Interventions to Reduce Unhealthy Alcohol Use among Primary Care Patients with HIV: the Health and Motivation Randomized Clinical Trial

Abstract

BACKGROUND: Unhealthy alcohol use has adverse effects on HIV treatment. Screening, brief intervention, and referral to treatment (SBIRT) has some evidence of efficacy but may not be sufficient for those with low motivation or comorbid substance use. OBJECTIVE: To examine the effectiveness of motivational interviewing (MI) and emailed feedback (EF) among primary care HIV-positive patients, compared with treatment as usual care (UC) only, which included SBIRT. DESIGN: Randomized clinical trial. PARTICIPANTS: Six hundred fourteen adult HIV-positive patients in Kaiser Permanente Northern California who reported prior-year unhealthy alcohol use. INTERVENTION: Participants were randomized to either three sessions of MI (one in person and two by phone), information regarding alcohol risks via EF through a patient portal, or UC alone. MI and EF participants who reported unhealthy alcohol use at 6 months were offered additional MI and EF treatment, respectively. MAIN MEASURES: Participant-reported unhealthy alcohol use (defined as ≥ 4/≥ 5 drinks per day for women/ men), alcohol problems at 12 months, based on blinded telephone interviews. Secondary outcomes included drug use and antiretroviral (ART) adherence. KEY RESULTS: At 12 months, there were no overall group differences, but in all three arms, there were declines in unhealthy alcohol use and alcohol-related problems (p < 0.001). Participants reporting low motivation to reduce drinking at baseline were less likely to report unhealthy alcohol use if they received MI vs. EF and UC (p = 0.013). At 6 months, reported illegal drug use/misuse of prescription drugs other than marijuana was lower in the MI arm than EF or UC (p = 0.012). There were no differences in ART adherence between groups. CONCLUSIONS: In a randomized trial of HIV-positive patients using two behavioral interventions compared with SBIRT alone, participants in all three conditions reduced unhealthy alcohol use. MI may provide added benefit for patients with low motivation or who report illegal drug use/misuse of prescription drugs.

Alcohol and drug use, partner PrEP use and STI prevalence among people with HIV

“…This study examined data collected in the Health and Motivation Study, described in detail elsewhere 18. Briefly, the study was a randomised clinical trial of primary care-based behavioural interventions to reduce unhealthy alcohol use among 614 PWH in Kaiser Permanente Northern California (KPNC).…”

Integrated stepped alcohol treatment for patients with HIV and at-risk alcohol use: a randomized trial

“…Based on a systematic review of the literature and meta-analysis, Scott-Sheldon and colleagues reported in 2017 that there were only 21 studies that reported on individual-level interventions designed to address alcohol use among PWH, 71% of which were clinic-based [ 17 ]. Consistent with our approach, studies that targeted alcohol alone (vs. multiple HIV-related behaviors) and that were clinic-based (vs. recruiting from other/mixed settings), were found to be more successful at decreasing alcohol use[ 14 – 17 ], though these effects may vary based on baseline level of motivation and intervention strategy[ 13 ]. Building on this literature and our experiences evaluating ISAT among PWH with higher and lower levels of alcohol use[ 21 , 22 ], the current study provides additional support for approaches that include MI-based interventions that target alcohol use in clinic-based settings to promote alcohol reduction among PWH.…”

“…Such “stepped care models” allow for tailoring of treatment based on patient response while employing multidisciplinary team members as needed to deliver specific components of care to maximize resource allocation. Stepped care models have been successfully applied to a variety of medical conditions (e.g., depression, hypertension, chronic pain) [ 18 , 19 ] addressed in routine medical settings, but rarely applied to address alcohol use [ 20 ] and specifically among PWH [ 13 ]. We have recently reported the benefits of stepped alcohol treatment for PWH who have alcohol use disorder (as defined by the Diagnostic and Statistical Manual criteria to identify individuals with loss of control and adverse consequences from alcohol use) or lower levels of alcohol use in the presence of liver disease [ 21 , 22 ].…”

“…Despite its potential to improve individual and public health, brief intervention with subsequent indicated treatment is inconsistently delivered to PWH [11], and, to date, only a limited number of studies have been specifically designed to address unhealthy alcohol use (defined as the spectrum of alcohol use including at-risk drinking and alcohol use disorder) among PWH [12][13][14][15][16][17]. These studies have generally focused on evaluation of a specific medication (i.e., naltrexone) [12] or behavioral intervention [13][14][15][16] and some focused on a specific patient population (e.g., women, men who have sex with men). None of these studies offered a comprehensive package that allowed evaluation of initial patient response to a lower intensity intervention prior to adding additional services.…”

Capsule Commentary on Satre et al., “Interventions to Reduce Unhealthy Alcohol Use among Primary Care Patients with HIV: the Health and Motivation Randomized Clinical Trial”

“…A total of 614 adult HIV-positive patients in Kaiser Permanente, San Francisco, who reported prior year unhealthy alcohol use were randomized to receive either 3 sessions of (a) motivational interviewing (MI), (b) information regarding alcohol risks by emailed feedback (EF) through an EHR patient portal, or (c) usual care (UC), which included Screening, Brief Intervention, and Referral to Treatment. 1 The interventions were carried out by behavioral health specialists embedded in the primary care clinics. At 12 months all three arms reported declines in unhealthy alcohol use and alcohol related problems, with no significant differences between the groups.…”