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. Author manuscript; available in PMC: 2012 Apr 16.
Published in final edited form as: HIV Clin. 2011 Fall;23(4):8–13.

Brief screening for alcohol use disorders in HIV primary care

Julia M Hormes 1, Kelly R Gerhardstein 2, Phillip T Griffin 3
PMCID: PMC3327161  NIHMSID: NIHMS363852  PMID: 22263250

In spite of multiple adverse consequences, including accelerated disease progression and increased risk for further disease transmission, alcohol use is common among individuals living with HIV/AIDS. There is an urgent need for widespread implementation of brief screening for alcohol use problems in HIV primary care settings. More work is needed to identify the screening measures that may be most useful in this patient population and setting.

In this article we briefly discuss some of the ways in which drinking negatively impacts outcomes in individuals living with HIV/AIDS and the prevalence of alcohol abuse and dependence among HIV-positive patients. We review formal diagnostic criteria for alcohol use disorders and present two of the briefest screening instruments for alcohol abuse and dependence that have been developed and validated. Both are available for use in the public domain and may be helpful in identifying HIV-positive patients in need of further assessment and referral for substance use treatment. Finally, we briefly review current research on screening for problem drinking in primary care settings and discuss ways in which findings may be applied to HIV primary care.

Contribution of alcohol to the HIV/AIDS epidemic

The relationship between alcohol use and HIV/AIDS is complex and involves a variety of mechanisms that remain to be fully elucidated. As of now, at least three ways in which alcohol use contributes to the HIV epidemic have been identified:

(1) Alcohol consumption significantly lowers the likelihood that patients will be adherent to highly active antiretroviral therapies (HAART) (Arnsten, Demas, Grant, Gourevitch, Farzagedan, Howard et al., 2002; Hendershot, Stoner, Pantalone & Simoni, 2009; Lucas, Gebo, Chaisson & Moore, 2002; Parsons, Rosof & Mustanski, 2008; Samet, Horton, Meli, Freedberg & Palepu, 2004). In fact, alcohol use has been shown to be the most significant predictor of non-adherence to HAART (Samet et al., 2004). On days on which patients consume alcohol, odds of medication non-adherence are nine times higher, compared to non-drinking days, and each additional drink consumed increases the odds of skipped or delayed medication doses by an additional 20% (Parsons et al., 2008). HIV-positive patients who use any alcohol, regardless of frequency or quantity of drinking, are only 50–60% as likely to be adherent as abstainers (Hendershot et al., 2009).

The strong association between alcohol use and medication non-adherence in HIV/AIDS is due to accidental as well as intentional skipping or delaying of doses. Many HIV-positive patients who report alcohol-related non-adherence state that they do not take their medication when drinking out of fear of toxicity or other harmful side effects (Kalichman, Amaral, White, Swetsze, Pope, Kalichman et al., 2009). Thus, at a time when the availability of HAART has significantly decreased overall morbidity and mortality in HIV/AIDS (Amico, Harman & Johnson, 2006), many alcohol-using patients do not achieve the minimum 95% adherence necessary for sustained viral suppression and prevention of the development of a resistant virus (Hecht, Grant, Petropoulos, Dillon, Chesney, Tian et al., 1998; McNabb, Ross, Abriola, Turley, Nightingale & Nicolau, 2001; Paterson, Swindells et al. 2000; Race, Dam, Obry, Paulous, & Clavel, 1999; Vervoort, Grypdonck, de Grauwe, Hoepelman & Borleffs, 2009).

(2) A growing body of research suggests that alcohol consumption accelerates disease progression even if medications are taken correctly, by adversely impacting drug absorption and metabolism (Miguez, Shor-Posner, Morales, Rodriguez & Burbano, 2003). Findings remain mixed to some extent with some studies showing that patients receiving HAART and consuming moderate to at-risk levels of alcohol have lower CD4 counts and higher HIV RNA levels, compared to non-drinking controls (Samet, Horton, Traphagen, Lyon & Freedberg, 2003), while others find that alcohol use negatively impacts CD4 counts only in those patients not receiving antiretroviral medications (Samet, Cheng, Libman, Nunes, Alperen & Saitz, 2007). While more work is needed to establish with some certainty the mechanisms by which alcohol accelerates disease progression in HIV/AIDS, it is evident that alcohol use, and heavy consumption in particular, has detrimental effects.

