Associations between alcohol use and HIV care cascade outcomes among adults undergoing population-based HIV testing in East Africa

Abstract

Objective: To assess the impact of alcohol use on HIV care cascade outcomes.

Design: Cross-sectional analyses.

Methods: We evaluated HIV care cascade outcomes and alcohol use in adults (≥15 years) during baseline (2013--2014) population-based HIV testing in 28 Kenyan and Ugandan communities. 'Alcohol use' included any current use and was stratified by Alcohol Use Disorders Identification Test-Concise (AUDIT-C) scores: nonhazardous/low (1--3 men/1--2 women), hazardous/medium (4--5 men/3--5 women), hazardous/high (6--7), hazardous/very-high (8--12). We estimated cascade outcomes and relative risks associated with each drinking level using targeted maximum likelihood estimation, adjusting for confounding and missing measures.

Results: Among 118 923 adults, 10 268 (9%) tested HIV-positive. Of those, 10 067 (98%) completed alcohol screening: 1626 (16%) reported drinking, representing 7% of women (467/6499) and 33% of men (1 159/3568). Drinking levels were: low (48%), medium (34%), high (11%), very high (7%). Drinkers were less likely to be previously HIV diagnosed (58% [95% CI: 55--61%]) than nondrinkers [66% (95% CI: 65-67%); RR: 0.87 (95% CI: 0.83-0.92)]. If previously diagnosed, drinkers were less likely to be on ART [77% (95% CI: 73-80%)] than nondrinkers [83% (95% CI 82-84%); RR: 0.93 (95% CI: 0.89-0.97)]. If on ART, there was no association between alcohol use and viral suppression; however, very-high-level users were less likely to be suppressed [RR: 0.80 (95% CI: 0.68-0.94)] versus nondrinkers. On a population level, viral suppression was 38% (95% CI: 36-41%) among drinkers and 44% (95% CI: 43-45%) among nondrinkers [RR: 0.87 (95% CI 0.82-0.94)], an association seen at all drinking levels.

Conclusion: Alcohol use was associated with lower viral suppression; this may be because of decreased HIV diagnosis and ART use.

Conflict of interest statement

Conflicts of Interest and Source of Funding:

DK, JAH, EDC, CRC, MRK, MLP, DVH, and GC have received grants from the National Institutes of Health (NIH). GC and CRC have received grants from the Bill & Melinda Gates Foundation. DVH has received non-financial support from Gilead Sciences. CRC has also received grants CIFF, personal fees from legal consulting about a malpractice case, and personal fees from Symbiomix. All other authors declare no competing interests.

Figures

Figure 1.

HIV care cascade outcomes by level of current alcohol use in 28 rural communities as assessed during baseline universal HIV testing: estimates adjusted* for confounding and incomplete measurement with TMLE shown in Figure (with black vertical lines for 95% confidence intervals) and unadjusted estimates† with absolute numbers shown in corresponding table. [Table: see text]