Association of Alcohol Use with COVID-19 Infection and Hospitalization Among People Living with HIV in the United States, 2020

Alcohol use was associated with elevated COVID-19 risk in the general population. People with HIV (PWH) have high prevalences of alcohol use. To evaluate the effect of alcohol use on COVID-19 risks among PWH, we estimated the risk of COVID-19 diagnosis and COVID-19-related hospitalization among PWH in routine care at 8 HIV primary care centers that contributed data to the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort according to their alcohol use just prior to the COVID-19 pandemic. The CNICS data repository includes demographic characteristics, clinical diagnoses, and laboratory test results from electronic medical records and other sources. Alcohol use, substance use, and mental health symptoms were self-reported on tablet-based standardized surveys. Alcohol use was categorized according to standard, sex-specific Alcohol Use Disorder Identification Test-Consumption instrument cut-offs. We followed 5,496 PWH (79% male, 48% Black race, median age = 53 years) from March 1, 2020 to December 31, 2020. Relative to PWH with no baseline alcohol use, the adjusted hazard ratio (aHR) of COVID-19 diagnosis was 1.09 (95% confidence interval [CI]: 0.78, 1.51) for lower-risk drinking and 1.19 (95%CI: 0.81, 1.73) for unhealthy drinking. The aHR of COVID-19-related hospitalization was 0.82 (95%CI: 0.33, 1.99) for lower-risk drinking and 1.25 (95%CI: 0.50, 3.09) for unhealthy drinking. Results were not modified by recent cocaine or non-prescribed opioid use, depressive symptoms, or diagnoses of alcohol use disorder. The study suggested a slightly increased, but not statistically significant risk of COVID-19 diagnosis and hospitalization associated with unhealthy alcohol use.

Efficacy of Two Evidence-Based Alcohol Consumption Interventions on Positive, Negative, and Neutral Days Among Hazardous Alcohol Users Living with HIV in Vietnam

Social events and stressful settings can be catalysts for alcohol consumption. Motivational enhancement therapy (MET) and cognitive behavioral therapy (CBT) are widely used in alcohol interventions. We assessed how alcohol consumption varied across three types of days (positive/social, negative/stressful, and neutral) among hazardous alcohol users living with HIV in Vietnam. We further evaluated how those consumption patterns changed after two MET/CBT alcohol reduction interventions versus the standard of care (SOC). The 'combined' intervention offered 6 individual sessions and 3 group sessions; the 'brief' intervention offered 2 individual sessions and 2 phone calls. A 30-day timeline follow-back was administered at study visits, detailing daily drinks and events. Days were categorized as neutral, positive/social, or negative/stressful; negative binomial models and generalized estimating equations were used to estimate drinks consumed by type of day at baseline and 12 months. Prior to intervention, more drinks were consumed on positive/social days (5.2 drinks; 95% Confidence Interval [CI]:4.8, 5.7) than negative/stressful (1.5; 95% CI:1.3, 1.9) and neutral days (2.2; 95% CI: 1.9, 2.5). After the brief intervention, drinks consumed decreased on neutral days (ratio: 0.5: 95% CI: 0.4, 0.7). After the combined intervention, drinks consumed decreased on neutral days (ratio: 0.4; 95% CI: 0.3, 0.6), positive/social days (ratio: 0.6; 95% CI: 0.5, 0.7) and negative/stressful days (ratio: 0.3; 95% CI: 0.2, 0.6). No reductions in consumption were observed in the SOC group. Social/positive days had the highest alcohol consumption prior to intervention, and the combined intervention showed the greatest decrease in consumption on those days. CLINICAL TRIAL REGISTRATION: The study is registered at clinicaltrials.gov (NCT02720237).

Joint effects of substance use disorders and recent substance use on HIV viral non-suppression among people engaged in HIV care in an urban clinic, 2014-2019

AIMS

To estimate the joint effects of substance use disorder (SUD) and recent substance use on human immunodeficiency virus (HIV) non-suppression.

DESIGN

Retrospective clinical cohort study with repeated observations within individuals.

SETTING

Baltimore, Maryland, United States.

PARTICIPANTS

1881 patients contributed 10 794 observations.

MEASUREMENTS

The primary independent variable was the combination of history of SUD and recent substance use. History of SUD was defined as any prior International Classification of Diseases 9/10 code for cocaine or opioid disorder. Recent substance use was defined as the self-report of cocaine or non-prescribed opioid use on the National Institute of Drug Abuse-modified Alcohol, Smoking and Substance Involvement Screening Test or clinician-documented cocaine or opioid use abstracted from the medical record. The outcome was viral non-suppression, defined as HIV RNA >200 copies/mL on the first viral load measurement within 1 year subsequent to each observation of substance use. We adjusted for birth sex, Black race, age, HIV acquisition risk factors, years in care and CD4 cell count. In secondary analyses, we also adjusted for depressive, anxiety and panic symptoms, cannabis use and cannabis use disorder.

FINDINGS

On their first observation, 31% of patients had a history of an SUD and 18% had recent substance use. Relative to no history of SUD and no recent substance use, the 1-year fully adjusted risk difference (RD) for viral non-suppression associated with cocaine and opioid use disorder and recent substance use was 7.7% (95% CI = 5.3%-10.0%), the RD was 5.5% (95% CI = 1.2%-9.7%) for history of cocaine use disorder without recent substance use, and the RD was 4.6% (95% CI = 2.7%-6.5%) for recent substance use without a SUD.

CONCLUSIONS

Substance use and substance use disorders appear to be highly prevalent among, and independently associated with, viral non-suppression among people with HIV.

Alcohol use and the longitudinal HIV care continuum for people with HIV who enrolled in care between 2011 and 2019

PURPOSE

We described the impact of alcohol use on longitudinal engagement in HIV care including loss to follow-up, durability of viral suppression, and death.

METHODS

We followed a cohort of 1781 people with HIV from enrolled in care at one of seven US clinics, 2011-2019 through 102 months. We used a multistate, time-varying Markov process and restricted mean time to summarize engagement in HIV care over follow-up according to baseline self-reported alcohol use (none, moderate, or unhealthy).

RESULTS

Our sample (86% male, 54% White) had median age of 35 years. Over 102 months, people with no, moderate, and unhealthy alcohol use averaged 62.3, 61.1, and 59.5 months virally suppressed, respectively. People who reported unhealthy or moderate alcohol use spent 5.1 (95% confidence intervals (CI): 0.8, 9.3) and 7.6 (95%CI: 3.1, 11.7) more months lost to care than nondrinkers. Compared to no use, unhealthy alcohol use was associated with 3.4 (95%CI: -5.6, -1.6) fewer months in care, not virally suppressed. There were no statistically significant differences after adjustment for demographic and clinical characteristics.

CONCLUSIONS

Moderate or unhealthy drinking at enrollment in HIV care was associated with poor retention in care. Alcohol use was not associated with time spent virally suppressed.

A Digital Counselor-Delivered Intervention for Substance Use Among People With HIV: Development and Usability Study

BACKGROUND

Substance use disorders are prevalent and undertreated among people with HIV. Computer-delivered interventions (CDIs) show promise in expanding reach, delivering evidence-based care, and offering anonymity. Use in HIV clinic settings may overcome access barriers. Incorporating digital counselors may increase CDI engagement, and thereby improve health outcomes.

OBJECTIVE

We aim to develop and pilot a digital counselor-delivered brief intervention for people with HIV who use drugs, called "C-Raven," which is theory grounded and uses evidence-based practices for behavior change.

METHODS

Intervention mapping was used to develop the CDI including a review of the behavior change research in substance use, HIV, and digital counselors. We conducted in-depth interviews applying the situated-information, motivation, and behavior skills model and culturally adapting the content for local use with people with HIV. With a user interaction designer, we created various digital counselors and CDI interfaces. Finally, a mixed methods approach using in-depth interviews and quantitative assessments was used to assess the usability, acceptability, and cultural relevance of the intervention content and the digital counselor.

RESULTS

Participants found CDI easy to use, useful, relevant, and motivating. A consistent suggestion was to provide more information about the negative impacts of drug use and the interaction of drug use with HIV. Participants also reported that they learned new information about drug use and its health effects. The CDI was delivered by a "Raven," digital counselor, programmed to interact in a motivational interviewing style. The Raven was perceived to be nonjudgmental, understanding, and emotionally responsive. The appearance and images in the intervention were perceived as relevant and acceptable. Participants noted that they could be more truthful with a digital counselor, however, it was not unanimously endorsed as a replacement for a human counselor. The C-Raven Satisfaction Scale showed that all participants rated their satisfaction at either a 4 (n=2) or a 5 (n=8) on a 5-point Likert scale and all endorsed using the C-Raven program again.