(3) There is strong evidence for positive associations between alcohol use and high-risk sexual behavior in individuals living with HIV/AIDS (Hendershot et al., 2009; Raj, Reed, Santana, Walley, Welles, Horsburgh et al., 2009; Shuper, Joharchi, Irving & Rehm, 2009), increasing the risk of further HIV transmission, infection with other sexually transmitted diseases (e.g. Seth, Wingood, DiClemente & Robinson, 2011), “super- or co-infections” (i.e. infection with a new and/or drug-resistant strain of the virus) (Smith, Richman & Little, 2005), and resistance to drug treatments in those consuming risky amounts of alcohol (Little, Holte, Routy, Daar, Markowitz, Collier et al., 2002).

Prevalence of alcohol use, abuse and dependence among HIV-positive patients

In spite of its multiple adverse consequences, alcohol use remains widespread among individuals living with HIV/AIDS. Around half of HIV-positive patients currently in care report consumption of any alcohol (Galvan, Bing, Fleishman, London, Caetano, Burnam et al., 2002; Kalichman et al., 2009). Rates of heavy drinking are thought to be twice as high among HIV-infected individuals, compared to the general population (Galvan et al. 2002; Greenfield, Midanik & Rogers, 2000). Studies of HIV-positive patients presenting for treatment at primary care clinics estimate lifetime histories of alcohol abuse or dependence in as many as half of individuals surveyed (Phillips, Freedberg, Traphagen, Horton & Samet, 2001).

Diagnosing alcohol abuse and dependence

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR, American Psychiatric Association [APA], 2000) distinguishes between substance abuse and substance dependence. Both substance abuse and substance dependence are broadly defined as “a maladaptive pattern of substance use leading to clinically significant impairment or distress,” which occurs within a 12-month period (pp. 110, 114). However, substance dependence is identified as a more severe disorder. A pattern of substance abuse must be manifested by continued substance use despite the presence of only one of the following negative consequences: 1) “Failure to fulfill major role obligations at work, school, or home;” 2) “substance use in situations in which it is physically hazardous;” 3) legal problems related to substance use; and 4) “Persistent or recurrent social or interpersonal problems”(pp. 114–115) related to substance use. Substance dependence, as defined by the DSM-IV-TR, requires that a person exhibit three of the following criteria: 1) tolerance; 2) withdrawal; 3) taking a substance in “larger amounts or over a longer period than was intended;” 4) “unsuccessful efforts to cut down or control substance use;” 5) spending “a great deal of time trying to obtain the substance, using the substance, or recovering from its effects;” 6) giving up or reducing time spent in “important social, occupational, or recreation activities” due to substance use (p. 110); and 7) continuing substance use despite knowingly having a “persistent or recurrent physical or psychological problem” that is likely related to substance use (p. 111). An individual is said to have developed “tolerance” when he/she needs more of the substance to achieve the desired effect, or fails to achieve the same effect while using the same amount. Withdrawal is exhibited by a set of symptoms that either occur when an individual stops using a substance, or are avoided by continued use of the same or related substance. Withdrawal symptoms are specific to the substance. Withdrawal from alcohol is exhibited by at least two or more of the following symptoms: autonomic hyperactivity, increased hand tremor, insomnia, nausea/vomiting, transient visual, tactile or auditory hallucinations or illusions, psychomotor agitation, anxiety, and grand mal seizures. These symptoms will develop within several hours to a few days after an individual stops or reduces “heavy and prolonged” alcohol use (p. 121). It should be noted that although tolerance and withdrawal are typically viewed as hallmarks of substance dependence, based on the criteria outlined in the DSM-IV-TR, evidence of withdrawal and/or tolerance is neither sufficient nor necessary to diagnose substance dependence.

Brief screening for alcohol abuse and dependence

In many, if not most cases, it is a serious negative consequence of substance abuse that compels the abuser into treatment, i.e. failed relationship, lost job, missed appointments, erratic medication compliance, unlawful behavior and more. Identifying persons at risk for these negative consequences is obviously desirable through whatever mechanism possible. A major goal of screening in a primary care setting is to identify the disease at an early stage and initiate an intervention to avoid dire future consequences (Jones, 2011). It has been recommended that such screening instruments should be validated, simple, and acceptable to the population being assessed (National Institute on Alcohol Abuse and Alcoholism guidelines). Brevity is also a concern so we focus here only on very brief instruments. In terms of content, the most effective screening tools for alcohol-related problems tend to inquire about amount typically consumed, evidence for increased tolerance, negative consequences and risks associated with drinking, and emotions related to use (Smith, Herrmann & Bartlett, 2011).

