Alcohol Use, Abuse in HIV HIV Quality of Care Advisory Committee Thursday, December 14

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Alcohol Use, Abuse in HIVHIV Quality of Care
Advisory CommitteeThursday, December 14

• Joseph Conigliaro, MD, MPH
• Center for Enterprise Quality and Safety
• University of Kentucky

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Objectives

• To review present data assessing the role of
  alcohol use and abuse among patients with
  HIV/AIDS
• Outline potential therapeutic approaches

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Spectrum of Alcohol Problems
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Hazardous Safe Drinking
Hazardous Drinking Men 16 drinks/week Women
12 drinks/week Sanchez-Craig Am J Pub Health
1995 Safe Drinking Men 14 drinks/week Women
7 drinks/week NIAAA 1995
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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
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Alcohol Use in VACS 3
p lt0.0005
Conigliaro, et al JAIDS 2003
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Why is alcohol use/abuse important in HIV/AIDS?
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Conigliaro, et al Med Care 2006
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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.

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High Alcohol Intake
Evidence suggests that acute alcohol consumption
and binge drinking transiently suppresses immune
responses and impairs host defenses
Implications Enhanced susceptibility to
infectious diseases and cancer
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Alcohol Abuse

• Increases incidence of some cancers
• Oral cavity and pharynx
• Larynx
• Esophagus
• Liver
• Moderately associated with
• Breast cancer
• Colorectal cancer

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Chronic Alcohol Use

• Increases incidence of
• Bacterial pneumonia
• Septicemia
• Tuberculosis
• Hepatitis C
• HIV (?)
• Less common diseases such as
• Meningitis
• Lung abscess
• Diphtheria
• Cellulitis

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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)

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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

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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 0.76

Chander et al JAIDS 2006
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Alcohol and HIV/AIDS
Conigliaro, et al JAIDS 2003
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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
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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

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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

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Transaminases in Current Drinkers
plt0.0005
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Alcohol and HIV/AIDS

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

McGinnis, et al J Clin Onc 2006
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Alcohol Use in HIV

• Alcohol Use/Abuse/ HIV and Neuropsychological
  Performance
• Heavy drinkers (gt21 d/week) performed worse
• Psychomotor speed
• Reaction time
• Motor speed

Durvasula et al JCEN 2006
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Alcohol and HIV/AIDS

• Risky sexual behavior
• HIV negative/Problem Drinking
• Unprotected anal intercourse
• Irwin et al AIDS and Behavior 2006
• HIV positive
• Multiple sexual partners
• Unprotected sex
• Cook et al Medical Care 2006

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Alcohol and HIV

• We dont 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

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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
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Patient Outcomes
Aging
Comorbid Disease (Alcohol Use/Abuse)
Primary Disease (HIV)
Primary Disease Treatment
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Changing Profile of HIV Conditions

• Lower prevalence of HIV related conditions
• pnuemocystis, Kaposis, mycobacterium
• Increased prevalence of Non HIV related
  conditions
• hepatitis, hyperlipidemia, diabetes
• now exceed HIV related conditions

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Comorbid Disease in HIV

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HIV/AIDS Conditions

Justice et al Med Care 2006
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AIDS-Defining Conditions
30

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20
15

• Current hazard ltpast abuse.
• Conditions additive for some.

10
5
Plt0.003 for each comparison
0
Thrush
Herpes
Wasting
Parasites
Bact. Pneumonia
Justice et al Med Care 2006
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Medical Comorbidity
100
90
80
70
60
50
40
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• Current hazard ltpast abuse.
• Diabetes and cancer decrease.

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10
0
Plt0.02 for each comparison
Cancer
Diabetes
Hepatitis C
Depression
Justice et al Med Care 2006
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Laboratory Findings

• Current hazard ltpast abuse.
• Conditions additive for AST,ALT.

Plt0.001 for AST,ALT only anemia ns.
Justice et al Med Care 2006
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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

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Provider Awareness of Alcohol
Conigliaro, et al JAIDS 2003
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Provider Awareness of Alcohol

• AUDIT ? 8 and/or Binge and provider report of
  drinking too much
• Kappa 0.20
• Sensitivity 22
• Specificity 95

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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)

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Percent of Current Drinkers Told to Cut Back
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Motivational Enhancement

• Feedback
• Specific and relative to mental, physical
  psychosocial health
• Responsibility
• Stated explicitly by CALM
• Advice
• Simple and explicit given as a prescription
• Menu 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

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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 use

Naar-King et al, 2006 AIDS Education and
Prevention
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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

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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

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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

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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

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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

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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

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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

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