CONCLUSIONS

CDIs show promise in extending access to care and improving health outcomes but their development necessarily requires integration from multiple disciplines including behavioral medicine and computer science. We developed a cross-platform compatible CDI led by a digital counselor that interacts in a motivational interviewing style and (1) uses evidence-based behavioral change methods, (2) is culturally adapted to people with HIV who use drugs, (3) has an engaging and interactive user interface, and (4) presents personalized content based on participants' ongoing responses to a series of menu-driven conversations. To advance the continued development of this and other CDIs, we recommend expanded testing, standardized measures to evaluate user experience, integration with clinician-delivered substance use treatment, and if effective, implementation into HIV clinical care.

Longitudinal Trajectories of Alcohol Use in Vietnamese Adults with Hazardous Alcohol Use and HIV

A three-armed drinking cessation trial in Vietnam found that both a brief and intensive version of an intervention effectively reduced hazardous drinking in people living with HIV. We used group-based trajectory modeling (GBTM) to assess the extent to which findings may vary by latent subgroups distinguished by their unique responses to the intervention. Using data on drinking patterns collected over the 12 months, GBTM identified five trajectory groups, three of which were suboptimal ["non-response" (17.2%); "non-sustained response" (15.7%), "slow response" (13.1%)] and two optimal ["abstinent" (36.4%); "fast response" (17.6%)]. Multinomial logistic regression was used to determine that those randomized to any intervention arm were less likely to be in a suboptimal trajectory group, even more so if randomized to the brief (vs. intensive) intervention. Older age and higher baseline coping skills protected against membership in suboptimal trajectory groups; higher scores for readiness to quit drinking were predictive of it. GBTM revealed substantial heterogeneity in participants' response to a cessation intervention and may help identify subgroups who may benefit from more specialized services within the context of the larger intervention.

Phosphatidylethanol and self-reported alcohol consumption among people living with HIV in Thai Nguyen, Vietnam

BACKGROUND

Phosphatidylethanol (PEth) is a biomarker for recent alcohol consumption that would ideally validate self-reported alcohol consumption behaviors. We assessed the relationship between PEth and several self-reported alcohol consumption metrics among hazardous alcohol users living with HIV in Vietnam.

METHODS

Participants in a three-arm randomized controlled trial assessing two alcohol interventions reported recent alcohol consumption on a 30-day timeline follow-back interview and had a PEth assessment at enrollment, 3 months, and 12 months of the study follow-up. We examined the relationship between self-reported alcohol consumption and quantitative PEth results using Spearman rank correlation and receiver-operating characteristic (ROC) curves to calculate the area under the curve (AUC). We assessed associations between categorical PEth results and self-reported drinking behaviors using prevalence ratios calculated with regression models and generalized estimating equations.

RESULTS

Among 1221 study visits (n = 439 participants; 425 (97%) men), the median PEth result was 71 ng/mL (Interquartile range (IQR): 20, 212), and participants reported a median of 11 (IQR: 4, 24) drinking days and 25 (IQR: 8, 71) standard drinks in the previous 28 days. Quantitative PEth results were moderately correlated with drinking days (ρ = 0.26-0.35) and standard drinks consumed (ρ = 0.23-0.38) in the same period. AUCs ranged from 0.54 (any binge drinking in the past 28 days) to 0.82 (any alcohol consumed in the past 21 days). Positive PEth results (≥50 ng/mL) were 2.24 (95% Confidence Interval [CI]: 1.49, 3.35) times as prevalent among participants who reported drinking in the previous 28 days compared with those who did not.

CONCLUSIONS

Although PEth values and self-reported alcohol use were correlated, the observed associations were modest. Additional research into the dynamics of PEth production and elimination is warranted across diverse populations to better understand how PEth assessments can best be integrated into research and clinical care.

Alcohol consumption upon direct-acting antiviral therapy for hepatitis C among persons with human immunodeficiency virus in the United States

BACKGROUND

Direct-acting antivirals (DAA) are highly effective against hepatitis C virus (HCV) infection among persons with human immunodeficiency virus (PWH). However, alcohol use post-DAA treatment poses a continued threat to the liver. Whether the focus on liver health alone during HCV treatment can impact alcohol consumption is unclear. Therefore, we examined the change in alcohol use among HCV-coinfected PWH who received DAA therapy by non-addiction medical providers.

METHODS

In our longitudinal clinical cohort study, we identified HCV-coinfected PWH who received interferon-free DAA therapy between January 2014 and June 2019 in the Centers for AIDS Research Network of Integrated Clinical Systems. The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) was the alcohol screening instrument. We used mixed-effects logistic regression models to estimate the longitudinal change in alcohol use upon DAA therapy.

RESULTS

Among 738 HCV-coinfected PWH, 339 (46 %) reported any alcohol use at the end of HCV treatment, including 113 (15 %) with high-risk use (i.e., AUDIT-C ≥3 for women, ≥4 for men). Concurrently, 280 (38 %) PWH noted active drug use, and 357 (48 %) were currently smoking. We observed no changes in the odds of any alcohol or high-risk alcohol use over time with DAA therapy. Findings were similar in the PWH subgroup with a history of alcohol use before DAA treatment.

CONCLUSIONS

For PWH with HCV, alcohol use did not change following interferon-free DAA treatment by non-addiction medical providers. Thus, clinicians should consider integrating targeted alcohol use interventions into HCV care to motivate reduced alcohol consumption and safeguard future liver health.

Impact of community health worker intervention on PrEP knowledge and use in Rakai, Uganda: A mixed methods, implementation science evaluation

BACKGROUND

Effective models of support for HIV pre-exposure prophylaxis (PrEP) are needed for populations at elevated risk. In a hyperendemic Ugandan fishing community, PrEP counseling was provided through a situated Information, Motivation, and Behavioral Skills (sIMB)-based community health worker (CHW) intervention. We evaluated the intervention using a mixed-methods, implementation science design.

METHODS

We surveyed all community members aged 15-49 through the Rakai Community Cohort Study. We used multivariable logistic regressions with generalized estimating equations to estimate the intervention's effect on PrEP knowledge and utilization. To understand intervention experiences and mechanisms, we conducted 74 qualitative interviews with 5 informant types (clients, CHWs, program staff, community leaders, health clinic staff) and analyzed data using an iterative, deductive approach. A mobile phone application provided intervention process implementation data.

RESULTS

Individuals self-reporting receipt of the CHW intervention showed significantly higher PrEP knowledge (N = 1848, PRR: 1.10, 95% CI: 1.06-1.14, p = <.0001), PrEP ever use (N = 1176, PRR: 1.77, 95% CI: 1.33-2.36, p = <.0001), and PrEP current use (N = 1176, PRR: 1.86, 95% CI: 1.22-2.82, p = 0.0039) compared to those who did not. Qualitative findings attributed positive PrEP outcomes to CHW counseling and effective use of motivational interviewing skills by CHWs. Salient themes across the RE-AIM framework included support for the CHW intervention and PrEP across clients, community, and implementers. Mobile application data demonstrated consistent delivery of the PrEP module throughout implementation.

CONCLUSIONS

CHWs improved PrEP knowledge and use among clients in an HIV hyperendemic fishing community. Mixed-methods, implementation science evaluations can inform adaptation of similar PrEP implementation strategies.

Effects of Two Alcohol Reduction Interventions on Depression and Anxiety Symptoms of ART Clients in Vietnam

Little is known about the potential mental health impacts of cognitive behavioral therapy and motivational interviewing interventions that focus on alcohol reduction among people with HIV (PWH). Our study aimed to assess the impact of two evidence-based alcohol reduction interventions on depression and anxiety symptoms of antiretroviral therapy (ART) clients with hazardous alcohol use. We conducted a secondary data analysis of data from a three-arm randomized controlled trial among ART clients in Thai Nguyen, Vietnam that evaluated the impacts of two alcohol reduction interventions in Vietnam. ART clients 18 years old or more with hazardous alcohol use (based on the Alcohol Use Disorders Identification Test-Consumption) were enrolled and randomized into one of three arms: Combined intervention, Brief intervention, and Standard of care (SOC). Symptoms of depression, measured with the Patient Health Questionnaire-9, and anxiety, measured with the Generalized Anxiety Disorder-7 scale, were assessed at baseline and 3, 6, and 12 months post-intervention. Generalized estimating equations were used to evaluate the effects of the interventions on depression and anxiety symptoms. The prevalence of depression and anxiety symptoms at baseline was 25.1% and 16.1%, respectively. Decreases in depression and anxiety symptoms were observed in all three arms from baseline to 12-month follow-up. There were no significant differences in depression and anxiety symptoms among participants receiving either intervention, relative to the SOC. Interventions with a dual focus on alcohol and mental health are needed to achieve more pronounced and sustainable improvements in depression and anxiety symptoms for PWH with hazardous alcohol use.

