Expanding research on the role of alcohol consumption and related risks in the prevention and treatment of HIV/AIDS

Assessing the associations between known genetic variants and substance use in people with HIV in the United States

BACKGROUND

The prevalence of substance use in people with HIV (PWH) in the United States is higher than in the general population and is an important driver of HIV-related outcomes. We sought to assess if previously identified genetic associations that contribute to substance use are also observed in a population of PWH.

METHODS

We performed genome-wide association studies (GWAS) of alcohol, smoking, and cannabis use phenotypes in a multi-ancestry population of 7,542 PWH from the Center for AIDS Research Network of Integrated Clinical Systems (CNICS). We conducted multi-ancestry GWAS for individuals of African (n = 3,748), Admixed American (n = 1,334), and European (n = 2,460) ancestry. Phenotype data were self-reported and collected using patient reported outcomes (PROs) and three questions from AUDIT-C, an alcohol screening tool. We analyzed nine phenotypes: 1) frequency of alcohol consumption, 2) typical number of drinks on a day when drinking alcohol, 3) frequency of five or more alcoholic drinks in a 30-day period, 4) smoking initiation, 5) smoking cessation, 6) cigarettes per day, 7) cannabis use initiation, 8) cannabis use cessation, 9) frequency of cannabis use during the previous 30 days. For each phenotype we considered a) variants previously identified as associated with a substance use trait and b) novel associations.

RESULTS

We observed evidence for effects of previously reported single nucleotide polymorphisms (SNPs) related to alcohol (rs1229984, p = 0.001), tobacco (rs11783093, p = 2.22E-4), and cannabis use (rs2875907, p = 0.005). We also report two novel loci (19p13.2, p = 1.3E-8; and 20p11.21, p = 2.1E-8) associated with cannabis use cessation.

CONCLUSIONS

Our analyses contribute to understanding the genetic bases of substance use in a population with relatively higher rates of use compared to the general population.

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.

Maternal depression, alcohol use, and transient effects of perinatal paraprofessional home visiting in South Africa: Eight-year follow-up of a cluster randomized controlled trial

BACKGROUND

South African mothers confront synergistic challenges from depression, alcohol use, and HIV/AIDS. The importance of maternal functioning for child development motivates interventions, yet long-term outcomes seldom are tracked. Furthermore, little is known about trajectories and the role of social-cultural factors in maternal depression and alcohol use across parenthood in low- and middle-income countries.

METHODS

We examined maternal outcomes at 5- and 8-years' post-birth, from the Philani Intervention Program (PIP), a randomized controlled trial of a prenatally-initiated home visiting intervention lasting through 6 months' post-birth which yielded some benefits for children and mothers through 3 years. Longitudinal Bayesian mixed-effects models assessed intervention effects for maternal depression and alcohol use from pre-birth through 8 years post-birth. We plotted trajectories of depression and alcohol use and analyzed their relationship over time.

RESULTS

Maternal benefits appeared limited and intervention outcomes differed at 5 and 8 years. Reduced depression in PIP versus standard care (SC) mothers at 3 years disappeared by 5 and 8 years. Depression prevalence declined from 35.1% prenatally to 5.5% at 8 years, independent of intervention or alcohol use. Alcohol use in both groups rebounded from a post-birth nadir; fewer PIP than SC mothers drank alcohol and reported problematic use at 5 but not 8 years. HIV+ prevalence did not differ by condition and increased from 26% to 45% over the reported period.

CONCLUSIONS

Dissipation of early child benefits from home visiting by age 8 years likely reflects lack of durable change in maternal behaviors compounded by social-cultural factors and cumulative effects of community deprivation. High prenatal rates warrant screening and treatment for depression in standard antenatal care. Low-and-middle income countries may need sustained interventions, including alcohol use reduction, to capitalize on initial gains from targeted interventions and address community social-cultural factors. HIV/AIDS continues to spread in this population.

Associations between alcohol and cigarette use and type 1 and 2 myocardial infarction among people with HIV

OBJECTIVES

People with HIV have a higher risk of myocardial infarction (MI) than the general population, with a greater proportion of type 2 MI (T2MI) due to oxygen demand-supply mismatch compared with type 1 (T1MI) resulting from atherothrombotic plaque disruption. People living with HIV report a greater prevalence of cigarette and alcohol use than do the general population. Alcohol use and smoking as risk factors for MI by type are not well studied among people living with HIV. We examined longitudinal associations between smoking and alcohol use patterns and MI by type among people living with HIV.

DESIGN AND METHODS

Using longitudinal data from the Centers for AIDS Research Network of Integrated Clinical Systems cohort, we conducted time-updated Cox proportional hazards models to determine the impact of smoking and alcohol consumption on adjudicated T1MI and T2MI.

RESULTS

Among 13 506 people living with HIV, with a median 4 years of follow-up, we observed 177 T1MI and 141 T2MI. Current smoking was associated with a 60% increase in risk of both T1MI and T2MI. In addition, every cigarette smoked per day was associated with a 4% increase in risk of T1MI, with a suggestive, but not significant, 2% increase for T2MI. Cigarette use had a greater impact on T1MI for men than for women and on T2MI for women than for men. Increasing alcohol use was associated with a lower risk of T1MI but not T2MI. Frequency of heavy episodic alcohol use was not associated with MI.

CONCLUSIONS

Our findings reinforce the prioritization of smoking reduction, even without cessation, and cessation among people living with HIV for MI prevention and highlight the different impacts on MI type by gender.

Patient perceptions of facilitators and barriers to reducing hazardous alcohol use among people living with HIV in East Africa

BACKGROUND

Hazardous alcohol use among people living with HIV is associated with poor outcomes and increased morbidity and mortality. Understanding the hazardous drinking experiences of people living with HIV is needed to reduce their alcohol use.

METHODS

We conducted 60 interviews among people living with HIV in East Africa with hazardous drinking histories. Interviews and Alcohol Use Disorder Identification Test (AUDIT) scores were conducted 41 - 60 months after their baseline assessment of alcohol use to identify facilitators and barriers to reduced alcohol use over time.

RESULTS

People living with HIV who stopped or reduced hazardous drinking were primarily motivated by their HIV condition and desire for longevity. Facilitators of reduced drinking included health care workers' recommendations to reduce drinking (despite little counseling and no referrals) and social support. In those continuing to drink at hazardous levels, barriers to reduced drinking were stress, social environment, alcohol accessibility and alcohol dependency.

CONCLUSIONS

Interventions that capacity-build professional and lay health care workers with the skills and resources to decrease problematic alcohol use, along with alcohol cessation in peer support structures, should be explored.

Binge Drinking Relates to Worse Neurocognitive Functioning Among Adults Aging with HIV

OBJECTIVE

Given the aging population of people with HIV (PWH), along with increasing rates of binge drinking among both PWH and the general older adult population, this study examined the independent and interactive effects of HIV, binge drinking, and age on neurocognition.

METHOD

Participants were 146 drinkers stratified by HIV and binge drinking status (i.e., ≥4 drinks for women and ≥5 drinks for men within approximately 2 h): HIV+/Binge+ (n = 30), HIV-/Binge+ (n = 23), HIV+/Binge- (n = 55), HIV-/Binge- (n = 38). All participants completed a comprehensive neuropsychological battery measuring demographically-corrected global and domain-specific neurocognitive T scores. ANCOVA models examined independent and interactive effects of HIV and binge drinking on neurocognitive outcomes, adjusting for overall alcohol consumption, lifetime substance use, sex, and age. Subsequent multiple linear regressions examined whether HIV/Binge group moderated the relationship between age and neurocognition.

RESULTS

HIV+/Binge+ participants had worse global neurocognition, processing speed, delayed recall, and working memory than HIV-/Binge- participants (p's < .05). While there were significant main effects of HIV and binge drinking, their interaction did not predict any of those neurocognitive outcomes (p's > .05). Significant interactions between age and HIV/Binge group showed that HIV+/Binge+ participants demonstrated steeper negative relationships between age and neurocognitive outcomes of learning, delayed recall, and motor skills compared to HIV-/Binge- participants (p's < .05).

