Health System-Based Unhealthy Alcohol Use Screening and Treatment Comparing Demographically Matched Participants With and Without HIV

Abstract

Background: Unhealthy alcohol use among persons living with HIV (PLWH) is linked to significant morbidity, and use of alcohol services may differ by HIV status. Our objective was to compare unhealthy alcohol use screening and treatment by HIV status in primary care.

Methods: Cohort study of adult (≥18 years) PLWH and HIV-uninfected participants frequency matched 20:1 to PLWH by age, sex, and race/ethnicity who were enrolled in a large integrated healthcare system in the United States, with information ascertained from an electronic health record. Outcomes included unhealthy alcohol screening, prevalence, provider-delivered brief interventions, and addiction specialty care visits. Other predictors included age, sex, race/ethnicity, neighborhood deprivation index, depression, smoking, substance use disorders, Charlson comorbidity index, prior outpatient visits, insurance type, and medical facility. Cox proportional hazards models were used to compute hazard ratios (HR) for the outcomes of time to unhealthy alcohol use screening and time to first addiction specialty visit. Poisson regression with robust standard errors was used to compute prevalence ratios (PR) for other outcomes.

Results: 11,235 PLWH and 227,320 HIV-uninfected participants were included. By 4.5 years after baseline, most participants were screened for unhealthy alcohol use (85% of PLWH and 93% of HIV-uninfected), but with a lower rate among PLWH (adjusted HR 0.84, 95% CI 0.82 to 0.85). PLWH were less likely, compared with HIV-uninfected participants, to report unhealthy drinking among those screened (adjusted PR 0.74, 95% CI 0.69 to 0.79), and among those who screened positive, less likely to receive brief interventions (adjusted PR 0.82, 95% CI 0.75 to 0.90), but more likely (adjusted HR 1.7, 95% CI 1.2 to 2.4) to have an addiction specialty visit within 1 year.

Conclusions: Unhealthy alcohol use was lower in PLWH, but the treatment approach by HIV status differed. PLWH reporting unhealthy alcohol use received less brief interventions and more addiction specialty care than HIV-uninfected participants.

Keywords: Alcohol Use; Epidemiology; HIV; Primary Care; Substance Abuse.

Figure 1.. Time to primary-care based alcohol screening for persons living with HIV and HIV-uninfected participants.

Percentage screened for unhealthy alcohol use obtained from Kaplan-Meier curves and displayed with solid red line for persons living with HIV and dashed blue line for HIV-uninfected participants. Numbers adjacent to curves are the percentage screened at each year following baseline. Crude and adjusted hazard ratios (HR) from Cox Proportional Hazards models are also shown. Adjusted models include terms for age, sex, race/ethnicity (Black, White, Hispanic, Other/Unknown), modified Charlson index (excluding AIDS), prior outpatient visits, census-based SES, smoking, depression, alcohol specific substance use disorder, and insurance, and KPNC facility.

Figure 2.. Time to first visit to addiction specialty care for persons living with HIV and HIV-uninfected participants reporting unhealthy drinking.

Results shown for (a) those reporting unhealthy alcohol use (4+/5+ drinks in a day at least once or average 8+/15+ drinks in a week for women/men); and (b) those reporting frequent unhealthy alcohol use (: 4+/5+ drinks in a day for 5 or more days in past 90 days. Percentage with an addiction specialty care visit obtained from Kaplan-Meier curves and displayed with solid red line for persons living with HIV and dashed blue line for HIV-uninfected participants. Numbers adjacent to curves are the percentage screened by one year. Crude and adjusted hazard ratios (HR) from Cox Proportional Hazards models are also shown. Adjusted models include terms for age, sex, race/ethnicity (Black, White, Hispanic, Other/Unknown), neighborhood deprivation index, KPNC facility, and insurance type.