Stepped care programme helps to reduce drinking in those with HIV

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People with HIV who drink too much were more likely to reduce drinking after undergoing an approach to care known as integrated stepped alcohol treatment, according to a Yale University-led study.

The finding supports greater use of this treatment model in HIV clinics to improve outcomes for patients with both HIV and drinking problems, the researchers said.

Stepped care is used to treat some patients with chronic diseases such as hypertension and depression. It entails the use of different treatments that are “stepped up,” or increased in intensity over time, in response to patients’ needs. Prior to this new study, little research had been done to evaluate the impact of stepped care for patients struggling with alcohol use disorder, and none had been conducted in HIV treatment settings, the researchers said.

The research team recruited 128 individuals from one of five Veterans Affairs-based HIV clinics. They randomised the patients into one of two groups – those given integrated stepped alcohol treatment and an equal number receiving treatment as usual.

The stepped-care patients were offered evidence-based treatments, including medication, motivational therapy, and specialty care at either an outpatient or residential treatment facility. By comparison, the treatment-as-usual patients were referred to specialty addiction treatment at the VA at the discretion of their HIV clinician.

At the end of the study period, the researchers found that patients who received integrated stepped care fared better overall. After 52 weeks, stepped-care patients had fewer heavy drinking days, drank less per drinking day, and had more days of abstinence, the researchers noted.

“We saw overall improvements in drinking,” said Dr Jennifer Edelman, lead author and associate professor in internal medicine. “We also found improved HIV outcomes at the 52-week mark.”

The improvements in patients’ HIV status were presumably associated with the reduced alcohol use, Edelman noted. “Over time, the patients receiving integrated stepped care showed decreases in alcohol use and a higher rate of undetectable HIV viral load, likely related to improved HIV medication adherence,” she said.

The study results support the expanded use of integrated stepped care for alcohol misuse in settings where patients are already being treated for HIV, the researchers said.

This work was supported by grants from the National Institute on Alcohol Abuse and Alcoholism. Edelman was supported as a Yale-Drug Abuse, HIV and Addiction Research Scholar.

Abstract
Background: We examined the effectiveness of integrated stepped alcohol treatment (ISAT) on alcohol use and HIV outcomes among patients living with HIV and alcohol use disorder.
Methods: In this multisite, randomised controlled trial, conducted in five Veterans Affairs-based HIV clinics in the USA (Atlanta, GA; Brooklyn-Manhattan, NY; Dallas and Houston, TX; and Washington, DC), we recruited people living with HIV and an alcohol use disorder who were not otherwise receiving formal alcohol treatment. Patients were eligible if they were aged 18 years or older, HIV positive, English speaking, and met criteria for alcohol use disorder by the Diagnostic and Statistical Manual for Mental Disorders-IV criteria for alcohol abuse or dependence. Key exclusion criteria included if the patient was acutely suicidal or had a psychiatric condition that affected their ability to participate in counselling interventions, or if they had any medical conditions that would preclude completing the study or cause harm during the course of the study. Using a web-based clinical trial management system, we randomly assigned participants (1:1) to receive ISAT or treatment as usual; patients, investigators, and clinicians were unmasked to allocation. ISAT involved three steps: step 1, addiction physician management, comprising eight sessions; step 2, addiction physician management plus motivational enhancement therapy, comprising four sessions; and step 3, specialty referral. Participants were stepped up at weeks 4 and 12 if they exceeded a priori drinking criteria. Treatment as usual involved referral to substance use treatment services. The primary outcome was number of drinks per week over the past 30 days at week 24 by use of the timeline followback method, assessed in the intention-to-treat population. Adverse events were tracked throughout the study period in all randomly assigned participants. This trial is registered at ClinicalTrials.gov, number NCT01410123.
Findings: Between Jan 28, 2013, and July 14, 2017, 128 of 351 patients assessed for eligibility were eligible and randomly assigned to receive ISAT (n=63) or treatment as usual (n=65). Mean age was 54 years (range 23–70), 125 (98%) of 128 participants were men, and 101 (79%) were black. 25 (20%) were lost to follow-up. In the ISAT group, of 57 participants who did not die or withdraw, 30 (52%) advanced to step 2, and 17 (57%) of 30 advanced to step 3. 32 (51%) of 63 participants assigned to ISAT versus 17 (26%) of 65 assigned to treatment as usual received at least one alcohol treatment medication (p=0·004). Participants in both groups decreased their alcohol consumption, but at week 24 we did not detect a difference in number of drinks per week between the groups (least squares mean 10·4 drinks per week [SD 16·5] in the ISAT group vs 15·6 drinks per week [SD 17·6] in the treatment as usual group; adjusted mean difference −4·2, 95% CI −9·4 to 0·9; p=0·11). One adverse event occurred that was possibly related to treatment occurred in the ISAT group (headache).
Interpretation: ISAT increases the receipt of alcohol treatment medications and counselling without changes in drinking at week 24. Strategies to implement and enhance ISAT are needed. Future efforts should focus on promoting ISAT with attention to enhancing patient engagement and retention in alcohol-related care.

Authors
E Jennifer Edelman, Stephen A Maisto, Nathan B Hansen, Christopher J Cutter, James Dziura, Yanhong Deng, Lynn E Fiellin, Patrick G O’Connor, Roger Bedimo, Cynthia L Gibert, Vincent C Marconi, David Rimland, Maria C Rodriguez-Barradas, Michael S Simberkoff, Janet P Tate, Amy C Justice, Kendall J Bryant, David A Fiellin

Yale University material
The Lancet HIV abstract


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