associated with adherence or dual-risk outcome. On a continuous scale, for each increase by 1 day of unhealthy drinking in the prior month, the odds of being 95% adherent decreased by 6% (OR 0.94, 95% CI 0.88, 1.00, P = 0.04).

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.

Social Desirability Bias Impacts Self-Reported Alcohol Use Among Persons With HIV in Uganda

BACKGROUND

Self-report is widely used to assess alcohol use in research and clinical practice, but may be subject to social desirability bias. We aimed to determine if social desirability impacts self-reported alcohol use.

METHODS

Among 751 human immunodeficiency virus (HIV)-infected patients from a clinic in southwestern Uganda, we measured social desirability using the Marlowe-Crowne Social Desirability Scale (SDS) Short Form C, self-reported alcohol use (prior 3 months) Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), and phosphatidylethanol (PEth), a biomarker of prior 3 weeks' drinking. We conducted multiple regression analyses to assess the relationship between SDS score (low, medium, and high levels) and (i) any self-reported recent alcohol use, among those who were PEth-positive (≥8 ng/ml), and (ii) continuous AUDIT-C score, among those reporting any recent alcohol use. We controlled for PEth level, age, gender, education, economic assets, marital status, religion, spirituality/religiosity, social support, and study cohort.

RESULTS

Of 751 participants, 59% were women; the median age was 31 years (interquartile range [IQR]: 26 to 39). Median SDS score was 9 (IQR: 4 to 10). Two-thirds (62%) self-reported any recent alcohol use; median AUDIT-C was 1 (IQR: 0 to 4). Among those who were PEth-positive (57%), 13% reported no recent alcohol use. Those with the highest SDS tertile had decreased odds of reporting any recent alcohol use compared to the lowest tertile, but the association did not reach statistical significance in multivariable analyses (adjusted odds ratio 0.55 [95% confidence interval (CI): 0.25, 1.23]). Among participants self-reporting recent alcohol use, SDS level was negatively associated with AUDIT-C scores (adjusted β: -0.70 [95% CI: -1.19, -0.21] for medium vs. low SDS and -1.42 [95% CI: -2.05, -0.78] for high vs. low SDS).

CONCLUSIONS

While use of objective measures (e.g., alcohol biomarkers) is desirable for measuring alcohol use, SDS scores may be used to adjust self-reported drinking levels by participants' level of social desirability in HIV research studies.

Stigma, Coping, and Alcohol Use Severity Among People Living With HIV: A Prospective Analysis of Bidirectional and Mediated Associations

Background

HIV-related stigma is associated with health consequences among people living with HIV, including increased risk for alcohol problems. Theory suggests that maladaptive coping may mediate the relationship between HIV-related stigma and alcohol outcomes, and these variables may be bidirectionally associated over time. However, no studies have examined the temporal relationships among these variables in people living with HIV.

Purpose

This study examined prospective bidirectional and mediated associations among HIV-related stigma, maladaptive coping, and alcohol use severity in patients enrolled in the Ontario HIV Treatment Network Cohort study.

Method

Patients receiving care for HIV (N = 1,520) at one of several clinics completed self-report measures annually. Data were analyzed in a four-wave, cross-lagged panel model.

Results

Greater HIV-related stigma at each wave consistently predicted increased maladaptive coping 1 year later. Similarly, maladaptive coping consistently predicted greater subsequent HIV-related stigma. Further, we observed some evidence that maladaptive coping mediated the prospective associations between HIV-related stigma and alcohol use severity in both directions (i.e., stigma to subsequent alcohol use severity and vice versa) although these associations were not observed across all waves.

Conclusion

Results suggest that HIV-related stigma and maladaptive coping are bidirectionally associated with one another over time. This study also provides some evidence that coping may be a relevant mediator of these associations, although findings were less consistent for mediated pathways. Future research should examine whether interventions addressing stigma and coping among people living with HIV may help to minimize health risks such as hazardous drinking.

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

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

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

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.

