Alcohol use is increasing in sub-Saharan Africa (SSA) where it commonly intersects with the HIV/AIDS epidemic. Hazardous alcohol use increases HIV transmission, impedes uptake and retention on antiretroviral therapy (ART), and ultimately reduces HIV viral suppression (VS). Approximately 20-50% of persons living with HIV (PLWH) on ART drink hazardously; however, most clinics in SSA offer only brief interventions (BIs) for alcohol reduction that are ineffective for many patients. BIs have limited ability to address more severe alcohol use disorders (AUDs) or comorbid mental health or substance use issues (hereafter called `comorbidities') that are common among PLWH. In preliminary studies, we found that 40% of male and 20% of female PLWH on ART in Zambia had hazardous alcohol use, that ~60% failed to respond to current BIs, and that >50% had comorbidities. We previously developed and demonstrated the effectiveness of a novel cognitive-behavioral therapy intervention, Common Elements Treatment Approach (CETA), which trains lay health workers to address both AUDs and comorbidities. Our central hypothesis is that a stepped care approach to alcohol use, where interventions ranging in time and resource intensity are provided according to symptom severity, can be utilized by HIV treatment programs in SSA to effectively and efficiently address hazardous alcohol use and improve HIV outcomes. In this application, we propose a Stage 1 hybrid effectiveness-implementation study to adapt and pilot test CETA at two Zambian HIV clinics for PLWH who report hazardous alcohol use and are less likely to respond to BIs (i.e., those with moderate-to-severe alcohol use disorders (AUDs) and/or comorbidities). This project leverages (a) our development of CETA, (b) a prospective cohort of HIV-infected individuals that was created by the NIAID-funded International Epidemiological Databases to Evaluate AIDS, and (c) >10 years of HIV and mental health research in Zambia.
Aim 1 will adapt the current CETA manual for HIV-infected individuals and HIV clinics with input from PLWH, health workers, and key informants in the health system.
In Aim 2, PLWH who screen positive for hazardous alcohol use will be enrolled and assessed for AUD and comorbidities. Those with moderate-to-severe AUD and/or comorbidities (n=160) will be randomized 1:1 to receive BI alone or BI+CETA. Participants with subthreshold/mild AUD and without comorbidities will also receive the BI. Changes in alcohol use, comorbidities, and HIV outcomes (ART retention and HIV viral suppression) will be measured over 6 months of follow-up and the impact of the interventions will be evaluated. Urine Ethyl glucuronide testing will be used to augment self-reported alcohol measures.
Aim 3 will investigate feasibility, acceptability, and other implementation factors related to delivery of BI and CETA. This study will: (1) result in an HIV-adapted CETA manual, (2) generate preliminary effectiveness and implementation data on CETA and BI in PLWH drinkers with comorbidities, and (3) inform an R01 application to further test a stepped care approach to address hazardous drinking in HIV care settings.

Public Health Relevance

Current interventions for alcohol use disorders (AUD) and co-occurring mental health problems are inadequate within HIV treatment clinics in sub-Saharan Africa, which is a critical gap given the negative impacts that AUD and mental health problems can have on HIV outcomes, including retention in care, ART adherence, and viral suppression. This study will adapt, integrate, and pilot test an evidence-based transdiagnostic cognitive behavioral therapy, Common Elements Treatment Approach (CETA), for use in HIV care facilities in Zambia. The data generated will support the development of a stepped care approach to management of alcohol and mental health problems within HIV care settings in Africa and has potential to be an important piece of the strategy to reaching the 90-90-90 goals and reducing HIV transmission.

Agency
National Institute of Health (NIH)
Institute
National Institute on Alcohol Abuse and Alcoholism (NIAAA)
Type
Planning Grant (R34)
Project #
1R34AA027200-01
Application #
9623505
Study Section
Behavioral and Social Consequences of HIV/AIDS Study Section (BSCH)
Program Officer
Roach, Deidra
Project Start
2018-08-05
Project End
2021-04-30
Budget Start
2018-08-05
Budget End
2019-04-30
Support Year
1
Fiscal Year
2018
Total Cost
Indirect Cost
Name
Johns Hopkins University
Department
Other Health Professions
Type
Schools of Public Health
DUNS #
001910777
City
Baltimore
State
MD
Country
United States
Zip Code
21205