Alcohol Use Disorder and Recent Alcohol Use and HIV Viral Non-Suppression Among People Engaged in HIV Care in an Urban Clinic, 2014-2018

We estimated joint associations between having history of alcohol use disorder (AUD) (based on prior ICD-9/ICD-10 codes) and recent self-reported alcohol use and viral non-suppression (≥ 1 viral load measurement > 20 copies/mL in the same calendar year as alcohol consumption was reported) among patients on ART enrolled in routine care, 2014-2018, in an urban specialty clinic. Among 1690 patients, 26% had an AUD, 21% reported high-risk alcohol use, and 39% had viral non-suppression. Relative to person-years in which people without AUD reported not drinking, prevalence of viral non-suppression was higher in person-years when people with AUD reported drinking at any level; prevalence of viral non-suppression was not significantly higher in person-years when people with AUD reported not drinking or person-years when people without AUD reported drinking at any level. No level of alcohol use may be "safe" for people with a prior AUD with regard to maintaining viral suppression.

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

•

Unhealthy alcohol use is prevalent among women attending STI clinics.

•

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

•

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

•

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

•

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

Objective

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

Methods

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

Results

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

Conclusions

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

Bacterial Vaginosis and Alcohol Consumption: A Cross-Sectional Retrospective Study in Baltimore, Maryland

BACKGROUND

Bacterial vaginosis (BV) is the most cited cause of vaginal complaints among women of reproductive age. Its etiology and associated risk factors are not entirely understood. Here we examined the association between BV and at-risk alcohol consumption in women attending 2 sexually transmitted infection (STI) clinics in Baltimore, MD.

METHODS

This was a retrospective cross-sectional analysis using data from first clinic visits from 2011-2016. At-risk alcohol use was defined as heavy episodic ("binge") drinking within the last 30 days or a self-report of having had vaginal or anal sex in the context of alcohol consumption. Pearson χ2 test and Student t test were used to assess baseline associations. Log binomial models were used to estimate prevalence ratios (PRs) before and after adjustments for potential confounding factors.

RESULTS

Of the 10,991 women included in the analysis, 2173 (19.7%) met the clinical diagnostic criteria for BV. Having had vaginal or anal sex in the context of alcohol consumption was associated with an increased risk of BV (PR, 1.25; 95% confidence interval, 1.13-1.37), as was binge drinking (PR, 1.15; 95% confidence interval, 1.04-1.27) after adjustment for confounders.

CONCLUSIONS

In this population, at-risk alcohol consumption was associated with an increased risk of BV. The mechanisms remain uncertain. Future prospective studies are needed to verify and evaluate causality in these associations.

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

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

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

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

Depression and HIV viral nonsuppression among people engaged in HIV care in an urban clinic, 2014-2019

OBJECTIVE

The aim of this study was to describe the risk of viral nonsuppression across the depression care cascade.

DESIGN

A clinical cohort study.

METHODS

We used depressive symptoms (PHQ-8 ≥ 10) self-reported on computer-assisted surveys, clinical diagnoses of depression in the medical record in the prior year and pharmacologic (any prescription for an antidepressant) and psychologic treatments for depression (attendance at at least two mental health visits in the prior year) to classify patients into groups: no history of depression; prior depression diagnosis; current indication for depression treatment (symptoms or clinical diagnosis); and treated depression (stratified by presence of persistent symptoms). We associated position in the depression care cascade with viral nonsuppression (>200 copies/ml) 7 days before to 6 months after the index self-report of depressive symptoms.

RESULTS

History of depression [adjusted risk difference (aRD) relative to no history = 5.9%, 95% confidence interval (95% CI): 1.5-10.3] and current depression (symptoms or diagnosis) in the absence of treatment (aRD relative to no current depression or depression treatment = 4.8%, 95% CI: 1.8-7.8) were associated with a higher risk of viral nonsuppression than no history of depression. Depression treatment mitigated this association (aRD = -0.4%, 95% CI: -2.5 to 1.7).

CONCLUSION

The relationship between depression care cascade and viral suppression is complex. Untreated depression and clinically unrecognized depressive symptoms were both related to viral nonsuppression. Treated depression was not associated with viral nonsuppression; however, a high proportion of treated patients still had depressive symptoms. Depression treatment should be titrated if patients' symptoms are not responsive and patients with a history of depression should be monitored for ART adherence.

Evaluating the effects of two alcohol reduction counseling interventions on intimate partner violence perpetration: secondary analysis of a three-arm randomized controlled trial among Vietnamese men with HIV

BACKGROUND AND AIMS

Evidence suggests that alcohol reduction interventions decrease intimate partner violence (IPV) perpetration, although this remains untested in low- and middle-income countries and among men with human immunodeficiency virus (HIV). This study evaluates the effectiveness of alcohol reduction counseling interventions on IPV perpetration among men on anti-retroviral therapy (ART) and tests whether alcohol use explains the intervention effects.

DESIGN

Secondary analysis of data from a three-arm randomized controlled trial among ART patients with hazardous alcohol use. Participants were recruited from March 2016 to May 2017.

SETTING

Thai Nguyen, Vietnam.

PARTICIPANTS, INTERVENTIONS AND COMPARATORS

Male participants (n = 426). Participants received a two-session brief intervention (BI), a six-session combined intervention (CoI) or the standard of care (SOC), comprising alcohol treatment referrals. Alcohol reduction counseling interventions were guided by cognitive-behavioral therapy and motivational enhancement therapy delivered by psychosocial counselors over 3 months.

MEASUREMENTS

IPV perpetration was measured using the shortened Conflict Tactics Scale 2 and alcohol use was measured using timeline followback.

FINDINGS

BI and CoI participants reported reduced IPV perpetration at 3 months compared with SOC participants [BI: adjusted odds ratio (aOR) = 0.27, 95% confidence interval (CI) = 0.11, 0.65; CoI: aOR = 0.50, 95% CI = 0.22, 1.13]; the association was only significant for the BI group. Intervention effects were not sustained at 6 and 12 months. There was little evidence that alcohol use acted as a mediator (indirect effect, BI: aOR = 0.84, 95% CI = 0.63, 1.04; indirect effect, CoI: aOR = 0.86, 95% CI = 0.66, 1.03).

CONCLUSIONS

Among Vietnamese men receiving anti-retroviral therapy, alcohol reduction counseling interventions appeared to reduce intimate partner violence perpetration immediately post-intervention, but reductions were not sustained at 6 and 12 months and were not explained by alcohol reduction.

The longitudinal association between depression, anxiety symptoms and HIV outcomes, and the modifying effect of alcohol dependence among ART clients with hazardous alcohol use in Vietnam

INTRODUCTION

Mental health disorders may negatively impact HIV outcomes, such as viral suppression (VS) and antiretroviral (ART) adherence among people with HIV (PWH) with hazardous alcohol use. This study evaluates the longitudinal association between depression, anxiety symptoms, VS and complete ART adherence among ART clients with hazardous alcohol use in Vietnam; and examines alcohol dependence as a modifier in this association.

METHODS

This was a secondary data analysis of a trial for hazardous drinking ART clients in Thai Nguyen, Vietnam. From March 2016 to May 2018, 440 ART clients with an Alcohol Use Disorders Identification Test-Concise (AUDIT-C) score ≥4 for men and ≥3 for women were enrolled. Individuals were randomized to either a combined intervention, a brief intervention or a standard of care. Data on sociodemographics, depression, anxiety symptoms, alcohol use, VS and ART adherence were collected at baseline, three, six, and twelve months. Generalized estimating equation models controlling for intervention exposure were used to estimate time-lagged associations. Risk ratios were estimated using Poisson regression with robust variance estimation.

RESULTS

The mean age of participants was 40.2. The majority was male (96.8%), had at least some secondary school education (85.0%) and had a history of injection drug use (80.9%). No overall effect of depression and anxiety symptoms on VS was observed. When stratified by time, increased anxiety symptoms at six months were associated with VS at 12 months (adjusted risk ratio (aRR) = 1.09; 95% CI 1.02 to 1.17). An increase in depression or anxiety symptoms was associated with a decreased probability of complete ART adherence (depression symptoms: aRR = 0.95; 95% CI: 0.91 to 0.99; anxiety symptoms: aRR = 0.93; 85% CI: 0.88 to 0.99). The negative effects of anxiety symptoms on ART adherence were stronger among participants with alcohol dependence, compared to those without.

CONCLUSIONS

Depression and anxiety symptoms had no overall effect on VS, although they were associated with a lower probability of complete ART adherence. Interventions focusing on mental healthcare for PWH with hazardous alcohol use are needed, and integration of mental healthcare and alcohol reduction should be implemented in HIV primary care settings.

