The influence of different types of alcoholic beverages on disrupting highly active antiretroviral treatment (HAART) outcome

Moderating effects of social support on the relationship between substance use disorders and HIV viral load and medication adherence among Black women living with HIV in the United States

Substance use may predict lower rates of antiretroviral therapy (ART) adherence and viral suppression among Black Women Living with HIV (BWLWH). We assessed how perceived social support (PSS) moderates the relationship between substance use disorder (SUD) and viral load (VL) and ART adherence. 119 BWLWH provided information on PSS, SUD, alcohol use disorder (AUD) and adherence (via Wisepill). Higher PSS from friends (β = -.263, p = .008) and significant others (β = -.219, p = .025) predicted lower VL. SUD predicted low Wisepill adherence (a) in the past week (β = -.273, p = .035) and past two weeks (β = -.273, p = .033) only for women low in PSS from friends, and (b) in the past two weeks only for women low in total PSS (β = -.294, p = .024). Ironically, for women high in total PSS, SUD predicted higher adherence in the past four weeks (β = .360, p = .006). Adherence and VL may be bolstered by understanding the role of various forms of PSS and SUDs.

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.

Is Alcohol Use Associated With Increased Risk of Developing Adverse Health Outcomes Among Adults Living With Human Immunodeficiency Virus: A Systematic Review

BACKGROUND

Alcohol use is associated with many HIV-related behaviors that are associated with increased risk of reinfection, transmission, and poorer health outcomes in people living with HIV (PLHIV). The population of middle-aged and older PLHIV is growing because of increased life longevity and aging trend.

METHODS

A systematic review across three databases was conducted to evaluate existing studies that examined the association between alcohol use and medication adherence, high-risk sex behaviors, HIV progression, depression, resource utilization, and survival among studies of PLHIV with an average age of 40 years and above.

RESULTS

Among the 47 included studies, most found a positive association between alcohol use and depression, risky sex behaviors, medication nonadherence, and healthcare resource utilization among PLHIV. The association between alcohol use and response to treatment was variable. The association between alcohol use and survival warrants further study because of lack of existing studies.

CONCLUSIONS

The results of this review support that alcohol use negatively impacts middle-aged and older PLHIV in many aspects; however, there is lack of studies exclusively targeting older PLHIV, and more relevant studies in the future are needed.

Alcohol use disorder and associated factors among human immunodeficiency virus infected patients attending antiretroviral therapy clinic at Bishoftu General Hospital, Oromiya region, Ethiopia

Background

Alcohol consumption among patients with HIV/AIDS increases the burden of the disease. HIV/AIDS is an epidemic among Sub-Saharan African countries. Excessive use of alcohol causes a large degree of health problems, social and economic burden in societies. However, the prevalence and associated factors of alcohol use disorder among this group of people has not been studied very well. Therefore, this study sought to assess the magnitude and associated factors of alcohol use disorder among HIV patients attending the antiretroviral (ART) clinic.

Methods

A hospital based cross sectional study design was conducted at Bishoftu General Hospital from May to June 2015. Systematic random sampling technique was used to select the study participants. Data was collected by face to face interview and chart review. Alcohol Use Disorder Identification Test (AUDIT) was used to assess alcohol use disorder. Bivariate and multivariate logistic regression analysis was carried out to identify associated factors and P-value < 0.05 was taken as statistically significant.

Results

A total of 527 participants were enrolled in the study with a response rate of 100%. The prevalence of alcohol use disorder (AUD) was 14.2%. Factors associated with alcohol use disorder were educational status AOR = 8.5 (95%CI: 1.70, 42.99), social support AOR = 0.5(95%CI: 0.26, 0.95), cigarette smoking AOR = 3.49(95%CI: 1.01, 12.13), khat chewing AOR = 5.11 (95% CI: 1.60, 16.33), family history of alcohol use AOR = 3.58 (95% CI: 1.52, 8.47), and missing ART drugs AOR 3.05 (95% CI: 1.302, 7.131).

Conclusion

The prevalence of alcohol use disorder was high as compared to similar epidemiological studies. Educational status, social support, cigarette smoking, khat chewing, and family history of alcohol use were independent predictors. Providing health education about alcohol use and proper screening of alcohol use disorder among patients with HIV/AIDS is crucial. Strengthening the referral linkage with the psychiatric unit will decrease the burdens of the problem.

