Among patients with unhealthy alcohol use, those with HIV are less likely than those without to receive evidence-based alcohol-related care: A national VA study

Highlights

• Disparities in receipt of alcohol-related care among HIV+ and HIV- patients exist.

• Alcohol use is disproportionality under-addressed among PLWH relative to HIV-.

• Special efforts may be needed to ensure that HIV+ patients receive adequate care.

Abstract

Background

Alcohol use has important adverse effects on people living with HIV (PLWH). This study of patients with recognized unhealthy alcohol use estimated and compared rates of alcohol-related care received by PLWH and HIV- patients.

Methods

Outpatients from the Veterans Health Administration who had one or more positive screen(s) for unhealthy alcohol use (AUDIT-C ≥ 5) documented in their medical records 10/2009-5/2013 were eligible. Primary and secondary outcomes were brief intervention documented ≤14 days after a positive alcohol screen, and a composite measure of any alcohol-related care (brief intervention, specialty addictions treatment or pharmacotherapy documented ≤365 days), respectively. Unadjusted and adjusted regression analyses compared alcohol-related care outcomes in PLWH and HIV- patients.

Results

The sample included 830,825 outpatients (3,514 PLWH), reflecting 1,172,606 positive screens (1–5 per patient). For PLWH, 57.0% (95% confidence interval 55.4–58.5%) of positive screens were followed by brief intervention, compared to 73.8% (73.7–73.9%) for HIV- patients [relative rate: 0.77 (0.75–0.79), p < 0.001]. After adjustment, comparable proportions were 61.0% (59.3–62.6%) for PLWH and 73.7% (73.6–73.8%) for HIV- patients [adjusted RR = 0.83 (0.80–0.85); p < 0.001]. Secondary outcome results were similar: for PLWH and HIV- patients, 67.1% (65.7–68.6%) and 77.7% (95% CI 77.7–77.8%) of positive screens, respectively, were followed by any alcohol-related care after adjustment [adjusted RR = 0.86 (0.85–0.88), p < 0.001].

Conclusions

In this large national sample of VA outpatients with unhealthy alcohol use, PLWH were less likely to receive alcohol-related care than HIV- patients. Special efforts may be needed to ensure alcohol-related care reaches PLWH.

Introduction

Alcohol use is associated with over 60 medical conditions and adversely impacts health in diverse ways (Rehm et al., 2010). Alcohol screening followed by brief intervention for patients screening positive for unhealthy alcohol use are recommended for all adult primary care patients (National Institute on Alcohol Abuse and Alcoholism, 2007) and were designated as essential benefits under health care reform (HealthCare.gov, 2013a, HealthCare.gov, 2013b) based on efficacy trials demonstrating decreased drinking among primary care patients (Jonas et al., 2012). For patients with the most severe unhealthy alcohol use—alcohol use disorders—specialty addictions treatment and/or pharmacotherapy are effective and recommended (National Institute on Alcohol Abuse and Alcoholism, 2007).

Human immunodeficiency virus (HIV) is now a chronic disease (Taddei et al., 2016) that is negatively influenced by alcohol use in multiple ways (Conigliaro et al., 2006, Williams et al., 2016b), including decreased engagement with and retention in HIV care (Hendershot et al., 2009, Monroe et al., 2016, Vagenas et al., 2015), complications of common comorbid conditions (Bryant et al., 2010, Freiberg et al., 2010, Gonzalez-Reimers et al., 2011, Neuman et al., 2012, Sarkar et al., 2015), increased frailty (Justice et al., 2016), and poorer survival (Justice et al., 2016). Further, evidence suggests that, at similar levels of drinking, alcohol use may have greater negative influences on patients living with HIV (PLWH) than HIV- patients, including such patients’ being more likely to “feel a buzz” and having a higher risk for mortality and frailty (Justice et al., 2016, McGinnis et al., 2016). Therefore, receiving evidence-based alcohol-related care may be particularly important for PLWH.

Despite increased risks of unhealthy alcohol use for PLWH, little is known about whether unhealthy alcohol use is appropriately addressed among PLWH (Conigliaro et al., 2003, Metsch et al., 2008). While previous studies have suggested gaps in the quality of alcohol-related care provided to PLWH with unhealthy alcohol use (Conigliaro et al., 2003, Korthuis et al., 2011, Metsch et al., 2008, Strauss et al., 2009), they did not compare receipt of alcohol-related care among those with and without HIV. Moreover, they were conducted in small (Chander et al., 2016) and/or recruited (Chander et al., 2016, Conigliaro et al., 2003, Metsch et al., 2008) samples and in settings that had not yet implemented routine alcohol screening and brief intervention. However, even in settings with routine implementation of alcohol-related care for unhealthy alcohol use, PLWH may be less likely to receive recommended alcohol-related care than HIV- patients due to the complex care needs of PLWH and/or the possibility that HIV specialty care providers might be less prepared to address unhealthy alcohol use than generalist providers (Strauss et al., 2009). On the other hand, PLWH are recommended to have regular and frequent visits to manage their HIV (The White House, 2013, U.S. Department of Health and Human Services, 2016). Because frequent visits may offer increased opportunities to receive alcohol-related care, PLWH may be more likely to receive alcohol-related care than HIV- patients with less frequent visits.

The objective of this study was to estimate and compare rates of alcohol-related care received by PLWH and HIV- patients with recognized unhealthy alcohol use. We conducted this study in the Veterans Health Administration (VA), which is the largest provider of HIV care in the U.S. (Department of Veterans Affairs, 2010, Fultz et al., 2006) and has been recognized as a leader among healthcare systems in implementing alcohol screening and brief intervention (Moyer and Finney, 2010, Williams et al., 2011). Results of this study can help determine whether special efforts are needed to reach PLWH with unhealthy alcohol use when health systems implement screening and brief interventions for unhealthy alcohol use.