Commonly used screening instruments for alcohol abuse and dependence are the Alcohol Use Disorders Identification Test (AUDIT; Babor, Fuente & Saunders, et al., 1992), which contains ten items, and the Michigan Alcohol Screening Test (MAST; Selzer, 1971), which contains 24 items. Both of these screening instruments have shorter versions available but neither has the research validation of the original versions. Among the briefest of scales, the CAGE (Ewing, 1984) and the Rapid Alcohol Problems Screen (RAPS4; Cherpitel, 2000) are two of the most widely used screening tools for alcohol use disorders. Both measures consist of four items and are presented in their entirety below. The CAGE assesses perceived need to cut down on alcohol use, experiences of others getting annoyed with one’s alcohol use, feelings of guilt about use, and need for alcohol in the morning in order to start the day (“eye opener”). Like the CAGE, the RAPS4 also assesses guilt about alcohol use (“remorse”) and need for alcohol in the mornings (“starter/eye opener”); in addition it inquires about episodes of memory loss when drinking (“amnesia”) and failure to fulfill major role obligations due to alcohol use (“perform”). Of note, the CAGE and RAPS4 are designed to inquire about lifetime histories of alcohol-related problems; both are easily modified or amended to inquire about current abuse or dependence.

CAGE

Have you ever felt you should cut down on your drinking? (Cut down)

Have people annoyed you by criticizing your drinking? (Annoyed)

Have you ever felt bad or guilty about your drinking? (Guilty)

Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? (Eye opener)

Scoring: Each positive response is assigned one point. A score of two points or higher on the CAGE is thought to be indicative of the presence of past or current alcohol abuse or dependence (Ewing 1984).

RAPS4

Have you had a feeling of guilt or remorse after drinking? (Remorse)

Has a friend or a family member ever told you about things you said or did while you were drinking that you could not remember? (Amnesia)

Have you failed to do what was normally expected of you because of drinking? (Perform)

Do you sometimes take a drink when you first get up in the morning? (Starter)

Scoring: A positive response to one or more items is considered indicative of the presence of alcohol dependence (Cherpitel, 2000; Cherpitel, 2002).

Both the CAGE and RAPS4 have been shown to be useful in detecting the presence of alcohol use disorders in the general population; however, there is evidence to suggest that the RAPS4 does so with greater sensitivity than the CAGE (Cherpitel, 2002; Fiellin, Reid & O’Connor, 2000). Although both the CAGE and RAPS4 have four items with two items overlapping (remorse about drinking, and morning eye-opener) the RAPS4 requires only one item endorsement to identify problem alcohol consumption; the CAGE requires two which may be one reason the RAPS4 seems to have the edge in many side-by-side comparisons. Also, the RAPS4 inquires about specific events or incidents, such as amnesia and failed expectations, while CAGE items lean toward the subjective and allow for some interpretative latitude.

Of note, both the CAGE and the RAPS4 have been validated cross culturally. Cremonte, Ledesma, Cherpitel, and Borges (2010) found the scales efficacious as measured against a DSM IV-based clinical interview with American, Mexican and Argentine populations. Cherpitel, Moskalewicz, and Swiatkiewicz (2005) validated both instruments against ICD-10 and DSM IV criteria with a Polish sample. In both studies the RAPS4 performed slightly better than the CAGE in accurately identifying individuals with alcohol abuse or dependence.

Quantity/Frequency

A brief assessment of overall quantity and frequency of alcohol consumption can easily be added to both the CAGE and the RAPS4 brief screening tools. It has been suggested that doing so can increase their specificity and sensitivity in detecting patients with or at risk for hazardous drinking (Cherpitel, 1997; Cherpitel, 2002). The following are examples of questions that can be used to assess quantity and frequency of consumption, developed by the National Institute on Alcohol Abuse and Alcoholism and used widely by physicians and in primary care settings:

  1. Typically, on how many days per week do you drink alcohol?

  2. On a typical day drinking, how many drinks do you have?

  3. What is the maximum number of drinks you had on any given occasion during the past month?

Cutoff points on the quantity/frequency measures that are considered indicators of possible problem drinking are 14+ drinks per week/4+ drinks in one sitting for men and 7+ drinks per week/3+ drinks in one sitting for women (National Institute on Alcohol Abuse and Alcoholism criteria).

The use of brief screening tools in HIV primary care

Screening for alcohol abuse and dependence in primary care settings is encouraged by the National Institute on Alcohol Abuse and Alcoholism, but remains underused in spite of strong evidence supporting its effectiveness in identifying and referring patients in need of services and treatment (Kypri, Langley, Saunders, Cashell-Smith & Herbison, 2008). HIV primary care providers have been shown to be particularly susceptible to missing opportunities to identify patients with alcohol-related problems, especially in the absence of obvious evidence of alcohol abuse and dependence, such as accelerated disease progression or signs of liver disease (Conigliaro, Gordon, McGinnis, Rabeneck & Justice, 2003). The proposed screening tools could easily be incorporated into standard annual (or more frequent) clinical assessments conducted in most HIV outpatient settings.

