Alcohol s Impact on HIV Incidence, Treatment Adherence, and Health Outcomes

Transcription

1 Alcohol s Impact on HIV Incidence, Treatment Adherence, and Health Outcomes Paul A. Shuper, Ph.D. 1,2,3,4 October 24, Senior Scientist Centre for Addiction and Mental Health Toronto, Ontario, Canada 2 Assistant Professor Department of Psychology University of Toronto; Toronto, Ontario, Canada 3 Affiliate Institute for Collaboration on Health, Intervention, and Policy University of Connecticut; Storrs, CT, USA 4 Associate Member of Staff Alcohol, Tobacco and other Drug Research Unit South African Medical Research Council Pretoria, South Africa

2 Presenter Disclosure Presenter: Paul Shuper, Ph.D. Relationships with Commercial Interests Grants/Research Support: CIHR, OHTN, NIH (NIMH, NIAAA), SA MRC, PAHO Speakers Honoraria: WHO (reimbursement for travel expenses only) NIAAA (reimbursement for travel expenses only) Consulting Fees: None (see above reimbursement for travel) Other: Employee of CAMH

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4 Alcohol and HIV Acquisition/Transmission

5 Alcohol and Condomless Sex

6 Evidence for an Alcohol- Condomless Sex Association Systematic Reviews and Meta-analyses Sub-Saharan Africa (e.g., Kalichman et al., 2007; Kiene et al., 2013; Woolf & Maisto, 2011) China (Li et al., 2010) Gay and bisexual men (e.g., Woolf & Maisto, 2009; Heath et al., 2011) University students (e.g., Cooper, 2002; Leigh, 2002) HIV-positive populations (e.g., Shuper et al., 2009)

7 Alcohol s Causal Role in Condomless Sex?

8 Alcohol and Condomless Sex Intentions: Controlled Laboratory Experiments Alcohol Placebo Hypothetical Scenarios Intentions to Use Condoms Shuper et al., (2016)

9 Alcohol and Condomless Sex Intentions: Meta-Analyses Rehm, Shield, Joharchi, & Shuper (2012) Scott-Sheldon et al. (2016) Findings and Conclusions Alcohol directly causes condomless sex intentions Effect is increased with sexual arousal Alcohol results in weaker communication/ condom negotiation skills

10 Alcohol and HIV Incidence

11 Alcohol and HIV Incidence: Meta-Analysis of Prospective Studies Methods Comprehensive literature review prospective studies on HIV incidence Results 873 articles identified 10 studies yielded Baliunas, Rehm, Irving, & Shuper (2010)

12 Alcohol and HIV Incidence: Meta-Analysis of Prospective Studies Results: Any alcohol consumption Effect % Author & Year size (95% CI) Weight Koblin (1.22, 2.09) Kapiga (1.54, 3.82) Page-Shafer (0.90, 3.45) Celentano (0.61, 4.85) 4.27 Overall 1.78 (1.43, 2.20) Relative risk Baliunas, Rehm, Irving, & Shuper (2010)

13 Alcohol and HIV Incidence: Meta-Analysis of Prospective Studies Results: Binge drinking Effect % Author & Year size (95% CI) Weight Plankey (0.81, 1.56) Read (1.10, 11.40) Koblin (1.32, 2.96) Nopkesorn (1.00, 10.90) Chesney (2.42, 3.88) Overall 2.20 (1.29, 3.74) Relative risk Baliunas, Rehm, Irving, & Shuper (2010)

14 Alcohol and HIV Incidence: Meta-Analysis of Prospective Studies Results: Alcohol consumption prior to sex Effect % Author & Year size (95% CI) Weight Read (1.05, 6.28) 9.59 Zablotska (1.51, 2.09) Figueroa (1.53, 31.00) 3.68 Clentano (0.91, 2.58) Overall 1.86 (1.39, 2.51) Relative risk Baliunas, Rehm, Irving, & Shuper (2010)

