Integrated treatment for AUD and HIV improves health outcomes


New clinical research supported by the National Institutes of Health shows that increasing the intensity of treatment for alcohol use disorder (AUD) over time improves alcohol-related outcomes among people with HIV.

This stepped approach to AUD treatment also improves HIV-related disease measures in this patient population.

A report of the new study, led by researchers at Yale University, is now online in The Lancet HIV.

“These research findings demonstrate the potential of integrated treatment for AUD and HIV in improving health outcomes,” said George F. Koob, Ph.D., director of the NIH’s National Institute on Alcohol Abuse and Alcoholism (NIAAA), which provided primary funding for the new research, with additional funding provided by the National Institute on Drug Abuse (NIDA).

“Moreover, it underscores the importance of integrating treatment for alcohol problems into mainstream health care.”

In the United States, estimates of the prevalence of people with HIV who either drink heavily, or who have AUD, range from 8 percent to 42 percent.

Alcohol misuse can increase risky behaviors that increase the likelihood of acquiring HIV or transmitting it to others.

Alcohol misuse may also speed the progression of HIV in individuals with HIV infection and make it harder to follow medication regimens.

“Many people with HIV are unaware of, or not seeking treatment for, their alcohol use problems,” said first author E. Jennifer Edelman, M.D., M.H.S., associate professor of medicine at Yale School of Medicine.

“In addition, HIV clinicians often do not realize that there are effective medications and counseling that they can easily integrate into their practice for patients with alcohol use problems.”

Noting that previous studies have found that integrating the treatment of opioid use disorder into HIV clinics improves both HIV and substance-related outcomes, the researchers wanted to evaluate whether such a model would similarly benefit people with HIV and AUD.

Treatment for AUD often occurs apart from an individual’s HIV clinical care.

The current study integrates the treatment for AUD with treatment for HIV.

Dr. Edelman and her colleagues conducted a randomized clinical trial in five Veterans Affairs-based HIV clinics with 128 people who had HIV infection and AUD.

The researchers investigated integrated stepped alcohol treatment (ISAT) – an approach that involved consecutive steps of increased AUD treatment intensity if lower intensity treatment did not produce desired results.

People in the ISAT group started their AUD treatment with an on-site addiction psychiatrist, focusing on the use of medications for AUD.

If that step did not stop heavy drinking, the next step included the addition of a behavioral intervention conducted on-site to boost motivation to change drinking behavior and teach coping skills for managing high-risk situations.

Researchers defined heavy drinking as five drinks or more per day for men and four drinks or more per day for women, on one or more days during the previous 14 days.

Patients who continued to engage in heavy drinking were advanced to the final step of referral to specialty addiction treatment – such as intensive outpatient treatment or residential treatment depending on locally available resources.

Patients in the control group received treatment as usual – which included alcohol screening, brief intervention, and referral to specialty addiction treatment at the VA at the discretion of their HIV clinician.

At the end of the six-month study, while both groups reported reduced alcohol intake, the researchers found no differences in drinks per week or HIV outcomes between the ISAT and control groups.

Both groups then continued AUD treatment under treatment as usual (control) conditions.

At the 12-month follow up, individuals who had initially received ISAT were found to have fared better than individuals who only received treatment as usual.

People in the ISAT group, for example, reported having fewer drinks per drinking day than people in the control group and a greater percentage of days abstinent.

The ISAT group also had a higher percentage of people who reported no heavy drinking days.

“Importantly, we also observed that participants randomized to stepped AUD treatment were more likely to achieve an undetectable HIV viral load,” said Dr. Edelman.

“We believe that with decreased alcohol consumption, participants in the ISAT group were more likely to take their HIV medications consistently, translating into improved HIV viral control.”

In an invited commentary on the new research in The Lancet HIV, co-authors Lorenzo Leggio, M.D., Ph.D., Senior Investigator in the NIH Intramural Research Program at NIAAA and NIDA, and Roberta Agabio, M.D., a psychiatrist at the University of Cagliari in Italy welcomed the new findings as important for the HIV field and beyond.

“Stepped care approaches have been found to be effective for treating a variety of chronic diseases,” said Dr. Leggio.

