Abstract
Individuals are initiating antiretroviral therapy (ART) at earlier HIV disease stages. Unhealthy alcohol use is a known barrier to successful HIV treatment outcomes, yet it is unclear whether the problem varies by disease stage. We measured alcohol use with an objective biomarker (phosphatidylethanol [PEth]), comparing individuals (n = 401) with early (CD4 > 350 cells/mL, WHO Stage 1) versus late (CD4 < 200 cells/mL) ART initiation in HIV care in Uganda and South Africa (SA). We examined the association between CD4 count and biomarker results using multivariable regression modeling, and compared PEth results to self-report to assess underreporting. Overall, 32.2% (n = 129) had unhealthy alcohol use (PEth ≥ 50 ng/ml). Early ART initiation was significantly associated with unhealthy alcohol use in Uganda (AOR 2.65; 95% CI: 1.05–6.72), but not SA (AOR 1.00; 95% CI: 0.46–2.17). In Uganda, 23.2% underreported unhealthy alcohol use versus 11.6% in SA (χ2 = 9.30; p < 0.01). Addressing unhealthy alcohol use is important as patients initiate ART earlier, yet challenging due to underreporting.
Highlights
New universal access initiatives may bring 23 million people on antiretroviral therapy (ART) at healthier stages than previously, when ART was given only to those with low CD4 cell counts [1]
This study assessed how CD4 count at ART initiation related to biomarker-measured unhealthy alcohol use among individuals living with HIV at two sites in sub-Saharan Africa
Previous research among individuals living with HIV/AIDS in Uganda showed that unhealthy alcohol use at ART initiation was associated with fewer physical health symptoms [10], and similar research in other chronic conditions has showed that worsening physical health status is associated with reduced alcohol consumption [11, 12]
Summary
New universal access initiatives may bring 23 million people on antiretroviral therapy (ART) at healthier stages than previously, when ART was given only to those with low CD4 cell counts [1]. In areas with generalized HIV epidemics, such as sub-Saharan Africa, one of the primary barriers to successful HIV treatment and secondary prevention is unhealthy alcohol use [2,3,4]. Unhealthy alcohol use is a consistent risk factor for HIV acquisition, as well as poorer HIV treatment outcomes due to ART nonadherence [5,6,7,8,9]. As individuals will be initiating ART earlier than ever before, the extent to which alcohol use is a problem among those starting ART at high CD4 cell counts is unknown. As individuals are initiating ART when they are more likely to be asymptomatic and with fewer physical symptoms, unhealthy alcohol use at ART initiation may be a barrier to ART adherence and successful treatment outcomes
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