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. Author manuscript; available in PMC: 2020 Dec 1.
Published in final edited form as: West J Nurs Res. 2020 Apr 2;42(12):1155–1162. doi: 10.1177/0193945920912946

A Modified Alcohol SBI for Use among Older Adults Living with HIV

Annie L Nguyen 1, Jordan E Lake 2,4, Diane Preciado 3, Diana Liao 3, Alison A Moore 3,5, Homero E del Pino 3,6
PMCID: PMC7529890  NIHMSID: NIHMS1609381  PMID: 32238110

Abstract

Older adults living with HIV may have health conditions that amplify the potentially negative health effects of alcohol use. We adapted the Comorbidity Alcohol Risk Evaluation Tool (CARET) screening tool for at-risk drinking to reflect HIV/AIDS and related conditions, medications, and behaviors. The adapted CARET-HIV along with a brief intervention was administered to 27 older men living with HIV. The CARET-HIV identified the same number of at-risk drinkers as the original CARET (n = 24) but identified more risk domains. Most participants welcomed receiving information about risks associated with their drinking, but some felt “embarrassed” or “guilty” discussing their drinking. This is particularly salient within the context of HIV discourse, which has historically assigned blame of HIV infection on personal choices. The SBI was generally acceptable to participants. The modified CARET can help providers integrate discussion of alcohol use into the context of HIV care for personalized feedback.

Keywords: alcohol screener, unhealthy alcohol use, screening tool

Older adults accounted for half of all people living with HIV in the United States in 2016 (Centers for Disease Control and Prevention [CDC], 2018). Older adults living with HIV refer to people ages 50 years and older (Auld et al., 2016) because people living with HIV experience earlier onset of age-related conditions (Effros et al., 2008). They are more likely than persons of the same age without HIV to be frail, have multiple non-AIDS comorbidities and depression, and have more complex cases of cognitive impairment (Cahill & Valadez, 2013; Saag, 2011; Sangarlangkarn & Appelbaum, 2016).

Alcohol Use among Older Adults Living with HIV

Alcohol use is commonly reported among people living with HIV, with 63% reporting alcohol consumption in the past year and 15% reporting binge drinking in the past month (CDC, 2019). However, in the context of HIV management, alcohol consumption can have negative impacts. Compared to people without HIV, people living with HIV experience increased rates of harm at lower levels of alcohol consumption (Justice et al., 2016). Among people living with HIV, greater reported alcohol consumption is associated with poorer engagement in care and viral suppression (Williams et al., 2019), greater likelihood of medication no-adherence (Ramsey et al., 2019), and increased likelihood of engaging in unprotected anal sex (Shuper et al., 2009).

There are also age and health-related reasons for older adults living with HIV specifically to limit their alcohol use. Compared to younger adults, older adults experience higher blood alcohol concentration (BAC) levels for a given dose of alcohol due to age-related physiological changes causing the effects of alcohol to be more pronounced in older adults (Moore et al., 2006). Older adults who consume three or more drinks per day may have increased blood pressure and worsening cognition (Moore et al., 2006, 2011). The relationship between alcohol use and cognitive impairment may resemble a J-shaped relationship where low levels of drinking has a protective effect compared to abstinence, but high levels of drinking is associated with the greatest risk (Topiwala & Ebmeier, 2018). Alcohol use can also interact with medications and exacerbate or reduce therapeutic effects, decrease drug metabolism, and interfere with drug effectiveness (Moore et al., 2007; Weathermon & Crabb, 1999). Because people living with HIV may be particularly vulnerable to the potentially deleterious effects of alcohol use, health professionals are advised to screen and counsel people living with HIV on alcohol use (Schneider et al., 2012).

