Key Takeaways
- Prevalence of Unhealthy Alcohol Use in Persons with HIV: Unhealthy alcohol use is common among individuals with HIV and has been associated with lower antiretroviral therapy (ART) adherence, reduced HIV viral suppression, and increased sexual risk behaviors. This study focuses on persons with HIV experiencing unhealthy alcohol use and evaluates the effectiveness of a culturally adapted, skills-based alcohol counseling intervention compared to standard care.
- Intervention Design and Outcomes: The intervention involved a multi-session alcohol counseling program based on the Information, Motivation, and Behavioral skills model, with participants receiving in-person counseling sessions, “booster” phone-based sessions, and viral load and adherence counseling. While the intervention resulted in significant reductions in unhealthy alcohol use, it did not show a statistically significant improvement in viral suppression compared to the control group at the 24-week mark.
- Study Implications: Despite the observed reduction in unhealthy alcohol use, the study suggests that the counseling intervention did not have a significant impact on viral suppression among persons with HIV at the 24-week follow-up. The findings highlight the complex relationship between alcohol use and HIV outcomes, emphasizing the need for further research to understand and refine interventions that address both aspects of care for persons with HIV.
The unhealthy use of alcohol is common among persons with HIV (PWH) and has been associated with lower antiretroviral therapy (ART) adherence, lower HIV viral suppression, and increased sexual risk behaviors. The lack of these precautions can contribute to HIV transmission, according to the authors of a study published in Journal of the International AIDS Society. The study investigators compared the effectiveness of a culturally adapted, skills-based alcohol counseling intervention with standard care for PWH with unhealthy alcohol use and risk of viral non-suppression.
The trial recruited participants aged 18 years and older who were HIV-positive and who are considered Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) positive for unhealthy alcohol use (≥ 4 for men and ≥ 3 for women). Participants were then randomly assigned to receive either alcohol counseling intervention or standard-of-care (SOC; control group). Participants in the control group received advice on the harmful effects of alcohol and safe levels of drinking at the baseline visit in line with the county’s SOC, viral load feedback, and adherence counseling at their post-baseline clinical visit. In addition, each participant had 1 of the following risk factors for non-suppression: HIV RNA non-suppression in the prior 12 months (> 400 copies/ml), missed clinic visit in the past 6 months (>2 weeks to ≤90 days from the last scheduled visit), out of care in the past 6 months (>90 days from last scheduled visit), or new HIV diagnosis (not yet on ART or ART started < 4 weeks).
At baseline, participants received a questionnaire and were asked to self-assess on demographics, AUDIT-C adapted to the prior 3 months, ART use, and current tobacco or other substance use. Further, laboratory assessments included HIV-1 RNA viral load, CD4 cell count, and phosphatidylethanol (PEth) level—a quantitative biomarker of recent alcohol consumption—at baseline, and a viral load and PEth at week 24.
Intervention consisted of multi-session alcohol counseling based on the Information, Motivation, and Behavioral skills model, which in a prior intervention was shown to be effective in reducing alcohol use among women in the United States. In addition, intervention included 2 in-person counseling sessions—1 performed at baseline and 1 during week 12—with brief phone-based “booster” counseling sessions performed every 3 weeks between in-person sessions. In-person sessions were designed to reflect on the consequences of alcohol use on one’s health and HIV treatment, identify moods and situations that precede the use of alcohol, build skills for alternative behaviors, and set individualized goals to check progress and provide positive reinforcement when appropriate. In addition, intervention participants received viral load and adherence counseling depending on results from the baseline study visit.
A total of 401 adults were enrolled in the study, of which 203 were in the control group and 197 were in the intervention group. Of the total participants, 239 (60%) were considered virally suppressed at baseline, and participants had met eligibility criteria for risk of HIV viral non-suppression for recent unsuppressed viral load (n = 141; 35%), missed clinic visit or visits (n = 111; 28%), new HIV diagnosis (n = 109; 27%), and re-engagement in care (n = 39; 10%). In addition, 321 participants (80%) were on ART at baseline, with the majority (n = 279; 96%) having a prior HIV diagnosis.
Among the 197 participants in the intervention arm, 196 (99%) had completed the baseline in-person counseling session and 184 (93%) had completed the second session. In addition, booster calls were completed for 160 (81%), 148 (75%), and 151 (77%) at weeks 3, 6, and 9, respectively.
From 60% at baseline in both arms, viral suppression increased to 83% (95% CI: 78%-89%) in the intervention arm and 82% (95% CI: 78%-87%) in the control arm at 24 weeks, with a non-statistically significant improvement of 1%. The study authors note that findings were similar across subgroups that were defined based on age, sex, country, baseline alcohol use, baseline non-suppression risk factor, and baseline HIV viral suppression status.
The study authors noted that significant reductions in unhealthy alcohol use (AUDIT-C positive or Peth ≥ 50 ng/ml) at 24 weeks were present in the intervention group compared to control group, with unhealthy alcohol use declining from 98% at baseline in both groups to 73% (95% CI: 68%-78%) in the intervention group and 84% (95% CI: 80%-89%) in the control group.
Limitations of the study include the potential for trial arms to discuss or share counseling resources, resulting in an impact on alcohol reduction or viral suppression among control participants; COVID-19 pandemic-related government restrictions during the trial that potentially could influence alcohol use; and the potential impact of reduced alcohol use among intervention participants on the burden of HIV- and alcohol-associated comorbidities, financial wellbeing, and intimate partner violence. In addition, the authors noted that control group participants with baseline viral non-suppression received viral load counseling depending on laboratory testing performed for the trial; these individuals could have accelerated adherence interventions, affecting the generalizability of the findings.
Despite the reductions in levels of unhealthy alcohol use, intervention through counseling had no effect compared to the control group on viral suppression among PWH at 24 weeks. According to the authors, alcohol interventions—a driver of HIV-associated comorbidities—can potentially improve the health of PWH, therefore minimizing the number of comorbidities and improving overall health; however, additional research is needed to confirm these findings.
Reference
Puryear, SB, Mwangwa, F, Opel, F, et al. Effect of a brief alcohol counselling intervention on HIV viral suppression and alcohol use among persons with HIV and unhealthy alcohol use in Uganda and Kenya: a randomized controlled trial. J Int AIDS Soc., 26: e26187. doi:10.1002/jia2.26187
