The Impact of Alcohol Use and Related Disorders on the HIV Continuum of Care: a Systematic Review
Alcohol and the HIV Continuum of Care
Alcohol use is prevalent globally with numerous adverse consequences to human health, including HIV progression, in people living with HIV (PLH).
The HIV continuum of care, or treatment cascade, represents a sequence of targets for intervention that can result in viral suppression, which ultimately benefits individuals and society. The extent to which alcohol impacts each step in the cascade, however, has not been systematically examined.
International targets for HIV treatment as prevention aim for:
- 90 % of PLH to be diagnosed
- 90 % of PLH to be prescribed with antiretroviral therapy (ART)
- 90 % to achieve viral suppression
- Currently, only 20 % of PLH are virally suppressed.
This systematic review, from 2010 through May 2015, found 53 clinical research papers examining the impact of alcohol use on each step of the HIV treatment cascade. The results found a 77% negative association between alcohol consumption on one or more stages of the treatment cascade. Lack of consistency in measurement, however, reduced the ability to draw consistent conclusions.
The strong negative correlations suggest that problematic alcohol consumption should be targeted, preferably using evidence-based behavioral and pharmacological interventions, to indirectly increase the proportion of PLH achieving viral suppression, to achieve treatment as prevention mandates, and to reduce HIV transmission.
This systematic review examined the impact of alcohol use and AUDs on the HIV treatment cascade in recent years, as ART is being expanded to more patients. As guidelines emerge to include immediate ART for all patients irrespective of CD4 counts, factors that influence the HIV care continuum may differ, especially for the latter part of the cascade since ART is sometimes withheld from patients perceived to have problems with alcohol.
It is, thus, crucial to holistically establish broad-based interventions that target problematic alcohol consumption so that they may exert their influence across the entire spectrum of the HIV care continuum.
Moreover, findings here point to the need for standardization of measures, not only for each step of the treatment cascade but also for measures of alcohol consumption, with an eye towards AUDs that are amenable to treatment.
From an international perspective, the use of the AUDIT is validated on every continent and is highly specific and sensitive for identifying AUDs, including levels of severity. The challenge with using the AUDIT, however, is that it relies on individuals to accurately quantify a standard drink, when drinks are context specific, have varying levels of alcohol content, and are not consistently quantified.
EBIs that target alcohol use, as well as those targeting the individual stages of the continuum, are needed and should be adequately scaled for high-risk individuals and PLH globally, as part of a concerted effort to reduce both primary and secondary HIV transmission, to improve both individual and public health mandates, and to help eliminate HIV for future generations. Such EBIs may include the Holistic Health Recovery Program (HHRP) , which has previously been used to reduce HIV risk and promote ART adherence specifically for PLH with opioid use disorders.
Recently, this EBI has been adapted for individuals with AUDs  and, if found to be effective, can be disseminated in a variety of settings, including in clinical care, addiction treatment, and community-based settings.
Additionally, the CDC, WHO, and UNAIDS have called for integration of addiction treatment in HIV specialty and primary care settings [106, 107], including pharmacological interventions, and there is ongoing research to determine best practices. Such integration has not yet included alcohol treatment within clinical care settings.
Ultimately, the best results for improving HIV treatment outcomes in PLH with AUDs will be to ensure high-quality integration of prevention and treatment services that use a wide range of options that are suitable to patients.