THE RELATIONSHIP BETWEEN ALCOHOL USE, MENTAL HEALTH SYMPTOMS, AND RETENTION IN CARE IN WOMEN LIVING WITH HUMAN IMMUNODEFICIENCY VIRUS

At-risk drinking is defined as drinking above the recommended limits, which is no more than four drinks (one drink contains 14 grams of pure alcohol) in one day for men (three for women) and no more than 14 drinks in one week for men (seven for women). At-risk drinking is associated with adverse health outcomes in the general population. For persons with HIV (PHIV), they may have increased risk for developing adverse outcomes even at lower levels of consumption such as increased risk of liver damage, more rapid virus growth, increased risk of depression, decreased medication adherence, and increased engagement in high risk sexual behaviors, resulting in the possibility of reinfection with HIV or other sexually transmitted infections (STIs). What’s worse, the use of alcohol in PHIV is a concern not only for younger adults but also for those in older cohorts. However, there are lack of studies on how alcohol use affects health outcomes exclusively targeting PHIV with advanced age. This is especially concerning because with the development of antiretroviral therapy (ART), the number of aged PHIV is growing. In the first manuscript, a systematic review as conducted to evaluate existing studies on the association between alcohol use and medication adherence, engagement in high risk sex behaviors, resource utilization, HIV progression, depression, and survival in studies that included PHIV with an average age 40 and above. Anxiety is prevalent among PHIV, especially among women with HIV (WHIV). It may have both direct and indirect effects on HIV/AIDS progression. Although the relationship between alcohol use and depression has been extensively examined, studies on alcohol use and anxiety among PHIV are limited. Thus, in the second manuscript, I examined the association between changes in generalized anxiety and changes in alcohol use among WHIV over a period of 12 months. Engagement in health care system for clinical appointments and treatment, is one step in the HIV Care Continuum that is important for PHIV to suppress viral load and decrease mortality. Unfortunately, a significant proportion of PHIV have poor engagement in HIV care. Although there are extensive literature demonstrating the negative relationship between mental health symptoms and medication adherence, there have not been much studies examining mental health symptoms and likelihood of attending primary care visits among PHIV, especially WHIV. Thus, in the third manuscript, I examined the impact of baseline alcohol use, anxiety, and depression on likelihood of attending primary care visits among WLHV. Data of the second and third manuscript came from two concurrently recruited cohorts of WHIV. One was a randomized controlled trial (RCT) designed to test the effectiveness of a brief alcohol intervention (BI) among WHIV with baseline at-risk drinking (defined as 8 or more drinks/week, 2 or more binge drinking episodes [defined as 4 or more drinks/occasion] in the past six months, or TWEAK score ≥2). The TWEAK alcohol screening consists of five-questions with a total score of 7 points (the first two questions counts for 2 points each, other questions worth 1 point). A total score ≥2 indicates at-risk drinking. The second cohort was a concurrently recruited sample of WHIV without at-risk drinking at baseline from the same clinic. The parent studies were registered at clinicaltrials.gov: NCT00127231 and were approved by the Johns Hopkins Medicine Institutional Review Board. Participants were recruited between March 2006 and September 2010 through several methods, including clinic flyers, provider referral, waiting room recruitment, and review of drinking data obtained from an audio-computer-assisted-self-interview (ACASI) routinely administered to patients who have consented to enroll in the HIV Clinical Cohort every six months. Parent studies inclusion criteria included women who 1) had a confirmed HIV infection; 2) received outpatient care at the Johns Hopkins HIV Clinic; 3) were 18 years of age or older; 4) were not receiving treatment for an alcohol use disorder (AUD); 5) not pregnant; and 6) had no history of psychosis at the time of enrollment. Women in the RCT had visits at baseline and three, six, and twelve months post-enrollment; women in the non-at-risk drinking cohort had visits at baseline, and six, and twelve months post-enrollment