As of now, few studies have systematically examined the use of brief screening tools for alcohol abuse and dependence specifically in HIV-positive patients. The measures most frequently used to assess alcohol use in HIV-positive patients are the CAGE, AUDIT and DSM-IV criteria (Hendershot et al. 2009). Two studies that used the CAGE to screen for alcohol abuse in HIV-positive patients in primary care found that it performed well in this population, yielding a positive predictive value of 95% for lifetime diagnoses of alcohol abuse or dependence (Phillips et al. 2001; Samet et al., 2004). The RAPS4 has been used in studies of HIV-positive patients (e.g. Wagner, Bogart, Galvan, Banks & Klein, 2011); however, its sensitivity and specificity in detecting possible alcohol abuse and dependence in HIV primary care settings has yet to be evaluated systematically. The focus of the RAPS4 on functional impairment may render it particularly suitable for use in HIV-positive patients who might be overpathologized by the reliance of the CAGE on assessing more subjective experiences (i.e., guilt regarding use and feeling that one would benefit from cutting back on consumption). Patients who are aware of the negative effects of any alcohol use on HIV disease progression may give positive responses to these items, even in the absence of any formal diagnostic criteria for alcohol use disorders. The RAPS4 may also be particularly suitable for use with HIV-positive patients because the question about role obligations can help start a conversation between providers and patients about responsibilities when it comes to disclosing a seropositive status to sex partners. The possibility that the RAPS4 may perform particularly well in HIV primary care should be assessed in future research.

Of note, screening for alcohol abuse and dependence in primary care has been shown to be easily and effectively combined with brief interventions and referral to treatment (SBIRT), providing an evidence-based, cost-effective approach to addictions treatment outside of specialty settings (Ballesteros, Duffy, Querejeta, Arino & Gonzales-Pinto, 2004; Ballesteros, Gonzales-Pinto, Querejeta & Arino, 2004). As little as a single session of a brief intervention following a positive screen, administered via web in a primary care setting, was shown to effectively reduce hazardous drinking for up to a year (Kypri, Langley, Saunders, Cashell-Smith & Herbison, 2008). An evaluation of the extent to which SBIRT for alcohol use disorders can be translated into HIV primary care has been called for in the literature (Conigliaro, Gordon, McGinnis, Rabeneck & Justice, 2003) and should be a major focus of future research.

With high rates of problem drinking in HIV-positive patients and considering its multiple adverse consequences, implementing regular screening procedures in primary care HIV clinics is critical in order to ensure that individuals in need of substance abuse treatment can be identified and referred for services. Due to time constraints in these types of settings, conducting lengthy clinical interviews is oftentimes not feasible and the use of brief screening tools may be preferable. We hope that the tools and references provided here will contribute to a more widespread adoption of routine screening for alcohol abuse and dependence in HIV primary care.

Footnotes

Helpful online resources and references

National Institute on Alcohol Abuse and Alcoholism: “A Pocket Guide for Alcohol Screening and Brief Intervention” (online publication): http://pubs.niaaa.nih.gov/publications/practitioner/pocketguide/pocket_guide.htm

“Screening Tests” (online publication): http://pubs.niaaa.nih.gov/publications/arh28-2/78-79.htm “Alcohol Research and Health” (NIAAA’s quarterly peer-reviewed journal)

Issue on Alcohol & HIV/AIDS: http://pubs.niaaa.nih.gov/publications/arh333/toc33_3.htm

Issue on Brief Screening and Intervention: http://pubs.niaaa.nih.gov/publications/arh28-1/toc28-1.htm and http://pubs.niaaa.nih.gov/publications/arh28-2/toc28-2.htm

Center for Disease Control and Prevention Resources on Alcohol Screening (including a step-by-step guide for implementing SBIRT): http://www.cdc.gov/InjuryResponse/alcohol-screening/ resources.html

Contributor Information

Julia M. Hormes, Post-doctoral fellow with the Comprehensive Alcohol Research Center and the School of Public Health Epidemiology Program, Louisiana State University Health Sciences Center, New Orleans..

Kelly R. Gerhardstein, Post-doctoral fellow with the Department of Psychiatry Section of Psychology, School of Medicine, Louisiana State University Health Sciences Center, New Orleans..

Phillip T. Griffin, Professor and Chief of Psychology, Department of Psychiatry, School of Medicine, Louisiana State University Health Sciences Center, New Orleans..

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