Alcohol Types and HIV Disease Progression Among HIV-Infected Drinkers Not Yet on Antiretroviral Therapy in Russia and Uganda

In HIV-infected drinkers, alcohol types more likely to cause inflammation could plausibly increase the risk of HIV disease progression. We therefore assessed the association between alcohol type and plasma HIV RNA level (HIV viral load) among HIV-infected drinkers not on antiretroviral therapy (ART) in Russia and Uganda. We analyzed the data of participants from cohorts in Russia and Uganda and assessed their HIV viral load at enrollment by the alcohol type predominantly consumed. We defined predominant alcohol type as the alcohol type contributing >50% of total alcohol consumption in the 1 month (Russia) or 3 months (Uganda) prior to enrollment. Using multiple linear regression, we compared log₁₀ HIV viral load by predominant alcohol type, controlling for age, gender, socioeconomic status, total number of standard drinks, frequency of drinking ≥6 drinks/occasion, and in Russia, history of injection drug use. Most participants (99.2% of 261 in Russia and 98.9% of 352 in Uganda) predominantly drank one alcohol type. In Russia, we did not find evidence for differences in viral load levels between drinkers of fortified wine (n = 5) or hard liquor (n = 49), compared to drinkers of beer/low-ethanol-content cocktails (n = 163); however, wine/high-ethanol-content cocktail drinkers (n = 42) had higher mean log₁₀ viral load than beer/low-ethanol-content cocktail drinkers (β = 0.38, 95% CI 0.07-0.69; p = 0.02). In Uganda, we did not find evidence for differences in viral load levels between drinkers of locally-brewed beer (n = 41), commercially-distilled spirits (n = 38), or locally-distilled spirits (n = 43), compared to drinkers of commercially-made beer (n = 218); however, wine drinkers (n = 8) had lower mean log₁₀ HIV viral load (β = -0.65, 95% CI -1.36 to 0.07, p = 0.08), although this did not reach statistical significance. Among HIV-infected drinkers not yet on ART in Russia and Uganda, we observed an association between the alcohol type predominantly consumed and the HIV viral load level in the Russia sample. These exploratory results suggest that, in addition to total number of drinks and drinking patterns, alcohol type might be a dimension of alcohol use that merits examination in studies of HIV and alcohol related outcomes.

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.

Effects of Heavy Drinking on T-Cell Phenotypes Consistent with Immunosenescence in Untreated HIV Infection

BACKGROUND

The role of alcohol consumption in HIV-related adaptive immune dysfunction is debated. We hypothesized that heavy drinking would be associated with greater evidence of immunosenescence (i.e., aging-related decline of adaptive immune function) among antiretroviral therapy (ART)-naïve HIV-infected individuals.

METHODS

Using data from the Russia ARCH cohort study, we conducted a cross-sectional analysis of ART-naïve HIV-infected individuals recruited between 2012 and 2014.

INDEPENDENT VARIABLE

Heavy drinking defined as >4 standard drinks in a day (or >14 standard drinks per week) for men and >3 per day (or >7 per week) for women, respectively.

DEPENDENT VARIABLES

Percentage of CD8+ and CD4+ T-cells with a phenotype consistent with immunosenescence (i.e., expressing CD28- CD57+, or memory [CD45RO+ CD45RA+] phenotype and not the naïve [CD45RO- CD45RA+] phenotype).

STATISTICAL ANALYSIS

Multiple linear regression adjusted for confounders.

RESULTS

Of 214 eligible participants, 61% were heavy drinkers. Mean age was 33 years and the cohort was predominantly male (72%). Hepatitis C prevalence was high (87%) and mean log10 HIV-1 RNA copies/ml was 4.6. We found no significant differences by drinking status in the percentage of immunosenescent, memory, or naïve CD8+ or CD4+ T-cells.

CONCLUSIONS

In this cross-sectional analysis, heavy drinking in the setting of untreated HIV infection did not appear to be associated with alterations in T-cell phenotypes consistent with immunosenescence. To substantiate these findings, longitudinal studies should assess whether changes in alcohol consumption are associated with changes in these and other immunosenescent T-cell phenotypes.

