An adapted intervention for problematic alcohol use in people living with AIDS and its impact on alcohol use, general functional ability, quality of life and adherence to HAART : a cluster randomized control trial at Opportunistic Infections Clinics in Zimbabwe

Madhombiro, Munyaradzi (2018-12)

Thesis (PhD)--Stellenbosch University, 2018.

Thesis

ENGLISH SUMMARY : With the advent of antiretroviral therapy, the HIV pandemic has become a chronic illness requiring lifelong treatment. The 90-90-90 strategy, adopted by UNAIDS, aims for (i) 90% of HIV infected persons knowing their status, (ii) 90% on antiretroviral therapy; and (iii) 90% achieving viral suppression. The goal is to reach these aims by 2020. Alcohol use affects the attainment of the 90-90-90 goals. Research shows that people living with HIV (PLWH) drink twice as much as their HIV negative counterparts. Alcohol use disorders (AUD) in PLWH are associated with poor adherence to ART. Recommendations have been made to include interventions for AUDs in HIV prevention and treatment strategies. Brief interventions are recommended for hazardous alcohol use; however, for alcohol dependence a stepped care model incorporating behavioural/psychological treatments and pharmacological interventions may be required. Pharmacological treatments may lead to a higher pill burden and psychological interventions are, therefore, the treatment of choice. Psychological interventions have traditionally been delivered by a highly skilled workforce. However, in low and medium income countries (LMIC) where the HIV prevalence is high, there is a shortage of a skilled workforce. Task sharing has been recommended as a way of scaling up the delivery of services. The aim of this study was to adapt an evidence-based intervention for HIV and AUDs in Zimbabwe and to assess its effectiveness in a cluster randomized controlled trial (RCT). To achieve this, we first conducted a systematic review of the evidence for the effectiveness of psychological interventions. Second, a qualitative study was done to understand knowledge and perceptions of AUDs among PLWH and potential barriers and facilitators of interventions for AUDs. Third, we conducted a pilot and feasibility study in preparation for the RCT. The systematic review found limited evidence for the effectiveness of psychological interventions for AUDs, particularly on the frequency of drinking. Motivational interviewing (MI) alone and in combination with mobile technology, and cognitive behavioural therapy (CBT) were found to be effective. Additionally, MI was effective in reducing risky sexual behaviour, adherence to ART, other substance use disorders, viral load reduction, and increase in CD4 count. The qualitative study found that PLWH had adequate knowledge of the direct and indirect effects of alcohol use on HIV transmission and adherence to treatment, and were concerned about the stigma faced by PLWH who have and AUDs. Furthermore, participants were concerned about the stigma faced by PLWH who have AUDs. They called for stigma reduction strategies to be implemented and were receptive of the idea of interventions for AUDs. Following a pilot study which indicated that an intervention for AUDs was feasible, a cluster RCT was carried out at 16 HIV care clinics. The adapted intervention included motivational interviewing blended with cognitive behavioural therapy (MI/CBT). The comparator intervention was the alcohol use section of the World Health Organisation (WHO) mental health Gap Action Program Intervention Guide (mh GAP IG). The MI/CBT and mh GAP IG interventions were delivered by registered general nurses (RGN) embedded in HIV care clinics. The primary outcome was a reduction in alcohol use as measured by the Alcohol Use Disorders Identification Test (AUDIT) score. Secondary outcome measures included: (i) HIV disease parameters, as measured by the viral load and CD4 count; (ii) functionality, as assessed by the WHO Disability Assessment Schedule (WHODAS 2.0); and (iii) quality of life, as measured by the WHO Quality of Life HIV (WHOQOL HIV). The cluster RCT demonstrated that RGNs can be trained to deliver an MI/CBT intervention for AUDs in PLWH. Additionally, the MI/CBT intervention significantly reduced alcohol consumption in PLWH. While the reduction in alcohol consumption was maintained in the MI/CBT arm at 6 months, this effect was only maintained in the mh GAP IG arm up to 3 months. Additional improvements were seen in HIV treatment outcomes (especially viral load), functionality, and quality of life. Finally, it was feasible to deliver an MI/CBT intervention using a task sharing model. In terms of implementation, this can be done with a modest increase in staffing. Given the negative role AUDs play in the HIV treatment cascade, reduction in alcohol use can help in achieving the UNAIDS’ 90-90-90 goals. Further, effectiveness trials are needed in LMIC with a high prevalence of HIV. When conducting these trials, attention should be paid to patient experiences, such as the ‘double’ stigma of HIV and AUDs.