Substance use and its effect on antiretroviral treatment adherence among male fisherfolk living with HIV/AIDS in Uganda

Background

Fisherfolk are a most-at-risk population for HIV being prioritized for the scale up of HIV treatment in Uganda. Heavy alcohol use and potential drug use may be a major barrier to treatment adherence for men in this setting.

Objective

This study examines the prevalence of substance use, and its influence on antiretroviral treatment (ART) adherence, among male fisherfolk on ART in Wakiso District, Uganda.

Methods

This cross-sectional study included structured questionnaires (N = 300) with men attending HIV clinics near Lake Victoria. Using generalized logistic modeling analyses with a binomial distribution and logit link, we conducted multivariate models to test the association between each alcohol variable (quantity and frequency index, hazardous drinking) and missed pills, adjusting for covariates, and tested for interactions between number of pills prescribed and alcohol variables.

Results

Thirty-one percent of men reported sub-optimal adherence. Half (46.7%) reported drinking, of which 64.8% met criteria for hazardous drinking. Illicit drug use was low (6%). In the multivariate model, men with greater scores on the alcohol frequency and quantity index were more likely to report missed pills compared to those reporting no drinking (AOR: 1.60, 95% CI: 1.29–1.97). Hazardous drinking had a greater effect on missed ARV doses among men taking twice daily regimens compared to once daily (AOR: 4.91, 95% CI: 1.68–14.37).

Conclusions

Our findings highlight the need for targeted alcohol-reduction interventions for male fisherfolk on ART who drink at high quantities to improve ART adherence and to prevent the known negative health effects of alcohol for HIV-infected individuals.

The Longitudinal Effects of Non-injection Substance Use on Sustained HIV Viral Load Undetectability Among MSM and Heterosexual Men in Brazil and Thailand: The Role of ART Adherence and Depressive Symptoms (HPTN 063)

The effect of non-injection substance use on HIV viral load (VL) is understudied in international settings. Data are from HPTN063, a longitudinal observational study of HIV-infected individuals in Brazil, Thailand, and Zambia, with focus on men with VL data (Brazil = 146; Thailand = 159). Generalized linear mixed models (GLMM) assessed whether non-injection substance use (stimulants, cannabis, alcohol, polysubstance) was associated with VL undetectability. ART adherence and depressive symptoms were examined as mediators of the association. In Thailand, substance use was not significantly associated with VL undetectability or ART adherence, but alcohol misuse among MSM was associated with increased odds of depression (AOR = 2.75; 95% CI 1.20, 6.32, p = 0.02). In Brazil, alcohol misuse by MSM was associated with decreased odds of undetectable VL (AOR = 0.34; 95% CI 0.13, 0.92, p = 0.03). Polysubstance use by heterosexual men in Brazil was associated with decreased odds of ART adherence (AOR = 0.25; 95% CI 0.08, 0.78, p = 0.02). VL suppression appears attainable among non-injection substance users. Substance use interventions among HIV-positive men should address depression, adherence, and VL undetectability.

Alcohol Use and HIV Disease Progression in an Antiretroviral Naive Cohort

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Role of Religious Service Attendance, Psychosocial and Behavioral Determinants of Antiretroviral Therapy (ART) Adherence: Results from HPTN 063 Cohort Study

Early and sustained antiretroviral therapy (ART) adherence can suppress the HIV virus in individuals and reduce onward transmission of HIV in the population. Religiosity has been associated with better HIV clinical outcomes. Data are from a longitudinal, observational study of 749 HIV-infected individuals from Brazil, Zambia, and Thailand (HPTN 063). Ordered logistic regression assessed whether religious service attendance was associated with ART adherence (self-reported and plasma HIV-RNA) and moderated the association between alcohol problems and ART adherence. In each country, > 80% of participants reported high self-reported ART adherence (good/very good/excellent). Religious service attendance exceeded 85% but was statistically unrelated to adherence. In combined-country models, (p = 0.03) as alcohol problems increased, the probability of high self-reported ART adherence, as well as viral-load, became weaker at higher compared to low service attendance frequency. Future studies should evaluate spirituality variables and replicate the moderation analyses between religious attendance and alcohol problems.