Alcohol screening and brief interventions (SBI) are evidence-based methods used to identify and address at-risk drinking. Brief interventions typically involve structured advice or motivational interviewing that last 5–20 minutes and are delivered over as few as one session. SBIs have been shown to successfully reduce alcohol consumption (Edelman et al., 2019; Kaner et al., 2009; Satre et al., 2019). Common alcohol use screeners include the AUDIT or AUDIT-C (Allen et al., 1997) and the CAGE (Mayfield et al., 1974). However, because they are meant for broad use, these screeners do not consider the individual’s age, existing comorbidities, or medication use as part of the risk assessment (Moore et al., 2006, 2011). As a result, these assessments are not targeted to identify risk factors in any specific population. In response to these limitations, the Comorbidity Alcohol Risk Evaluation Tool (CARET) was developed to assess drinking risks among older adults, specifically, and it takes into account alcohol consumption in combination with select comorbidities and medications (Barnes et al., 2010). The CARET has demon-strated face, content, and criterion validity (i.e., sensitivity and specificity of 82%) for assessing at-risk drinking among older adults across different populations (Fink, Morton, et al., 2002; Fink, Tsai, et al., 2002; Moore et al., 2002). An example of at-risk drinking identified from the CARET is an older adult who consumes two drinks daily and takes a medication that causes sedation.

Purpose

Because the CARET was developed for use among general populations of older adults, it does not capture the context and factors that are unique to older adults living with HIV such as HIV diagnosis and medications used to treat HIV and associated conditions. In this study, we adapted the CARET and an accompanying brief intervention previously used with older adults (Ettner et al., 2014; Moore et al., 2011), for older adults living with HIV. The adapted CARET-HIV and BI was then pilot-tested and assessed for usability and acceptability.

Methods

We implemented the project in two phases: (a) adaptation of the materials and (b) assessment of usability and acceptability. This study was approved by the UCLA Institutional Review Board and all participants provided written informed consent prior to data collection.

Phase 1: Adapting the CARET and Brief Intervention

In the original CARET (Barnes et al., 2010), respondents are classified as “at-risk” if they meet drinking thresholds for any of the 13 items assessed (see non-bolded items in Table 1). The amount of drinking considered to be “at-risk” varies across items because a given level of alcohol consumption may be low-risk in certain situations but at-risk in a different context (Fink, Morton, et al., 2002; Fink, Tsai, et al., 2002; Moore et al., 2002, 2006, 2007, 2011). For example, someone with liver disease or pancreatitis who consumes any amount of alcohol is considered “at-risk” according to the CARET. An individual with hypertension or diabetes would have to consume five drinks/day at any frequency, or four drinks/day at least twice a month, or three drinks/day at least four times a week, to be “at-risk.”

Table 1.

Items and At-risk Threshold of the Comorbidity Alcohol Risk Evaluation Tool (CARET) HIV.

Item Amount of Alcohol Considered At-risk
Alcohol use and behaviors in the last 12 months
a. Number of drinks and frequency of drinking a. ≥5/day at any frequency, 4/day at least 2 times/month, 3/day at least 4 times/week
b. Four or more drinks on one occasion (heavy episodic drinking) b. At least 1 time/week
c. Driving within two hours of drinking three or more drinks c. Any frequency
d. Someone was concerned about participant’s alcohol use d. Any amount
e. Someone was concerned about participant’s alcohol use more than 12 months ago e. ≥4/day at any frequency, 2–3/day at least 4 times/week
f. Missed a dose of HIV medication f. ≥4/day at any frequency, 2–3/day at least 4 times/week
g. Use of marijuana or tobacco products g. ≥4/day at any frequency, 2–3/day at least 4 times/week
Alcohol use and medications taken at least three-four times per week currently
h. Medications that may cause bleeding, dizziness, sedation h. ≥4/day at any frequency, 2–3/day at least 4 times/week
i. Medications used for gastroesophageal reflux, ulcer disease, depression, HIV, erectile dysfunction i. ≥4/day at any frequency, 2–3/day at least 4 times/week
j. Medications for hypertension j. ≥five/day at any frequency, four/day at least 2 times/week, 3/day at least 4 times/week
Alcohol use and comorbidities in the past 12 months
k. Liver disease, pancreatitis k. Any amount
l. Gout, depression, HIV/AIDS l. ≥four/day at any frequency, three/day at least two times/week, two/day at least four times/week
m. High blood pressure, diabetes m. five/day at any frequency, four/day at least two times/month
n. Sometimes have problems with sleeping, falling, memory problems, heartburn, stomach pain, nausea, vomiting, or feel sad/blue n. five/day at any frequency, four/day at least two times/month, three/day at least two times/week
o. Often have problems with sleeping, falling, memory, heartburn, stomach pain, nausea, vomiting, or feel sad/blue o. ≥four/day at any frequency, two-three/day at least two times/week
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Note: Items in bold were added to create the CARET-HIV.

