Alcohol consumption at harmful or hazardous levels among HIV-positive (HIV+) persons exacerbates health problems and accelerates HIV disease progression. Antiretroviral therapy (ART) has been the single most important treatment for people living with HIV to optimize viral suppression and slow disease progression. Adherence to ART has considerable public health implications, particularly given that optimal adherence decreases morbidity and mortality, decreases the potential for the development of drug resistant strains of HIV, and reduces HIV infectiousness. Project PLUS (Positive Living through Understanding and Support) was the first (and to our knowledge only) theory-based behavioral intervention, which integrates motivational interviewing and cognitive-behavioral skills training, to demonstrate significant improvements in viral load, CD4 cell count, and self-reported adherence among a racially and ethnically diverse sample of HIV+ women and men enrolled in a randomized controlled trial, and the first intervention for hazardous drinkers to demonstrate any significant effects. A clinic-based replication is the crucial next step in studying the intervention's effectiveness in the real world when delivered by HIV clinic providers to their patients. In collaboration with medical providers at the Center for Comprehensive Care (CCC) at St. Luke's-Roosevelt Hospital Center, the largest provider of HIV medical care in the New York City area with over 5000 active HIV+ patients, our goals are to better understand alcohol-related outcomes among HIV+ persons over the lifespan and to conduct a multisite comparative effectiveness trial with three intensities of treatment-the PLUS intervention, an enhanced treatment as usual (eTAU) condition, and treatment as usual (TAU) condition-to test the clinical and cost-effectiveness of the PLUS intervention in reducing alcohol use and improving ART adherence, viral load, and CD4 counts among HIV+ hazardous drinkers. We will achieve our goals through four specific aims: 1) adapt the PLUS intervention for delivery in HIV clinic settings by mental health providers, and incorporate booster sessions to sustain longer-term effects;2) test the effectiveness of the PLUS intervention relative to eTAU and TAU alone for HIV+ hazardous drinkers when delivered in a consortium of HIV clinics in New York City;3) assess the cost-effectiveness of PLUS to an eTAU condition and TAU alone as estimated over 5- and 10-year windows;and 4) analyze retrospective cohort data and prospective natural history data via CCC's Electronic Medical Records. Working together with CCC experts will help to address practical problems at the frontline of medical service provision to pave the way for a comprehensive program in reducing alcohol use and improving ART adherence and health outcomes among HIV+ persons. Our project has the potential to exert a sustained and powerful impact not only on the effectiveness of ART interventions for HIV+ persons with problematic drinking, but also on the effective use of EMR data to examine the relationship among alcohol and HIV-related outcomes in a large urban and diverse cohort of HIV+ clinic patients.
Alcohol use is increasingly recognized as a key factor in morbidity and mortality among HIV-positive individuals and represents an important public health concern, given its associations with medication non-adherence, increases in viral load, poor immunologic outcomes (lower CD4 counts), drug resistance, lower health care utilization, comorbidities (HIV/viral hepatitis coinfection), and poor health outcomes overall. Adherence to HIV medications has a double public health benefit, both in terms of slowing disease progression and improving health outcomes among HIV-positive individuals and in helping to curb the sexual transmission of HIV. To make significant contributions to the field and advance science, we will utilize the electronic medical records of over 5000 HIV-positive men and women to examine the natural history of the relationship between HIV/AIDS and alcohol-related outcomes and to test the clinical and cost effectiveness of an efficacious, theory-based behavioral intervention to improve HIV/AIDS and alcohol-related outcomes when delivered by mental health providers in clinic settings. !