Among those with HIV infection (HIV+) on antiretroviral therapy (ART), polypharmacy is three times more common than among those without infection and occurs 10 years earlier. Likely due to greater physiologic frailty, polypharmacy (5+ chronic medications) among those with HIV is also associated with greater mortality. Potentially inappropriate medications (PIMs) are those which likely cause more harm than benefit due to drug interactions and adverse reactions and these increase with polypharmacy. While criteria for PIMs among 65+ year olds (Aging PIMs) are established, they have not been validated among HIV+ individuals. Further, ART and alcohol use also increase PIMs. We do not know which non ART pharmacotherapies (co medications) are helpful and which are actually harmful among HIV+ who drink. Conversely, HIV and alcohol use may also be a barrier to receipt of helpful co medications. In the face of limited evidence, providers may be reluctant to treat Alcohol Use Disorder (AUD) with medications among HIV+ individuals due to safety concerns. Further, alcohol use is a relative contraindication for HCV treatment. As a result, drinkers may choose to under report alcohol use to gain access to direct acting agents (DAAs) but may experience more harm and less benefit. We draw on the rich, longitudinal clinical data in the Veterans Aging Cohort Study and enhance it with strategic additional data collection and innovative techniques to correct for systematic error in measurement and confounding by indication. We will quantify the impact of Aging, ART and Alcohol PIMs and of pharmacotherapies for AUD and HCV on patient salient outcomes (PSOs) including mortality, hospitalization, medically significant falls, bacterial pneumonia, and delirium to inform prioritization of medications and limit harm from polypharmacy among HIV+ individuals. Our study is timely and innovative. Polypharmacy is the norm, AUD is under treated, and DAAs for HCV have only recently become available. While others have quantified PIMs, we will measure their actual impact on PSOs. We will also measure the benefit from pharmacotherapy for AUD and HCV among HIV+ and uninfected individuals who drink. These studies will be instrumental in the design of eHealth interventions facilitating personalized care and simplification of co medications among HIV+ individuals (see U24s CHAMP & RIB). While we have successfully recruited 79 participants to date into the interventional arm (FIRST Trial), we are currently behind targets. To address this problem and in the context of a newly fostered collaboration that has developed between our team and Dr. Patricia Molina?s group at Louisiana State University Health Sciences Center (LSUHSC) over the past year, we request an administrative supplement to cover salary support and patient payments to create the required infrastructure at the HIV Outpatient Clinic at LSUHSC, directed by Dr. Lauren Richey, as a new study site. Given the prevalence of unhealthy alcohol use, we believe this addition will help ensure that we are able to successfully meet recruitment targets and broaden our reach to the underserved population in the deep South. The LSUHSC team is well-positioned to recruit 30 subjects by August 31, 2020.
Untreated alcohol problems threaten the health of people who are infected with the HIV virus and are a major cause of illness and death. The goals of this study are to optimize the treatment of HIV disease by decreasing alcohol consumption, improving HIV immune markers, and improving overall health in patients with unhealthy alcohol use. The current project will serve to advance this area of research and expand the types of care that HIV-infected patients receive.
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