We added items to the CARET to reflect risks that are unique to older adults living with HIV (see Table 1). Two new items were added and two items were modified. Alcohol consumption in combination with missing a dose of HIV medication (item F) was added to reflect the potentially negative effects of alcohol use on adherence to HIV medications (Papas et al., 2010). Marijuana and tobacco use (item G) was added because frequent use of marijuana is associated with missed clinic appointments, and marijuana users have increased odds of low social engagement and under- or un-employment compared to non-users (Kipp et al., 2017). People who consume alcohol and marijuana also have poorer medication adherence than those who consume only alcohol (Parsons et al., 2014). We included tobacco products because smoking is associated with a twofold increase in mortality and decreased life expectancy for people living with HIV (Helleberg et al., 2013), and is associated with neurocognitive deficits after controlling for heavy drinking and age (Monnig et al., 2016). Among heavy drinkers, smokers are more likely to report lower medication adherence than non-smokers (Cioe et al., 2017). We included HIV medications and erectile dysfunction drugs (item I) to the group of medications of potential concern when combined with alcohol. Alcohol use among people taking antiretroviral therapies is associated with increased hepatoxicity (Chander, 2011) and decreased viral suppression (Williams et al., 2016). We added erectile dysfunction drugs because they increase nitric oxide production and facilitate coronary vasodilation (Kelly et al., 2016), which may result in hypotension in combination with alcohol. Lastly, we included HIV/AIDS as a comorbidity of potential concern when combined with alcohol consumption (item L). After adding the new items, based on the existing literature and with input from the study clinicians (AAM and JEL), we then revised the original CARET scoring algorithm to include them.

The brief intervention accompanying the CARET typically uses an individual’s response to define their personal risks. It consists of a personalized risk report as well as an educational booklet focused on alcohol and aging. The personalized risk report provides feedback on the respondent’s answers to the CARET and a statement about the potential consequences of the respondent’s alcohol use: “You are at an increased risk of developing or making the following problems worse.” This is followed by the list of items in each domain that contribute to increased risk for adverse outcomes for that individual. For this study, we used an adapted booklet developed by the New York State Department of Health on alcohol use and HIV (“HIV and Alcohol- A Mix You Can Avoid”). The adapted booklet included information on local services and resources and links to publications on HIV.

Phase 2: Assessing the Usability and Acceptability of the Adapted CARET-HIV Recruitment and Enrollment

We recruited a convenience sample from community-based organizations and clinics in Los Angeles that serve people living with HIV. Our sample size goal was driven by established parameters for usability testing. A minimum sample of 25 participants is typical to pretest the usability of surveys (Oksenberg et al., 1991). Potential participants were screened for the following inclusion criteria: (a) at least 50 years old, (b) self-reports as HIV-positive, (c) consumes four or more drinks of alcohol in the past week, (d) not currently in treatment for an alcohol or substance use disorder, (e) at least one positive response to the CAGE questionnaire, and (f) able to complete study in English. We intentionally recruited individuals with high levels of alcohol consumption in order to ensure a significant proportion of people would meet at-risk thresholds on the CARET in order to test CARET-HIV and accompanying brief intervention.

Interviews to Assess Usability and Acceptability

Participants completed a short demographic questionnaire and were given the CARET-HIV to complete. Upon completion, participants were given their personalized risk report along with an educational booklet to review. After participants reviewed the materials, a research assistant conducted semi-structured interviews using an interview guide developed to determine the acceptability and usability of the SBI (Table 2). All study participants received $20 for participation.

Table 2.

Interview Guide to Elicit Responses about Usability and Acceptability of the CARET-HIV.

