Alcohol Use, Abuse in HIVHIV Quality of Care Advisory Committee

Thursday, December 14

Joseph Conigliaro, MD, MPHCenter for Enterprise Quality and Safety

University of Kentucky

Objectives

To review present data assessing the role of alcohol use and abuse among patients with HIV/AIDS

Outline potential therapeutic approaches

Spectrum of Alcohol Problems

Alcohol Abuse/Dependence

Harmful Drinking

Hazardous Drinking

Non-Hazardous Drinking

TertiaryPrevention

PrimaryPrevention

SecondaryPrevention

Problem Drinking

Hazardous & Safe Drinking

Hazardous DrinkingMen: 16 drinks/week

Women: 12 drinks/weekSanchez-Craig Am J Pub Health 1995

Safe DrinkingMen: 14 drinks/week

Women: 7 drinks/weekNIAAA 1995

Converging Epidemics• HIV/AIDS

– 40,000-60,000 new cases per year

• Alcohol– 110 million use– 32-40 million hazardous drinkers– 11-14 million alcohol dependent

• Both– 21% hazardous drinking HIV– 32% alcohol abuse/dependence

Bryant, Substance Use and Misuse 2006

Alcohol Use in VACS 3Alcohol Use in VACS 3

0

10

20

30

40

50

60

70

Never Drank Past Use Current Use

Pe

rce

nt

HCV +

HCV -

Total

p <0.0005

Conigliaro, et al JAIDS 2003

Why is alcohol use/abuse important in HIV/AIDS?

Conigliaro, et al Med Care 2006

High Alcohol Intake

• Decreases immune response - predisposes to infectious diseases and cancer.

• Immune deficiencies become more pronounced as liver function and nutritional status is compromised.

• Cells affected include: neutrophils, monocyte/macrophages, CD4 T lymphocytes (TH1 And TH2), and natural killer cells.

Evidence suggests that acute alcohol consumption and binge drinking transiently suppresses immune responses and impairs host defenses

Implications:Enhanced susceptibility to infectiousdiseases and cancer

High Alcohol Intake

Alcohol Abuse

Increases incidence of some cancers•Oral cavity and pharynx•Larynx•Esophagus•Liver

Moderately associated with:•Breast cancer•Colorectal cancer

Chronic Alcohol UseIncreases incidence of:

• Bacterial pneumonia• Septicemia• Tuberculosis• Hepatitis C • HIV (?)

Less common diseases such as:• Meningitis• Lung abscess• Diphtheria• Cellulitis

Alcohol and HIV/AIDS• Increased viral load• Risky sexual behavior• Decreased adherence/Non adherence to antiretroviral

therapy• Increased susceptibility to ADRs• Susceptibility to CNS injury• Susceptibility to immune dysfunction• Greater comorbidity (TB, HCV, Heart, Liver, Neurologic

Disease)

Alcohol and HIV

• Alcohol use among HIV infected persons affects adherence to antiretroviral therapy and may be associated with higher viral load

Cook et al JGIM 2001; Samet et al JGIM 2000

Alcohol and HIV/AIDS

• Hazardous Drinking

• Reduced adherence, increased viral replication– Decreased ART utilization OR 0.65– 2 week Adherence OR 0.46– Viral Suppression OR 0.76Chander et al JAIDS 2006

Alcohol and HIV/AIDS

AUDIT 8 and/or Binge

No (562) Yes (310) P

CD4 <200 mm3 (%) 27 30 .3

Median CD4 (mm3) 333 330 .6

VL>500 cps/ml (%) 47 65 <.001

Median VL (copies/ml) 385 2199 <.001

Conigliaro, et al JAIDS 2003

Alcohol/HIV and Immune Function

• Chronic Binge Alcohol Consumption accelerates progression of SIV disease

• More rapid disease progression to end-stage disease

Bagby et al Alc Clin Exp Res 2006

Hepatitis C and Alcohol

• Alcohol use may accelerate hepatitis C (HCV)– Progression to cirrhosis

– Risk of hepatocellular carcinoma

– Decreases response to HCV treatment

• HCV Treatment Guidelines– “abstinence … before and during antiviral therapy”

