Journal Article Annotations
2023, 4th Quarter
Annotations by John A R Grimaldi MD, Mary Ann Cohen MD, FACLP, Kelly Cozza MD, DFAPA, FACLP, Luis Pereira MD
This meta-analysis examined the effect of brief interventions (BI) for alcohol misuse among people with HIV (PWH). Only randomized controlled trials with subjects meeting criteria for hazardous or heavy drinking were included. Those studies of PWH with alcohol use disorder or dependence were excluded. The overall analysis found that BI had a significant effect on the number of drinks consumed on drinking days, compared to the control condition. BI also significantly reduced the number of heavy drinking days, compared to controls, 3-6 months post-intervention. BI did not improve either adherence to antiretroviral therapy (ART) or viral suppression, compared to controls, at 6-12 months. However, there was a significant reduction in the odds of mortality in PWH who received BI, compared to controls, at 12 months post-intervention. BI did not reduce the risk of progression to harmful drinking.
Strengths and limitations:
This meta-analysis comprised randomized controlled trials conducted in the US, which accounted for the largest number of studies, as well as in South Africa, Uganda, Portugal, Russia, and Vietnam. By excluding participants with alcohol use disorder, the study population was more homogeneous than previous studies, thus adding strength to findings. This study focused on motivational interviewing-based BI, a scalable intervention that a range of healthcare professionals can be trained to perform and that can realistically be integrated into an HIV primary care clinic. Study limitations are as follows: This study utilized alcohol-focused interventions and treatments, hence, the use of interventions that targeted HIV outcomes may have resulted in more favorable ART adherence and virologic suppression. Only English-language studies were included, and outcomes were measured 3-6 months post-intervention. Longer duration studies may have yielded different results. Studies utilized self-report instruments which introduced social desirability and recall bias. Across studies, there was non-uniform reporting of ethnicity and no representation of indigenous cultures.
When identified, alcohol misuse often goes untreated or undertreated. Additionally, PWH are at greater risk for not only alcohol misuse, but also for medical complications of alcohol compared to the general population. This evidence points to the need for screening and brief intervention that can be practically integrated in HIV clinical care. It also stands to reason that addressing problematic drinking may promote the US goal to end the HIV epidemic.
Using data from the North American AIDS Cohort Collaboration on Research and Design, this study described the prevalence of mental health disorders (MHD) in people with HIV (PWH) – depression, anxiety, bipolar disorder (BD) and schizophrenia – and compared HIV outcomes in those participants with mental health disorders vs those without psychiatric morbidity. Overall, 55% of the study population was diagnosed with at least one MHD. Between 2008 and 2018, there was an increase in prevalence of both depression and anxiety. Depressed participants, compared to those without depression, had a lower annual prevalence of viral suppression. In adjusted models, this difference was nonsignificant. Viral suppression was lower by anxiety early in the reporting period. This difference disappeared in the final several years of the period. Unlike depression and anxiety, the prevalence of BD decreased over time. Similar to BD, there was a decline in prevalence of schizophrenia over time. A lower proportion of viral suppression among those participants diagnosed with schizophrenia, compared to those without schizophrenia, was not evident until the latter portion of the reporting period. The overall prevalence of participants with MH multimorbidity, defined as having 2 or more MHDs, was 24%. MH multimorbidity conferred a risk of viral non-suppression, but did not affect retention in care.
Strengths and limitations:
A major strength of this study was its use of a large, diverse, sample, representative of PWH in medical care in North America. The study was limited by not evaluating severity of and type of treatment for MHDs. The resulting heterogeneity may have masked more pronounced differences in HIV outcome measures among subgroups of varying severity and type of MH care participants were receiving. The generalizability of findings may not apply to clinical settings with less robust MH resources. The sensitivity of HIV continuum of care outcome definitions may have influenced findings. Other clinical features known to influence MH conditions were not measured: alcohol and drug use, socioeconomic status, family history of MHDs, and history of trauma.
The important role of MHDs in HIV transmission and at all points along the HIV cascade has been well-recognized since the beginning of the HIV epidemic. This study advances our understanding of the co-occurrence and effect of MHDs on the HIV continuum of care at a time coinciding with significant improvement in the medical management of HIV. Future research in this area will advance understanding of mental health manifestations of HIV CNS involvement and risk factors for developing psychiatric comorbidity. Similar investigations will promote the discovery of intervention targets for psychiatric aspects of HIV. Additionally, this study underscored the relevance that addressing MHDs has to ending the HIV epidemic in the US.