Heavy alcohol use hinders HIV therapy: Study
Heavy alcohol use hinders HIV therapy: Study
Researchers discuss findings and meaning
(Editor’s note: Gail Shor-Posner, PhD, professor of psychiatry and behavioral sciences, and Maria Jose Miguez, MD, PhD, assistant professor of psychiatry, both at the University of Miami School of Medicine, discuss their recent findings that HIV-infected drug users have worse treatment outcomes when they also are heavy alcohol users. Their study results were presented in an abstract at the annual meeting of the American Society of Addiction Medicine held in April 2001 in Los Angeles. AIDS Alert asked the investigators to explain their findings and to suggest some ways that clinicians can better deal with HIV patients when they continue to abuse alcohol.)
AIDS Alert: Why did you decide to do this particular study?
Shor-Posner: Our interest in alcohol use and HIV infection evolved from inspection of our current database showing widespread use of alcohol in HIV-1-infected chronic drug users. We were concerned about this finding, since alcohol use may contribute to impairment of immune function and affect neurocognition.
AIDS Alert: Tell us some details about the study.
Shor-Posner: It was funded by the National Institute of Drug Addiction in 1997 and was completed this year. Approximately 259 HIV-infected men and women were enrolled in a double-blind nutrition chemoprevention study. The participants have been followed longitudinally, and measurements of alcohol intake, drug use, disease progression, and cognitive function were determined every six months.
The data we are presenting here, for 220 subjects, were obtained at baseline, prior to intervention. For the analyses, our physicians reviewed the medical charts and confirmed that all the study participants were administered HIV-related treatments or had not received any antiretroviral medications for at least six months.
AIDS Alert: What were your most striking findings?
Miguez: The first important finding was that alcohol use was widespread. This is of particular interest, since there are conflicting reports regarding HIV and alcohol use in the literature. In one study by Ruchkina and colleagues, HIV-infected individuals were reported to increase their use of alcohol after being diagnosed with HIV.1 Another study, by Lefevre et al., however, described a reduction in alcohol use after infection with HIV.2
Shor-Posner: There is direct controversy in the literature regarding the prevalence of alcohol use, as well as the impact of alcohol on HIV replication and disease progression.
Miguez: We found that alcohol use is quite frequent among HIV-infected individuals. In fact, this seems to be daily use of alcohol, much more than social drinking. Some patients report drinking between three and four glasses of alcohol per day.
Shor-Posner: These HIV-1 infected participants are chronic drug users as well, which further complicates treatment.
Miguez: But despite drug abuse, most of the patients have reported that they were infected through sexual transmission.
AIDS Alert: Could you tell us about your findings regarding the effect of alcohol use on CD4 cell counts?
Miguez: This is one of the main findings, and is also an area of controversy. In contrast with previous investigations that have failed to demonstrate a relationship between CD4 cell counts and alcohol intake, we found that heavy alcohol users had significantly lower CD4 cell counts than drug users who were non-drinkers. Furthermore, our results indicate that heavy alcohol users who received antiretroviral therapy were two times less likely to achieve the goal of having CD4 cell counts above 500, as compared to light users or nondrinkers administered antiretrovirals.
Another area of controversy, which is very important for HIV-infected individuals, involves reports suggesting that alcohol use may increase replication of the HIV virus. Our findings demonstrated that heavy alcohol users have higher viral load levels than the burden levels of nondrinkers. Moreover, when we reviewed alcohol use in relationship to HAART [highly active antiretroviral therapy] and undetectable viral loads, we found that heavy alcohol users receiving HAART were four times less likely to have undetectable viral load levels than those who did not abuse alcohol.
AIDS Alert: Do you think HIV clinicians should more carefully screen patients for substance abuse given these findings, and what should they do if they find evidence of alcoholism or illicit drug use?
Shor-Posner: I think our data clearly indicate the importance of careful screening for social drinking, heavy drinking, and drug use in HIV-infected patients.
Miguez: Clinicians need to consider two important factors. First, the goal to reduce viral load and increase CD4 cell count may be affected by the use of alcohol. Frequently in clinical practice, HAART is prescribed, and the patient does not respond to treatment as well as expected. One possibility is the use of alcohol. The other important point is alcohol may affect adherence to therapy. If patients are consuming heavy amounts of alcohol, they may not be compliant with medications. A recent study by Chesney demonstrated that HIV-infected subjects who consume alcohol frequently skip doses, stop medications, and forget to get refills, compared to non-drinkers.3 It’s important for clinicians to take these findings into consideration.
AIDS Alert: Should clinicians recommend psychiatric counseling for HIV patients who are abusing substances?
Shor-Posner: Since our questionnaires indicated that the majority of the drug users continue to consume large amounts of alcohol despite HIV diagnosis, I think that clinicians need to focus on prevention of high-risk behaviors to promote adequate treatment.
Miguez: In the literature, there are a number of very good articles about the impact of alcohol in HIV. Two notable studies indicate that people under the influence of alcohol frequently engage in HIV high-risk behaviors.4,5 Some in vitro studies demonstrate that alcohol promotes HIV replication.6,7 And the third article reveals that the risk of getting infected through high-risk sexual behavior is higher when you consume alcohol, because alcohol use impairs cellular responses that are critical in the control of the HIV virus.8
AIDS Alert: If you were discussing your study and results with a group of clinicians, what would be your advice about how to use this information?
Shor-Posner: I would hope that clinicians would use this information to enhance their assessment of risk behaviors prior to administration of HAART, and to increase their awareness of alcohol’s potential impact on adherence and HIV disease progression.
Miguez: One of the strategies being used to promote adherence to medications in other diseases such as TB is directly observed therapy. If you have information that your HIV-infected patient abuses alcohol, perhaps a DOT [directly observed therapy] program needs to be implemented to ensure they’ll take their medications.
References
1. Ruchkina EV, Beliaeva V, Pokrovskii. Alcohol abuse in HIV infection. Ter Arkh 1996; 68:51-53.
2. Lefevre F, O’Leary B, Moran M, et al. Alcohol consumption among HIV-infected patients. J Gen Intern Med 1995; 10:458-460.
3. Chesney MA. Factors affecting adherence to antiretroviral therapy. Clin Infect Dis 2000; 30(Suppl 2):S171-S176.
4. Shillington AM, Cottler LB, Compton WM III, Spitznagel EL. Is there a relationship between "heavy drinking" and HIV high risk sexual behaviors among general population subjects? International Journal of the Addictions 1995; 30:1453-1478.
5. Stein MD, Hanna L, Natarajan R, et al. Alcohol use patterns predict high-risk HIV behaviors among active injection drug users. J Subst Abuse Treat 2000; 18:359-363.
6. Bagasra O, Bachman SE, Jew L, et al. Increased human immunodeficiency virus type 1 replication in human peripheral blood mononuclear cells induced by ethanol: potential immunopathogenic mechanisms. J Infect Dis 1996; 173:550-558.
7. Bagasra O, Kajdacsy-Balla A, Lischner HW, Pomerantz RJ. Alcohol intake increases human immunodeficiency virus type 1 replication in human peripheral blood mononuclear cells. J Infect Dis 1993; 167:789-797.
8. Bagasra O, Whittle P, Kajdacsy-Balla A, Lischner HW. Effects of alcohol ingestion on in vitro susceptibility of peripheral blood mononuclear cells to infection with HIV-1 and on CD4 and CD8 lymphocytes. Prog Clin Biol Res 1990; 345:351-358.
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