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.

Alcohol Use and Multimorbidity Among Individuals Living with HIV

Alcohol is prevalent among people living with HIV and can lead to multiple comorbid conditions (multimorbidity). The purpose of this study was to examine the relationship between alcohol use history and multimorbidity among people living with HIV. A retrospective cohort study design was conducted at an urban, academic infectious disease clinic in Kentucky. Individuals seeking care between 2010 and 2014 were included. Modified Poisson regression was used to examine the relationship between alcohol use history (never, current, and former use) and multimorbidity (≥ 2 conditions). A total of 949 individuals were included in the study, with 5.1 and 17.6% reporting former and current alcohol use, respectively. Sixty-five percent had ≥ 1 condition and 82.6% of those had ≥ 2 conditions diagnosed. The risk of multimorbidity was 1.70 (95% CI 1.35-2.14) times higher for a current user compared to a never user. Reductions in alcohol use may lead to lower rates of multimorbidity.

A longitudinal investigation of the association between cannabis use and alcohol use among people living with HIV

BACKGROUND

Both cannabis use and alcohol use are elevated among people living with HIV, but few studies have investigated the relationship between cannabis use and alcohol use in this population. This study examined the longitudinal association between cannabis use and alcohol use among people living with HIV and explored the moderating role of medicinal vs. recreational cannabis use.

METHOD

Participants were cannabis users (N=763) enrolled in the Ontario HIV Treatment Network Cohort Study (67% White, 88% male, 68% gay, median income in the $40,000-$50,000 range). Participants completed assessments of cannabis use, reasons for cannabis use, and alcohol use at baseline and at annual follow-ups (M = 3.42 completed assessments). Multilevel modeling was used to examine between-person and within-person associations between cannabis use and alcohol use over time.

RESULTS

Greater average frequency of cannabis use was associated with greater average alcohol consumption across participants. Participants classified as medicinal cannabis users reported more frequent cannabis use and less alcohol use on average than recreational cannabis users. Further, within-person changes in cannabis use over time were positively associated with corresponding changes in alcohol use for recreational cannabis users but not for medicinal users.

CONCLUSION

Cannabis use and alcohol use were positively associated over time among people living with HIV, although this association was specific to those using cannabis for recreational reasons. As alcohol use in this population poses significant health risks, more research on the link between cannabis use and alcohol use is needed, particularly in light of recent changes to cannabis regulations.

Liver as a target of human immunodeficiency virus infection

Liver injury is a characteristic feature of human immunodeficiency virus (HIV) infection, which is the second most common cause of mortality in HIV-infected patients. Now it is recognized that liver plays a key role in HIV infection pathogenesis. Antiretroviral therapy (ART), which suppresses HIV infection in permissive immune cells, is less effective in hepatocytes, thereby making these cells a silent reservoir of HIV infection. In addition to direct hepatotoxic effects of HIV, certain ART treatment modalities provide hepatotoxic effects. The exact mechanisms of HIV-triggered chronic hepatitis progression are not elucidated, but the liver is adversely affected by HIV-infection and liver cells are prominently involved in HIV-elicited injury. These effects are potentiated by second hits like alcohol. Here, we will focus on the incidence of HIV, clinical evidence of HIV-related liver damage, interactions between HIV and liver cells and the role of alcohol and co-infection with hepatotropic viruses in liver inflammation and fibrosis progression.

Influences of Economic, Social and Cultural Marginalization on the Association Between Alcohol Use and Sexual Risk Among Formerly Incarcerated Latino Men

Formerly incarcerated Latino men (FILM) have been significantly impacted by the HIV/AIDS and alcohol abuse epidemics in the United States. In this analysis, we examine the role of social, economic and cultural marginalization in the likelihood of alcohol-related sexual risk taking behavior among FILM. We recruited a non-random sample of FILM, ages 18-49 (n = 259). We performed logistic regression modeling to test four hypotheses examining the direct and moderating effects of socio-cultural factors. Drinking before sex was strongly associated with high likelihood of condomless intercourse (adjusted odds ratio, AOR = 2.93; 95% CI 1.74, 4.94). Low acculturation and social marginalization factors were significant moderators of the association between high-risk alcohol use and sexual risk behavior among FILM. Our data suggest that risk reduction initiatives geared towards reducing alcohol-related sexual risk taking among FILM should target FILM with low levels of acculturation, and those with high levels loneliness, anxiety, and/or depression.

