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Special Report: HIV Smoking and drinking
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Even HIV patients who have only the proverbial glass of red wine with dinner are at higher risk for poor outcomes than everyone once believed, experts say.
Doctors need to tell their HIV-positive patients that they should abstain from drinking just like pregnant women abstain from drinking because there is no evidence that even small amounts of red wine have any benefit for this population, says Kendall J. Bryant, PhD, director of alcohol and HIV/AIDS research in the Office of the Director, National Institute on Alcohol Abuse and Alcoholism (NIAAA) of the National Institutes of Health (NIH) in Rockville, MD.
"We see a lot of episodic people who go to parties and drink heavily on the weekends, and that's clearly very damaging," he says.
"We have seen homeless people who drink to blackout and drink until they fall down, and that's really damaging," Bryant adds.
"The advice you give people is it's really not good to drink at all," he adds. "Even in very big samples of 24,000 male HIV patients, there didn't seem to be any benefit from drinking, and this extends well beyond those who have alcohol dependence."
Dealing with patients' alcohol use is difficult because many people who drink enough to score high on screening tools do not see themselves as having a substance use problem, he notes.
Alcohol consumption goes hand-in-hand with smoking in an HIV population, says Matthew Freiberg, MD, MSc, an assistant professor of medicine and epidemiology at the University of Pittsburgh (PA).
"Alcohol can cause microbial translocation independent of HIV," he says.
Some HIV-positive patients also are infected with hepatitis C, which further damages their liver. So if they also drink alcohol, they risk further inflammation and problems, he adds.
"We're still trying to understand this but it may be that alcohol exacerbates cardiovascular disease because it enhances this immune activation that may increase cardiovascular risk," Freiberg says. "Alcohol may be a really bad habit to have if you are HIV infected, and it may cause noncompliance and make microbial translocation worse."
Alcohol has an additive and synergistic effect with HIV and HIV medications, Bryant says.
"There is a lot of flora and fauna in your gut that acts as an immunological barrier," he explains. "Unfortunately, alcohol is really good at damaging those systems."
Also, alcohol acts like a transport molecule for HIV, Bryant says.
"So you see there are these neurological junctions damaged by alcohol that make the blood-brain barrier much more permeable," he says. "Overall, from a biological point of view, people who have been drinking heavily when they became infected and have a history of heavy drinking probably also are harder to treat because they have some immune and organ issues and probably also have a different viral set point."
From the HIV clinician's perspective, the first step is to keep patients who use alcohol in treatment.
"People who drink heavily tend to fail antiretroviral therapy really quickly, and many are on salvage therapy," Bryant says. "They've exhausted all types of therapy and can sort of disappear out of care."
Another strategy is to encourage patients to cut down on their alcohol consumption through a behavioral intervention that focuses on harm reduction.
"Those are fairly effective," Bryant says. "We do get reductions in drinking with those, and we're also trying out pharmacotherapies for alcohol treatment."
More intensive behavioral approaches might include motivational interviewing that can be done in brief segments in a doctor's office.
"These can be modified for HIV patients," Bryant says. "Not only do you get reduced alcohol use, but these make patients more adherent to antiretrovirals and can reduce sexual risk behavior."
The Veterans Administration, which has the United States' largest population of HIV-infected individuals, has guidelines related to HIV patients and alcohol use, he notes.
A VA report on the guidelines notes that as HIV therapies become more effective, the HIV patients' health needs begin to mirror those of the general population and that problematic drinking often is undetected among HIV-infected veterans.
"Most of the AIDS issues focus on the virus, but what really kills patients now is their liver giving out or their heart getting damaged," Bryant says.
"Now, we're really focused on which interventions work, and we've developed a whole operations approach," he adds.
"This is not to just add one more thing to what the physician has to do, but it's an idea that if this is a critical issue in your population, then you should address it," Bryant explains. "In the VA system, one-third of individuals would be identified as an alcoholic use disorder currently, and 60% have a current or prior alcohol use disorder among men."
HIV providers and clinics are moving into a world of interventions as they focus on alcohol and tobacco use, Freiberg says.
"If we reduce these risk factors then we will have an impact on cardiovascular disease and quality of life, and a whole host of outcomes," he adds.