Changing Patterns of Alcohol Use and Probability of Unsuppressed Viral Load Among Treated Patients with HIV Engaged in Routine Care in the United States

We examined HIV viral load non-suppression ([Formula: see text] 200 copies/mL) subsequent to person-periods (3-18 months) bookended by two self-reports of alcohol use on a standardized patient reported outcome assessment among adults in routine HIV care. We examined the relative risk (RR) of non-suppression associated with increases and decreases in alcohol use (relative to stable use), stratified by use at the start of the person-period. Increases in drinking from abstinence were associated with higher risk of viral non-suppression (low-risk without binge: RR 1.16, 95% CI 1.03, 1.32; low-risk with binge: RR 1.35, 95% CI 1.11, 1.63; high-risk: RR 1.89, 95% CI 1.16, 3.08). Decreases in drinking from high-risk drinking were weakly, and not statistically significantly associated with lower risk of viral non-suppression. Other changes in alcohol use were not associated with viral load non-suppression. Most changes in alcohol consumption among people using alcohol at baseline were not strongly associated with viral non-suppression.

Psychiatric Disorders and Substance Use Among African American Women in HIV Care

African-American (AA) women are overrepresented among women with HIV (WWH). In the United States, psychiatric disorders are prevalent among WWH and associated with adverse outcomes. However, little research has examined psychiatric disorders among AA WWH. 315 AA women who were hazardous/heavy drinkers (HD) or moderate/non-drinkers (ND) were recruited from an HIV clinic in a study on alcohol use disorders. We compared sample prevalence of Axis-1 psychiatric diagnoses using the Structured Clinical Interview for DSM-IV with those from general population AA women in the National Comorbidity Survey-Replication (NCS-R). While 29.9% of general population AA women had any lifetime disorder, 66.9% of HD and 62.4% of ND WWH met criteria for a lifetime Axis-1 disorder. Specifically, lifetime PTSD and lifetime MDD were over threefold higher; current PTSD and current MDD respectively were 11-fold and threefold higher. PTSD was the most frequent comorbid diagnosis. HD and ND WWH did not differ in prevalence of psychiatric diagnoses despite significantly higher rates of substance use among HD women. Diagnostic evaluation and intervention for psychiatric disorders should be a priority in HIV medical care settings to improve health outcomes. Interventions should be tailored to address the particular stressors, challenges, and resiliencies among AA WWH.

Alcohol use, depressive symptoms, and intimate partner violence perpetration: A longitudinal analysis among men with HIV in northern Vietnam

Background

While the link between alcohol use and male-perpetrated intimate partner violence (IPV) has been well-established, research is needed to test whether psychosocial factors interact with alcohol use to exacerbate IPV perpetration. We tested whether depressive symptoms influenced the strength and/or direction of the alcohol-IPV relationship among men with HIV in Vietnam.

Methods

This study is a secondary analysis using data from a randomized controlled trial conducted in Thai Nguyen, Vietnam. Participants were clinic patients with HIV and hazardous alcohol use. Questionnaires were administered at baseline, three, six, and 12 months. Alcohol use was assessed as proportion of days alcohol abstinent. Analyses were restricted to males who reported being married/cohabitating at baseline (N = 313). Multilevel growth models were used to test whether time-varying depressive symptoms modified the time-varying effect of alcohol use on IPV perpetration.

Results

Time-varying depressive symptoms modified the effect of proportion of days alcohol abstinent on IPV perpetration. However, the pattern of effect modification was not as expected, as reporting depressive symptoms weakened the alcohol-IPV relationship. At times when participants screened negative for depressive symptoms, those who reported higher proportion of days alcohol abstinent than usual had significantly lower odds of IPV perpetration (Odds Ratio [OR] = 0.17, 95% Confidence Interval 0.06, 0.45, p = 0.0004). At times when participants screened positive for depressive symptoms, there was no observed effect of alcohol use on IPV perpetration (OR = 4.28, 95% CI 0.80, 22.78, p = 0.09).

Conclusion

The findings highlight the complex nature of the alcohol-IPV relationship and the need to investigate the intersection between hazardous drinking, mental health, and IPV. Men who concurrently report depressive symptoms and heightened alcohol use may be socially isolated from an intimate partner or experiencing fatigue, leading to less alcohol-related IPV perpetration. Mental health interventions addressing depression and alcohol misuse integrated into HIV services may reduce IPV perpetration.

Social support modifies the association between hazardous drinking and depression symptoms among ART clients in Vietnam

INTRODUCTION

Hazardous drinking is widespread among people with HIV (PWH). PWH are also vulnerable to depression due to HIV-related social stigma, and social support can play an important role in improving mental health for this population. No studies have explored whether social support modifies the association of hazardous drinking and depressive symptoms among PWH.

METHODS

We used baseline data from a randomized controlled trial of two evidence-based alcohol reduction interventions among antiretroviral therapy clients in Vietnam. Hazardous alcohol use was defined as having a score ≥8 for men and ≥ 7 for women on the Alcohol Use Disorders Identification Test. The presence of depression symptoms was defined as a score ≥ 5 on the Patient Health Questionnaire-9. Social support was measured with a 5-question modified version of the Medical Outcomes Study Social Support Instrument. Crude (CPRs) and adjusted prevalence ratios (aPRs) of the association were presented.

RESULTS

Hazardous drinking was significantly associated with increased likelihood of having depressive symptoms (aPR = 1.26;95%CI 1.04-1.52). Hazardous drinking and depression symptoms were not associated among those with high social support (aPR = 1.01;95%CI 0.76-1.35), but were associated among those with medium (aPR = 1.24;95%CI 0.92-1.69) and low social support (aPR = 1.71;95%CI 1.25-2.34).

CONCLUSIONS

Social support significantly modified the association between hazardous drinking and depression symptoms among ART clients in Vietnam. Interventions to decrease hazardous alcohol use are broadly indicated for PWH in Vietnam and other low-resource settings, but special attention or modifications may be needed to support mental health among those with lower levels of social support.

Alcohol abstinence stigma and alcohol use among HIV patients in Thai Nguyen, Vietnam

Background

Hazardous alcohol use is prevalent among people living with HIV (PWH), leading to sub-optimal HIV treatment outcomes. In Vietnam, alcohol use is highly normative making it socially challenging for PWH to reduce or abstain. We used mixed methods to develop a quantitative scale to assess alcohol abstinence stigma and examined the association between alcohol abstinence stigma with alcohol use among PWH in Vietnam.

Methods

We conducted qualitative interviews with 30 PWH with hazardous alcohol use from an antiretroviral therapy (ART) clinic in the Thai Nguyen to inform item development. Alcohol use was assessed using the Alcohol Use Disorders Identification Test. We tested items in a survey of 1,559 ART clinic patients to assess internal consistency and structural validity. We used log binomial modeling to estimate associations between any reported alcohol abstinence stigma and alcohol use.

Results

Using the results from the qualitative interview data, we developed the alcohol abstinence stigma scale with seven final items with scores ranging from 0 (no stigma) to 28 (high stigma). The scale had good internal consistency (α = 0.75). Exploratory factor analysis suggested the presence of three factors: internalized, experienced, and anticipated stigma that explained 56.9% of the total variance. The mean score was 2.74, (SD = 4.28) and 46% reported any alcohol abstinence stigma. We observed a dose-response relationship between alcohol abstinence stigma and alcohol use. PWH who reported any alcohol abstinence stigma had greater hazardous alcohol use (aPR = 1.32, 95% CI: 1.12, 1.56), harmful alcohol use (aPR = 2.26, 95% CI: 1.37, 3.72), and dependence symptoms (aPR = 3.81, 95% CI: 2.19, 6.64).

Conclusion

Alcohol abstinence stigma is associated with increased alcohol levels of alcohol use among PWH in Vietnam, signaling challenges for alcohol reduction. Consideration of alcohol abstinence stigma will be essential for the design of effective alcohol reduction interventions and policy efforts to prevent adverse health consequences of alcohol use among PWH.

Perpetration of Intimate Partner Violence Among Men Living with HIV in Northern Vietnam

We examined the prevalence of intimate partner violence (IPV) perpetration and characteristics of HIV-infected male perpetrators. The cross-sectional study was conducted in Vietnam with male antiretroviral treatment clients (N = 1099; mean age = 40.2 years). Bivariable associations were tested between psychological or physical/sexual IPV perpetration in the last 12 months and sociodemographic, psychosocial, and sexual behavioral factors using prevalence ratios. Factors significant at p < 0.10 were entered in multivariable models for each IPV outcome using a modified Poisson approach. Results showed 15.6% (N = 171/1099) reported perpetrating psychological IPV and 7.6% (N = 84/1099) perpetrating physical/sexual IPV in the last 12 months. HIV risk behaviors, including hazardous drinking and multiple sexual partners, having witnessed interparental violence as a child, and depressive symptoms were associated with perpetrating IPV. HIV interventions targeting HIV-infected men in Vietnam should intervene on IPV perpetration by addressing the co-occurring factors of sexual risk, depression, alcohol use, and child maltreatment that are correlated with IPV.