CONCLUSIONS

Results showed adverse additive effects of HIV and binge drinking on neurocognitive functioning, with older adults demonstrating the most vulnerability to these effects. Findings support the need for interventions to reduce binge drinking, especially among older PWH.

Event-Level Association Between Daily Alcohol Use and Same-Day Nonadherence to Antiretroviral Therapy Among Young Men Who Have Sex With Men and Trans Women Living With HIV: Intensive Longitudinal Study

BACKGROUND

Young trans women (TW) and men who have sex with men (MSM) are disproportionately impacted by HIV. Optimizing adherence to antiretroviral therapy (ART) is one mechanism by which public health experts aim to achieve favorable HIV health outcomes while reducing disease transmission. However, alcohol use is prevalent among young TW and MSM and threatens optimal adherence. In addition, the daily variations in alcohol use and ART adherence and their association with each other are poorly understood, warranting more appropriate methodological approaches, such as analysis of ecological momentary assessment (EMA) data.

OBJECTIVE

The aim of this analysis is to characterize the association between daily alcohol use and same-day ART nonadherence captured by an EMA study of young MSM and TW living with HIV in San Francisco.

METHODS

Young MSM and TW enrolled in the Health eNav digital HIV care navigation intervention were included in the analytic sample (N=113). Data on alcohol and ART use were collected by daily EMA surveys administered via text messaging and were analyzed over 30 days of follow-up. A multivariable mixed-effects logistic regression model adjusting for baseline sociodemographic characteristics was specified to investigate whether daily alcohol use was associated with same-day ART nonuse.

RESULTS

Daily alcohol use was associated with higher same-day ART nonuse. On average, participants drank alcohol on 15.20 (SD 8.93) days and used ART on 15.19 (SD 10.16) days out of 30 days. Daily alcohol use was associated with 1.89 (95% CI 1.14-3.15) times the adjusted odds of same-day ART nonuse for each participant.

CONCLUSIONS

Results are consistent with other analyses of daily alcohol and ART use and underscore the importance of individually targeted interventions that are sensitive to each participant's dynamic risk environment.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/16406.

Genetic variation in alcohol dehydrogenase is associated with neurocognition in men with HIV and history of alcohol use disorder: preliminary findings

The co-occurrence of HIV and alcohol use disorder (AUD) amplifies risk for neural injury and neurocognitive deficits. However, the substantial neurocognitive heterogeneity across HIV+/AUD+ individuals suggests inter-individual differences in vulnerability to the neurotoxicity of comorbid HIV/AUD. Genetic variation in alcohol dehydrogenase (ADH), which metabolizes ethanol, may contribute to inter-individual neurocognitive variability. We evaluated associations between five ADH single-nucleotide polymorphisms (SNPs) and neurocognition in men stratified by HIV and lifetime AUD status. Neurobehavioral assessments were administered to 153 men. Three-way ANOVAs examined the interaction of HIV, AUD, and ADH SNPs on global and domain-specific demographically corrected T scores. Follow-up ANCOVAs adjusted for age, estimated verbal IQ, depression, and remote non-alcohol substance use disorders. HIV/AUD groups differed globally and for verbal fluency, working memory, executive function, and processing speed T scores specifically, with HIV+/AUD+ exhibiting the poorest performance. ADH4 (rs1126671) was associated with large effects on working memory (d = - 1.16, p = .001) and executive function (d = - 0.77, p = .028) selectively in HIV+/AUD+, which remained significant in ANCOVA models. ADH1A (rs3819197) moderated the deleterious effects of HIV+/AUD+ on processing speed such that HIV+/AUD+ related to slower information processing in A allele carriers but not GG homozygotes (ps < 0.03). Preliminary findings suggest genetic variation in the ADH pathway moderates the deleterious neurocognitive effects of comorbid HIV/AUD. Differential metabolism of heavy ethanol exposure may compromise neurocognition under conditions of neurobiological stress, such as in HIV infection. The functional effects on ethanol metabolism of ADH SNPs examined in this study remain poorly understood, warranting further examination of pharmacokinetic mechanisms mediating ADH gene-neurobehavior relationships in HIV.

Safer sex intentions modify the relationship between substance use and sexual risk behavior among black South African men who have sex with men

Due to the global burden of HIV, a better understanding of the relationship between substance use and HIV risk behavior is a public health priority, particularly among populations with high rates of HIV infection. The current study explored the moderating effects of psychosocial factors on the relationship between substance use and sexual risk behavior. Among 480 black South African men who have sex with men recruited using respondent-driven sampling, a cross-sectional survey was conducted that included questions about their last sexual event that involved anal sex. Substance use was not associated with unprotected anal intercourse (UAI) ( P = 0.97). The effect of substance use on UAI was modified by safer sex intentions ( P = 0.001). Among those with higher safer sex intentions, substance use was positively associated with UAI (aOR = 5.8, 95%CI = 1.6–21.3, P < 0.01). This study found that among men who have sex with men with high intentions to engage in safer sex, substance use was associated with increased risky sexual behavior.

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.

Spectrum of female commercial sex work in Bangui, Central African Republic

Classification of professional and non-professional female sex workers (FSWs) into different categories, never previously reported in the Central African Republic (CAR), may be useful to assess the dynamics of the human immunodeficiency virus (HIV) epidemic, design operational intervention programmes to combat HIV and other sexually transmitted infections (STIs) and to adapt these programmes to the broad spectrum of sexual transactions in the CAR. Our study proposes a socio-behavioural classification of FSWs living in the CAR and engaged in transactional and commercial sex. Thus, the aims of the study were these: (i) to categorize FSWs according to socio-anthropologic criteria in Bangui and (ii) to examine the association between a selection of demographic and risk variables with the different categories of female sex work as an outcome. A cross-sectional questionnaire survey was conducted in 2013 to describe the spectrum of commercial sex work (CSW) in Bangui among 345 sexually active women having more than 2 sexual partners, other than their regular partner, during the prior 3 months and reporting to have received money or gifts in return for their sexual relationships. According to socio-behavioural characteristics, FSWs were classified into six different categories. Professional FSWs, constituting 32.5% of the interviewed women, were divided in two categories: pupulenge (13.9%), i.e., dragonflies (sometimes called gba moundjou, meaning literally look at the White) consisting of roamers, who travel around the city to hotels and nightclubs seeking wealthy clients, with a preference for French men; and the category of kata (18.6%), i.e., FSWs working in poor neighbourhoods. Non-professional FSWs, constituting 67.5% of the interviewed women, were divided into four categories: street and market vendors (20.8%), students (19.1%), housewives (15.7%) and unskilled civil servants (11.9%). In general, CSW in the CAR presents a remarkably heterogeneous phenomenon. Risk-taking behaviour regarding STI/HIV infection appears to be different according to the different categories of female CSW. The groups of katas and street vendors were poorer and less educated, consumed more alcohol or other psycho-active substances (cannabis, tramadol and glue) and, consequently, were more exposed to STI. Our results emphasise the high level of vulnerability of both poor professional FSWs (kata) and non-professional sex workers, especially street vendors, who should be taken into account when designing prevention programmes targeting this population for STI/HIV control purposes.

Alcohol retail sales licenses and sexually transmitted infections in Texas counties, 2008-2015

BACKGROUND

Research suggests that reduced retail alcohol outlet density may be associated with lower prevalence of HIV and other sexually transmitted infections (STIs). On-premise sale of alcohol for immediate consumption is theorized as increasing social interactions that can lead to sexual encounters.

OBJECTIVE

We examined associations between on- and off-premise retail alcohol sales licenses and number of newly diagnosed HIV and STI cases in Texas counties.

METHODS

Retail alcohol sales license data were obtained from the Texas Alcoholic Beverage Commission. HIV and bacterial STI data were obtained from the Texas Department of State Health Services. Associations between retail alcohol sales licenses and STIs were estimated using spatial linear models and Poisson mixed effects models for over-dispersed count data.