“These findings are a first indication of their potential value for treating AUD in the context of HIV treatment.

What is an alcohol use disorder?

An alcohol use disorder (AUD) is drinking that causes distress and harm. It is a medical condition in which you

  • Drink alcohol compulsively
  • Can’t control how much you drink
  • Feel anxious, irritable, and/or stressed when you are not drinking

Types of AUDs include alcoholism (also called alcohol dependence), and alcohol abuse.

What are the treatments for alcohol use disorder?

Most people with an alcohol use disorder can benefit from some form of treatment. Medical treatments include medicines and behavioral therapies.

For many people, using both types gives them the best results. People who are getting treatment for AUD may also find it helpful to go to a support group such as Alcoholics Anonymous (AA).

If you have an AUD and a mental illness, it is important to get treatment for both.

Some people may need intensive treatment for AUD. They may go to a residential treatment center for rehabilitation (rehab).

Treatment there is highly structured. It usually includes several different kinds of behavioral therapies. It may also include medicines for detox (medical treatment for alcohol withdrawal) and/or for treating the AUD.

Which medicines can treat alcohol use disorder?

Three medicines are approved to treat AUD:

  • Disulfiram causes unpleasant symptoms such as nausea and skin flushing whenever you drink alcohol. Knowing that drinking will cause these unpleasant effects may help you stay away from alcohol.
  • Naltrexone blocks the receptors in your brain that make you feel good when you drink alcohol. It can also reduce your craving for alcohol. This can help you cut back on your drinking.
  • Acamprosate helps you avoid alcohol after you have quit drinking. It works on multiple brain systems to reduce your cravings, especially just after you have quit drinking.

Your health care provider can help you figure out if one of these medicines is right for you. They are not addictive, so you don’t have to worry about trading one addiction for another. They are not a cure, but they can help you manage AUD. This is just like taking medicines to manage a chronic disease such as asthma or diabetes.

Which behavioral therapies can treat alcohol use disorder?

Another name for behavioral therapies for AUD is alcohol counseling. It involves working with a health care professional to identify and help change the behaviors that lead to your heavy drinking.

  • Cognitive-behavioral therapy (CBT) helps you identify the feelings and situations that can lead to heavy drinking. It teaches you coping skills, including how to manage stress and how to change the thoughts that cause you to want to drink. You may get CBT one-on-one with a therapist or in small groups.
  • Motivational enhancement therapy helps you build and strengthen the motivation to change your drinking behavior. It includes about four sessions over a short period of time. The therapy starts with identifying the pros and cons of seeking treatment. Then you and your therapist work on forming a plan for making changes in your drinking. The next sessions focus on building up your confidence and developing the skills you need to be able to stick to the plan.
  • Marital and family counseling includes spouses and other family members. It can help to repair and improve your family relationships. Studies show that strong family support through family therapy may help you to stay away from drinking.
  • Brief interventions are short, one-on-one or small-group counseling sessions. It includes one to four sessions. The counselor gives you information about your drinking pattern and potential risks. The counselor works with you to set goals and provide ideas that may help you make a change.

Is treatment for alcohol use disorder effective?

For most people, treatment for an AUD is helpful. But overcoming an alcohol use disorder is an ongoing process, and you may relapse (start drinking again). You should look at relapse as a temporary setback, and keep trying.

Many people repeatedly try to cut back or quit drinking, have a setback, then try to quit again. Having a relapse does not mean that you cannot recover.

If you do relapse, it is important to return to treatment right away, so you can learn more about your relapse triggers and improve your coping skills. This may help you be more successful the next time.

The results warrant further investigation on how to optimize its use among people with HIV, and to explore its integration in other medical care settings.

Indeed, the study is a compelling example of the need for trained clinicians across the spectrum of health care to recognize and treat AUD as a medical disorder amenable to a variety of treatment approaches.”

More information: Roberta Agabio et al. HIV and alcohol use disorder: we cannot ignore the elephant in the room, The Lancet HIV (2019).

Edelman E, et al (2019). Integrated stepped alcohol treatment for patients with HIV and alcohol use disorder: A randomised controlled trial. The Lancet

Provided by National Institutes of Health


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