Among this sample of HIV-infected individuals in primary care in the USA, the overall 4-week prevalence of any alcohol use was 40%, with 11% drinking at hazardous levels and 29% drinking at moderate levels. Active illicit drug use, decreased antiretroviral adherence and a nadir CD4 count > 500 cells/μL were associated with increased odds of hazardous alcohol use, while > 7 primary care visits was associated with lower odds of hazardous alcohol use. Male sex, higher educational attainment, private insurance (compared to Medicaid) and HAART use were associated with any alcohol use, but not with hazardous use.
The prevalence of any alcohol use was lower in our sample compared to the HIV Cost and Services Utilizations Survey (HCSUS), a USA-based national survey of HIV-infected adults in care, where the 1-month prevalence of alcohol use was 53% with 8% classified as heavy drinkers [1
]. This difference may be explained partially by the increased proportion of women and Hispanic people in this HIVRN interview sample – two groups in the USA that have a lower prevalence of alcohol use (compared to men or non-Hispanic people) [26
]. In addition, this lower prevalence of alcohol use may reflect sampling bias. Although the interview participants were similar to the overall cohort, the sample was largely one of convenience and non-drinkers may have been more likely to participate in the interview.
The 11% prevalence of hazardous use in our population was greater than the prevalence of heavy drinking in HCSUS (8%) and may in part be explained by a broader definition of hazardous use in this study compared to ‘heavy’ alcohol use in HCSUS (defined as five or more drinks on ≥ 4 days in the previous 4 weeks). Despite the differences in prevalence, factors associated with alcohol use did not differ significantly between our sample (in the current HAART era) and HCSUS (in the early HAART era). Both studies demonstrate that men, individuals with a college education and illicit drug users are more likely to consume alcohol, and that persons with higher CD4 cell counts and illicit drug users are more likely to drink at hazardous levels. The consistency between our findings and those of HCSUS suggest that the increased longevity and clinical benefits of HAART have not changed the correlates of alcohol consumption.
That illicit drug use was associated with both any use and hazardous levels of alcohol use was not surprising, because alcohol and illicit drug use frequently co-occur [27
]. The association of > 7 primary care visits with decreased hazardous alcohol use may reflect a population with advanced disease who may be too sick to drink alcohol. Consistent with this finding, CD4 nadir > 500 cells/μL compared to < 50 cells/μL was associated with hazardous alcohol use, suggesting that those with more advanced immunosuppression may be too ill to drink at this level [28
Male sex was associated with any alcohol use, which is consistent with multinational studies examining the epidemiology of alcohol use [29
]. Other factors associated with any alcohol use included higher educational attainment, private insurance and HAART use. These variables may be capturing aspects of socioeconomic status, suggesting an association between higher socioeconomic status and any alcohol use [30
In applying the results of this study to clinical settings, it is important to note that the definition of hazardous alcohol use varies among countries, as does the grams of alcohol comprising a standard drink. Because this is a USA-based study, we defined hazardous use by the NIAAA definition of hazardous drinking, and we used standard drinks as our unit of measurement. Fourteen grams of alcohol is equivalent to one US standard drink. As a comparison, 8 g of alcohol is equivalent to one British unit of alcohol. Notably, the cut-off for hazardous alcohol use in the USA is lower than in many other countries such as Australia, which defines hazardous use as > 280 g per week or > 60 g per occasion in men, and > 140 g per week or > 40 g per occasion in women [33
]. What is considered hazardous use in the USA may be considered moderate use in other countries, where the threshold for hazardous alcohol use is higher. Thus in countries where the cut-off for hazardous drinking is higher than in the USA and the UK, the adverse effects of alcohol use may occur at what they consider to be moderate levels of alcohol consumption.
Our study has potential limitations. Firstly, this is a cross-sectional study, so we are unable to make any causal inferences based on these data. Secondly, alcohol use is based on self-report, which may be subject to bias – individuals frequently underestimate how much alcohol they consume. Thirdly, the interview sample was largely one of convenience; as a result, there may have been a selection bias. However, our sample did reflect the demographics of the larger HIVRN population. Also, the sample is not representative and does not generalize to all HIV patients. However, the sites from which patients were sampled do encompass a broad geographic distribution, and multi-site studies afford greater generalizability than single-site studies.
In conclusion, any alcohol use and hazardous drinking are prevalent among HIV-infected individuals participating in primary care, and are associated with a variety of socioeconomic and demographic characteristics, and markers of disease severity. Efforts should be made to identify individuals with alcohol use because alcohol use is a modifiable risk factor for adverse HIV-associated outcomes. Screening for hazardous alcohol consumption among all HIV-infected individuals is an important aspect of comprehensive HIV care.