RESULTS

Adjusting for county-specific confounders, there was no evidence of residual spatial correlation. In Poisson models, each additional on-premise (e.g., bar and restaurant) alcohol license per 10,000 population in a county was associated with a 1.5% increase (95% CI: 0.4%, 2.6%) in the rate of HIV and a 2.4% increase (95% CI: 1.9%, 3.0%) in the rate of bacterial STIs, adjusting for potential confounders. In contrast, number of off-premise licenses (e.g., take-out stores) was inversely associated with the incidence of STI and HIV, although the association with HIV was not statistically significant.

CONCLUSIONS

This study adds to the limited literature on the association between retail alcohol availability and STIs. Additional research is needed on the role of alcohol availability (and policies affecting availability) in the spread of HIV and other STIs.

Feasibility and Acceptability of a Motivational Intervention Combined with Text Messaging for Alcohol and Sex Risk Reduction with Emergency Department Patients: A Pilot Trial

BACKGROUND

Interventions aimed at reducing co-occurring heavy drinking and risky sexual behavior among Emergency Department (ED) patients require feasibility and acceptability to optimally engage individuals.

OBJECTIVES

This pilot study explored the feasibility and acceptability of an interactive text-messaging (TM) supplement to a brief in-person intervention previously found successful in reducing alcohol use and condomless sex.

METHODS

Using a mixed-method design, ED patients with past hazardous alcohol use and condomless sex (N= 20) were randomly assigned to receive either a Motivational Intervention + TM or Brief Advice + TM. All participants completed exit interviews at four weeks follow-up, and transcripts were transcribed and coded to identify themes. We evaluated feasibility through quantitative assessment of TM response rates and latency to response, while acceptability was evaluated through thematic analysis of exit interviews.

RESULTS

Findings provide support for the delivery of an integrated and personalized MI and TM. Participants engaged positively with the TM intervention and qualitative interviews offered strong support for the acceptability while offering information necessary to enhance the TM component.

CONCLUSIONS

Integrating MI with TM is feasible and acceptable to at-risk ED patients and could facilitate behavior changes beyond MI alone.

Predictors of Longitudinal Trajectories of Alcohol Consumption in People with HIV

BACKGROUND

Our aim was to describe alcohol consumption trajectories in a cohort of people living with HIV and determine clinical and sociodemographic predictors of each trajectory.

METHODS

This is a prospective cohort study of 7,906 patients in the 7 Centers for AIDS Research Network of Integrated Clinical Systems sites. Alcohol consumption was categorized as none, moderate, and alcohol misuse. Predictors included age, race/ethnicity, depressive or anxiety symptoms, illicit drug use (opioids, methamphetamines, cocaine/crack), marijuana use, hepatitis C virus (HCV) infection, HIV transmission risk factor, and HIV disease progression. We estimated sex-stratified alcohol consumption trajectories and their predictors.

RESULTS

We found 7 trajectories of alcohol consumption in men: stable nondrinking and increased drinking (71% and 29% of initial nondrinking); stable moderate, reduced drinking, and increased alcohol misuse (59%, 21%, and 21% of initial moderate alcohol use); and stable alcohol misuse and reduced alcohol misuse (75% and 25% of initial alcohol misuse). Categories were similar in women, except lack of an increase to alcohol misuse trajectory among women that begin with moderate use. Older men and women were more likely to have stable nondrinking, while younger men were more likely to increase to or remain in alcohol misuse. Minorities, people with depressive or anxiety symptoms, HCV-infected individuals, and people who injected drugs were more likely to reduce use. Illicit drug use was associated with a reduction in overall drinking, while marijuana use was associated with stable moderate drinking or misuse.

CONCLUSIONS

Longitudinal trajectories of increasing alcohol use and stable misuse highlight the need to integrate routine screening and alcohol misuse interventions into HIV primary care.

Prevalence of Alcohol Use, Sexual Risk Behavior, and HIV Among Russians in High-Risk Settings: a Systematic Review and Meta-Analysis

PURPOSE

The purpose of this study was to examine the (a) prevalence of and (b) association between alcohol, risky sex, and HIV among Russians at risk for primary or secondary HIV transmission.

METHOD

Electronic databases were searched to locate studies that sampled Russians, assessed alcohol use, and included either a behavioral measure of risk or a biological measure of HIV. Weighted mean (logit) effect sizes were calculated using random-effects assumptions. Moderator analyses were conducted using meta-regression.

RESULTS

Studies (19) sampled 12,916 Russians (M _age = 29; 36 % women). Participants were recruited from clinical (52 %; e.g., sexually transmitted infection (STI) clinic, drug treatment), other high-risk community settings (32 %; e.g., sexual/drug networks), or both (16 %). Findings indicate that a substantial proportion of the participants used alcohol (77 %; 55 % heavy drinking). One half of participants reported using condoms (52 %), but only 29 % used condoms consistently. Most participants reported drinking before sex (64 %). Of the studies testing for HIV, 10 % of participants tested positive. Meta-regression analyses indicated that hazardous/harmful alcohol use was associated with increased risky behaviors (i.e., multiple partners, inconsistent condom use).

CONCLUSION

These findings support the need for and potential benefit of addressing alcohol use in HIV prevention programming in Russia.

Determinants of hazardous drinking among black South African men who have sex with men

BACKGROUND

There is a known heavy burden of hazardous drinking and its associated health risks among black South African MSM; however, no study to date has identified risk factors for hazardous drinking among this nor any other African MSM population.

METHODS

A cross-sectional survey was conducted among 480 black South African MSM recruited using respondent-driven sampling. All analyses were adjusted using an RDS II estimator. Multivariable logistic regression was used to assess the relationship between demographic characteristics, psychosocial factors, behavioral attributes and hazardous drinking.

RESULTS

More than half of the men (62%, 95%CI=56%-68%) screened positive as hazardous drinkers. In multivariable analyses, living in a township (versus the city of Pretoria) (aOR=1.9, 95%CI=1.2-3.1, p<.01), more gender dysphoria (aOR=1.4, 95%CI=1.0-1.8, p=.03), having ever received money or other incentives in return for sex (aOR=2.4, 95%CI=1.3-4.3, p<.01), having been sexually abused as a child (aOR=2.6, 95%CI=1.1-6.4, p=.03), having anxiety (aOR=5.4, 95%CI=1.2-24.3, p=.03), and social network drinking behavior (aOR=5.4, 95%CI=1.2-24.3, p=.03) were positively associated with hazardous drinking. Being sexually attracted only to men (aOR=0.3, 95%CI=0.1-0.8, p=.01) was negatively associated with hazardous drinking.

DISCUSSION

Hazardous drinking is highly prevalent among black South African MSM. Multiple indicators of social vulnerability were identified as independent determinants of hazardous drinking. These findings are of heightened concern because these health problems often work synergistically to increase risk of HIV infection and should be taken into consideration by efforts aimed at reducing hazardous drinking among this critical population.

