Heavy alcohol drinking lowered chances of keeping HIV care appointments more than 20%, according to results of a 9694-person U.S. study.1 The analysis also linked binge drinking to worse appointment keeping.
Once a person begins care for HIV infection and starts taking antiretroviral therapy, keeping all HIV clinic appointments is crucial to successful treatment and overall health. In the United States more than half of people who test positive for HIV fail to enter care or remain in care.2 It is important for people with HIV and for their providers to understand specific problems that lead to missed office visits because those problems can often be solved.
About half of HIV-positive people in the United States drink alcohol and almost 10% are heavy drinkers.3,4 The National Institute on Alcohol Abuse and Alcoholism defines heavy drinking as more than 4 drinks daily or more than 14 drinks weekly for men, and more than 3 drinks daily or more than 7 drinks weekly for women.
Studies show that both moderate and heavy drinking raise the risk of death in people with HIV. Reasons for this link could include poor antiretroviral pill-taking by HIV-positive alcohol users (see "Main Barriers to Antiretroviral Pill Taking in Adults, Adolescents and Children" in this issue5) and missing HIV care visits. Because the impact of heavy drinking on HIV care visits is poorly understood, U.S. researchers conducted this study.
How the Study Worked
The study focused on HIV-positive adults seen at 7 clinics across the United States. Participants reported alcohol and drug use at least every 6 months and had health assessments as directed by their provider. This analysis considered study visits between January 2011 and June 2014. Everyone in this study had HIV primary care visits covering at least 1 year.
Researchers used a standard 3-question test* to rate each person for drinking frequency (never, moderate, or heavy) and binge drinking frequency (never, monthly or less than monthly, or weekly or daily). Binge drinking meant 5 or more drinks at a time for men and 4 or more drinks at a time for women. The research team also collected standard personal data (like age, sex, and race) and other health data (like CD4 count, viral load, illegal drug use, and depressive symptoms).
The researchers measured HIV clinic attendance (keeping appointments) in two ways: (1) 2 visits in 12 months: attending at least two HIV care visits within 12 months with each visit separated by at least 90 days, and (2) proportion of HIV care visits kept: visits kept divided by (scheduled visits plus kept visits). The investigators used standard statistical methods to determine the impact of alcohol use on these two measures of appointment keeping. This kind of analysis considers several risk factors at the same time; in this way the analysis can identify alcohol use as an independent risk factor, regardless of whatever other risk factors a person has.
What the Study Found
The study involved 9694 people, 65% gay or bisexual men, 17% heterosexual men, and 17% women. The group averaged 44 years in age, 46% were white, 35% black, and 14% Hispanic. Almost half of study participants had a CD4 count above 500, and three quarters had an undetectable viral load. Only 15% of participants currently used illegal drugs or party drugs.
Among all people studied, 37% reported never drinking, 38% moderate drinking, and 25% heavy drinking. While 69% reported never binge drinking, 25% reported binge drinking monthly or less, and 6% reported binge drinking daily or weekly. Gay/bisexual men were more likely to report moderate or heavy drinking than never drinking. White participants were also more likely to report moderate or heavy drinking than never drinking. In the first year of observation, 89% of the study group made at least 2 visits in 12 months, and the proportion of visits kept was 84%.
First the researchers looked for factors that independently affected chances of making at least 2 visits in 12 months. They identified three factors that lowered chances of making at least 2 visits in 12 months (Figure 1): heavy drinking lowered chances by 22%, monthly or less binge drinking lowered chances 11%, and current illegal or party drug use lowered chances by 13%. Having depression symptoms raised chances of making at least 2 visits in 12 months by 15%. These factors affected appointment-keeping by themselves, regardless of whatever other risk factors a person had.
Next the researchers looked for factors that independently affected proportion of HIV care visits kept (Figure 2). Daily or weekly binge drinking lowered chances of keeping a scheduled visit by 10%. Current illegal or party drug use lowered chances of keeping an appointment by 26%, panic symptoms lowered chances by 15%, and depression symptoms lowered chances by 8%. Again these factors lowered chances of appointment keeping regardless of whatever other risk factors a person had.
What the Results Mean for You
This large U.S. study found that heavy alcohol drinking and binge drinking lowered chances of good HIV care appointment keeping. Heavy alcohol drinkers had lower chances of keeping even 2 appointments per year. The links between alcohol overuse and poor appointment keeping held true regardless of whatever risk factors a person had for poor appointment keeping, like drug use or depression.
These findings are important for two reasons: (1) keeping all care appointments is critical to HIV control and to the overall health of people with HIV, and (2) alcohol use can be controlled with reliable programs and medicines that have helped millions of people.
Do you have an alcohol problem? It can be hard for a person to judge whether they drink too much alcohol because alcohol overuse often develops slowly over time. The U.S. National Institute on Alcohol and Alcohol Abuse (NIAAA) has a simple online form people can complete in private to learn if their drinking behavior indicates an alcohol use disorder. Click on the link at reference 6 below.
If you believe you may have an alcohol use problem -- or if you know you do -- the NIAAA advises talking to your primary health provider.7 Another option is to talk to a counselor in an HIV/AIDS service organization. These professionals can further evaluate your alcohol use pattern and determine whether you need treatment. Successful treatment may involve three strategies, either alone or combined: (1) professional counseling, (2) one of three medicines, and (3) support groups including other people with alcohol problems. For more details, see the online NIAAA page "Treatment for alcohol problems" at the link following reference 7 below. The NIAAA offers many other online brochures and fact sheets listed at the link after reference 8 below.
Besides contributing to poor HIV care appointment keeping, drinking too much alcohol can impair health in many ways and can directly lead to death. The NIAAA estimates that almost 88,000 people die every year from alcohol-related problems in the United States.9 Almost 10,000 automobile accident deaths can be traced to drunk driving every year. Alcohol overuse is the fourth leading preventable cause of death in the United States.9 Don't add yourself to these statistics. One third of people treated for alcohol problems have no alcohol abuse symptoms 1 year later, and many others greatly reduce their drinking.
* Alcohol Use Disorders Identification Test-C (AUDIT-C).
- Monroe AK, Lau B, Mugavero MJ, et al. Heavy alcohol use is associated with worse retention in HIV care. J Acquir Immune Defic Syndr. 2016;73:419-425.
- Mugavero MJ, Amico KR, Horn T, et al. The state of engagement in HIV care in the United States: from cascade to continuum to control. Clin Infect Dis. 2013;57:1164-1171.
- Galvan FH, Bing EG, Fleishman JA, et al. The prevalence of alcohol consumption and heavy drinking among people with HIV in the United States: results from the HIV cost and services utilization study. J Stud Alcohol. 2002;63:179-186.
- Chander G, Josephs J, Fleishman JA, et al. Alcohol use among HIV-infected persons in care: results of a multi-site survey. HIV Med. 2008;9:196-202.
- Shubber Z, Mills EJ, Nachega JB, et al. Patient-reported barriers to adherence to antiretroviral therapy: a systematic review and meta-analysis. PLoS Med. 2016;13:e1002183.
- National Institute on Alcohol and Alcohol Abuse (NIAAA). Symptoms of alcohol use disorder.
- National Institute on Alcohol and Alcohol Abuse (NIAAA). Treatment for alcohol problems: finding and getting help.
- National Institute on Alcohol and Alcohol Abuse (NIAAA). Brochures and fact sheets.
- National Institute on Alcohol and Alcohol Abuse (NIAAA). Alcohol facts and statistics.