Hazardous alcohol consumption and alcohol-related problems are associated with unknown and HIV-positive status in fishing communities in Uganda

In Uganda, alcohol consumption is associated with higher HIV prevalence. However, research is needed to better understand how different patterns of alcohol consumption and alcohol-related problems may drive this association. In this cross-sectional study, we examined how hazardous alcohol use and alcohol-related problems such as psychological, physical, and social harms are associated with HIV status in fishing communities in Uganda. 300 (132 male, 168 female) residents of fishing communities in Uganda (75 participants from each of the following occupational groups: fishmongers, alcohol sellers, commercial sex workers (CSW), and fishermen) completed an interviewer-assisted computerized interview. We captured information on sociodemographics and HIV testing history. Prior 12-month hazardous alcohol consumption patterns and alcohol-related problems were assessed with the AUDIT and AUDADIS. 19.7%, 58.0%, and 23.3% of the sample reported being HIV positive, being HIV negative from a test within the prior 12 months, and not knowing their HIV status respectively. 18.7% reported the co-occurrence of hazardous alcohol consumption patterns and alcohol-related problems. 7.7% reported either hazardous alcohol consumption patterns or alcohol-related problems. Compared to non-drinkers, those with co-occurring hazardous consumption and alcohol-related problems had greater odds of being HIV positive (adjOR 2.75, 95% CI 1.17-6.43) and of unknown HIV status (adjOR 3.35, 95% CI 1.52-7.42). Reporting only hazardous consumption levels, only alcohol-related problems, or low-risk drinking, did not increase the odds of being HIV positive or of unknown status. Among those not HIV positive, those with co-occurring hazardous consumption and alcohol-related problems had greater odds of never having had an HIV test (adjOR 3.78, 95% CI 1.63-8.68). The co-occurrence of hazardous alcohol use and alcohol related problems appears to be a prominent risk factor for HIV infection, not knowing one's HIV status, and never testing for HIV in this setting.

Point-of-Care Urine Ethyl Glucuronide Testing to Detect Alcohol Use Among HIV-Hepatitis B Virus Coinfected Adults in Zambia

In an HIV-hepatitis B virus (HIV-HBV) coinfection cohort in Zambia, we piloted a qualitative point-of-care (POC) test for urine Ethyl glucuronide (uEtG), assessed concordance between uEtG and alcohol use disorders identification test-consumption (AUDIT-C), and identified epidemiological factors associated with underreporting (defined as uEtG-positivity with last reported drink > 7 days prior). Among 211 participants (40.8% women), there were 44 (20.8%) lifetime abstainers, 32 (15.2%) former drinkers, and 135 (64.0%) current drinkers, including 106 (50.2%) with unhealthy drinking per AUDIT-C. Eighty-seven (41.2%) were uEtG-positive including 64 of 65 (98.5%) who drank ≤ 3 days prior and 17 of 134 (12.7%) underreported, all of whom admitted to recent drinking when results were discussed. uEtG was moderately concordant with AUDIT-C. Past drinking (versus lifetime abstinence) and longer time on antiretrovirals (≥ 12 months) were associated with underreporting. These data support further use of POC alcohol biomarkers in HIV and hepatitis research and clinical settings.