Effect of 2 Integrated Interventions on Alcohol Abstinence and Viral Suppression Among Vietnamese Adults With Hazardous Alcohol Use and HIV: A Randomized Clinical Trial

IMPORTANCE

Hazardous and heavy alcohol use is common among people living with HIV and may decrease antiretroviral therapy (ART) adherence, but limited data exist from randomized clinical trials about the effects of interventions on viral load.

OBJECTIVE

To compare the efficacy of 2 scalable ART clinic-based interventions on alcohol use and viral suppression.

DESIGN, SETTING, AND PARTICIPANTS

This 3-group randomized clinical trial was conducted among 440 adults with HIV who were being treated at 7 ART clinics in Thai Nguyen, Vietnam. Adults receiving ART with hazardous alcohol use (Alcohol Use Disorders Identification Test-Consumption score ≥4 for men or ≥3 for women) and no plans to leave Thai Nguyen were included. Data were collected from March 2016 to May 2018 and analyzed from June 2018 to February 2020.

INTERVENTIONS

Participants were randomly assigned (1:1:1) to standard of care (SOC), a combined intervention of motivational enhancement therapy and cognitive behavioral therapy (6 in-person sessions of 1 hour each and 3 optional group sessions), or a brief intervention with similar components as the combined intervention but consisting of 2 shorter in-person sessions and 2 telephone sessions.

MAIN OUTCOMES AND MEASURES

The primary study outcomes were percentage of days abstinent from alcohol, confirmed using the alcohol biomarker phosphatidylethanol, and viral suppression at 12 months after enrollment.

RESULTS

A total of 440 eligible individuals (mean [SD] age, 40.2 [5.8] years; 426 [96.8%] men) were enrolled; 147 (33.4%) were assigned to the combined intervention, 147 (33.4%) to the brief intervention, and 146 (33.2%) to SOC. In the combined intervention group, 112 participants (76.2%) attended all 6 sessions, and in the brief intervention group, 124 (84.4%) attended all 4 sessions; in the whole sample, 390 (88.6%) completed 12 months of follow-up. At 12 months, the mean (SE) percentage of days abstinent was 65% (3.1%) among those in the combined intervention group, 65% (3.2%) among those in the brief intervention group, and 50% (3.4%) among those in the in the SOC group (Cohen d for combined intervention vs SOC and brief intervention vs SOC: 39%; 95% CI, 15% to 64%). Viral suppression (ie, <20 copies of HIV-1 RNA per milliliter) at 12 months was higher after the brief intervention than SOC (difference, 11%; 95% CI, 2% to 20%), but the difference between the combined intervention and SOC was not significantly different (difference, 5%; 95%, CI, -5% to 15%).

CONCLUSIONS AND RELEVANCE

In this study, the brief intervention resulted in a significant increase in percentage of days abstinent from alcohol and a significant increase in viral suppression after 12 months. Future implementation science studies evaluating scale-up of the brief intervention are needed.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02720237.

Longitudinal analysis of alcohol use and intimate partner violence perpetration among men with HIV in northern Vietnam

BACKGROUND

Alcohol use is a known risk factor for male-perpetrated intimate partner violence (IPV), although few studies have been conducted globally and among men with HIV (MWH). We estimated the longitudinal effects of alcohol use on IPV perpetration among MWH.

METHODS

This study is a secondary analysis of randomized controlled trial data among male and female antiretroviral treatment patients with hazardous alcohol use in Thai Nguyen, Vietnam. Analyses were restricted to male participants who were married/cohabitating (N = 313). Alcohol use was assessed as proportion days alcohol abstinent, heavy drinking, and alcohol use disorder (AUD) using the Timeline Followback and Mini International Neuropsychiatric Interview questionnaire. Multilevel modeling was used to estimate the effects of higher versus lower average alcohol use on IPV perpetration (between-person effects) and the effects of time-specific deviations in alcohol use on IPV perpetration (within-person effects).

RESULTS

Participants with higher average proportion days alcohol abstinent had decreased odds of IPV perpetration (adjusted Odds Ratio [aOR] = 0.43, p = 0.03) and those with higher average heavy drinking and AUD had increased odds of IPV perpetration (Heavy drinking: aOR = 1.05, p = 0.002; AUD: aOR = 4.74, p < 0.0001). Time-specific increases in proportion days alcohol abstinent were associated with decreased odds of IPV perpetration (aOR = 0.39, p = 0.02) and time-specific increases in AUD were associated with increased odds of IPV perpetration (aOR = 2.95, p = 0.001). Within-person effects for heavy drinking were non-significant.

CONCLUSIONS

Alcohol use is associated with IPV perpetration among Vietnamese men with HIV. In this context, AUD and frequent drinking are stronger correlates of IPV perpetration as compared to heavy drinking.

Alcohol Use Patterns and Subsequent Sexual Behaviors Among Women, Men who have Sex with Men and Men who have Sex with Women Engaged in Routine HIV Care in the United States

Among people with HIV, alcohol use is associated with increased prevalence of sexual transmission behaviors. We examined associations between alcohol use in the prior year and sexual behaviors approximately six months later among 1857 women, 6752 men who have sex with men (MSM) and 2685 men who have sex with women (MSW). Any alcohol use was associated with increased risk of unsafe vaginal sex among women; anal sex and =>2 anal sex partners among MSM; and anal sex, =>2 anal or vaginal sex partners, and unsafe vaginal sex among MSW. In particular, among women >7 alcoholic drinks/week and among MSW =>5 alcoholic drinks/drinking day increased the likelihood of certain subsequent sexual behaviors. For all groups, especially women, the risk of sex under the influence of drugs/alcohol markedly increased with increases in quantity and frequency of alcohol consumption. These different patterns of drinking and sexual behaviors indicate the importance of tailored counseling messages to women, MSM and MSW.

Do Symptoms of Depression Interact with Substance Use to Affect HIV Continuum of Care Outcomes?

Few studies examine how depression and substance use interact to affect HIV control. In 14,380 persons with HIV (PWH), we used logistic regression and generalized estimating equations to evaluate how symptoms of depression interact with alcohol, cocaine, opioid, and methamphetamine use to affect subsequent retention in care, maintaining an active prescription for ART, and consistent virologic suppression. Among PWH with no or mild depressive symptoms, heavy alcohol use had no association with virologic suppression (OR 1.00 [0.95-1.06]); among those with moderate or severe symptoms, it was associated with reduced viral suppression (OR 0.80 [0.74-0.87]). We found no interactions with heavy alcohol use on retention in care or maintaining ART prescription or with other substances for any outcome. These results highlight the importance of treating moderate or severe depression in PWH, especially with comorbid heavy alcohol use, and support multifaceted interventions targeting alcohol use and depression.

"[Drinking is] Like a Rule That You Can't Break": Perceived Barriers and Facilitators to Reduce Alcohol Use and Improve Antiretroviral Treatment Adherence among People Living with HIV and Alcohol Use Disorder in Vietnam

BACKGROUND

Alcohol use, a highly normative behavior in Vietnam that is associated with high rates of HIV infection and lower antiretroviral treatment (ART) adherence, has been largely overlooked by HIV prevention efforts.

OBJECTIVES

Using the risk environment framework, this qualitative study aims to explore the perceived microenvironmental (community-level) and endogenous (individual-level) barriers and facilitators to alcohol reduction among people living with HIV (PLHIV) with alcohol use disorders (AUDs) in Vietnam.

METHODS

From June-July 2014, semi-structured interviews were conducted with thirty PLHIV (18 men; 12 women) recruited from an outpatient ART clinic in Thai Nguyen province, Vietnam. All participants had scores of ≥8 on the Alcohol Use Disorders Identification Test and ten of the 30 participants were currently using injection drugs. Interviews were transcribed, translated, and analyzed to identify perceived barriers and facilitators to alcohol reduction.

RESULTS

Most participants reported a spike in alcohol consumption at the time of HIV diagnosis. Most perceived barriers existed at the microenvironmental level, including perceived inability to refuse alcohol in the context of community-level social norms and lack of alcohol treatment programs. Two commonly mentioned endogenous barriers were compensatory behaviors when reducing injection drug use and using alcohol as a coping strategy for HIV-related sadness. Those who were able to successfully reduce alcohol use and adhere to ART reported having social support to buffer community-level social pressure and cope with sadness.

CONCLUSIONS

It may be effective to introduce targeted alcohol reduction interventions in health care centers to address individual risk practices and microenvironmental social norms.

