Catherine Yang

Treating alcohol use problems in HIV-positive patients may lead to better management of the virus and its treatment, according to a new study done by Yale researchers in collaboration with the University of Connecticut and Louisiana State University.

In a systematic review of published literature, the researchers found that alcohol use disorders correlate with negative outcomes at every stage of HIV treatment. The Human Immunodeficiency Virus is responsible for acquired immunodeficiency syndrome. For instance, the study found that individuals with HIV who are also heavy alcohol users were less likely to be diagnosed, enrolled in care and prescribed antiviral drugs to treat their HIV. Additionally, fewer achieved viral suppression, a state where patients have low levels of the virus in their blood, stay healthy and are unlikely to transmit the virus to others.

“There is such a wide range of issues that affect the success of HIV treatment, from mental health to drug addiction to health care issues, and we need to draw more attention to these problems,” said Panagiotis Vagenas, first study author and research scientist involved in the AIDS program at the Yale School of Medicine.

Coauthor Marwan Azar, infectious disease specialist at Yale-New Haven Hospital, said that while previous studies have shown that alcohol leads to worse outcomes for HIV/AIDS patients, there was little understanding of how alcohol consumption affected each step along the HIV continuum of care. The continuum of care is a series of stages laid out by the Centers for Disease Control and Prevention outlining the path from diagnosis to viral suppression, Azar explained.

Many studies have looked at how alcohol use affects patient compliance to antiviral therapy, with fewer focusing on the early stages, Vagenas said. Out of 53 papers the group examined, 33 investigated whether alcohol users were less likely to adhere to the prescribed treatment, but only two looked at whether patients diagnosed with HIV were less likely to be connected to the specialized care they needed if they had alcohol use problems.

This disparity in research is striking, especially given CDC data that reveals a chasm between HIV diagnosis and linkage to care, Vagenas said. According to the CDC, fewer than half of patients diagnosed with HIV get linked to HIV medical care. In contrast, four-fifths of patients prescribed antiviral therapies achieve viral suppression.

The researchers found that alcohol abuse negatively impacts outcomes at every stage of the continuum of care, with the adherence stage  — the stage in which patients adhere to prescribed medication — appearing to be the one that is most affected, Azar said.

The team is still working to establish a causal link between alcohol use and adverse HIV outcomes, Vagenas said. But because the findings are consistent across a diverse range of countries and regions, alcohol use is likely responsible for the observed effect, he added.

“This paper should raise awareness amongst treating physicians of the role of alcohol on disease management,” said co-author Patricia Molina, professor of physiology at the Louisiana State University School of Medicine and director of the Alcohol and Drug Abuse Center of Excellence. “Less than half of treating physicians address alcohol use with their patients,” she said, adding that primary care physicians need more systems of support put in place to effectively address this issue.

One new approach that is gathering momentum is the use of drugs to treat alcohol and drug abuse, Vagenas said. Naltrexone, in particular, has shown promise in treating alcohol addiction, and the team is running clinical trials in Connecticut and Peru to determine whether the drug can improve HIV health outcomes in patients with alcohol use disorders, Vagenas added.

Frederick Altice, the paper’s senior author and professor at the Yale School of Medicine, said behavioral interventions like Alcoholics Anonymous and cognitive behavioral therapy, while often recommended, actually have very minimal benefit.

“In randomized controlled trials comparing pharmacological with behavioral interventions, the pharmacological ones have proven markedly superior in achieving improved alcohol treatment outcomes,” said Altice, who also directs clinical and community research at the Yale University AIDS program.

Should clinical trials with Naltrexone show superior outcomes, the team hopes for a greater acceptance of pharmacological treatment of alcohol dependence, Azar said.

Over 1 million Americans are HIV-positive and an estimated five percent of all Americans meet the criteria for alcohol use disorder.