The effect of a brief intervention and motivational interviewing on alcohol misuse and anti-retroviral therapy adherence in patients with human immuno-deficiency virus and a history of alcohol misuse: a systematic review protocol

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Abstract

Review question/objective

The objective of this systematic review is to determine the effect of a brief intervention and motivational interviewing on alcohol misuse and highly active anti-retroviral therapy (HAART) adherence in patients with human immunodeficiency virus (HIV) with a history of alcohol misuse.

Background

Alcohol use is high among people living with HIV (PLHIV). For instance, a systematic review by Nakimuli-Mpungu et al. on alcohol use, depression and adherence to antiretroviral therapy (ART) in patients with HIV showed a prevalence of alcohol use between 2.5 and 51%.1 Studies in several African countries have shown a causal link between alcohol use and HIV, and have shown that alcohol use has effects on the course of HIV, including adherence to ART. The prevalence of HIV is considerably higher in adults who have a history of high or frequent alcohol consumption than in adults who do not use alcohol.2,3,4,5 A systematic review and meta-analysis by Fisher et al. confirmed the strong association between alcohol use and HIV infection.6

Background

Alcohol use disorder can be hazardous drinking or harmful drinking. Hazardous drinking is defined as a quantity or pattern of alcohol consumption that places patients at risk of adverse health consequences, while harmful drinking is defined as alcohol consumption that results in adverse consequences (for example, physical or psychological harm).7Problem level alcohol consumption is a common issue in the treatment of individuals with HIV infection.8 For instance, Myer et al. reported a prevalence of alcohol dependence/abuse in 7% of patients with HIV in Cape Town.9

Background

Researchers believe alcohol consumption may have an impact on HIV viral replication, disease progression, and drug toxicity10 and may impair immune system function11,11,12,13,14 HIV disease progression is accelerated by alcohol use, which is shown by a more likely decline of CD4 T cells to ≤200 cells/μl and a more frequent detectable viral load in frequent alcohol users. These effects occur independent of baseline CD4 cell count and HIV viral load, ART use over time, the time since HIV diagnosis, age and gender.15,16,17

Background

Heavy consumption or hazardous drinking is likely to lead to increased risk for toxicity from antiretroviral therapy because it intensifies conditions that also place a strain on the liver, such as hepatitis C or chronic hepatitis B.10

Background

The negative effects of alcohol use on individuals with HIV are numerous. High alcohol use is associated with high risk sexual behavior and the risk of HIV.18,19 Once individuals are infected with HIV, alcohol use is related to low participation in prevention of mother-to-child transmission (PMTCT), pre-test and posttest counseling (including returning for test results).20,21 In addition, there is a late presentation to HIV care in patients who use alcohol, compared with those who do not use alcohol.22

Background

Alcohol consumption has been linked to lower rates of adherence to HAART regimens.23 HIV-positive patients who drink have worse adherence than those who do not.24Non-adherence increases with the level of drinking severity.25 Among HIV-positive persons with alcohol problems, alcohol was the most significant predictor of non-adherence,26 and problem drinkers are more likely than non-drinkers to report forgetting medication, taking medication off schedule, or running out of medications.23

Background

Lack of adherence results in inadequate suppression of the virus and viral replication, low potency of the antiretroviral regimens, and pharmacokinetic interactions27 causing inadequate drug delivery.28 Non-adherence risks the development of drug resistance and failure of therapy.29,30

Background

Screening and brief alcohol intervention is an example of secondary preventive care for people with problem drinking.31 It aims to identify hazardous or harmful drinking at an early stage (before people are consciously aware of [or seeking help for] problems), and then provide advice or counseling to help reduce consumption levels.

Background

Parsons et al. have conducted a randomized controlled trial on the effects of motivational interviewing and cognitive-behavioral intervention on adherence among hazardous drinkers. The study demonstrated that an eight session behavioral intervention resulted in improvements in self-report and biological markers (CD4 cell count and HIV viral load) after three months relative to those participants provided with education(factual information through didactic methods and formal discussions) only.32

Background

In comparison, Samet et al. conducted a randomized controlled trial to enhance antiretroviral therapy adherence in patients with a history of alcohol problems. They employed multi-component interventions that included: i) assessment and discussion of the patient's alcohol and other substance use based on the stage of readiness for behavioral change; ii) use of a watch that served as a medication timer device and a practical aid to improving adherence; iii) enhancement of perceived efficacy of medications; and iv) individualized HIV counseling and exploration of ways to tailor medication use to specific circumstances. Subjects randomized to the intervention group were scheduled for an initial 60-minute individual appointment, a follow-up home visit within the first three weeks and two subsequent 15- to 30-minute appointments at one month and three months with the nurse interventionist who delivered the adherence enhancement intervention. In that study, a multi-component intervention showed no significant differences in adherence, CD4 count, viral load or alcohol consumption compared to those who were assigned to standard care (verbal or written instruction about optimal medication adherence strategies).33

Background

However, no previous synthesis has been identified on the effects of interventions on people with HIV with a history of alcohol misuse and problems on HAART adherence and alcohol use and virological outcomes. Therefore, in order to have an evidence-based health care practice in reducing alcohol use related problems and HIV viral load, and in improving the CD4 count, the findings of studies should be synthesized. The current review is aimed at generating evidence from studies conducted on the effect of motivational interviewing and brief interventions on patients with HIV and alcohol use problems.

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