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Pressing need to address heavy drinking among MSM with HIV

Among the more than 1m people in the US living with HIV, 19% meet the criteria for an alcohol use disorder. The consequences can be severe, with heavy drinking associated with increased liver disease, greater engagement in risky sexual behaviour, lower adherence to antiretroviral therapy and greater risk of death.

Men who have sex with men (MSM) comprise nearly half of the country’s HIV patients and show relatively high rates of alcohol use disorders, but little research has been conducted to identify the most effective ways to reduce drinking in MSM living with HIV.
Yet a study finds that a simple intervention using a technique called “motivational interviewing” during routine HIV care can have strong and lasting effects. Compared to treatment as usual, MSM exposed to the intervention and a few brief follow-up sessions reported fewer drinks per week, fewer days of heavy drinking and less condomless sex over one full year.

The researchers say the need to address heavy drinking among MSM with HIV is pressing and that the reductions in alcohol use they saw among participants were considerable. “Individuals with HIV who actively manage their illness by taking antiretroviral therapy are now expected to have comparable lifespans as those without the virus,” said lead author Christopher Kahler, scientific director at the Brown University Alcohol Research Centre on HIV and professor of behavioural and social sciences at the University’s School of Public Health. “Yet they are much more vulnerable if they drink heavily. If a patient can even cut drinking in half, this can greatly reduce the risk of mortality.”

Participants in the study, conducted from 2011 to 2016, were 180 heavy-drinking MSM living with HIV who were recruited from the Fenway Health Community Health Centre in Boston. Half were exposed to interventions during routing visits for HIV care while the other half continued to receive treatment as usual. The intervention consisted of an initial in-person counselling session of up to 60 minutes, two brief sessions at three- and six-month follow-up visits, and two brief phone calls.

The researchers employed “motivational interviewing” because the approach is ideal to use opportunistically, especially with individuals who are not necessarily seeking to change behaviour.

In the initial sessions, counsellors asked participants about drinking patterns, positive and negative effects of alcohol use, and connections between their drinking and HIV care. They also shared information on how patients’ drinking compared to drinking in other MSM, gave feedback on health indicators and discussed the potential for behaviour change related to their alcohol use.

“This is an empathic, non-confrontational approach that can reduce stigma,” Kahler said. “Counsellors identify areas of concern, but work to understand the participants’ experiences and perspectives.”

Over 12 months, the average number of drinks per week consumed by those who received the intervention dropped from 16 to just seven – and the number of heavy drinking days per month decreased from five days to one. Among those reporting condomless sex with non-steady partners, the intervention resulted in significantly lower rates of this behaviour at three and 12 months compared to those who received treatment as usual.

“The study demonstrates that open, non-confrontational discussions about alcohol use with individuals in HIV care can create a significantly positive change in behaviour,” Kahler said. “What we don’t yet know is how necessary it is to have the more intensive motivational interviewing sessions with feedback from trained counsellors or whether brief advice from a clinician would be enough to prompt change.”

The implications of that follow-up question – which Kahler and colleagues are currently investigating – prove significant in shaping approaches to intervention and care. “This work is extremely important, since problem alcohol use is among the most common behavioural health challenges that can impede the optimal use of modern antiretroviral therapy that extends and improves the lives of HIV-infected MSM and other people living with HIV,” said co-author Kenneth Mayer, medical research director at Fenway Health and professor of medicine at Harvard Medical School.

The collaborative study included researchers from the Brown University’s School of Public Health, Centre for Alcohol and Addiction Studies and Warren Alpert Medical School, with colleagues from Lifespan hospitals, Fenway Health and other institutions.

The Brown University Alcohol Research Centre on HIV was launched with a $7.5m grant from the National Institutes of Health and focuses on the health effects of heavy drinking and the physiological and behavioural questions raised by the combination of alcohol use and HIV.

In addition to Kahler and Mayer, authors included Peter Monti, David Pantalone, Nadine Mastroleo, Bharat Ramratnam, Tao Liu and Gerald Bove.

Abstract
Objective: This randomized controlled trial tested the efficacy of motivational interviewing (MI) to reduce alcohol use among heavy drinking men who have sex with men (MSM) who are engaged in HIV care but not currently receiving addictions treatment.
Method: One hundred eighty MSM living with HIV—recruited regardless of interest in changing drinking—were randomly assigned to MI or an assessment-only treatment as usual (TAU) control. MI comprised one in-person session followed by two brief phone calls and in-person booster sessions at 3 and 6 months. The Timeline Follow-Back Interview assessed past 30-day alcohol use and sexual behavior at 3, 6, and 12 months postbaseline, and serum samples and medical records assessed viral load, CD4 cell count, and liver function.
Results: At 6 and 12 months, MI compared to TAU resulted in significantly fewer drinks per week (6 months: b = −8.72, 95% confidence interval (CI) [−12.69, −4.76]; 12 months: b = −5.98, 95% CI [−9.77, −2.19]) and lower number of heavy drinking days (6 months: incidence rate ratio = 0.55, 95% CI [0.38, 0.79]; 12 months: incidence rate ratio = 0.50, 95% CI [0.33, 0.78]). Effects on viral load, CD4 cell count, and liver function were nonsignificant. Among those reporting condomless sex with nonsteady partners at baseline, MI resulted in significantly lower rates of this behavior at 3 and 12 months compared to TAU.
Conclusions: In MSM living with HIV, MI shows substantial promise for reducing heavy drinking and for reducing condomless sex among those at risk.

Authors
Kahler, Christopher W; Pantalone, David W; Mastroleo, Nadine R; Liu, Tao; Bove, Gerald; Ramratnam, Bharat; Monti, Peter M; Mayer, Kenneth H

[link url="https://news.brown.edu/articles/2018/08/interventions"]Brown University material[/link]
[link url="http://psycnet.apa.org/record/2018-35470-001?doi=1"]Journal of Consulting and Clinical Psychology abstract[/link]

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