Research Priorities for the Intersection of Alcohol and HIV/AIDS in Low and Middle Income Countries: A Priority Setting Exercise

The harmful use of alcohol is a component cause for more than 200 diseases. The association between alcohol consumption, risk taking behavior and a range of infectious diseases such as HIV/AIDS is well established. The prevalence of HIV/AIDS as well as harmful alcohol use in low and middle income countries is high. Alcohol has been identified as a modifiable risk factor in the prevention and treatment of HIV/AIDS. The objective of this paper is to define research priorities for the interaction of alcohol and HIV/AIDS in low and middle income countries. The Child Health and Nutrition Research Initiative (CHNRI) priority setting methodology was applied in order to assess research priorities of the interaction of alcohol and HIV/AIDS. A group of 171 global and local experts in the field of alcohol and or HIV/AIDS related research were identified and invited to generate research questions. This resulted in 205 research questions which have been categorized and refined by senior researchers into 48 research questions to be evaluated using five criteria: answerability, effectiveness, feasibility, applicability and impact, as well as equity. A total of 59 experts participated independently in the voluntary scoring exercise (a 34% response rate). There was substantial consensus among experts on priorities for research on alcohol and HIV. These tended to break down into two categories, those focusing on better understanding the nexus between alcohol and HIV and those directed towards informing practical interventions to reduce the impact of alcohol use on HIV treatment outcomes, which replicates what Bryant (Subst Use Misuse 41:1465–1507, 2006) and Parry et al. (Addiction 108:1–2, 2012) found. Responses from experts were stratified by location in order to determine any differences between groups. On average experts in the LMIC gave higher scores than the HIC experts. Recent research has shown the causal link between alcohol consumption and the incidence of HIV/AIDS including a better understanding of the pathways through which alcohol use affects ARV adherence (and other medications to treat opportunistic infections) and CD4 counts. The results of this process clearly indicated that the important priorities for future research related to the development and assessment of interventions focusing on addressing alcohol and HIV/AIDS, addressing and exploring the impact of HIV risk and comorbid alcohol use, as well as exploring the risk and protective factors in the field of alcohol and HIV/AIDS. The findings from this priority setting exercise could guide international research agenda and make research funding more effective in addressing the research on intersection of alcohol and HIV/AIDS

At-Risk Alcohol Use is Associated with Antiretroviral Treatment Nonadherence Among Adults Living with HIV/AIDS

BACKGROUND

Alcohol use is a risk factor for nonadherence to antiretroviral therapy (ART) among people living with HIV/AIDS (PLWHA); however, differences in ART adherence across levels of alcohol use are unclear. This study examined whether "at-risk" alcohol use, defined by National Institute of Alcohol Abuse and Alcoholism guidelines, was associated with ART nonadherence among PLWHA.

METHODS

Participants were 535 HIV-infected adults enrolled in studies at the HIV Neurobehavioral Research Program. ART nonadherence was identified by either self-reported missed dose or plasma viral load detectability (≥50 copies/ml). Potential covariates for multivariable logistic regression included demographics, depression, and substance use disorders.

RESULTS

Using a stepwise model selection procedure, we found that at-risk alcohol use (OR = 0.64; p = 0.032) and low education (OR = 1.09 per 1 year increase in education; p = 0.009) significantly predict lower ART adherence.

CONCLUSIONS

A greater focus on the treatment of at-risk alcohol use may improve ART adherence among HIV-infected persons.

Prevalence and Factors Associated with Hazardous Alcohol Use Among Persons Living with HIV Across the US in the Current Era of Antiretroviral Treatment

Hazardous alcohol use is associated with detrimental health outcomes among persons living with HIV (PLWH). We examined the prevalence and factors associated with hazardous alcohol use in the current era using several hazardous drinking definitions and binge drinking defined as ≥5 drinks for men versus ≥4 for women. We included 8567 PLWH from 7 U.S. sites from 2013 to 2015. Current hazardous alcohol use was reported by 27% and 34% reported binge drinking. In adjusted analyses, current and past cocaine/crack (odd ratio [OR] 4.1:3.3-5.1, p < 0.001 and OR 1.3:1.1-1.5, p < 0.001 respectively), marijuana (OR 2.5:2.2-2.9, p < 0.001 and OR 1.4:1.2-1.6, p < 0.001), and cigarette use (OR 1.4:1.2-1.6, p < 0.001 and OR 1.3:1.2-1.5, p < 0.001) were associated with increased hazardous alcohol use. The prevalence of hazardous alcohol use remains high in the current era, particularly among younger men. Routine screening and targeted interventions for hazardous alcohol use, potentially bundled with interventions for other drugs, remain a key aspect of HIV care.

Substance Use and Sexual Risk Behavior Among Black South African Men Who Have Sex With Men: The Moderating Effects of Reasons for Drinking and Safer Sex Intentions

Research studies suggest an association between substance use and sexual risk behavior, but are not completely consistent. The moderating effects of other psychosocial factors might help explain these inconsistencies. The current study therefore assessed whether substance use is associated with sexual risk behavior, and whether this relationship is modified by expectancies about the effects of alcohol, reasons for consuming alcohol, or intentions to engage in safe sex. A cross-sectional survey was conducted among 480 black South African men who have sex with men recruited using respondent-driven sampling. In multivariable analyses, the effect of alcohol use on unprotected receptive anal intercourse (URAI) was modified by drinking to enhance social interaction (R² change = 0.03, p < 0.01). The effect of drug use on URAI was modified by safe sex intentions (R² change = 0.03, p < 0.001). Alcohol use was positively associated with URAI only among those who drink to enhance social interaction (β = 0.08, p < 0.05). Drug use was positively associated with URAI only among those with high safe sex intentions (β = 0.30, p < 0.001). Our findings suggest that efforts to minimize the impact of substance use on HIV risk behavior should target men who drink to enhance social interaction and men who intend to engage in safer sex. Efforts made to increase safer sex intentions as a way to reduce HIV risk behavior should additionally consider the effects of substance use.

Task-shifting alcohol interventions for HIV+ persons in Kenya: a cost-benefit analysis

Background

Among HIV+ patients, alcohol use is a highly prevalent risk factor for both HIV transmission and poor adherence to HIV treatment. The large-scale implementation of effective interventions for treating alcohol problems remains a challenge in low-income countries with generalized HIV epidemics. It is essential to consider an intervention’s cost-effectiveness in dollars-per-health-outcome, and the long-term economic impact —or “return on investment” in monetary terms.

Methods

We conducted a cost-benefit analysis, measuring economic return on investment, of a task-shifted cognitive-behavioral therapy (CBT) intervention delivered by paraprofessionals to reduce alcohol use in a modeled cohort of 13,440 outpatients in Kenya. In our base-case, we estimated the costs and economic benefits from a societal perspective across a six-year time horizon, with a 3% annual discount rate. Costs included all costs associated with training and administering task-shifted CBT therapy. Benefits included the economic impact of lowered HIV incidence as well as the improvements in household and labor-force productivity. We conducted univariate and multivariate probabilistic sensitivity analyses to test the robustness of our results.

Results

Under the base case, total costs for CBT rollout was $554,000, the value of benefits were $628,000, and the benefit-to-cost ratio was 1.13. Sensitivity analyses showed that under most assumptions, the benefit-to-cost ratio remained above unity indicating that the intervention was cost-saving (i.e., had positive return on investment). The duration of the treatment effect most effected the results in sensitivity analyses.

Conclusions

CBT can be effectively and economically task-shifted to paraprofessionals in Kenya. The intervention can generate not only reductions in morbidity and mortality, but also economic savings for the health system in the medium and long term. The findings have implications for other countries with generalized HIV epidemics, high prevalence of alcohol consumption, and shortages of mental health professionals.

Trial registration

This paper uses data derived from “Cognitive Behavioral Treatment to Reduce Alcohol Use Among HIV-Infected Kenyans (KHBS)” with ClinicalTrials.gov registration NCT00792519 on 11/17/2008; and preliminary data from “A Stage 2 Cognitive-behavioral Trial: Reduce Alcohol First in Kenya Intervention” (NCT01503255, registered on 12/16/2011).

Developmental Patterns of Adolescent Marijuana and Alcohol Use and Their Joint Association with Sexual Risk Behavior and Outcomes in Young Adulthood

Urban populations disproportionately experience poor sexual outcomes, including high rates of teenage pregnancy and sexually transmitted infections. However, the contribution of substance use across adolescence to poor sexual outcomes in young adulthood has not been investigated in depth, despite offering opportunities for more targeted prevention. This study aimed to estimate joint trajectories of adolescent alcohol and marijuana use to determine if they relate differently to four sexual outcomes: multiple sexual partners, sex without a condom, teenage pregnancy, and contraction of a sexually transmitted infection in young adulthood (by age 25). Data came from a longitudinal study of urban youth followed from age 6 to age 25, with annual assessments during adolescence and young adulthood (n = 608). The sample showed high levels of sexual risk, with young adults on average having sex without a condom once in the past month, 28.5% having multiple sexual partners in the past month, one quarter having contracted a sexually transmitted infection, and over 60% of the women being pregnant as a teenager and 36% of the men having gotten a partner pregnant. Applying longitudinal latent profile analysis to estimate joint trajectories of alcohol and marijuana use from grades 8-12, we identified four classes representing high dual use, moderate alcohol use, moderate alcohol use with increasing marijuana use, and non-use. Class membership differently predicted all four outcomes investigated with high dual users having the highest level of teenage pregnancy and the increasing marijuana trajectory having the highest risk of engaging with multiple sexual partners in the past month. Results suggest implications for both sexual risk and substance use prevention for urban youth.

Using Video Conferencing to Deliver a Brief Motivational Intervention for Alcohol and Sex Risk to Emergency Department Patients: A Proof-of-Concept Pilot Study

Brief motivational intervention (MI) is an efficacious approach to reduce heavy drinking and associated sexual risk behavior among Emergency Department (ED) patients, but the intensity of demands placed on ED staff makes the implementation of in-person MIs logistically challenging. This proof-of-concept pilot study examined the acceptability and logistic feasibility of using video-conferencing technology to deliver an MI targeting heavy drinking and risky sexual behavior to patients in an ED setting. Rigorous screening procedures were employed to ensure that the pilot sample represents the target portion of ED patients who would benefit from this multi-target MI. Mixed qualitative and quantitative data from a sample of seven ED patients (57% Female; Mage = 35 years) who received MI by video conference consistently demonstrated high levels of satisfaction, engagement, and acceptability. The observed completion rate supports logistic feasibility, and patient feedback identified methods to improve the experience by using high-definition hardware, ensuring stronger network connectivity, and effectively communicating information regarding protection of privacy. Post-intervention patient ratings and independent ratings of the audio-recorded sessions (using the Motivational Interviewing Skills Coding system) were very high, suggesting that intervention fidelity and MI adherence was not compromised by delivery modality. Collectively, these data suggest video conferencing is a viable technology that can be employed to implement brief evidence-based MIs in ED settings.

HIV-Alcohol Risk Reduction Interventions in Sub-Saharan Africa: A Systematic Review of the Literature and Recommendations for a Way Forward

Sub-Saharan Africa bears 69 % of the global burden of HIV, and strong evidence indicates an association between alcohol consumption, HIV risk behavior, and HIV incidence. However, characteristics of efficacious HIV-alcohol risk reduction interventions are not well known. The purpose of this systematic review is to summarize the characteristics and synthesize the findings of HIV-alcohol risk reduction interventions implemented in the region and reported in peer-reviewed journals. Of 644 citations screened, 19 met the inclusion criteria for this review. A discussion of methodological challenges, research gaps, and recommendations for future interventions is included. Relatively few interventions were found, and evidence is mixed about the efficacy of HIV-alcohol risk reduction interventions. There is a need to further integrate HIV-alcohol risk reduction components into HIV prevention programming and to document results from such integration. Additionally, research on larger scale, multi-level interventions is needed to identify effective HIV-alcohol risk reduction strategies.

Prediction of HIV Sexual Risk Behaviors Among Disadvantaged African American Adults Using a Syndemic Conceptual Framework

The focus of this paper is on HIV sexual risk taking among a community-based sample of disadvantaged African American adults. The objective is to examine multiple factors associated with sexual HIV risk behaviors within a syndemic conceptual framework. Face-to-face, computer-assisted, structured interviews were conducted with 1535 individuals in Atlanta, Georgia. Bivariate analyses indicated a high level of relationships among the HIV sexual risks and other factors. Results from multivariate models indicated that gender, sexual orientation, relationship status, self-esteem, condom use self-efficacy, sex while the respondent was high, and sex while the partner was high were significant predictors of condomless sex. Additionally, a multivariate additive model of risk behaviors indicated that the number of health risks significantly increased the risk of condomless sex. This intersection of HIV sexual risk behaviors and their associations with various other behavioral, socio-demographic, and psychological functioning factors help explain HIV risk-taking among this sample of African American adults and highlights the need for research and practice that accounts for multiple health behaviors and problems.

Alcohol Use and HIV Testing in a National Sample of Women

The HIV/AIDS epidemic continues to disproportionately affect racial and ethnic minority groups and women in the United States. Prevention research suggests that reduced alcohol use and increased HIV testing are associated with lower incidence of HIV transmission among high-risk populations. Multivariable logistic regression analyses of the 2009 National Health Interview Survey data were performed for a national sample of 15,470 adult women to examine the relationship between alcohol use and likelihood of HIV testing. There is a significant association between level of alcohol use and HIV testing. Women who identified as heavy drinkers and moderate drinkers were significantly less likely to report ever testing for HIV. Findings add to the limited literature on the association between alcohol use and HIV testing behaviors among women. Given the incidence of HIV among women, this study highlights the importance of HIV testing, especially for alcohol-using women.

A review of 5-HT transporter linked promoter region (5-HTTLPR) polymorphism and associations with alcohol use problems and sexual risk behaviors

Alcohol use and sexual risk behaviors are multidimensional phenomena involving many genetic and environmental factors. 5-HT transporter linked promoter region (5-HTTLPR) polymorphism constitutes an important factor affecting alcohol use problems and risky sexual behaviors. This paper narratively reviews studies on 5-HTTLPR polymorphism and its associations with alcohol use problems and sexual risk behaviors. We searched the electronic databases, PubMed, Ovid, and Google Scholar for articles using MeSH terms. Relevant articles were reviewed and eligible articles were selected for the study. Many studies have reported a significant but moderate association between 5-HTTLPR polymorphism and alcohol use problems. These studies have implicated the presence of at least one S allele to be associated with significant increases in alcohol use problems. Similarly, some studies associate the S allele with increased sexual risk behaviors. Effective alcohol cessation initiatives and STI/HIV prevention programs should be modified to account for 5-HTTLPR polymorphism before planning interventions; genetic effects could moderate the intervention effect.

Alcohol Use, Partner Violence, and Depression: A Cluster Randomized Controlled Trial Among Urban South African Mothers Over 3 Years

INTRODUCTION

Pregnant South African women with histories of drinking alcohol, abuse by violent partners, depression, and living with HIV are likely to have their post-birth trajectories over 36 months significantly influenced by these risks.

DESIGN

All pregnant women in 24 Cape Town neighborhoods were recruited into a cluster RCT by neighborhood to either: (1) a standard care condition (n=12 neighborhoods, n=594 mothers); or (2) a home-visiting intervention condition (n=12 neighborhoods, n=644 mothers).

SETTING/PARTICIPANTS

Pregnant women residing in urban, low-income neighborhoods in Cape Town, South Africa.

INTERVENTION

Home visiting included prenatal and postnatal visits by community health workers (Mentor Mothers) focusing on general maternal and child health, HIV/tuberculosis, alcohol use, and nutrition.

MAIN OUTCOME MEASURES

Mothers were assessed in pregnancy and at 18 and 36 months post birth: 80.6% of mothers completed all assessments between 2009 and 2014 and were included in these analyses performed in 2014. Longitudinal structural equation modeling examined alcohol use, partner violence, and depression at the baseline and 18-month interviews as predictors of maternal outcomes at 36 months post birth.

RESULTS

Relative to standard care, intervention mothers were significantly less likely to report depressive symptoms and more positive quality of life at 36 months. Alcohol use was significantly related to use over time, but was also related to depression and HIV status at each assessment and partner violence at 36 months.

CONCLUSIONS

Alcohol, partner violence, and depression are significantly related over time. A home-visiting intervention improved the emotional health of low-income mothers even when depression was not initially targeted.