Alcohol and Cannabinoids Differentially Affect HIV Infection and Function of Human Monocyte-Derived Dendritic Cells (MDDC)

During human immunodeficiency virus (HIV) infection, alcohol has been known to induce inflammation while cannabinoids have been shown to have an anti-inflammatory role. For instance cannabinoids have been shown to reduce susceptibility to HIV-1 infection and attenuate HIV replication in macrophages. Recently, we demonstrated that alcohol induces cannabinoid receptors and regulates cytokine production by monocyte-derived dendritic cells (MDDC). However, the ability of alcohol and cannabinoids to alter MDDC function during HIV infection has not been clearly elucidated yet. In order to study the potential impact of alcohol and cannabinoids on differentiated MDDC infected with HIV, monocytes were cultured for 7 days with GM-CSF and IL-4, differentiated MDDC were infected with HIV-1Ba-L and treated with EtOH (0.1 and 0.2%), THC (5 and 10 μM), or JWH-015 (5 and 10 μM) for 4–7 days. HIV infection of MDDC was confirmed by p24 and Long Terminal Repeats (LTR) estimation. MDDC endocytosis assay and cytokine array profiles were measured to investigate the effects of HIV and substances of abuse on MDDC function. Our results show the HIV + EtOH treated MDDC had the highest levels of p24 production and expression when compared with the HIV positive controls and the cannabinoid treated cells. Although both cannabinoids, THC and JWH-015 had lower levels of p24 production and expression, the HIV + JWH-015 treated MDDC had the lowest levels of p24 when compared to the HIV + THC treated cells. In addition, MDDC endocytic function and cytokine production were also differentially altered after alcohol and cannabinoid treatments. Our results show a differential effect of alcohol and cannabinoids, which may provide insights into the divergent inflammatory role of alcohol and cannabinoids to modulate MDDC function in the context of HIV infection.

Outcomes of highly active antiretroviral therapy and its predictors: a cohort study focusing on tuberculosis co-infection in South West Ethiopia

BACKGROUND

In this study, we hypothesized that TB co-infection independently increases the risk of poor treatment outcomes in such patients even if they are on antiretroviral therapy (ART). Therefore, this study was aimed at investigating this hypothesis among cohort of adult PLWHs in South West Ethiopia.

METHODOLOGY

Cohort study comparing the immunologic and clinical outcomes of 130 HIV/TB co-infected and 520 only HIV patients starting ART was enrolled. Chi square and student t test were used to compare outcome variables and logistic regression was used to assess the effect of TB on treatment failure.

RESULTS

In this study, TB co-infection didn't increase immunologic failure even in univariate analysis at both 6 [OR, 1.10 (0.59-1.69), P = 0.85] and 12 months [OR, 1.06 (0.58-1.93), P = 0.89] of ART initiation. However, it increased the risk of clinical failure at both 6 [Adjusted Odd Ratio (AOR), 2.90 (1.41-6.09), P = 0.028] and 12 months [AOR, 2.93 (1.41-6.09), P = 0.004] of ART initiation.

CONCLUSION

This study showed that TB co-infection didn't adversely affect the immunologic outcomes, weight and hemoglobin responses even though it increased the risk of clinical failure nearly three times. Therefore, beside the concern given for TB prevention and treatment, several patient and policy related factors need to be addressed to maximally benefit from highly active antiretroviral therapy rollout in resource limited settings.

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.

Beyond the Brain: The Role of Brain-Derived Neurotrophic Factor in Viroimmune Responses to Antiretroviral Therapy among People Living with HIV with and without Alcohol Use

OBJECTIVE

Given the emerging data suggesting the key role of brain-derived neurotrophic factor (BDNF) in the immune system, we assessed longitudinally whether BDNF depletions induced by hazardous alcohol use (HAU) would impact a response to antiretroviral therapy (ART).

METHODS

In a prospective single-site cohort, virological and immunological responses to ART in 200 hazardous and 200 nonhazardous users were obtained, along with plasma BDNF levels.

RESULTS

Hazardous drinkers were more likely to have BDNF levels <4000 pg/mL (odds ratio [OR] = 1.6, P = .01). Participants with BDNF <4000 pg/mL were less likely to have CD4 counts of more than 500 cells/mm(3) (P = .02) and to achieve viral suppression over the follow-up period (OR = 1.5, P = .03). Multivariate analysis confirmed the significant role of HAU and low BDNF in predicting viroimmune responses.

CONCLUSION

Hazardous alcohol use was associated with BDNF alterations, which in turn were linked to a limited response to ART in terms of viral suppression and CD4 count improvements.

Mood Disorders and BDNF Relationship with Alcohol Drinking Trajectories among PLWH Receiving Care

Background

Despite the excessive rates of Hazardous Alcohol Use (HAU) among people living with HIV (PLWH), although largely speculated, psychological and physiological components associated with HAU, has not been actively measured. Therefore, the present study was geared toward determining: 1) the rates of mood disorders and its relationship with HAU, and 2) to assess the impact of Brain Derived Neurotrophic Factor (BDNF), a well-known regulator of alcohol and mood disorders.

Methods

For this study, participants of the longitudinal PADS Study n=400, were followed over time. Alcohol use (Alcohol Use Disorders Identification Test –AUDIT- and the Alcohol Dependence Scale –ADS) and moods (depression, anxiety, and stress) were assessed repeatedly.

Results

A cluster analyses shows three distinctive trajectories. The first one, revealed a group with increased drinking (Cluster 1: n=140), constant alcohol intake (Cluster 2: n = 60), and one with decreased consumption (Cluster 3: n =120).

Analyses discovered higher AUDIT scores across the clusters with Cluster 1 being followed by Clusters 2 and 3 (1: 14.5 ± 8 vs. 2=8.7 ± 7.5 vs. 3= 6.6 ± 4.2, p = 0.001). Women in Clusters 1 and 2 had higher levels of stress (1:21 ± 7.5; 2:19.3 ± 7) and lower BDNF levels (7904 ± 1248 pg/ml and 10405 ± 909 pg/mL) than their counterparts in Cluster 3 (PSS: 3: 16.6 ±5, p = 0.02 BDNF: 10828 ± 1127 pg/mL, p = 0.08). Men in Cluster 1 differed in terms of stress (19.8 ± 7 vs. 21 ± 7.5 score) and BDNF levels (Cluster 1: 5204 ± 818 vs. Cluster 2: 7656 ± 843 pg/ml, p = 0.002) but not in the number of years living with HIV. The proportion of subjects with multiple mood comorbidities was disturbingly higher (26%), and all were members of Cluster 1. Multiple logistic regression analyses indicated that participants reporting high relative to low levels of perceived stress, dual mood comorbidity, altered BDNF levels and low income increased the likelihood of being a member of Cluster 1.

Conclusion

This study found that stress and overlaying psychiatric comorbidities are linked with persistent alcohol use. Findings suggest that BDNF and social support seems to be a logical target as it seems to be the bridge linking mood disorders and alcohol consumption.

Alcohol Consumption, Progression of Disease and Other Comorbidities, and Responses to Antiretroviral Medication in People Living with HIV

The present paper describes the possible connection between alcohol consumption and adherence to medicine used to treat human deficiency viral (HIV) infection. Highly active antiretroviral therapy (HAART) has a positive influence on longevity in patients with HIV, substantially reducing morbidity and mortality, including resource-poor settings such as South Africa. However, in a systematic comparison of HAART outcomes between low-income and high-income countries in the treatment of HIV-patients, mortality was higher in resource-poor settings. Specifically, in South Africa, patients often suffer from concomitant tuberculosis and other infections that may contribute to these results. Alcohol influences the use of medicine for opportunistic infections (e.g., pneumonia, tuberculosis), or coinfections HIV-hepatitis viruses-B (HBV) and C (HCV), cytomegalovirus, or herpes simplex virus. Furthermore, alcohol use may negatively impact on medication adherence contributing to HIV progression. The materials used provide a data-supported approach. They are based on analysis of published (2006–2011) world literature and the experience of the authors in the specified topic. Intended for use by health care professionals, these recommendations suggest approaches to the therapeutic and preventive aspects of care. Our intention was to fully characterize the quality of evidence supporting recommendations, which are reflecting benefit versus risk, and assessing strength or certainty.