1. How easy was it to read the materials? Please explain.
2. Do you feel that this took up too much time or was it just right? Please explain.
3. How do you feel about the CARET-HIV and the feedback?
4. How would you feel if your healthcare provider or a case manager asked you these questions (refer to materials)?
5. Were any of the questions hard to understand?
6. Would you ask any of these questions in a different way?
7. Would you use different words to describe unhealthy alcohol use?
8. What, if anything, would you change about the materials presented to you?
9. What are some of the barriers to asking questions about alcohol use?
10. What are some of the things that might make it easier to ask older, HIV+ adults to reduce alcohol use?
11. What do you like best about the materials?
12. What do you like the least about the materials?
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Data Analysis

We calculated descriptive statistics for the quantitative data and identified at-risk drinking using the criteria in both the original CARET and the revised CARET-HIV for comparison. For the qualitative data, we conducted thematic analyses to explore the participants’ overall experience with the materials. Interviews were coded and interpreted through an inductive and data-driven, grounded-theory method and involved an iterative process of taxonomic organization and content analyses (Charmaz, 2006). Text from the interviews were “clustered” around single words or phrases, then coded and organized into a hierarchy of categories to build thematic content. An abundance of data on the differences in acceptance of the instruments and reactions to the personalized risk report warranted compiling these variances into themes. Themes were refined to ensure that they captured the range of experiences that participants described.

Results

We enrolled a total of 27 participants. All participants were male; 55% identified as African American, 30% as white, and 15% as mixed race. Additionally, 22% identified as Hispanic/Latino ethnicity. The mean age of participants was 54 years (range 50–63 years). Roughly half (48%) of participants completed greater than high school education and 70% had an annual income of less than $20,000. Forty-four percent had a history of alcohol or substance use treatment and 56% had a history of a mental health disorder diagnosis.

Based on the scoring, the original CARET classified 24 participants as at-risk drinkers and the CARET-HIV similarly classified 24 participants as at-risk drinkers. The average number of items that contributed to meeting thresholds for risk was six on the CARET and nine on the CARET-HIV. In other words, although the CARET-HIV did not detect additional individuals who met the threshold for at-risk drinking, it detected more risks based on items not assessed on the CARET. Twenty-three people met threshold for at-risk drinking based on their responses to items related to alcohol use and behaviors on the CARET. The CARET-HIV included “missed dose of HIV medications” and “marijuana or tobacco product use,” but these items did not identify additional people for at-risk drinking. For the items in the risk category of alcohol use and medications, the CARET identified 17 people to be at-risk whereas the CARET-HIV identified 18 people to be at-risk; the additional individual met threshold for at-risk drinking in combination with taking HIV medications. Items related to alcohol use and comorbidities identified 22 people to be at-risk drinkers using the CARET as well as the CARET-HIV (Table 3).

Table 3.

Risk Classification Differences between CARET and CARET-HIV (n = 27).

CARET n (%) CARET-HIV n (%)
Individuals meeting “at-risk” domains
 Alcohol use and behaviors 23 (85) 23 (85)
 Alcohol use and medications 17 (63) 18 (67)
 Alcohol use and comorbidities 22 (81) 22 (81)
Total individuals classified as “at risk” 24 (89) 24 (89)
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Qualitative Interview Themes

Overall, participants found the materials easy to read and understand. No one reported difficulties reading, completing, or understanding the CARET-HIV, personalized risk report, and informational booklet.

Theme 1: Materials were informative and prompted reflection or action.

Most participants reported that they enjoyed reading the materials because of the usefulness of the information conveyed. These participants learned new information and gained knowledge to better understand their health. One participant said the informational booklet “made a lot of good points about what’s going to happen to me if I don’t stop [drinking] and think about mixing my alcohol with my drug use and my pill use.” Others reported that the materials were “easy to read,” “informative,” and “straight forward”.

As a result of reviewing the educational materials, some participants expressed appreciation at the opportunity to reflect on drinking and its relationship to health. For example, one participant said:

I felt it was something good for me to read, for me to think about. And maybe get a little bit of a chance to look at myself and the points where I need to kind of maybe stop doing a few things, and more focus on my body and myself.