15 Alcohol Consumption and HIV Treatment

16 Alcohol and the HIV Treatment Cascade See Reviews from Azar et al. (2010) and Vagenas et al. (2015)

17 Alcohol Consumption and HIV Diagnosis

18 Alcohol and HIV Diagnosis Vagenas, Ludford, Gonzales, et al. (2014) Biobehavioural survey of 5,148 MSM in Peru Alcohol assessment; HIV testing Results HIV+ N=420 (8.2%) 57% AUD Status Aware N=43 (10.2%) Status Unaware N=377 (89.8%)

19 Alcohol Consumption and Retention in Care

20 Alcohol and Retention in Care Pecoraro, Mimiaga, O'Cleirigh,et al. (2015) 240 PLWH in St. Petersburg, Russia Examined factors associated with loss-to-care (nonattendance in ART care for > 12 months) Results Drinking alcohol past 30 days ~3X risk of loss-to-care 63% reported drug and/or alcohol use as reason for attrition

21 Alcohol Consumption and ART Adherence

22 Potential Pathways Linking Alcohol with ART Non-Adherence? Cognitive impairment Decreased access to ART; Poorer retention in care (e.g., Tucker et al., 2004) Inaccurate perceptions cannot take ART if drinking (Kalichman et al., 2009; 2012)

23 Evidence for an Alcohol - Non-Adherence Association

24 Meta Analysis: Alcohol and ART Adherence Methods Comprehensive literature review and meta-analysis Studies reporting associations between alcohol use and ART adherence Results 259 articles yielded 40 studies Hendershot et al., 2009

25 Meta Analysis: Alcohol and ART Adherence Alcohol Categorization Alcohol Users/ Consumption vs. Non-Users/ Consumption Problem Drinkers vs. Non-Problem Drinkers/Abstainers Moderate Drinkers vs. Abstainers/ Consumption Any use vs. No-use (past year) Result OR (95% CI) 0.55 ( ) 0.47 ( ) 0.48 ( ) 0.60 ( ) Hendershot et al., 2009

26 Evidence for a Causal Alcohol- Non-Adherence Association? Temporal and Dose-Response Associations

27 Braithwaite et al Methods Telephone surveys with >2000 participants (US) alcohol consumed; missed doses Results: Among drinkers: 4% missed doses on non-drinking days 6% missed doses on drinking days (without binge) 14% missed doses on binge drinking days Braithwaite et al., 2005

28 Parsons, Rosof, & Mustanski, 2008 Methods 272 (US) HIV+ with alcohol problems Alcohol consumed, ART doses taken Regimen complexity Results On days during which alcohol was consumed ~9X increased likelihood of non-adherence (OR=8.8, CI= ) Each drink increased the odds of non-adherence by 20% (OR=1.20, CI= ) Parsons et al., 2008

29 Regimen Less Complex More Complex

30 De Boni et al Temporal Relationship between Alcohol and ART Adherence Method 255 PLWH in LMICs Weekday vs. weekend adherence Binge drinking occasions

31 De Boni, Zheng, Rosenkranz, et al Temporal Relationship between Alcohol and ART Adherence Weekending

32 Alcohol Consumption and Treatment Outcomes

33 Alcohol and Treatment Outcomes Kader, Seedat, Govender, et al. (2015) 1,503 PLWH attending South African HIV clinics Predictors of CD4 count

34 Alcohol and Treatment Outcomes Diess, Mesner, Agan, et al. (2016) 752 HIV+ US military personnel - US Military Natural History Study Predictors of virologic failure (2 consecutive VL measurements>200 copies/ml, 6 months post ART initiation)

35 Summary and Implications

36 Williams, Hahn, Saitz, et al., 2016

37 Summary and Implications Individual-level interventions Alcohol screening and counselling targeted populations Combined initiatives Structural interventions HIV prevention in alcohol establishments Condom availability, outreach counselling/testing, peer leaders, prevention cues Government Alcohol taxation, availability, and marketing

38 Questions? Contact details: Paul A. Shuper, Ph.D. Centre for Addiction and Mental Health 33 Russell Street Toronto, ON, M5S 2S1, Canada Office: , ext Fax: