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This prospective, nonrandomized implementation study evaluated a computerized brief intervention (CBI) for persons with HIV (PWH) and heavy/hazardous alcohol use. CBI was integrated into two HIV primary care clinics. Eligible patients were engaged in care, ≥18 years old, English speaking, endorsed heavy/hazardous alcohol use on the Alcohol Use Disorders Identification Test - C (AUDIT-C). Two 20-minute computerized sessions using cognitive behavioral techniques were delivered by a 3-D avatar on touch screen tablets. Of 816 eligible AUDIT-C scores, 537 (66%) resulted in CBI invitation, 226 (42%) of invited patients enrolled, and 176 (78%) of enrolled patients watched at least one session. CBI enrollment was associated with a significant average reduction of 9.1 drinks/week (95% CI: −14.5, −3.6) 4–12 months post-enrollment. Among those who participated in one or both sessions, average reduction in drinks/week was 11.7 drinks/week (95% CI: −18.8, −4.6). There was corresponding improvement in AUDIT-C scores. Overall patients reported high levels of intervention satisfaction, particularly among older and Black patients. These promising results point to a practical intervention for alcohol reduction in this vulnerable patient population with elevated rates of heavy/hazardous drinking. Future research should examine strategies to increase initial engagement, strengthen intervention effects to increase the number of patients who achieve non-hazardous drinking, and examine the duration of therapeutic effects.

High mortality rates among persons with HIV with a history of injection drug use (PWID) are thought to be driven in part by higher rates of external cause-related mortality. We followed 4,796 persons aged 18–70 engaged in continuity HIV care from 2001–2015 until death or administrative censoring. We compared cause-specific (csHR) and subdistribution hazards (sdHR) of death due to external causes among PWID and persons who acquired their HIV infection through other routes (non-IDU). We standardized estimates on age, sex, race, and HIV-related health status. The standardized csHR for external cause-related death was 3.57 (95% CI: 2.39, 5.33), and the sdHR was 3.14 (95% CI: 2.16, 4.55). The majority of external cause-related deaths were overdose-related and standardized sdHR was 4.02 (95% CI: 2.40, 6.72). Absolute rate of suicide was low but the csHR for PWID compared to non-IDU was most elevated for suicide (6.50, 95% CI: 1.51, 28.03). HIV-infected PWID are at a disproportionately increased risk of death due to external causes, particularly overdose and suicide.

INTRODUCTION: Few studies examine how depression and substance use interact to affect HIV control. METHODS: In 14,380 persons with HIV (PWH), we used logistic regression and generalized estimating equations to evaluate how symptoms of depression interact with alcohol, cocaine, opioid, and methamphetamine use to affect subsequent retention in care, maintaining an active prescription for ART, and consistent virologic suppression. RESULTS: Among PWH with no or mild depressive symptoms, heavy alcohol use had no association with virologic suppression (OR 1.00 [0.95–1.06]); among those with moderate or severe symptoms, it was associated with reduced viral suppression (OR 0.80 [0.74–0.87]). We found no interactions with heavy alcohol use on retention in care or maintaining ART prescription or with other substances for any outcome. DISCUSSION: These results highlight the importance of treating moderate or severe depression in PWH, especially with comorbid heavy alcohol use, and support multifaceted interventions targeting alcohol use and depression.

Persons with HIV who have entered care but have viral load > 1500 copies/mL may be the source of the majority of new HIV infections in the United States. We followed patients engaged in continuity care in the Johns Hopkins HIV Clinical Cohort between January 2010 and August 2015. We estimated person-time spent with viral load > 1500 copies/mL while in care after antiretroviral therapy (ART) initiation, while in care, and while alive. Person-time was classified according to the most recent viral load measurement. Of 11,283.1 person-years in care on after ART initiation, 11,954.7 person-years in care and 13,990.0 total person-years of follow-up spent alive, 12.5, 14.8%, and between 12.6 and 27.2%, respectively (depending on assumptions about the viral load of persons lost to clinic) were spent with viral load > 1500 copies/mL. Patients with lower baseline CD4 cell count, younger age, black race, history of injection drug use, or baseline hazardous alcohol use spent more time with viral load > 1500 copies/mL after ART initiation.

Compared to HIV-infected persons who do not inject drugs (non-IDU), persons who inject drugs (PWID) experience disparities in linking to medical care, initiating antiretroviral therapy (ART) and achieving viral suppression. There has been little attention to changes in these disparities over time. We estimated the proportion of PWID and non-IDU retained in care, on ART, and virally suppressed each year from 2001–2012 in the Johns Hopkins HIV Clinical Cohort (JHHCC). We defined active clinic patients as those who had ≥1 clinical visit, CD4 cell count, or viral load between July 1 of the prior year, and June 30 of the analysis year. Within a calendar year, retention was defined as ≥2 clinical visits or HIV-related laboratory measurements >90 days; ART use was defined as ≥1 ART prescription active ≥30 days; and viral suppression was defined as ≥1 HIV viral load

Heavy alcohol use has adverse effects in women with HIV. We examined the association between changes in alcohol use (measured with Timeline Followback) and changes in antiretroviral therapy adherence (medication possession ratio) and viral suppression (HIV RNA), measured over 6-month intervals. Among women who were (1) non-adherent or not virologically suppressed and (2) infrequent binge drinkers or non-heavy drinkers at baseline, increasing drinking was significantly associated with lower odds of subsequently improving adherence or viral suppression (OR of becoming adherent of 0.90 in infrequent binge drinkers; OR of becoming suppressed of 0.81 and 0.75 in infrequent binge drinkers and non-heavy drinkers, respectively). Our findings suggest that for these women, increasing drinking may be a barrier to achieving viral suppression. Addressing this barrier by integrating proactive alcohol counseling strategies into routine HIV care may be key to improving viral suppression rates among women retained in HIV care.