– “even moderate levels of consumption may accelerate disease progression”

HIV/HCV Coinfection• Common because of modes of

transmission– National VA – 29% by ICD-9 codes– VACS 3 – 43% of those tested

• HIV infection may accelerate– Progression of HCV infection– Alcohol induced liver damage– May complicate HCV treatment

Transaminases in Current DrinkersLevels of Transaminases

0

10

20

30

40

50

60

70

80

90

Neither HCVnor Alcohol

Alcohol Alone HCV Alone Both HCV andAlcohol

Per

cen

t

<=2 ULN

>2 ULN

p<0.0005

Alcohol and HIV/AIDS

• Higher incidence of Hepatocellular carcinoma– Alcohol/abuse-dependence OR 1.85

McGinnis, et al J Clin Onc 2006

Alcohol Use in HIV

• Alcohol Use/Abuse/ HIV and Neuropsychological Performance

• Heavy drinkers (>21 d/week) performed worse:– Psychomotor speed– Reaction time– Motor speed

Durvasula et al JCEN 2006

Alcohol and HIV/AIDS

• Risky sexual behavior– HIV negative/Problem Drinking

• Unprotected anal intercourseIrwin et al AIDS and Behavior 2006

– HIV positive• Multiple sexual partners

• Unprotected sexCook et al Medical Care 2006

Alcohol and HIV

We don’t know to what extent:• alcohol exacerbates HIV disease progression or

HIV associated conditions• alcohol mitigates effectiveness and increases

toxicity of antiretroviral treatment• HIV infection increases the risk of common

complications of alcohol

HIV/AIDS Is a Chronic Disease– Median estimated survival from diagnosis 15-20

yrs (Markov modeling)• twice expected survival prior to 1992

• people are growing older with HIV

• more effective antiretroviral treatment

– Older people are contracting HIV infection • # of persons 65 years at diagnosis has grown 10-fold

in 10 years

King et al Medical Decision Making 2000

Patient Outcomes

““Primary” Disease Primary” Disease TreatmentTreatment

““Primary” DiseasePrimary” Disease(HIV)(HIV)

AgingAging

Comorbid DiseaseComorbid Disease(Alcohol Use/Abuse)(Alcohol Use/Abuse)

Changing Profile of HIV Conditions

• Lower prevalence of “HIV related conditions”– pnuemocystis, Kaposi’s, mycobacterium

• Increased prevalence of “Non HIV related conditions”– hepatitis, hyperlipidemia, diabetes

– now exceed HIV related conditions

27 28 28 26

15 1310 10

7 7 7 6 4 2 2 2

3633

13

05

1015202530354045505560

Comorbid Disease in HIV

%

13

5 4 3 3 3 2 2 1

129

18

05

1015202530354045505560

HIV/AIDS Conditions

%

Justice et al Med Care 2006

AIDS-Defining Conditions*

0

5

10

15

20

25

30

Parasit

es

Wasting

Bact. Pneumonia

Thrush

Herpes

*P<0.003 for each comparison

•Current hazard <past abuse.

•Conditions additive for some.

Justice et al Med Care 2006

Neither

Abuse Hx

Current Hazard

Both

Medical Comorbidity*

0102030405060708090100

Diabetes

Cancer

Hepatitis

C

Depress

ion*P<0.02 for each comparison

•Current hazard <past abuse.

•Diabetes and cancer decrease.

Justice et al Med Care 2006

Neither

Abuse Hx

Current Hazard

Both

Laboratory Findings*

0

5

10

15

20

25

30

Anemia

AST or ALT>2 ULN

Neither

Abuse Hx

Current Hazard

Both

*P<0.001 for AST,ALT only; anemia ns.

•Current hazard <past abuse.

•Conditions additive for AST,ALT.