Alcohol Use, HIV Treatment Adherence, and Sexual Risk Among People with a History of Injecting Drug Use in Vietnam

Alcohol use can limit the effectiveness of antiretroviral therapy (ART) for people living with HIV (PLH) who have a history of injecting drug use. This study described the patterns of alcohol use among PLH with a history of injecting drug use in Vietnam and examined the relationships between alcohol use, adherence to ART, and sexual risks. We utilized cross-sectional data of 109 PLH on ART collected from a randomized controlled intervention trial in Vietnam. Approximately 30 and 46% of the participants were frequent and occasional drinkers, respectively. Frequent drinkers reported the highest number of missed medication days. About 61% of frequent drinkers reported having sex after using alcohol. Additionally, 23, 34, and 24% of nondrinkers, occasional drinkers, and frequent drinkers, respectively, reported inconsistent condom use during sex. Future intervention programs should address the issues of alcohol use and sexual risks to maximize the effectiveness of HIV treatment programs in Vietnam.

Analysis of the Association of Nonsynonymous Polymorphisms in ADH Genes with Hazardous Drinking in HIV-1-Positive Individuals

BACKGROUND

Hazardous drinking (HD) is a serious health problem in people infected with human immunodeficiency virus type 1 (HIV-1). Single nucleotide polymorphisms (SNPs) in alcohol dehydrogenase (ADH) genes have been associated with HD in different populations, but there were no data about this in HIV-1-positive individuals. This study investigated the association of 4 nonsynonymous SNPs in ADH genes (Arg48His and Arg370Cys in ADH1B gene; Arg272Gln and Ile350Val in ADH1C gene) with HD in people living with HIV-1.

METHODS

This case-control study included 365 HIV-1-positive individuals (121 with HD and 244 without HD). Sociodemographic variables were collected with a standardized individual questionnaire. HD (score ≥8) and binge drinking (BD) (drinks on the same occasion ≥5) were detected with the Alcohol Use Disorders Identification Test. The 4 SNPs were genotyped by the polymerase chain reaction-restriction fragment length polymorphism method. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated using logistic regression analysis. The Bonferroni correction was used (considering the 4 SNPs studied).

RESULTS

There were no significant differences in the frequencies of Arg370Cys, Arg272Gln, and Ile350Val polymorphisms between HD cases and controls. Otherwise, Arg/His genotype (rs1229984) in ADH1B gene showed a protective effect against HD (aOR = 0.36; 95% CI: 0.14 to 0.90) and BD (aOR = 0.49; 95% CI: 0.21 to 0.95). Nevertheless, these differences were no longer significant after Bonferroni correction.

CONCLUSIONS

The results of this study suggest a possible effect of the Arg48His genotype on the protection against HD in HIV-1-positive individuals.

Marijuana use and HIV treatment outcomes among PWH receiving care at an urban HIV clinic

BACKGROUND

While marijuana use is prevalent among persons with HIV (PWH), few studies have examined the relationship between marijuana use and HIV treatment outcomes independent of alcohol and other drug use.

METHODS

We conducted a prospective cohort study to examine the relationships between frequency of marijuana use and antiretroviral therapy (ART) adherence and viral suppression in patients enrolled in the Johns Hopkins HIV Clinical Cohort between September 2013 through November 2015 (N=1377). We categorized marijuana use as no use, none in the last 3months, monthly use or less, weekly/daily. Our outcomes of interest were use of ART, ≥90 ART adherence, and viral suppression (HIV1-RNA<200 copies). We conducted multivariable analyses to examine associations between the frequency of marijuana use and our treatment outcomes, using generalized estimating equations to account for repeated measures. Other independent variables of interest included alcohol use, other drug use, and depressive symptoms. Analyses were adjusted for age, race, sex and HIV acquisition risk factor.

RESULTS

In multivariable analyses we found no statistically significant association between frequency of marijuana use and our treatment outcomes. Alcohol use, other drug use and depressive symptoms were associated with lower odds of ART adherence and viral suppression.

CONCLUSIONS

In this sample of PWH in care, frequency of marijuana use independent of other substance use does not appear to be associated with negative HIV treatment outcomes. Our results indicate that unlike alcohol, other substances and depression, marijuana use may not be a barrier to the effective treatment of HIV.