Bars and nightclubs associated with higher HIV prevalence

BACKGROUND

Alcohol outlet density is positively associated with alcohol consumption and a number of related risk behaviors. However, very little is known about the effects of different types of alcohol outlets on HIV prevalence. The current cross-sectional study examines associations between the number of each type of alcohol outlet and HIV prevalence within 350 cities located in 26 U.S. metropolitan statistical areas.

METHODS

State and local health department and U.S. Census Bureau surveillance data were analyzed from 1056 ZIP codes, where an estimated 39 million people reside. Multilevel negative binomial regression models were used to examine the association between the number of each type of alcohol outlet in ZIP codes and HIV prevalence.

RESULTS

Number of on-premise alcohol outlets within a ZIP code was associated with greater HIV prevalence. In this sample, the presence of one additional on-premise outlet in a ZIP code was associated with a 1.5% increase in the HIV prevalence rate in that location.

CONCLUSION

This study extends previous research by examining the relationship between alcohol outlets and HIV prevalence in a large sample of U.S. ZIP codes. Research is needed to more closely examine the mechanisms by which on-premise alcohol outlets may affect HIV transmission. Effective policies to reduce HIV transmission may include limiting the density of on-premise alcohol establishments.

Prevalence of Heavy Drinking and Risky Sexual Behaviors in Adult Emergency Department Patients

BACKGROUND

The study aim was to assess the prevalence and co-occurrence of alcohol and sexual risk behaviors among emergency department (ED) patients in community hospitals.

METHODS

Systematic screening of ED patients (N = 6,486; 56.5% female) was conducted in 2 community hospitals in the northeast during times with high patient volume, generally between the hours of 10 AM to 8 PM, Monday through Saturday. Screening occurred from May 2011 through November 2013. Assessment included validated measures of alcohol use and sexual risk behavior.

RESULTS

Overall results identified high rates of alcohol use, sexual risk behaviors, and their co-occurrence in this sample of ED patients. Specifically, ED patients in between the ages of 18 and 35 were consistently highest in hazardous alcohol use (positive on the Alcohol Use Disorders Identification Test or endorsing heavy episodic drinking [HED]), sexual risk behaviors, and the co-occurrence of alcohol and sex-risk behaviors.

CONCLUSIONS

Findings show a high co-occurrence of hazardous drinking and unprotected sex among ED patients and highlight the role of HED as a factor associated with sexual risk behavior. Efforts to integrate universal screening for the co-occurrence of alcohol and sexual risk behavior in ED settings are warranted; brief interventions delivered to ED patients addressing the co-occurrence of alcohol and sexual risk behaviors have the potential to decrease the risk of sexually transmitted infections and HIV among a large number of patients.

HIV and Alcohol Research Priorities of City, State, and Federal Policymakers: Results of a Delphi Study

We identified the research areas related to HIV and alcohol consumption that were of highest priority to city, state, and federal policymakers. From June to July 2014, we conducted a 3-round Delphi study to elicit from experts a list of alcohol- and HIV-related clinical trial research questions that were important to fund and rank order the list to identify questions of highest priority. Translating evidence into practice must be improved because some questions that have been extensively studied with results published in peer-reviewed journals were identified by the panel as areas needing additional research.

Alcohol, Intercourse, and Condom Use Among Women Recently Involved in the Criminal Justice System: Findings from Integrated Global-Frequency and Event-Level Methods

The scientific literature on alcohol and sexual risk behavior is marked by multiple theoretical perspectives and inconsistent findings from global-frequency and event-level studies. Multilevel measures of alcohol use and multiple sexual risk outcomes can be used to evaluate these perspectives and resolve these inconsistencies. Among women recently involved in the criminal justice system in Portland, Oregon, daily alcohol use and sexual behavior were measured during four 30-day intervals over one year. In mixed effects models, person-level, month-level, and day-level alcohol use were significantly associated with the occurrence of intercourse but not with the use of condoms during intercourse. Findings are also reported for main, casual, and exchange partners. The relationships between alcohol use and sexual risk behavior are complex: No single theoretical perspective is sufficient to account for the study findings, and increased risk may be mediated through changes in intercourse rather than through changes in condom use.

Antiretroviral treatment adherence as a mediating factor between psychosocial variables and HIV viral load

Psychosocial factors may directly impact HIV health measures such as viral load (VL) whether or not patients are taking antiretroviral treatment (ART) consistently. Structural equation modeling plus Baron and Kenny's (1986) four-step approach were used to test a mediated model predicting VL among 246 HIV-infected adults who were on ART. Exogenous variables were social support, barriers to adherence, and stress. Moderators were alcohol use, marijuana use, and neurocognitive impairment. A small positive association between marijuana use and ART adherence approached significance. Only barriers to adherence predicted a decrease in adherence rates and an increase in VL. No other factors were significantly associated with either VL or adherence, and no interaction effects between exogenous variables and moderators were identified. The association between barriers to adherence and VL was partially mediated by ART adherence. Findings provide modest support for a direct link between psychosocial variables and a virologic response to ART.

Psychiatric Diagnoses among an HIV-Infected Outpatient Clinic Population

As individuals with HIV infection are living longer, the management of psychiatric disorders has increasingly been incorporated into comprehensive care. Individuals were recruited from an outpatient HIV clinic to assess the prevalence and related associations of current psychiatric disorders and biomarkers. Of the 201 participants who completed the interviews, the median age was 43.5 years, and the majority was male and African American. Most were receiving HIV therapy and 78% of those had achieved virologic suppression. Prevalent psychiatric diagnoses included major depressive disorder, generalized anxiety, and agoraphobia. Alcohol and cocaine/crack abuse and dependence were common substance use disorders. Current receipt of HIV therapy was less common among those diagnosed with generalized anxiety disorder. Agoraphobia was the only disorder associated with unsuppressed viral load. Psychiatric and substance use disorders are highly prevalent among an urban HIV clinic population, although we identified few associations between psychiatric diagnoses and HIV diseases status.

A history of alcohol dependence augments HIV-associated neurocognitive deficits in persons aged 60 and older

Excessive alcohol use is common among people living with HIV. Given the growing prevalence of older HIV+ adults and observations indicating higher risk for neurocognitive impairment in older adults with either HIV infection or alcoholism, an increased understanding of their combined impact in the context of this increasingly aged population is crucial. We conducted comprehensive neurocognitive assessment in 112 older HIV+ individuals aged 50 to 69 years. Regression analyses were conducted to examine the interaction between age and the presence of lifetime alcohol dependence on neurocognitive measures, controlling for years of education, hepatitis C serostatus, and lifetime non-alcohol substance use disorder. Significant interactions of age and alcohol dependence history were found for global neurocognitive function, which was driven by the domains of executive function, processing speed, and semantic memory. Follow-up analyses indicated adverse effects of alcohol use history on neurocognitive measures that were evident only in HIV+ individuals 60 years and older. While mounting evidence in younger cohorts indicates adverse synergistic HIV/alcohol effects on neurocognitive function, our novel preliminary findings in this elderly HIV+ cohort demonstrated the importance of even a relatively distant alcohol use history on the expression of HIV-associated neurocognitive disorders that may not become apparent until much later in life.

Exploring Substance Use and HIV Treatment Factors Associated with Neurocognitive Impairment among People Living with HIV/AIDS

Neurocognitive (NC) impairment remains prevalent among people living with HIV (PLWH) and may be exacerbated by alcohol and drug use. This cross-sectional study assesses the degree to which alcohol and other drug use, time from HIV diagnosis to treatment, and years living with HIV affect three areas of NC functioning among HIV-seropositive adults. NC functioning in 370 PLWH living in Miami, FL was assessed using the Auditory Verbal Learning Test, the Short Category Test, Booklet Format, and the Color Trails Test 2 (CTT2). Participants reported the number of days using alcohol, marijuana, and cocaine over the previous 3 months, the number of known years living with HIV and length of time from HIV diagnosis to seeking care. Bivariate linear regression and multivariate linear regression were used to test associations between independent and dependent variables. Mean scores on NC measures were significantly lower than published norms; 39% of participants scored ≥1 standard deviation below normative sample means on >2 NC tests. No significant associations were found between alcohol or cocaine use and any NC measure. Years living with HIV was associated with CTT2 in the bivariate analysis (β = 1.031; p = 0.007). In multivariate analysis, each day of marijuana use and years living with HIV were associated with a 0.32 (p = 0.05) point and 1.18 (p = 0.03) points poorer performance score on the CTT2, respectively. Results suggest that both marijuana use and duration of HIV infection may affect cognitive functioning among PLWH in ways that may impair their ability to follow important treatment guidance.

