Sunday, December 27, 2015

Advancing Behavioral HIV Prevention: Adapting an Evidence-Based Intervention for People Living with HIV and Alcohol Use Disorders

Alcohol use disorders (AUDs) are highly prevalent among people living with HIV/AIDS (PLWHA) and are associated with increased HIV risk behaviors, suboptimal treatment adherence, and greater risk for disease progression. 

We used the ADAPT-ITT strategy to adapt an evidence-based intervention (EBI), the Holistic Health Recovery Program (HHRP+), that focuses on secondary HIV prevention and antiretroviral therapy (ART) adherence and apply it to PLWHA with problematic drinking. Focus groups (FGs) were conducted with PLWHA who consume alcohol and with treatment providers at the largest HIV primary care clinic in New Orleans, LA. 

Overall themes that emerged from the FGs included the following: 
  1. negative mood states contribute to heavy alcohol consumption in PLWHA; 
  2. high levels of psychosocial stress, paired with few adaptive coping strategies, perpetuate the use of harmful alcohol consumption in PLWHA; 
  3. local cultural norms are related to the permissiveness and pervasiveness of drinking and contribute to heavy alcohol use; 
  4. healthcare providers unanimously stated that outpatient options for AUD intervention are scarce, 
  5. misperceptions about the relationships between alcohol and HIV are common; 
  6. PLWHA are interested in learning about alcohol's impact on ART and HIV disease progression. 
These data were used to design the adapted EBI.

...3.3.1. Reasons for Patient Engagement in Risky Behavior
The majority of providers who offered insight into this topic believed that their HIV+ patients engaged in risky substance use and unsafe sexual behavior due to habit and that these were the same behaviors that led to HIV infection. Responses included the following:

“They've already kind of created a pattern of behavior that probably is what caused them to get the virus in the first place.”

“Yeah I agree with the habit part too, because you know like they were practicing risky behaviors for so long beforehand and then as far as they're concerned, the worst thing that could have happened, happened to them already.”

Others believed that risky behaviors were more common in younger patients,
“I think my younger group, the younger population of our HIV… It's basically, I'm not going to be stigmatized or labeled that I am HIV positive so I'm just gonna act like everybody else is acting.”

3.3.2. Provider Insight regarding PLWHA Alcohol Use
Additionally, providers discussed possible determinants specifically for heavy alcohol use in their patients. They noted that common stressors such as poverty, chronic unemployment, and boredom may contribute to the use of alcohol as an inexpensive coping mechanism.
“I would say it's the same reason anybody becomes alcoholic. I mean, HIV, HIV positive and negative can become alcoholic for the same reason this genetic tendency to become addicted earlier or easier and then the reasons I..I think it's mostly to escape.”

They also noted that their patients often rely on alcohol as a coping mechanism and that this may exacerbate feelings of hopelessness and resistance to change drinking habits. As a result, all providers agreed that the adapted intervention should involve development of stress management skills.

3.3.3. Permissiveness and Pervasiveness of Drinking
All providers agreed that the local (New Orleans, LA) drinking culture is a contributor to heavy alcohol use in their patients living with HIV/AIDS. For example, many providers mentioned that beer and wine are often not considered alcoholic beverages and that this belief is not exclusive to their patients. Typical responses included the following:

“You gotta realize that, they say that wine is not an alcohol. I mean, in their minds they don't consider it. But in the minds of the professionals that work here too, it's not an alcohol!”

Others commented on cultural norms related to drinking,
“We have a lot of festivities where…laughter from group like Mardi Gras where the norm is to drink. The culture of the area sets it up to do a lot of parties.”

Some providers gave specific examples of these alcohol-related practices,
“Growing up in a culture like this, even the kids' parties that they have (alcohol). You go to a kid's or a toddler's party and you know they have the stuff for kids and they got the stuff for adults too! Which it always includes alcohol, so it's like, from birth, that's the way it is...”

Full article at:

By:   M. L. Armstrong, 1 A. M. LaPlante, 1 F. L. Altice, 2 , 3 M. Copenhaver, 4 and P. E. Molina 1 , *
1Comprehensive Alcohol Research Center and Alcohol and Drug Abuse Center, Department of Physiology, LSUHSC, New Orleans, LA 70112, USA
2Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT 06510, USA
3Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, CT 06510, USA
4Center for Health, Intervention, & Prevention (CHIP), University of Connecticut, Storrs, CT 06269, USA
*P. E. Molina: Email: ude.cshusl@nilomp

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