Hazardous alcohol consumption is not associated with CD4+ T-cell count decline among PLHIV in Kampala Uganda: A prospective cohort study

Introduction

There is limited data on the effects of alcohol on immunological response among persons living with HIV (PLHIV) in sub-Saharan Africa. We assessed the relationship between hazardous alcohol use and CD4+ T-cell count, among PLHIV in Uganda.

Methods

PLHIV aged ≥ 18 years were enrolled in a cohort study at the Infectious diseases clinic Kampala, Uganda. Alcohol consumption was assessed at enrolment (baseline) and 6 monthly thereafter using the alcohol use disorders identification test (AUDIT). The CD4+ T-cell counts, assessed at baseline and over the next 12 months were compared between alcohol use strata, using linear mixed effects regression. Using longitudinal mediation analysis methods, we estimated the effect of alcohol induced ART non-adherence on CD4+ T-cell count.

Results

Of the 1566 participants enrolled, 863(44.1%) were non-alcohol users (AUDIT score = 0), 433(27.7%) were non-hazardous (AUDIT score 1–7) alcohol users while 270 (17.2%) were hazardous (AUDIT score ≥ 8) alcohol users.

The overall median (IQR) baseline CD4+ T-cell count was 356 (243–516) cells/μl. There were no differences in the median baseline CD4+ T-cell count between hazardous and non-hazardous alcohol users compared to non-alcohol users in both the non-ART (p = 0.43) and ART group (p = 0.77).

The mean CD4+ T-cell count over 12 months was not different between hazardous alcohol users and non-alcohol users (non-ART group p = 0.88 and ART group p = 0.62), nor between non-hazardous alcohol users and non-alcohol users (and non-ART group p = 0.66 and ART group p = 0.20).

Alcohol use was not associated with a significant natural direct effect on CD4⁺ T-cell count (1.37 95%CI [-1.78, 4.52] cells/μl, p = 0.39) but had a statistically significant natural indirect effect on reduction of CD4⁺ T-cell count (-0.91 cells/μl [-1.36, -0.45], p < 0.001) mediated through ART non-adherence.

Conclusion

Hazardous alcohol use among PLHIV was not directly associated with lower CD4+ T-cell count but had a significant natural indirect effect on CD4+ T-cell count mediated through ART non-adherence. Among PLHIV with lower than expected CD4+ T-cell count, alcohol consumption should be excluded as an underlying factor for non-adherence to ART and any interventions targeting alcohol use should tackle possible ART non-adherence.

Long-term alcohol use patterns and HIV disease severity

OBJECTIVE

We examined the relationship between alcohol use trajectories and HIV disease severity among men and women participating in the Veterans Aging Cohort Study (VACS).

DESIGN

Prospective cohort of HIV-infected persons in care at eight US Veterans Health Administration sites.

METHODS

Between 2002 and 2010, we assessed alcohol consumption annually using the alcohol use disorders identification test-consumption (AUDIT-C). HIV disease severity was ascertained using the VACS index, a validated measure of morbidity and all-cause mortality. We examined the relationship between alcohol use and HIV disease severity patterns using joint trajectory modeling. Alcohol use trajectories were validated using phosphatidylethanol - a biomarker of alcohol consumption - measured between 2005 and 2006 among a subset of participants. We examined associations between membership in alcohol use and VACS index trajectories using multinomial regression.

RESULTS

Among eligible participants, we identified four alcohol consumption trajectories: abstainers (24% of the sample), lower risk (44%), moderate risk (24%), and higher risk drinkers (8%). Alcohol use trajectories were highly correlated with phosphatidylethanol (Cramér's V = 0.465, P < 0.001): mean concentrations were 4.4, 17.8, 57.7, and 167.6 ng/ml in the abstainer, lower risk, moderate risk, and higher risk groups, respectively. Four VACS index trajectories were identified: low (2%), moderate (46%), high (36%), and extreme (16%). Higher risk drinkers were most common in the extreme VACS index group, and were absent in the low index group. In multivariable analysis, the association between alcohol use and VACS index trajectory membership remained significant (P = 0.002).

