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

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

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  1. 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

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

  3. Alcohol Abuse/ Dependence Harmful Drinking Hazardous Drinking Non-Hazardous Drinking Tertiary Prevention Secondary Prevention Problem Drinking Primary Prevention Spectrum of Alcohol Problems

  4. 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

  5. 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

  6. Alcohol Use in VACS 3 p <0.0005 Conigliaro, et al JAIDS 2003

  7. Why is alcohol use/abuse important in HIV/AIDS?

  8. Conigliaro, et al Med Care 2006

  9. 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.

  10. 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

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

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

  13. 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)

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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”

  19. 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

  20. Transaminases in Current Drinkers p<0.0005

  21. Alcohol and HIV/AIDS • Higher incidence of Hepatocellular carcinoma • Alcohol/abuse-dependence OR 1.85 McGinnis, et al J Clin Onc 2006

  22. 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

  23. 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

  24. 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

  25. 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

  26. Patient Outcomes Aging Comorbid Disease (Alcohol Use/Abuse) “Primary” Disease (HIV) “Primary” Disease Treatment

  27. 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

  28. Comorbid Disease in HIV %

  29. HIV/AIDS Conditions % Justice et al Med Care 2006

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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

  35. Provider Awareness of Alcohol • AUDIT  8 and/or Binge and provider report of drinking too much • Kappa 0.20 • Sensitivity 22% • Specificity 95%

  36. 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%)

  37. Percent of Current Drinkers Told to Cut Back

  38. 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

  39. 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

  40. 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

  41. 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

  42. 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

  43. 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

  44. 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

  45. 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

  46. 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

  47. For more HIV-related resources, please visit www.hivguidelines.org

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