The role of personal and household members' substance use in health-related quality of life in women living with HIV/AIDS

Advances in HIV treatments have led to a greater focus on health-related quality of life (HRQOL) among people living with HIV/AIDS. The current study examined factors associated with HRQOL among 378 women in HIV care. HRQOL was measured using a modified version of the 12-Item Short Form Health Survey; scores were derived for the mental and physical composite summaries (MCS and PCS). We measured personal alcohol use and drug use. Household members' substance use were assessed by asking participants about the alcohol/drug status of persons with whom they live. Multivariate generalized linear models were used to estimate the linear association between MCS and PCS scores and personal and household members' alcohol and drug use. We found lower MCS scores were significantly associated with personal alcohol use and living with someone with alcohol or/and drug problems. Lower PCS scores were not significantly associated with personal alcohol use or living with someone with alcohol or/and drug problems. Findings suggest that universal screening and targeted interventions for alcohol use by the patient or household members may offer potential strategies for improving mental health quality of life among women living with HIV/AIDS.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Design and Implementation of a Community Health Worker HIV Treatment and Prevention Intervention in an HIV Hot Spot Fishing Community in Rakai, Uganda

Innovative approaches are needed to increase engagement in HIV treatment and prevention services, particularly in HIV hot spots. Here, we detail our design, training approach, and early implementation experiences of a community-based HIV intervention called "health scouts." The intervention, utilizing a novel, theory-based approach, trained 10 community residents in an HIV hot spot fishing community to use motivational interviewing strategies and a mobile phone-based counseling application. During the first 3 months, 771 residents (median 82/health scout, range 27-160) were counseled. A directly observed Motivational Interviewing Treatment Integrity scale-based evaluation found adequate performance (median score 20/25, range 11-23). The health scout intervention was feasible to implement in a high HIV-prevalence fishing community, and its impact on HIV care outcomes will be evaluated in an ongoing cluster randomized trial. If found to be effective, it may be an important strategy for responding to HIV in high-burden settings.

Acceptability of a mobile health intervention to enhance HIV care coordination for patients with substance use disorders

Background

Persons living with HIV and substance use disorders face barriers to sustained engagement in medical care, leading to suboptimal antiretroviral treatment outcomes. Innovative mobile technology tools such as customizable smartphone applications have the potential to enhance existing care coordination programs, but have not been rigorously studied.

Methods

We developed and implemented a two-component intervention consisting of peer health navigation supported by a smartphone application conducting ecologic momentary assessment (EMA) of barriers to care and medication adherence. Patients with a history of antiretroviral treatment failure and substance use were recruited to participate in the 9-month pilot intervention. Three peer health navigators were trained to provide social and logistical support while participants re-engaged in HIV care. We assessed the acceptability of the intervention components using qualitative analysis of in-depth interviews conducted with study participants and peer navigators.

Results

Of 19 patients enrolled in the study, 17 participated for at least 2 months and 15 completed the entire 9-month study protocol. The acceptability of the peer navigation intervention was rated favorably by all participants interviewed, who felt that peer support was instrumental in helping them re-engage in HIV care. Participants also responded favorably to the smartphone application, but described its usefulness mostly as providing reminders to take medications and attend appointments, rather than as a facilitator of patient navigation.

Conclusions

Peer health navigation and smartphone-based EMA are acceptable approaches to facilitating engagement in HIV care for drug using populations. Future studies to evaluate the efficacy of this approach for improving long-term retention in care and antiretroviral treatment outcomes are warranted.

ClinicalTrials.gov Identifier NCT01941108; registered on September 4, 2013

Anxiety, Anxiety Sensitivity, and Perceived Stress as Predictors of Recent Drinking, Alcohol Craving, and Social Stress Response in Heavy Drinkers

BACKGROUND

Stress and anxiety are widely considered to be causally related to alcohol craving and consumption, as well as development and maintenance of alcohol use disorder (AUD). However, numerous preclinical and human studies examining effects of stress or anxiety on alcohol use and alcohol-related problems have been equivocal. This study examined relationships between scores on self-report anxiety, anxiety sensitivity, and stress measures and frequency and intensity of recent drinking, alcohol craving during early withdrawal, as well as laboratory measures of alcohol craving and stress reactivity among heavy drinkers with AUD.

METHODS

Media-recruited, heavy drinkers with AUD (N = 87) were assessed for recent alcohol consumption. Anxiety and stress levels were characterized using paper-and-pencil measures, including the Beck Anxiety Inventory (BAI), the Anxiety Sensitivity Index-3 (ASI-3), and the Perceived Stress Scale (PSS). Eligible subjects (N = 30) underwent alcohol abstinence on the Clinical Research Unit; twice daily measures of alcohol craving were collected. On day 4, subjects participated in the Trier Social Stress Test; measures of cortisol and alcohol craving were collected.

RESULTS

In multivariate analyses, higher BAI scores were associated with lower drinking frequency and reduced drinks/drinking day; in contrast, higher ASI-3 scores were associated with higher drinking frequency. BAI anxiety symptom and ASI-3 scores also were positively related to Alcohol Use Disorders Identification Test total scores and AUD symptom and problem subscale measures. Higher BAI and ASI-3 scores but not PSS scores were related to greater self-reported alcohol craving during early alcohol abstinence. Finally, BAI scores were positively related to laboratory stress-induced cortisol and alcohol craving. In contrast, the PSS showed no relationship with most measures of alcohol craving or stress reactivity.

CONCLUSIONS

Overall, clinically oriented measures of anxiety compared with perceived stress were more strongly associated with a variety of alcohol-related measures in current heavy drinkers with AUD.

Interaction Between Alcohol Consumption Patterns, Antiretroviral Therapy Type, and Liver Fibrosis in Persons Living with HIV

We examined the longitudinal association between alcohol use and liver fibrosis, measured by FIB-4 Score, among HIV-infected individuals by (1) antiretroviral therapy (ART) class, and (2) the presence of hepatitis C (HCV) co-infection. This was a prospective cohort study of 550 individuals in the Johns Hopkins HIV Clinical Cohort initiating ART between 2000 and 2012. The relationship between alcohol consumption (defined using NIAAA categories of non-, moderate, and hazardous drinkers) and liver fibrosis (FIB-4 score) by ART class was assessed using linear mixed effects models. Additionally, we examined whether the presence of HCV modified and whether viral load mediated the relationship between alcohol use and liver fibrosis. Overall, FIB-4 levels were 15.6% higher in hazardous drinkers compared to moderate drinkers (p = 0.025) after adjusting by age, sex, and race. Hazardous drinkers on PI-based regimens had FIB-4 scores 26.9% higher than moderate drinkers (p = 0.015). However, there was no difference in FIB-4 levels between hazardous drinkers on non-PI-based regimens compared to moderate drinkers (1.83% versus moderate drinkers, p = 0.848). There was no significant difference in FIB-4 between nondrinkers and moderate drinkers, irrespective of ART regimen. These associations were not modified by HCV status or mediated by viral load changes. Individuals with hazardous alcohol consumption and on PI-based regimens had significantly increased liver fibrosis, as measured by the FIB-4. These data suggest that providers should consider level of alcohol consumption when choosing an ART regimen to minimize detrimental effects on the liver.

A qualitative study of barriers to and facilitators of optimal engagement in care among PLWH and substance use/misuse

BACKGROUND

Persons living with HIV (PLWH) and substance use/misuse experience significant barriers to engagement in HIV care at every step of the HIV care continuum including: (1) HIV testing and diagnosis (2) linkage to clinical care (3) retention in care pre-antiretroviral therapy (ART) (4) ART initiation and adherence (5) viral suppression. We qualitatively explored the facilitators of and barriers to participation in the HIV care continuum among PLWH with substance use/misuse.

METHODS

We performed semi-structured in-depth interviews with 34 PLWH in care with recent substance use. The transcripts were analyzed in an iterative process using an editing style analysis. Interviews were conducted until thematic saturation was achieved.

RESULTS

Participants attributed an escalation in drug use at the time of diagnosis to denial of their disease and the belief that their death was inevitable and cited this as a barrier to treatment entry. In contrast, participants reported that experiencing adverse physical effects of uncontrolled HIV infection motivated them to enroll in care. Reported barriers to retention and adherence to care included forgetting medications and appointments because of drug use, prioritizing drug use over HIV treatment and side effects associated with medications. Participants described that progression of illness, development of a medication taking ritual and a positive provider-patient relationship all facilitated engagement and reengagement in care.

CONCLUSIONS

PLWH with substance use engaged in care describe barriers to and facilitators of optimal engagement related to and distinct from substance use. Greater understanding of the biologic, psychological and social factors that promote and impair engagement in care can inform interventions and reduce the increased morbidity and mortality experienced by PLWH with substance use.

HIV primary care providers--Screening, knowledge, attitudes and behaviors related to alcohol interventions

BACKGROUND

Alcohol has particularly harmful health effects in HIV-infected patients; therefore, HIV clinics are an important setting for integration of brief alcohol intervention and alcohol pharmacotherapy to improve patient outcomes. Current practices of alcohol screening, counseling, and prescription of pharmacotherapy by HIV providers are unknown.

METHODS

We conducted a cross-sectional survey of HIV providers from 8 HIV clinical sites across the United States. Surveys queried knowledge and use of alcohol screening, brief advice, counseling and pharmacotherapy, confidence and willingness to prescribe pharmacotherapy and barriers to their use of alcohol pharmacotherapy. We used multivariable logistic regression to examine provider factors associated with confidence and willingness to prescribe pharmacotherapy.

RESULTS

Providers (N=158) were predominantly female (58%) and Caucasian (73%); almost half were infectious disease physicians and 31% had been in practice 10-20 years. Most providers (95%) reported always or usually screening for alcohol use, although only 10% reported using a formal screening tool. Over two-thirds never or rarely treated alcohol-dependent patients with pharmacotherapy themselves. Most (71%) referred alcohol-dependent patients for treatment. Knowledge regarding alcohol pharmacotherapy was low. The major barrier to prescribing pharmacotherapy was insufficient training on use of pharmacotherapy. Provider confidence ratings were positively correlated with their practice patterns.

CONCLUSIONS

HIV providers reported high rates of screening for alcohol use, though few used a formal screening tool. Most providers referred alcohol dependent patients to outside resources for treatment. Few reported prescribing alcohol pharmacotherapy. Increased training on alcohol pharmacotherapy may increase confidence in prescribing and use of these medications in HIV care settings.

Alcohol Use and Unintended Sexual Consequences among Women Attending an Urban Sexually Transmitted Infections Clinic

BACKGROUND

Although alcohol use has been linked with a variety of sexual behaviors, we lack an understanding of what precise events occur when women drink that may lead to emotional or physical harms.

METHODS

To fill this gap, we qualitatively explored the unintended sexual events occurring while drinking among a particularly at-risk clinic population: urban women attending a public sexually transmitted infections (STI) clinic. This was a secondary data analysis of 20 semistructured, in-depth interviews conducted between December 2009 and August 2010 with 20 sexually active adult women attending the Baltimore City Health Department STI Clinic. We purposively sampled women presenting for care in the STI clinic who reported either binge drinking in the past 6 months or engaging in vaginal or anal intercourse while under the influence of alcohol. Interviews were analyzed using a grounded theory approach.

RESULTS

Five major unintended sexual events emerged: sex with new partners; alternative sexual activities, including anal sex and "rough" sex; unprotected sex; blacked out sex or sex occurring during alcohol-related amnesia; and rape. Themes often overlapped, and sexual victimization was a common thread throughout multiple themes. An additional theme, alcohol and prey, largely occurring in bars and nightclubs, emerged as an important precursor to many of the unintended events described.

CONCLUSIONS

Alcohol use was associated with a variety of--often dangerous--unintended sexual events. Our results highlight the link between alcohol use and sexual victimization and the need for intervention development to reduce the emotional and physical harms resulting from the unintended consequences of alcohol use.

Sex-Related Alcohol Expectancies Among African American Women Attending an Urban STI Clinic

African American women are disproportionately affected by human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and sexually transmitted infections (STIs). Alcohol use is a significant risk factor for HIV/STI acquisition. Sex-related alcohol expectancies (SRAEs) may partially account for alcohol-related risky sexual behaviors. Using qualitative interviews we explored the link between alcohol use and risky sex among 20 African American women attending an STI clinic who had consumed four or more alcoholic drinks per drinking day (binge drinking) and/or reported vaginal or anal sex while under the influence of alcohol. Four SRAEs emerged, which we named drink for sexual desire, drink for sexual power, drink for sexual excuse, and drink for anal sex. While the desire SRAE has been documented, this study identified three additional SRAEs not currently assessed by expectancy questionnaires. These SRAEs may contribute to high-risk sex when under the influence of alcohol and suggests the importance of developing integrated alcohol-sexual risk reduction interventions for high-risk women.

A novel integration effort to reduce the risk for alcohol-exposed pregnancy among women attending urban STD clinics

Alcohol-exposed pregnancy (AEP) is a significant public health problem in the United States. Sexually transmitted disease (STD) clinics serve female clients with a high prevalence of heavy alcohol consumption coupled with ineffective contraceptive use. Project CHOICES (Changing High-Risk AlcOhol Use and Increasing Contraception Effectiveness) is an evidence-based, brief intervention to lower risk of AEP by targeting alcohol and contraceptive behaviors through motivational interviewing and individualized feedback. We describe our experience integrating and implementing CHOICES in STD clinics. This endeavor aligns with CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention's program collaboration and service integration strategic priority to strengthen collaborative work across disease areas and integrate services provided by related programs at the client level.

Alcohol use, anal sex, and other risky sexual behaviors among HIV-infected women and men

Effective sexual risk reduction strategies for HIV-infected individuals require an understanding of alcohol's influence on specific sexual behaviors. We conducted audio-computer-assisted-self-interviews on 910 patients from two HIV primary care programs. The association between alcohol use and risky sexual behaviors was examined using multivariable logistic regression adjusting for age, education, race/ethnicity and drug use. Frequent/binge drinking was associated with engaging in anal sex and having multiple sex partners among women, engaging in insertive anal sex among gay/bisexual men, and was unrelated to risky sexual behaviors among heterosexual men. Infrequent drinkers did not differ in sexual risk behaviors from abstainers among women or men. Finally, there was no interaction effect between race/ethnicity and alcohol use on the association with sexual risk behaviors. The study has yielded important new findings in several key areas with high relevance to HIV care. Results underscore the importance of routinely screening for alcohol use and risky sexual behaviors in HIV primary care.

Are smokers with HIV using information and communication technology? Implications for behavioral interventions

Smoking is highly prevalent among persons living with HIV/AIDS (PLWHA) and associated with adverse outcomes including malignancy and cardiovascular disease. Information and communication technology (ICT) may be effective in disseminating cessation interventions among PLWHA. This study examines the prevalence of ICT use among 492 PLWHA attending an urban clinic and characteristics associated with ICT use. Participants completed a survey of demographics, smoking status, and ICT use. Factors associated with ICT use were examined with logistic regression. Overall, 63% of participants smoked with 73% of smokers owning their own cell phone. Use of other modalities was lower, with 48% of smokers reporting any internet use, 39% text messaging, and 31% using email. Higher education was associated with the use of all modalities. Cell phone interventions may have the broadest reach among PLWHA, though with almost half using the internet, this may also be a low-cost means of delivering cessation interventions.

A systematic review of randomized controlled trials: Web-based interventions for smoking cessation among adolescents, college students, and adults

INTRODUCTION

Web-based treatments can deliver broad reaching, relatively inexpensive, and clinically tested methods for smoking cessation. We performed a systematic review of randomized controlled trials (RCTs) of smoking cessation to evaluate the efficacy of Web-based interventions in adults, college students, and adolescents.

METHODS

MEDLINE, EMBASE, The Cochrane Library, CINAHL, and PsycINFO were searched from January 1, 1990 through February 12, 2010 for RCTs examining the efficacy of Web-based smoking cessation programs. Paired reviewers abstracted data on study design, patient characteristics, and outcomes sequentially and did quality assessments independently.

RESULTS

Twenty-one RCTs met eligibility criteria, with 15 conducted among adults. Among adults, 2 RCTs found that a multicomponent intervention with Web and non-Web-based elements was more efficacious than a self-help manual, and one of 2 RCTs found that Web-based interventions may be more effective than no treatment. Three trials provided insufficient evidence to demonstrate whether Web-based interventions were more efficacious than counseling. By contrast, tailored Web sites in 2 RCTs and greater Web site exposure in 6 of 7 RCTs were associated with higher rates of abstinence. Among college students, evidence supporting use of Web-based interventions was insufficient because the one RCT conducted was also a multicomponent intervention. Five RCTs among adolescents demonstrated mixed results, with insufficient evidence supporting their efficacy.

CONCLUSIONS

Evidence supporting the use of Web-based interventions for smoking cessation is insufficient to moderate in adults and insufficient in college students and adolescents. These RCTs have, however, elucidated clinical, methodological, and statistical practices that are likely to improve future trial design and treatment delivery.

Alcohol consumption among HIV-infected women: impact on time to antiretroviral therapy and survival

OBJECTIVE

Alcohol use is prevalent among HIV-infected people and is associated with lower antiretroviral adherence and high-risk sexual and injection behaviors. We sought to determine factors associated with alcohol use among HIV-infected women engaged in clinical care and if baseline alcohol use was associated with time to combination antiretroviral therapy (cART) and death in this population.

METHODS

In an observational clinical cohort, alcohol consumption at the initial medical visit was examined and categorized as heavy, occasional, past, or no use. We used multinomial logistic regression to test preselected covariates and their association with baseline alcohol consumption. We then examined the association between alcohol use and time to cART and time to death using Kaplan-Meier statistics and Cox proportional hazards regression.