AFRIKAANSE OPSOMMING : HIV het ʼn kroniese siekte geword as gevolg van antiretrovirale tarapie. UNAIDS het die 90-90-90 strategie begin. Die strategie beoog dat: (i) 90% van HIV-positiewe mense hulle status moet ken; (ii) 90% moet antiretrovirale terapie (ART) ontvang; en (iii) 90% moet virale-onderdrukking bereik. UNAIDS beoog om die doelwitte teen 2020 te bereik. Alkoholgebruik beïnvloed die 90-90-90 strategie. Navorsing toon that mense wat met HIV leef (MHL) twee keer soveel alkohol drink as mense wat HIV-negatief is. Alkoholmisbruikversteurings (AMVs) word met swak nakoming vir antiretroviralebehandeling (ARB) geassosieer. Intervensies vir AMVs, as deel van HIV voorkoming en behandeling, word aanbeveel. Kort intervensies word vir gevaarlike alkoholgebruik aanbeveel, maar vir alkoholafhanklikheid is ʼn trap-vir-trap versorgings model wat gedrags/sielkundige- en farmakologiesebehandeling insluit moontlik nodig. Tog mag farmakologiesebehandeling tot ʼn hoër medikasie-lading lei. Geveloglik, is sielkundige intervensies ʼn beter keuse. Sielkundige intervensies word grotendeels deur hoogs-geskoolde werkers, wat nie in lae-middel inkomste lande (LMIL) waar HIV baie voorkom, volop beskikbaar is nie, aangebied. Taakdeling word aanbeveel as oplossing om die tekort aan hoogs geskoolde werkers aan te spreek. Hierdie studie beoog om ʼn bewys-gebasseered intervensie vir HIV en AMVs vir Zimbabwe aan te pas, sowel as om die effektiwiteit daarvan deur middel van ʼn groepe-ewekansige-beheerdetoets (GEBT) te bepaal. Om dit te doen het ons eerste ʼn sistematiese-literatuuroorsig oor die effektiwiteit van sielkundige intervensies gedoen. Dit is gevolg deur ʼn kwalitatiewe studie met die doel om die kennis en persepsies van AMVs, sowel as moontlike hindernisse en fasiliteerders van AMVs; onder MHL te verstaan. Ten derde het ons ʼn toets- en proefstudie in voorbereiding vir die GEBT gedoen. Die sistematiese-literatuuroorsig het weinige bewyse vir die effektiwiteit van sielkundige intervensies vir AMVs, veral in terme van die frekwensie van gebruik, getoon. Motiversingonderhoudvoering (MO), met en sonder die gebruik van selfoontegnelogie, en kognitiewegedragsterapie (KGT) is gevind om effektief te wees. Verdermeer is MO effektief in die vermindering van gevaarlike seksuele gedrag, die nakoming van ART, behandeling van ander substansmisbruikversteurings, die vermindering van viralelading, en die verhoging van CD4 tellings. Die kwalitatiewestudie het gevind dat MHL voldoende kennis van die direkte en indirekte invloed van alkoholverbruik op HIV oordrag en behandeling, het. Verdermeer het deelnemers daarop gedui dat hulle oor die stigma van MHL wat ook AMVs het, besorg is. Hulle het gevra dat strategieë wat die stigma verminder geimplimenteer moet word. MHL was ontvanklik in terme van AMV intervensies. Nadat die proefstudie daarop gedui het dat ʼn intervensie vir AMVs doenbaar is, is ʼn GEBT by 16 HIV-versorgingsklinieke uitgevoer. Die studie intervensies het gemengde motiveringsonderhoudvoering/kognitiewe gedragsterapie (MO/KGT) en die WHO se mh GAP intervensiegids (mh GAP IG) ingesluit. Geregistreerde algemene verpeegsters (GAV) by HIV versorgingsklinieke het die intervensies aangebied. Die vermindering van alkoholverbruik, soos deur die Alcohol Use Disorders Identification Test (AUDIT) gemeet, het as primêre uitkomste gedien. Die volgende het as sekondêre uitkomstes gedien: (i) HIV parameters, soos deur die viralelading en CD4 telling gemeet; (ii) funksionaliteit, soos deur die WHO Disability Assessment Schedule weergawe 2 (WHODAS 2.0) gemeet; en (iii) lewenskwaliteit, soos deur die WHO Quality of Life HIV (WHOQOL HIV) gemeet. Die GEBT het getoon dat GAV opgelei kan word om die MO/KGT intervensie vir MHL met AMV aan te bied. Verdermeer het die MO/KGT intervensie ʼn beduidende effek op die verminering van alkoholverbruik van MHL gehad. Die effek van die mh GAP IG intervensie is vir 3 maande volgehou, terwyl die effek van die MO/KGT vir 6 maande volgehou is. Daar is ook gevind dat ʼn vermindering in alkoholverbruik HIV terapie uitkomste verbeter, veral soos aangedui deur die vermindering in viralelading. Funksionaliteit en lewenskwaliteit het ook as gevolg van die intervensie verbeter. Laastens is dit bevind dat die lewering van ʼn MO/KGT intervensie deur middel van taakdeling, geldig is. Die implementasie van ʼn MO/KGT kan met ʼn matige vermeedering van die werksmag gedoen word. Gegewe die negatiewe effek van AMVs op die behandeling van MHL kan die vermindering van alkoholverbruik help om die UNAIDS se 90-90-90 doelwit te bereik. Verdere kliniese toetsings van die effektiwiteit van intervensies in LMIL met ʼn hoë HIV voorkoms, is nodig. Wanneer die toetsings toegepas word, moet daar aandag aan die dubbele-stigma van beide HIV en AMVs verleen word.

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