The impact of alcohol on HIV prevention and treatment for South Africans in primary healthcare

BACKGROUND

Antiretroviral treatment (ART) has substantially reduced morbidity and mortality for HIV patients. In South Africa, with the largest ART programme globally, attention is needed not only on the further expansion of ART coverage, but also on factors which undermine its effectiveness, such as alcohol use.

OBJECTIVE

Given the decentralised approach of nurse-initiated and -sustained ART in the South African primary health sector, it is important to document key aspects of alcohol use to be conveyed to HIV-positive individuals and those at risk for HIV.

METHOD

This study comprised a narrative review of relevant literature.

RESULTS

Alcohol acts through both behavioural and physiological pathways to impact on the acquisition, further transmission and then progression of HIV disease. Besides links to risky sex, alcohol undermines the immune system, raising susceptibility to contracting and then countering HIV and other infections. There are important drug interactions between alcohol and ART, or therapies for opportunistic infections and other co-morbidities. Moreover, alcohol undermines adherence to the medication which is essential for effective ART.

CONCLUSION

Primary healthcare clinic attendees need evidence-based information on the detrimental effects of alcohol consumption on HIV infection, which ensue throughout the clinical course of HIV. This spans the role of alcohol consumption as a risk factor for HIV infection, HIV replication in infected individuals, a person's response to HIV infection and HIV treatment. Primary healthcare workers, especially nurses and HIV counsellors, require training in order to screen for and provide appropriate interventions for HIV-positive patients, those on treatment and treatment-naïve patients, who will benefit from reduced alcohol consumption or the cessation thereof.

Alcohol and drug use outcomes among vulnerable women living with HIV: results from the Western Cape Women's Health CoOp

Alcohol and other drug use can negatively affect adherence to and retention in antiretroviral therapy (ART) among people living with HIV/AIDS. Yet, there are few brief interventions that reduce these behaviors among this population. This article presents the findings from a randomized field experiment that assessed the effects of a woman-focused intervention (the Women's Health CoOp [WHC]) on reducing alcohol and other drug use among vulnerable women in Cape Town, South Africa. The analyses were limited to 84 women living with HIV who reported drinking alcohol at baseline. Because of the small sample size, analyses were performed using an exact logistic regression procedure. At 12-month follow-up, women in the WHC arm were more likely to be abstinent from alcohol (odds ratio [OR] = 3.61; 95% confidence intervals [CI] = 1.23, 11.70; p = 0.016) and somewhat more likely to test negative for other drugs (OR = 3.07; 95% CI = 0.83, 12.31; p = 0.105), compared with women in the comparison arms. This study provides preliminary evidence of the efficacy of a brief, woman-focused intervention in reducing alcohol and other drug use among vulnerable women living with HIV and it has implications for HIV treatment.

Alcohol use and sexual risk behaviors among individuals infected with HIV: a systematic review and meta-analysis 2012 to early 2013

The purpose of this meta-analytic study is to summarize the current science concerning the (a) prevalence of alcohol use, (b) prevalence of sexual risk behaviors, and (c) association between alcohol use and sexual risk behaviors among people livingwithHIV/AIDS (PLWHA). Studies were included if they sampled PLWHA, evaluated both alcohol use and sexual risk behavior (e.g., condom use, multiple partners), and were published between January 1, 2012, and April 1, 2013. Comprehensive electronic database searches located 728 published studies with relevant keywords; 17 studies (k =19 reports) were included. Findings indicate that a substantial proportion of PLWHA use alcohol and engage in sexual risk behaviors. Among PLWHA, alcohol use was significantly associated with unprotected sex (d +=0.23, 95 % CI=0.05, 0.40; k =5). Secondary prevention programs for PLWHA that address alcohol use in the context of sexual behavior are needed.

Impact of medical comorbidity and risk of death in 680 patients with alcohol use disorders

BACKGROUND

The association between alcohol use disorders and increased risk of mortality is well known; however, there have been few systematic evaluations of alcohol-related organ damage and its impact on survival in younger alcoholics. Therefore, we assessed medical comorbidity with a clinical index to identify subgroups of alcoholic patients at high risk of premature death.

METHODS

Hospital-based cohort of alcohol-dependent patients admitted for detoxification between 1999 and 2008 in Barcelona, Spain. At admission, sociodemographic characteristics and a history of alcohol dependence and abuse of illegal drugs were obtained through clinical interviews and questionnaires. Medical comorbidity was assessed with the Cumulative Illness Rating Scale (Substance Abuse) (CIRS-SA). Dates and causes of death were obtained from clinical records and death registers. Survival was analyzed using Kaplan-Meier methods, and Cox regression models were used to analyze the risk factors for premature death.

RESULTS

Median age of the patients (686 total, 79.7% men) was 43.5 years (interquartile range [IQR], 37.8 to 50.4), average alcohol consumption was 200 g/d (IQR, 120 to 280 g/d), and duration of alcohol use disorder was 18 years (IQR, 11 to 24). Medical comorbidity by CIRS-SA at admission showed that the organs/systems most affected were liver (99%), respiratory (86%), and cardiovascular (58%). After median follow-up of 3.1 years (IQR, 1.5 to 5.1), 78 (11.4%) patients died with a mortality rate of 3.28 × 100 person-years; according to Kaplan-Meier estimates, 50% (95% confidence interval [95% CI], 24 to 69%) of patients with severe medical comorbidity died in the first decade after treatment. In multivariate analysis, severe medical comorbidity (hazard ratio [HR], 5.5; 95% CI, 3.02 to 10.07) and being treated with methadone at admission (HR, 2.60; 95% CI, 1.50 to 4.51) were independent risk factors for premature death.

CONCLUSIONS

Systematic assessment of alcohol-related organ damage is relevant for the identification and treatment of those at increased risk of death.

Taxonomy of Caribbean tourism alcohol venues: implications for HIV transmission

BACKGROUND

Tourism areas represent ecologies of heightened HIV vulnerability characterized by a disproportionate concentration of alcohol venues. Limited research has explored how alcohol venues facilitate HIV transmission.

METHODS

We spatially mapped locations of alcohol venues in a Dominican tourism town and conducted a venue-based survey of key informants (n=135) focused on three facets of alcohol venues: structural features, type of patrons, and HIV risk behaviors. Using latent class analysis, we identified evidence-based typologies of alcohol venues for each of the three facets. Focused contrasts identified the co-occurrence of classes of structural features, classes of types of patrons, and classes of HIV risk behavior, thus elaborating the nature of high risk venues.

RESULTS

We identified three categories of venue structural features, three for venue patrons, and five for HIV risk behaviors. Analysis revealed that alcohol venues with the greatest structural risks (e.g. sex work on-site with lack of HIV prevention services) were most likely frequented by the venue patron category characterized by high population-mixing between locals and foreign tourists, who were in turn most likely to engage in the riskiest behaviors.

CONCLUSION

Our results highlight the stratification of venue patrons into groups who engage in behaviors of varying risk in structural settings that vary in risk. The convergence of high-risk patron groups in alcohol venues with the greatest structural risk suggests these locations have potential for HIV transmission. Policymakers and prevention scientists can use these methods and data to target HIV prevention resources to identified priority areas.

