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