This participant further stated that the materials prompted him to consider abstaining from alcohol for the rest of the day. A different participant expressed a similar sentiment. He stated that he would consider “whether or not I need to take that fifth drink or not, or can I cut back today.” Some participants explained that the first step towards action is self-awareness, which were prompted by reading the materials. As one participated stated, “It gave you facts and not opinions and with facts, you can make better decisions and you can make better choices if you choose to.”

Theme 2: Information and increased awareness not always welcomed.

Some participants had negative reactions to the personalized risk report because of the negative information conveyed. These participants reported feeling “embarrassed,” “guilty,” or “bad” about their behaviors and choices. One participant stated, “I felt bad about the way I’ve chosen to live my life.” Another participant reported that the personalized risk report, “[makes] me feel like I’m not a responsible person or I don’t know any better…like I’m doomed.” One participant suggested changing the report to make it “more palatable.”

Several participants made a distinction between health issues and recreational choices, and that alcohol or substance use were matters of “personal business” outside the realm of health. One participant pointed to his autonomy and right to make his own decisions, “I have the right to choose not to do anything as well as to do something. People need to respect that.” Another participant shared that he disliked feeling “chastised” and “judged” about his drinking.

Theme 3: Information not new for people living with HIV for over 10 years.

In general, participants reported that the personalized risk report increased awareness of their individual risks associated with their specific drinking habits and medication use. However, many of the participants stated that they already knew about the adverse consequences of heavy drinking and expected others to know as well given their older age and time living with HIV. A participant said:

[Older persons are] pretty aware and familiar with [the consequences]…especially if they’re an older person who’s been infected, like me, with HIV for 31 years– either you’re very knowledgeable about what’s going on in your life and your health issues…or you’re not.

Another participant corroborated this view, and stated that the personalized risk report does not reveal anything that he was not already aware of. He said, “If I hadn’t spent the past 25 years worrying about my health and attempting to find help, this [personalized risk report] would be terrifying.” He continued: “I think you’re going to find that populations over 50 [years old] of men who have been HIV positive for any length of time, absolutely none of this should surprise them.” However, for someone who has “recently converted [to HIV positive serostatus]” and “hasn’t spent decades attending to their own health needs” may find the personalized risk report “terrifying.”

Theme 4: Considerations to improve usability and acceptability.

The majority of participants offered editorial suggestions for improvement of materials including feedback on wording and phrasing, including illustrations, and adding statistical information on the potentially adverse impacts of alcohol on health. However, the participants who reported negative reactions to the personalized risk report offered additional suggestions about the overall tone of the materials. One participant suggested that the materials did not acknowledge a “middle ground” for healthy drinking. Others recommended employing “non-judgmental” words that “imply all kinds of negativity.”

Discussion

To our knowledge, this is the first study to adapt an alcohol SBI specifically for older adults living with HIV. Alcohol use can be a difficult topic for clinicians to raise with patients. The utility of using a targeted screener for people living with HIV is that information about at-risk alcohol consumption can be delivered within the context of HIV infection for more personalized feedback. We modified the CARET to include this context so that conversations about alcohol reduction can occur within the context of HIV care. In this study, the CARET-HIV identified risk categories in a group of older adults living with HIV that the original CARET did not identify. Although the CARET-HIV did not identify new at-risk drinkers, we intentionally selected participants with high levels of alcohol consumption who would likely meet risk levels using the CARET. Further testing of the CARET-HIV among older adults living with HIV in general is warranted to determine the sensitivity of the tool in detecting at-risk drinking that the CARET otherwise may not.