Justice et al Med Care 2006

Provider Awareness of Alcohol• Health care providers often do not detect

alcohol problems among their patients• Assess HIV provider awareness of hazardous

alcohol use and what patient characteristics are associated with provider failure to identify it

Provider Awareness of Alcohol

AUDIT Score 8 Last year 20

Drinks 6 drinks on one occasion (Binge) 33

AUDIT 8 and/or Binge 36

Measure %

Provider reports patient currentlydrinks too much

13

Conigliaro, et al JAIDS 2003

Provider Awareness of Alcohol

• AUDIT 8 and/or Binge and provider report of drinking too much

• Kappa 0.20• Sensitivity 22%• Specificity 95%

Provider Awareness of Alcohol• HCV Negative

– 23 (12%) of 186 drinkers were recognized by provider• Kappa 0.07• Sensitivity 12% (8% - 18%)• Specificity 94% (90% - 97%)

• HCV Positive– 29 (33%) of 88 drinkers were recognized by provider

• Kappa 0.28• Sensitivity 33% (23% - 44%)• Specificity 91% (87% - 95%)

Percent of Current Drinkers Told to Cut Back

AUDIT <=8 AUDIT >8

HCV – 4% 70%

HCV + 14% 73%

Motivational EnhancementFeedback

– Specific and relative to mental, physical & psychosocial healthResponsibility

– Stated explicitly by CALMAdvice

– Simple and explicit; given as a prescriptionMenu of options

– Patient chooses goal that matches needs & situation– Increases perceived personal choice and control

Empathy– Acknowledge difficulty of change– By health care provider

Self efficacy– Statements of hope and optimism– By health care provider

Motivational Enhancement

• 4-sixty minute MI sessions over 12 weeks• 51 – intervention/control• Healthy Choices• Reductions in risky sexual behavior

(unprotected sex)• Improved viral load• Reduced alcohol useNaar-King et al, 2006 AIDS Education and Prevention

Supporting alcohol reduction in HIV+ patients: a training for HIV care providers

(1) Provider training to encourage implementation of NIAAA's BI– (a) how to screen patients for alcohol use,– (b) how to counsel to reduce using motivational interviewing;

(2) Training in 4 NYC AIDS Centers to obtain preliminary data regarding impact on provider (immediate, 1- and 4- months post- training) with knowledge, attitudes, self-efficacy, collective organizational efficacy, and use of Bl

(3) Preliminary data to examine impact of training on – (a) patients' alcohol reduction– (b) HIV provider organization- (i) organizational climate towards dealing with

alcohol and HIV and HIV/HCV co-infection; and (ii) organization's expansion of existing alcohol reduction services and/or implementation of new services to reduce alcohol consumption

Strauss National Development & Research Institutes

Interactive Computer Programs & BIs

• Assess drinking status & readiness to change• Initiate provider delivered BIs• Prepare patient & provider for targeted session• Saves time• Facilitate individualized feedback immediately

upon submission of data• Lower-cost & customized intervention to more

drinkers• Provide anonymity, convenience

Computer Assisted Lifestyle Management (CALM)

• Interactive Computer Program• Identifies hazardous drinkers

– Alcohol Use Disorders Identification Test (AUDIT)

– Quantity and frequency of consumption

– Alcohol related consequences

• Readiness to change

CALM

• Delivers Brief Intervention– Patients & providers explore ETOH severity,

consequences, goals & Rx barriers– Brief negotiation using FRAMES & Stages of

Change– Computer intervention pulls from electronic

medical record

Conclusions• Alcohol use and hazardous drinking are common among HIV/AIDS

– High rates of current alcohol use– More HCV + patients have quit drinking

– High prevalence of hazardous alcohol use– More HCV + drinkers are at hazardous levels

• Associated with HIV disease severity, hepatic comorbidity and anemia• Associated with comorbid disease

•

Conclusions

• Providers often unaware of alcohol use

• Providers more often missed alcohol problems among patients with less severe HIV and without evidence of liver disease.– Better awareness for HCV + drinkers

• Patients report seldom being counseled to stop or limit alcohol use

Implications• Increased screening for alcohol use/abuse,

especially in HCV + patients• Interventions targeted at alcohol use may

improve health of HIV patients• Brief Interventions based on motivational

interviewing promising• Use of interactive computers and provider

based training

For more HIV-related resources, please visit www.hivguidelines.org