Effectiveness of a psychological intervention delivered by general nurses for alcohol use disorders in people living with HIV in Zimbabwe: a cluster randomized controlled trial

Abstract

Introduction There have been very few randomized clinical trials of interventions for alcohol use disorders (AUD) in people living with HIV (PLWH) in African countries. This is despite the fact that alcohol use is one of the modifiable risk factors for poor virological control in PLWH on antiretroviral therapy. Methods Sixteen clinic clusters in Zimbabwe were selected through stratified randomization and randomized 1: 1 to Intervention and Control arms. Inclusion criteria for individual participants were being adult, living with HIV and a probable alcohol use disorder as defined by a score of 6 (women) or 7 (men) on the Alcohol Use Disorders Identification Test (AUDIT). In the Intervention clusters, participants received 8 to 10 sessions of Motivational Interviewing blended with brief Cognitive Behavioural Therapy (MI‐CBT). In the control clusters, participants received four Enhanced Usual Care (EUC) sessions based on the alcohol treatment module from the World Health Organisation mhGAP intervention guide. General Nurses from the clinics were trained to deliver both treatments. The primary outcome was a change in AUDIT score at six‐month post‐randomization. Viral load, functioning and quality of life were secondary outcomes. A random‐effects analysis‐of‐covariance model was used to account for the cluster design. Results Two hundred and thirty‐four participants (n = 108 intervention and n = 126 control) were enrolled across 16 clinics. Participants were recruited from November 2016 to November 2017 and followed through to May 2018. Their mean age was 43.3 years (SD = 9.1) and 78.6% (n = 184) were male. At six months, the mean AUDIT score fell by −6.15 (95% CI −6.32; −6.00) in the MI‐CBT arm, compared to a fall of − 3.09 95 % CI − 3.21; −2.93) in the EUC arm (mean difference −3.09 (95% CI −4.53 to −1.23) ( p = 0.05). Viral load reduced and quality of life and functioning improved in both arms but the difference between arms was non‐significant. Conclusions Interventions for hazardous drinking and AUD comprising brief, multiple alcohol treatment sessions delivered by nurses in public HIV facilities in low‐income African countries can reduce problematic drinking among PLWH. Such interventions should be integrated into the primary care management of AUD and HIV and delivered by non‐specialist providers. Research is needed on cost‐effectiveness and implementation of such interventions, and on validation of cut‐points for alcohol use scales in low resource settings, in partnership with those with lived experience of HIV and AUD.

Current Interventions for People Living with HIV Who Use Alcohol: Why Gender Matters

“…A majority of the interventions were conducted domestically within the USA; however, interventions conducted internationally were culturally adapted to suit the environment and population [63,67,69,70]. Regardless of location, most of the interventions contained a brief interview component.…”

“…Eight of the identified studies evaluated the efficacy or effectiveness of interventions to reduce alcohol use among PLWH but did not use a gender lens in the design or analyses [21,[61][62][63][64][65][66][67]. The sample sizes of these studies ranged from 93 to 614, with 75% reporting sample sizes of fewer than 250.…”

“…All the interventions evaluated incorporated motivational interviewing. Two interventions included cognitive behavioral therapy (CBT) components [63,67] and 3 interventions included medication-assisted treatment for alcohol use [21,61,62]. All interventions were delivered individually, with one intervention reporting additional optional group intervention components [63].…”

“…Some studies included in this review also measured viral load using HIV RNA and the cut-off for viral suppression ranged from <20 to <50 copies/ml. Although most studies reported that participants reported reduced alcohol use at follow-up, only 3 studies demonstrated statistically significant intervention effects [63,64,67]. Go and colleagues conducted a trial comparing a culturally adapted motivational enhancement therapy and a brief alcohol intervention to standard of care among 440 PLWH in Thai Nguyen, Vietnam [63].…”

“…Madhombiro and colleagues demonstrated Fig. 1 Search diagram the efficacy of a combined motivational interviewing and CBT intervention to reduce AUDIT scores among 234 PLWH in Zimbabwe [67]. Lastly, Naar and colleagues reported the effectiveness of Health Choices, a motivational interviewing-based intervention, among 183 youth living with HIV that was implemented in and tested intervention delivery (home as compared with clinic settings) [64].…”