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Alcohol Use, Abuse in HIV HIV Quality of Care Advisory Committee Thursday, December 14 Joseph Conigliaro, MD, MPH Center 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

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alcohol use abuse in hiv hiv quality of care advisory committee thursday december 14

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

objectives
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

Tertiary

Prevention

Secondary

Prevention

Problem Drinking

Primary

Prevention

Spectrum of Alcohol Problems
slide4

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

converging epidemics
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 3
Alcohol Use in VACS 3

p <0.0005

Conigliaro, et al JAIDS 2003

slide9

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.
slide10

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

slide11

Alcohol Abuse

  • Increases incidence of some cancers
    • Oral cavity and pharynx
    • Larynx
    • Esophagus
    • Liver
  • Moderately associated with:
    • Breast cancer
    • Colorectal cancer
slide12

Chronic Alcohol Use

  • Increases incidence of:
    • Bacterial pneumonia
    • Septicemia
    • Tuberculosis
    • Hepatitis C
    • HIV (?)
  • Less common diseases such as:
    • Meningitis
    • Lung abscess
    • Diphtheria
    • Cellulitis
alcohol and hiv aids
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
alcohol and hiv aids15
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

alcohol and hiv aids16

Median VL (copies/ml)

AUDIT  8 and/or Binge

385

2199

<.001

No (562)

Yes (310)

P

CD4 <200 mm3 (%)

27

30

.3

Median CD4 (mm3)

333

330

.6

VL>500 cps/ml (%)

47

65

<.001

Alcohol and HIV/AIDS

Conigliaro, et al JAIDS 2003

alcohol hiv and immune function
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
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
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
alcohol and hiv aids21
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 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 aids23
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

alcohol and hiv24
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

Alcohol and HIV
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

HIV/AIDS Is a Chronic Disease

King et al Medical Decision Making 2000

patient outcomes
Patient Outcomes

Aging

Comorbid Disease

(Alcohol Use/Abuse)

“Primary” Disease

(HIV)

“Primary” Disease

Treatment

changing profile of hiv conditions
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
slide29

HIV/AIDS Conditions

%

Justice et al Med Care 2006

slide30

Neither

Abuse Hx

Current Hazard

Both

AIDS-Defining Conditions*

30

25

20

15

  • Current hazard <past abuse.
  • Conditions additive for some.

10

5

*P<0.003 for each comparison

0

Thrush

Herpes

Wasting

Parasites

Bact. Pneumonia

Justice et al Med Care 2006

slide31

Neither

Abuse Hx

Current Hazard

Both

Medical Comorbidity*

100

90

80

70

60

50

40

  • Current hazard <past abuse.
  • Diabetes and cancer decrease.

30

20

10

0

*P<0.02 for each comparison

Cancer

Diabetes

Hepatitis C

Depression

Justice et al Med Care 2006

slide32

Neither

30

Abuse Hx

25

Current Hazard

Both

20

15

10

5

0

Anemia

AST or ALT>2 ULN

Laboratory Findings*

  • Current hazard <past abuse.
  • Conditions additive for AST,ALT.

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

Justice et al Med Care 2006

provider awareness of alcohol
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 alcohol34

Measure

%

AUDIT Score  8 Last year

20

33

Drinks  6 drinks on one occasion (Binge)

AUDIT 8 and/or Binge

36

Provider reports patient currently

drinks too much

13

Provider Awareness of Alcohol

Conigliaro, et al JAIDS 2003

provider awareness of alcohol35
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 alcohol36
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%)
motivational enhancement
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
motivational enhancement39
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

supporting alcohol reduction in hiv patients a training for hiv care providers
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
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
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
slide43
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
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
conclusions45
Conclusions
  • Providers often unaware of alcohol use
  • Providers more oftenmissed 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
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