CONCLUSION

Alcohol use trajectories characterized by persistent unhealthy drinking are associated with more advanced HIV disease severity among HIV-infected veterans in the United States.

Disrupted ER-to-Golgi Trafficking Underlies Anti-HIV Drugs and Alcohol-Induced Cellular Stress and Hepatic Injury

Endoplasmic reticulum (ER) stress and unfolded protein response (UPR) are involved in anti‐human immunodeficiency virus (HIV) drugs and alcohol‐induced liver disease in a significant number of patients infected with HIV. However, the precise mechanism by which the drugs and alcohol cause ER stress remains elusive. We found that ritonavir‐boosted lopinavir (RL) activated two canonical UPR branches without activation of the third canonical activating transcription factor 6 (ATF6) branch in either HepG2 cells or primary mouse hepatocytes. In the RL‐treated cells, ATF6 localization in the Golgi apparatus required for its activation was reduced; this was followed by Golgi fragmentation and dislocation/redistribution of Golgi‐resident enzymes. Severities of Golgi fragmentation induced by other anti‐HIV drugs varied and were correlated with the ER stress response. In the liver of mice fed RL, alcohol feeding deteriorated the Golgi fragmentation, which was correlated with ER stress, elevated alanine aminotransferase, and liver steatosis. The Golgi stress response (GSR) markers GCP60 and HSP47 were increased in RL‐treated liver cells, and knockdown of transcription factor for immunoglobulin heavy‐chain enhancer 3 of the GSR by small interfering RNA worsened RL‐induced cell death. Cotreatment of pharmacological agent H89 with RL inhibited the RL‐induced Golgi enzyme dislocation and ER stress. Moreover, the coat protein complex II (COPII) complexes that mediate ER‐to‐Golgi trafficking accumulated in the RL‐treated liver cells; this was not due to interference of RL with the initial assembly of the COPII complexes. RL also inhibited Golgi fragmentation and reassembly induced by short treatment and removal of brefeldin A. Conclusion: Our study indicates that ER‐to‐Golgi trafficking is disrupted by anti‐HIV drugs and/or alcohol, and this contributes to subsequent ER stress and hepatic injury. (Hepatology Communications 2017;1:122‐139)

Comparison of AUDIT-C collected via electronic medical record and self-administered research survey in HIV infected and uninfected patients

BACKGROUND

Using electronic medical record (EMR) data for clinical decisions, quality improvement, and research is common. While unhealthy alcohol use is particularly risky among HIV infected individuals (HIV+), the validity of EMR data for identifying unhealthy alcohol use among HIV+ is unclear. Among HIV+ and uninfected, we: (1) assess agreement of EMR and research AUDIT-C at validated cutoffs for unhealthy alcohol use; (2) explore EMR cutoffs that maximize agreement; and (3) assess subpopulation variation in agreement.

METHODS

Using data from the Veterans Aging Cohort Study (VACS), EMR AUDIT-C cutoffs of 2+, 3+, and 4+ for men (2+ and 3+ for women) were compared to research AUDIT-C 4+ for men (3+ for women). Agreement was compared by demographics, HIV, hepatitis C infection, and alcohol related diagnosis.

RESULTS

Among 1082 HIV+ and 1160 uninfected men, 14% and 22% had an EMR and research AUDIT-C 4+, respectively. Among 32 HIV+ and 115 uninfected women, 9% and 14% had an EMR and research AUDIT-C 3+. For men, EMR agreement with the research AUDIT-C 4+ was highest at a cutoff of 3+ (kappa=0.49). For women, EMR agreement with AUDIT-C 3+ was highest at a cutoff of 2+ (kappa=0.46). Moderate agreement was consistent across subgroups.

CONCLUSIONS

EMR AUDIT-C underestimates unhealthy alcohol use compared to research AUDIT-C in both HIV+ and uninfected individuals. Methods for improving quality of clinical screening may be in need of investigation. Researchers and clinicians may consider alternative EMR cutoffs that maximize agreement given limitations of clinical screening.