Impact of alcohol-focused interventions on treatment outcomes amongst HIV patients in Tanzania and South Africa: A feasibility study

Excessive use of alcohol is common in eastern and southern Africa, including among those people living with HIV (PLWH) and using antiretroviral therapy (ART). Using alcohol among PLWH is associated with poor usage of ART drugs and being lost to care and treatment programmes. This suggests that strategies that reduce alcohol use when implemented at HIV clinics may improve PLWH's ART drug usage and health. Our long-term plan is to conduct a trial to help increase ART usage among PLWH who use alcohol excessively with a goal of improving their health in Tanzania and South Africa.

The proposed current study will collect information required for preparing the future main trial; namely, information to (a) determine the extent of excessive alcohol use among PLWH in Tanzania where this information is lacking, (b) develop and adapt strategies to reduce excessive alcohol use, and (c) find out if the strategies are feasible and acceptable in Tanzania and South Africa.

We will collect information about the extent of alcohol use among 300 patients using ART drugs in Tanzania. We will then review published information on strategies to reduce excessive alcohol use, obtain survey data from 40 health workers (HWs) at four HIV clinics in each country, and conduct in-depth interviews (IDIs) with key stakeholders (including HWs, ministry of health officials, treatment supporters) and HIV patients. Results obtained will be reviewed at a workshop to develop a final strategy for reducing excessive alcohol use. Finally, the feasibility and acceptability of the strategy will be assessed.

Hazardous or harmful alcohol use is common in eastern and southern Africa, including among people living with HIV (PLWH) who drink alcohol and use anti-retroviral therapy (ART), and is associated with poorer ART adherence and lower retention in care and treatment. We hypothesise that effective alcohol reduction interventions delivered in HIV clinics could help increase ART adherence and improve treatment outcomes among PLWH who drink at harmful or hazardous levels. Our long-term goal is to implement a cluster randomised trial of an intervention, comprising individual and health facility elements, to improve treatment outcomes among PLWH on ART who engage in hazardous or harmful drinking in Tanzania and South Africa. The proposed study will collect information required to prepare for the main trial. Our specific objectives are to determine the prevalence of harmful and hazardous drinking among PLWH in Tanzania where this information is lacking; and develop and adapt the intervention, and evaluate its feasibility and acceptability in both Tanzania and South Africa.

We will interview 300 randomly selected patients using ART from four HIV clinics in Tanzania regarding their alcohol use. We will also conduct a literature review of alcohol reduction interventions, a survey of 40 health workers (HWs) at four ART clinics in each country, and in-depth interviews (IDIs) with (a) key stakeholders (including HWs, ministry of health officials, and treatment supporters), and (b) ART patients to assess their attitudes, patterns of alcohol use and perceptions of the treatment received at the HIV clinics. Results obtained will be presented in a workshop and used to develop a theoretical framework which will form a basis for developing the final intervention package. The feasibility and acceptability of the intervention will then be assessed in 20 patients in up-to-four clinics per country. Final results will be used to develop the main trial protocol.

The proposed research addresses two major global health issues - alcohol and HIV infection.
Alcohol is an important cause of morbidity in the world. Hazardous or harmful alcohol use is common in eastern and southern Africa, including among people living with HIV (PLWH) who drink alcohol and use anti-retroviral therapy (ART), and is associated with poorer ART adherence and lower retention in care and treatment. Effective interventions to reduce hazardous and harmful alcohol use among ART patients could help to increase ART adherence and improve treatment outcomes among PLWH.

The proposed research is set in Tanzania and South Africa, and is expected to help in developing a targeted alcohol intervention in preparation for a subsequent randomised controlled trial to evaluate the impact of the intervention on hazardous and harmful alcohol use and ART adherence. The population most likely to benefit from our research are HIV-infected patients who are hazardous or harmful drinkers. Motivational interviewing (MI) and cognitive behavioural therapy (CBT) interventions are patient-centred counselling approaches that helps people explore and resolve ambivalence about behaviour, and development of a MI intervention for the study population is likely to have benefits not only on ART adherence but also on reducing excessive drinking with concomitant benefits to quality of life and disability burden.

Our study may also benefit health workers working in the HIV clinics. As part of the research, clinic staff will acquire new skills and create a supportive environment in the health facilities which may help patients reduce hazardous and harmful alcohol drinking and improve ART adherence. The trained staff, in consultation with clinic managers, district health managers and Ministry of Health officials, will identify ways to incorporate work on alcohol into routine clinical practice.

Finally, findings from this study may benefit policy-makers within international organisations, and also national and local government organisations in both Tanzania and South Africa. Evidence from this research may help in formulation of policies to address hazardous and harmful alcohol drinking among HIV-infected patients using ART.