Alcohol and condom use among HIV-positive and HIV-negative female sex workers in Nagaland, India

This study examines the relationship between alcohol use, HIV status, and condom use among female sex workers in Nagaland, India. We analyzed data from a cross-sectional survey undertaken in 2009, using descriptive and multivariate statistics. Out of 417 female sex workers, one-fifth used alcohol daily and one-tenth were HIV-positive. HIV-positive female sex workers were more likely than HIV-negative female sex workers to consume alcohol daily (30.2% vs. 18.0%). HIV-positive daily alcohol users reported lower condom use at last sex with regular clients compared to HIV-positive non-daily alcohol users (46.2% vs. 79.3%), a relationship not evident among HIV-negative female sex workers. There is a need to promote awareness of synergies between alcohol use and HIV, and to screen for problematic alcohol use among female sex workers in order to reduce the spread of HIV.

Decreased injecting is associated with increased alcohol consumption among injecting drug users in northern Vietnam

BACKGROUND

Reducing injecting frequency may reduce the risk of HIV infection and improve health outcomes among injection drug users (IDUs). However, the reduction of one risk behavior may be associated with an increase in other risk behaviors, including the use of other risk-associated substances. Our objective was to determine if an association exists between a reduction in injecting and level of alcohol use among IDU.

METHODS

We conducted a longitudinal analysis of data collected for a randomized controlled trial examining the efficacy of a peer education intervention in reducing HIV risk among IDU and their network members in Thai Nguyen, Vietnam. Our analysis included active male injectors (n = 629) who were study participants and attended both baseline and 3-month visits. Frequency of alcohol consumption was assessed as the number of alcoholic drinks in the past 30 days. Change in risk and outcome behaviors was calculated as the difference in frequencies of behaviors between baseline and 3-month follow-up visits. The outcome of interest was concurrent decreased drug injection and increased alcohol consumption.

RESULTS

The mean difference between baseline and 3-month follow-up of alcohol consumption and injection frequency in the past 30 days was 19.03 drinks (93.68 SD) and 20.22 injections (35.66 SD), respectively. Participants who reported reduced injection frequency were almost three times as likely to report increased alcohol consumption (OR 2.8; 95% CI, 2.0, 4.0). The proportion that both decreased injecting and increased alcohol by any amount in the past 30 days was 35.6%. In multivariate analysis higher education was significantly associated with an increase in alcohol and decrease in injecting of any amount.

CONCLUSION

Male IDU may be at risk for increasing alcohol consumption when they reduce injection frequency. Interventions with male IDU that encourage reduction of injection may need to review specific strategies to limit alcohol consumption.

Falling through the cracks: a qualitative study of HIV risks among women who use drugs and alcohol in Northeast India

Background

HIV risks for women who inject drugs and those who engage in sex work are well documented. Women who are dependent on non-injecting drugs and alcohol are also likely to have increased vulnerability to HIV infection, but until they actually inject drugs or engage in sex work, are unlikely to come to the attention of HIV prevention programs.

Methods

We undertook a qualitative study involving nine focus group discussions (FGDs) and 27 key informant interviews to investigate the context of female drug and alcohol use in two high HIV prevalence states of India (Manipur and Nagaland) and to describe their HIV risks. The FGD and interview transcripts were thematically analyzed

Results

The women were relatively young (mean age 31 years in Manipur and 28 years in Nagaland), but 64% in Manipur and 35% in Nagaland were widowed or divorced. Both heroin and alcohol were commonly used by the women from Manipur, while alcohol was primarily used by the women from Nagaland, especially in the context of ‘booze joints’ (illicit bars). Reasons for drug and alcohol use included: to avoid symptoms of withdrawal, to suppress emotional pain, to overcome the shame of sex work, pleasure, and widowhood. HIV vulnerability was clearly described, not only in relation to injecting drug use and sex work, but also alcohol consumption.

Conclusions

The contribution of alcohol use to the HIV vulnerability of women is not currently considered when HIV prevention programs are being designed and implemented leaving a group of high-risk women uncovered by much needed services such as treatment for a range of health problems including alcohol dependence.

Alcohol consumption in relation to work environment and key sociodemographic characteristics among female sex workers in China

The study explores the variation in pattern of alcohol use and related risk behaviors by types of sex work environments and sociodemographic characteristics among female sex workers (FSWs) in China. Data were collected from 1,022 FSWs in Guangxi, China, through a self-administered questionnaire. Chi-square and analysis of variance (ANOVA) were used to assess the variations. Results showed that younger FSWs were more susceptible than older FSWs to nearly all the risk drinking behaviors. FSWs of non-Han ethnicity as compared with those of Han ethnicity were more at risk of drinking large amounts of alcohol and having sex under the influence of alcohol. FSWs in entertainment establishments were most likely to have all kinds of risk drinking behaviors. Street-based FSWs were least likely to drink alcohol but more or equally likely to engage in alcohol-related sexual risk behaviors. The study highlights a need to develop tailored alcohol risk reduction intervention that takes into consideration these differences.

Substance use and other risk factors for unprotected sex: results from an event-based study of homeless youth

This study used an event-based approach to understand condom use in a probability sample of 309 homeless youth recruited from service and street sites in Los Angeles County. Condom use was significantly less likely when hard drug use preceded sex, the relationship was serious, the partners talked about "pulling out", or sex occurred in a non-private place (and marginally less likely when heavier drinking preceded sex, or the partnership was monogamous or abusive). Condom use was significantly more likely when the youth held positive condom attitudes or were concerned about pregnancy, the partners talked about condom use, and the partners met up by chance. This study extends previous work by simultaneously examining a broad range of individual, relationship, and contexual factors that may play a role in condom use. Results identify a number of actionable targets for programs aimed at reducing HIV/STI transmission and pregnancy risk among homeless youth.

Perceptions of HIV risk among monogamous wives of alcoholic men in South India: a qualitative study

OBJECTIVE

To understand women's perceptions of their own HIV risk and to determine the feasibility of conducting an HIV prevention study.

METHODS

Two focus groups were conducted in November 2004 with wives of heavy drinkers admitted to the Deaddiction Unit at the National Institute of Mental Health and Neurosciences (NIMHANS) in Bangalore, India. Data were analyzed using content analysis.

RESULTS

Results focused on (1) awareness of the women regarding HIV/AIDS and condom use, (2) perception of personal risk for HIV/AIDS and the risk of their spouses, and (3) the feasibility of a future community-based HIV prevention study. Focus group findings indicated that although the majority of the women were aware of HIV/AIDS, there were important misconceptions about the mode of transmission. Women acknowledged the potential risk for HIV associated with their spouse's drinking, as well as their extramarital sexual activities, but expressed an inability to negotiate safer sex behaviors, such as condom use, within the context of marriage. This was often expressed as fear of being physically abused for attempting such negotiations. All women agreed that the HIV prevention study we proposed, originally developed in the West, would be acceptable if tailored to specific local needs. The women provided valuable suggestions for the effective implementation of the study.

CONCLUSIONS

The findings of this study indicate a critical need to develop culturally relevant HIV prevention programs directly targeted to wives that equip them with effective skills to negotiate safer sex behaviors with their spouses.

Alcohol and marijuana use outcomes in the Healthy Choices motivational interviewing intervention for HIV-positive youth

Healthy Choices is a motivational interviewing intervention targeting multiple risk behaviors among HIV-positive youth. This study investigated the effects of this intervention program specifically on alcohol and marijuana use. Youth living with HIV (n = 143, mean age = 20.7, 51.5% male) were recruited from four sites in the United States, and randomly assigned to intervention or control conditions. The four-session intervention focused on two of three possible problem behaviors based on entry screening; this study focused on 143 HIV-positive youth who received the intervention for substance use. At 15-month follow-up past-week alcohol use was significantly lower for intervention youth than control youth (39.7% versus 53.6%, χ2 = 2.81, 0.05 < p < 0.01); developmental trajectory analysis demonstrated significant reductions in alcohol use, but more importantly the intervention was effective over time in significantly reducing the adolescent's probability of being classified into the high-risk trajectory group. The intervention was less effective in reducing marijuana use.