RESULTS

Between 1997 and 2006, 1030 HIV-infected women enrolled in the cohort. Assessment of alcohol use revealed occasional and hazardous consumption in 29% and 17% of the cohort, respectively; 13% were past drinkers. In multivariate regression, heavy drinkers were more likely to be infected with hepatitis C than nondrinkers (relative risk ratios [RRR] 2.06, 95% confidence interval [CI] 1.29-3.44) and endorse current drug (RRR 3.51, 95% CI 2.09-5.91) and tobacco use (RRR 3.85 95% CI 1.81-8.19). Multivariable Cox regression adjusting for all clinical covariates demonstrated an increased mortality risk (hazard ratio [HR] 1.40, 95% CI 1.00-1.97, p < 0.05) among heavy drinkers compared to nondrinkers but no delays in cART initiation (1.04 95% CI 0.81-1.34)

CONCLUSIONS

Among this cohort of HIV-infected women, heavy alcohol consumption was independently associated with earlier death. Baseline factors associated with heavy alcohol use included tobacco use, hepatitis C, and illicit drug use. Alcohol is a modifiable risk factor for adverse HIV-related outcomes. Providers should consistently screen for alcohol consumption and refer HIV-infected women with heavy alcohol use for treatment.

Digital divide: variation in internet and cellular phone use among women attending an urban sexually transmitted infections clinic

We sought to describe: (1) the prevalence of internet, cellular phone, and text message use among women attending an urban sexually transmitted infections (STI) clinic, (2) the acceptability of health advice by each mode of information and communication technology (ICT), and (3) demographic characteristics associated with ICT use. This study is a cross-sectional survey of 200 English-speaking women presenting to a Baltimore City STI clinic with STI complaints. Participants completed a self-administered survey querying ICT use and demographic characteristics. Three separate questions asked about interest in receiving health advice delivered by the three modalities: internet, cellular phone, and text message. We performed logistic regression to examine how demographic factors (age, race, and education) are associated with likelihood of using each modality. The median age of respondents was 27 years; 87% were African American, and 71% had a high school diploma. The rate of any internet use was 80%; 31% reported daily use; 16% reported weekly use; and 32% reported less frequent use. Almost all respondents (93%) reported cellular phone use, and 79% used text messaging. Acceptability of health advice by each of the three modalities was about 60%. In multivariate analysis, higher education and younger age were associated with internet use, text messaging, and cellular phone use. Overall rate of internet use was high, but there was an educational disparity in internet use. Cellular phone use was almost universal in this sample. All three modalities were equally acceptable forms of health communication. Describing baseline ICT access and the acceptability of health advice via ICT, as we have done, is one step toward determining the feasibility of ICT-delivered health interventions in urban populations.

The relationship between recent alcohol use and sexual behaviors: gender differences among sexually transmitted disease clinic patients

BACKGROUND

Binge drinking is associated with risky sexual behaviors and sexually transmitted diseases (STDs). Few studies have investigated this by gender or in an STD clinic. This cross-sectional study examined the association between binge drinking and risky sexual behaviors/STDs among patients attending an urban STD clinic.

METHOD

A total of 671 STD clinic patients were tested for STDs, and queried about recent alcohol/drug use and risky sexual behaviors using audio computer-assisted-self-interview. The association between binge drinking and sexual behaviors/STDs was analyzed using logistic regression adjusting for age, employment, and drug use.

RESULTS

Binge drinking was reported by 30% of women and 42% of men. Gender differences were found in rates of receptive anal sex which increased linearly with increased alcohol use among women but did not differ among men. Within gender analyses showed that women binge drinkers engaged in anal sex at more than twice the rate of women who drank alcohol without binges (33.3% vs. 15.9%; p < 0.05) and 3 times the rate of women who abstained from alcohol (11.1%; p < 0.05). Having multiple sex partners was more than twice as common among women binge drinkers than women abstainers (40.5% vs. 16.8%; p < 0.05). Gonorrhea was nearly 5 times higher among women binge drinkers compared to women abstainers (10.6% vs. 2.2%; p < 0.05). The association between binge drinking and sexual behaviors/gonorrhea remained after controlling for drug use. Among men, rates of risky sexual behaviors/STDs were high, but did not differ by alcohol use.

CONCLUSION

Rates of binge drinking among STD clinic patients were high. Among women, binge drinking was uniquely associated with risky sexual behaviors and an STD diagnosis. Our findings support the need to routinely screen for binge drinking as part of clinical care in STD clinics. Women binge drinkers, in particular, may benefit from interventions that jointly address binge drinking and risky sexual behaviors. Developing gender-specific interventions could improve overall health outcomes in this population.

Audio computer assisted self interview and face to face interview modes in assessing response bias among STD clinic patients

BACKGROUND

Audio computer assisted self interview (ACASI) may minimise social desirability bias in the ascertainment of sensitive behaviours. The aim of this study was to describe the difference in reporting risk behaviour in ACASI compared to a face to face interview (FFI) among public sexually transmitted diseases (STD) clinic attendees.

STUDY DESIGN

Randomly selected patients attending a public STD clinic in Baltimore, Maryland, sequentially took an ACASI formatted risk behaviour assessment followed by an FFI conducted by a single clinician, with both interview modalities surveying sexual and drug use behaviours. Binary responses were compared using the sign test, and categorical responses were compared using the Wilcoxon signed rank test to account for repeated measures.

RESULTS

671 (52% men, mean age 30 years, 95% African American) of 795 clinic attendees screened consented to participate. Subjects affirmed sensitive sexual behaviours such as same sex contact (p = 0.012), receptive rectal sexual exposure (p < 0.001), orogenital contact (p < 0.001), and a greater number of sex partners in the past month (p < 0.001) more frequently with ACASI than with an FFI. However, there were no differences in participant responses to questions on use of illicit drugs or needle sharing.

CONCLUSIONS

Among STD clinic patients, reporting of sensitive sexual risk behaviours to clinicians was much more susceptible to social desirability bias than was reporting of illegal drug use behaviours. In STD clinics where screening of sexual risk is an essential component of STD prevention, the use of ACASI may be a more reliable assessment method than traditional FFI.

Depression and HIV risk behaviors among patients in a sexually transmitted disease clinic

OBJECTIVE

The authors' goal was to investigate the relationship between depression and HIV risk behaviors or sexually transmitted disease (STD) diagnosis at an urban STD clinic.

METHOD

Using audio computer-assisted self-interview, 671 STD clinic patients answered questions about HIV risk behaviors and depression in a large-scale, cross-sectional study. A subset of the patients (N=201) was evaluated for current major depressive disorder by interviewers using the nonpatient edition of the Structured Clinical Interview for DSM-IV.

RESULTS

Depressed patients were more likely to have sex for money or drugs, to have had sex with an intravenous drug user, to have sex when "high" on alcohol or drugs, to have a greater number of lifetime sex partners, and to abuse alcohol or drugs than were nondepressed patients. Associations of HIV risk behaviors with depression persisted after adjustment for substance abuse.

CONCLUSIONS

Depression in STD clinic patients is associated with HIV risk behaviors but not STD diagnosis. Identifying depression and developing strategies to intervene effectively may reduce HIV risk behaviors and improve health outcomes.

The Prevalence of Psychiatric Disorders in Sexually Transmitted Disease Clinic Patients and Their Association With Sexually Transmitted Disease Risk

BACKGROUND AND OBJECTIVES

Psychiatric disorders could limit the success of behavioral counseling strategies. We evaluated the prevalence of psychiatric disorders among sexually transmitted disease (STD) clinic patients and their association with STD risk.

METHODS

A systematic sample of 201 patients presenting to a public STD clinic in Baltimore, Maryland, participated in the structured clinical interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th edition.

RESULTS

Overall, 45% of 201 STD clinic patients interviewed had a current axis I disorder and 29% had an axis II personality disorder. Substance use disorders predominated among axis I diagnoses; antisocial personality disorder (ASPD) predominated among axis II diagnoses, with an ASPD prevalence of 29.4% in men. ASPD was associated with a diagnosis of an STD (odds ratio, 3.67; 95% confidence interval, 1.63-8.30; P = 0.002). Substance use was not associated with an STD diagnosis.

CONCLUSIONS

STD clinic patients have complex psychopathology that could increase HIV risk and compromise prevention interventions. Specialized counseling strategies, particularly targeting personality traits of ASPD, could improve prevention outcomes.

Psychiatric issues in the management of patients with HIV infection

Approximately 1 million persons are now infected with human immunodeficiency virus (HIV) in the United States. Evidence exists that psychiatric disorders are common in patients with HIV and that these patients may not receive optimal care because their psychiatric disorders are a barrier to medical care, communication with clinicians, and adherence to medical recommendations. We describe herein a complex case seen at The Johns Hopkins Hospital with several psychiatric conditions that are common in our HIV clinic population. We describe the collaborative treatment of the patient by a multidisciplinary team including both medical and mental health practitioners. We briefly describe a coherent diagnostic and treatment approach to patients in HIV clinics and the supporting rationale from the literature. We discuss the need for comprehensive evaluation, a multidisciplinary treatment team, and therapeutic optimism.