Substance use: impact on adherence and HIV medical treatment

Substance use is highly prevalent among people living with HIV/AIDS, is often comorbid with other mental health problems, related to poor HIV medical outcomes, and, is associated with poor medication and treatment adherence. The current review reports on the recent state of the literature in terms of substance use and its relation to HIV medication and treatment adherence, and offers recommendations for advancing treatment and secondary HIV prevention efforts. Identifying substance users within HIV primary care and developing, evaluating, and refining integrative substance use-mental health-adherence interventions may be clinically important targets for effective disease management and may contribute to secondary HIV prevention efforts.

Cholesterol as a Mediator of Alcohol-Induced Risks for Respiratory Disease Hospitalizations among People Living With HIV

We analyzed the role of cholesterol as a potential mediator of alcohol-increased risk of respiratory infections that required hospitalization in People Living with HIV (PLWH). Using a longitudinal clinic-based design, 346 PLWH were consecutively admitted and followed at Jackson Memorial Medical Center(enrolled in the study). Following national guidelines, PLWH were stratified according to cholesterol levels: <150 mg/dl (Hypocholesterolemia= HypoCHL), 151-200, and >200 mg/dl Hypercholesterolemia =HyperCHL), and compared on the basis of clinical outcomes, lymphocyte phenotypes and behavioral risks. Analyses indicated that compared to HyperCHL participants, HypoCHL subjects were more likely to be hospitalized, particularly for lower respiratory tract infections (LRTI). Excessive admissions were associated with more deviant lymphocyte profiles, particularly limited NK cells. In logistic regression analyses, smoking (OR=1.5), HypoCHL (OR=7.7), and alcohol (OR=1.2) were predictors of LRTI. These findings warrant further investigation of the potential use of HypoCHL as a risk marker, and the cost-effectiveness of switching prevention gears towards HypoCHL, alcohol and tobacco in PLWH.

Gender differences in retention and survival on antiretroviral therapy of HIV-1 infected adults in Malawi

BACKGROUND; There is currently a dearth of knowledge on gender differences in mortality among patients on ART in Africa.

METHODS

Using data from the national ART monitoring and evaluation system, a survival analysis of all healthcare workers, teachers, and police/army personnel who accessed ART in Malawi by June, September and December 2006 respectively, was undertaken. Gender differences in survival were analysed using Kaplan-Meier estimates and rate ratios were derived from Poisson regression adjusting for confounding.

RESULTS

4670 ART patients (49.8% female) were followed up for a median of 8.7 months after starting ART. Probability of death was significantly higher for men than women (p < 0.001). Controlling for age, WHO clinical stage and occupation, men experienced nearly 2 times the mortality of women RR 1.90 [95% CI: 1.57-2.29]. A higher proportion of men initiated ART in WHO stage 4 (p < 0.001).

CONCLUSION

Among healthcare workers, teachers, police/army personnel, men have higher mortality on ART than women. Possible reasons are unclear but could be biological or because men present for ART at a later clinical stage or have poorer adherence to therapy. Improving early access to ART may reduce mortality, especially among men. A gender difference in adherence to therapy needs further investigation.

Alcohol and HIV disease progression: weighing the evidence

Heavy alcohol use is commonplace among HIV-infected individuals; however, the extent that alcohol use adversely impacts HIV disease progression has not been fully elucidated. Fairly strong evidence suggests that heavy alcohol consumption results in behavioral and biological processes that likely increase HIV disease progression, and experimental evidence of the biological effect of heavy alcohol on simian immunodeficiency virus in macaques is quite suggestive. However, several observational studies of the effect of heavy alcohol consumption on HIV progression conducted in the 1990s found no association of heavy alcohol consumption with time to AIDS diagnosis, while some more recent studies showed associations of heavy alcohol consumption with declines of CD4 cell counts and nonsuppression of HIV viral load. We discuss several plausible biological and behavioral mechanisms by which alcohol may cause HIV disease progression, evidence from prospective observational human studies, and suggest future research to further illuminate this important issue.