In terms of usability and acceptability, a number of participants highlighted areas for improvement, but the results are promising. Our sample included people who engaged in frequent and heavy drinking, many of whom had a history of alcohol or substance-use treatment, and our preliminary findings suggest that the majority of our participants found the CARET-HIV and accompanying personalized risk report to be usable and useful. Many participants welcomed the feedback from the risk report and were prompted to consider changes to their drinking habits. However, findings from the qualitative interviews suggest that the tone in which the personalized risk report is delivered impacts the acceptability of the results. For participants who may already experience some degree of guilt or embarrassment about their drinking habits, it was not helpful to deliver the intervention in a way that emphasized the potentially negative impacts of their choices related to alcohol use on health outcomes. These participants felt chastised, which further reduced their desire to discuss or address their drinking habits. Historically, within the HIV/AIDS discourse, HIV infection has been blamed on behaviors such as promiscuity and drug addiction, and fault in personal choices rather than on structural factors and environments (Bolton, 1992). Thus, some people living with HIV may have past or current experiences with HIV-related stigma and attacks on their personal decisions. Administrators of the CARET-HIV in real-life settings need to maintain awareness and sensitivity to the implications of delivering negative news related to individual behaviors in the specific context of the HIV/AIDS discourse. Thus, further modification of the CARET-HIV is needed and should be further studied.

Our findings also suggest that long-term survivors may already be aware of the negative consequences of excessive drinking. This is consistent with research that found older adults living with HIV to have high awareness of the “bad news” associated with HIV infection and its consequences (Nguyen et al., 2017). Thus, SBI approaches aimed at increasing awareness of the potential negative health consequences of drinking may not be the most effective approach to encourage changes in drinking behaviors and a harm reduction approach is warranted. Further research should determine the barriers and motivations that factor into action towards reducing alcohol consumption.

The CARET-HIV and accompanying SBI is a comprehensive approach to assessing risk associated with alcohol use in older adults living with HIV. The CARET-HIV can potentially assist medical and social services providers to engage clients in counseling about potential risks associated with high levels of alcohol use. However, there are some limitations to note in this study. More research is needed to further test the performance of this tool with larger samples of people living with HIV in different settings outside of the research setting and with more diverse participants. The materials were tested with English speakers, leaving out monolingual Spanish-speaking Latino/as, a population that has higher rates of binge drinking and HIV prevalence than non-Hispanic whites (CDC, 2016). Women and transgender individuals were not represented in this sample of all men as the CARET-HIV and accompanying BI were adapted with a small, convenience sample. This study was performed in a research setting and, thus, participants were compensated for taking part in the study. Replication is needed in real-life, clinical encounters where individuals will present a range of drinking patterns including moderate or low alcohol consumption. It is possible that the usability and acceptability of this tool may change when tested among different groups.

To identify at-risk drinking among older adults living with HIV, screening that take into account age and HIV-related comorbidities are needed, as is a broad approach to medication and substance use. The CARET-HIV is a step towards this goal. The CARET-HIV identifies not only at-risk drinkers but also behaviors specific to older adults living with HIV that the original CARET was not designed to consider. In this regard, the CARET-HIV is more appropriate for older adults living with HIV because it is tailored to the experiences of living with HIV and gives providers a way to address alcohol consumption in the context of HIV care. This preliminary study lays the groundwork for a future, more extensive evaluation of the utility of the CARET-HIV, personalized risk reporting, and accompanying informational booklet with a larger sample of older adults living with HIV. Further research is needed to test the efficacy of this tool in reducing negative alcohol use behaviors among older adults living with HIV.

Acknowledgments

We would like to thank all the participants that supported this study. We also want to thank Dr. Thomas Yoshikawa for comments on an earlier draft of this manuscript. Contents are the responsibility of the authors and do not necessarily represent the official views of the sponsoring agencies.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported in part by the UCLA Older Americans Independence Center under NIH/NIA Grant P30AG028748-09S1 and P30AG028748, and the UCLA Center for the Health Improvement of Minority Elders under NIH/NIA Grant P30AG021684; by the UCLA CTSI under NIH/NCRR/NCATS Grant 1UL1TR001881; the UCLA CFAR under NIH/NIAID Grant 5P30AI028697 and NIH/NIAID Grant K23AI110532; NIH/NIAA Grant K24AA15957; by Charles R. Drew University of Medicine and Science under NIH/NIMHD Grants R25MD007610 (CRECD), S21MD000103 (Urban Health Institute), and U54MD007598 (AXIS); and by the Sustained Training in Aging and HIV Research program (STAHR; R25 MH108389).

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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