Abstract
Background:
Women living with HIV (WLWH) often report heavy alcohol use and may experience substantial alcohol-related problems, but it is unclear whether it is necessary to completely quit drinking to reduce such problems
Objectives:
To assess whether complete reduction of alcohol use produced significantly greater improvement in alcohol-related problems than a partial reduction of alcohol use (reducing alcohol use to ≤7 or ≤14 drinks per week).
Methods:
We used data from a randomized clinical trial examining the effectiveness of Naltrexone in WLWH who reported heavy drinking (>7 drinks/week) at baseline. The primary outcome (alcohol-related problems) was measured using the Short Inventory of Problems. The primary predictor (drinking status: quit drinking, reduced drinking, continue heavy drinking) was measured using a 30-day timeline followback.
Results:
The sample consisted of 163 WLWH (50% 50 years or older, 85% Black). WLWH who reported past violence had significantly greater mean SIP scores at baseline (19.9 vs. 10.5, p<.0001). Forty-eight percent of women quit drinking by 7 months and 28% reduced drinking to ≤7 drinks/week; these women had significant reduction in alcohol-related problems compared to those who continued heavy drinking (−8.2 and −4.8 vs. −0.8, p = 0.0003). Quitting and reducing drinking were also associated with statistically significant decreases among the physical, interpersonal, intrapersonal, and social subscales of the SIP (p<.05), although a similar pattern, while not statistically significant, exists for the impulse control subscale.
Conclusions:
While completely quitting drinking produced the greatest improvement, reducing drinking to ≤14 drinks per week can significantly reduce alcohol-related problems in WLWH.
Keywords: HIV, women living with HIV, alcohol problems, alcohol reduction, heavy drinking, longitudinal study
Introduction
Although the number of women receiving new HIV diagnoses has declined, women still make up approximately 19% of new HIV diagnoses in the United States (CDC, 2019). HIV disproportionally affects Black and Hispanic women, who account for 59% and 16% of new HIV diagnoses among women in the US, respectively (CDC, 2019). Additionally, women living with HIV (WLWH) and women at high-risk for HIV tend to have several barriers to receiving the care they need, such as poverty, cultural inequities, and past violence (Kaiser Family Foundation, 2014). Such structural and cultural barriers make it difficult for WLWH across the entire HIV care continuum, from diagnosis to achieving sustained viral suppression (Kaiser Family Foundation, 2014).
Heavy drinking, defined for women as consuming more than seven drinks per week (Office of Disease Prevention and Health Promotion, 2015), can also impact the HIV care continuum. Sub-optimal antiretroviral therapy (ART) adherence and decreased viral suppression has been associated with heavy drinking among persons living with HIV (PLWH)(Chander et al., 2006; Cook et al., 2017; Williams et al., 2016). Despite this, recent alcohol use is prevalent among PLWH, with 8% to 42% of PLWH reporting unhealthy alcohol use (Crane et al., 2017; Edelman et al., 2018; Galvan et al., 2002). Aside from poor HIV health outcomes, heavy drinking is often associated with increased comorbidities (Williams et al., 2016) and decreased quality of life (Kraemer et al., 2002). Heavy drinking may also lead to specific alcohol-related problems, such as consequences related to physical health (acute and chronic), mental health or personal beliefs (e.g. feeling guilty), relationships (e.g. ruining a friendship), failing to uphold social responsibilities, and impulse control issues (Feinn et al., 2003; Miller et al., 1995), all of which may further contribute to a decreased quality of life.
Alcohol-related problems may vary according to education level, race/ethnicity, sex, and previous domestic violence (Kaysen et al., 2007; Klein et al., 2016; Muthén & Muthén, 2000; Nolen-Hoeksema, 2004). While female sex tends to be protective against heavy drinking, women who drink typically have more alcohol-related problems than men (Kraemer et al., 2002). One study investigating alcohol-related problems among Black women indicated that 67% of women who had at least one alcoholic drink in the past year experienced at least one alcohol-related problem, with 50% wanting to quit or cut down on their drinking, 31% consuming more alcohol than they wanted to, and 28% craving alcohol (Klein et al., 2016). Additionally, experienced violence has been associated with both a greater likelihood of heavy alcohol consumption and a greater number of alcohol-related problems (Kaysen et al., 2007). It is plausible that the same factors that place women at high-risk for acquiring HIV also place them at high-risk for experiencing alcohol-related problems, yet little research has been published on how alcohol-related problems can be reduced among this vulnerable population.
Alcohol use is a modifiable behavior that can be a target for future interventions. While abstinence is often the goal of drinking interventions, there is evidence to suggest that a reduction in alcohol consumption may be sufficient for improved outcomes (Witkiewitz et al., 2018). Among heavy drinkers, a 30% reduction in alcohol use was associated with an improved quality of life and fewer alcohol-related consequences (Kraemer et al., 2002). Additionally, alcohol-reduction interventions among PLWH show that alcohol reduction is associated with increased ART adherence, decreased HIV viral load, and decreased risky sexual behaviors which may otherwise contribute to HIV transmission (Satre et al., 2019; Scott-Sheldon et al., 2017; Springer et al., 2018). Among WLWH, however, it is unclear whether a complete reduction in drinking compared to a partial reduction in drinking will result in significantly greater improvement of alcohol-related problems.
Through this study, we aim to increase the understanding of alcohol-related problem reduction among WLWH. The objectives of this study were to: (1) to assess whether complete reduction of alcohol use produced significantly greater improvement in alcohol-related problems than a partial reduction of alcohol use (reducing alcohol to ≤ 7 drinks per week). and (2) examine whether certain types of alcohol-related problems were more likely to improve with alcohol-reduction than other alcohol-related problems among WLWH.
We expected to observe a significant reduction in alcohol-related problems associated with a reduction in alcohol consumption, regardless of whether women quit or just reduced drinking to ≤ 7 drinks per week.
Materials and methods
Study procedures
We conducted a secondary analysis using data from the WHAT-IF (Will Having Alcohol Treatment Improve my Functioning?) trial, a randomized clinical trial examining the effectiveness of Naltrexone in WLWH who reported hazardous drinking (Cook et al., 2018). Hazardous drinking was defined as consuming more than seven alcoholic drinks per week (heavy drinking) or more than three alcoholic drinks in a day at least twice (binge drinking) in the past 90 days. Detailed study procedures for the WHAT-IF trial are described elsewhere (Cook et al., 2018), but briefly, 194 women were randomized to Naltrexone or placebo for four months, with visits occurring at baseline, 2-months, 4-months, and 7-months. Approximately half of the participants received Naltrexone and half received placebo for 4 months. Alcohol use was measured at each visit using the Timeline Followback (TLFB)(Sobell & Sobell, 1992). Audio Computer-Assisted Self-Interview (ACASI) program was used to administer the study questionnaire at each wave. All participants were recruited in Miami, Florida. The present study does not examine the main effect of the intervention, as the original study found that regardless of group assignment (Naltrexone vs. placebo), the proportion of WLWH who quit or reduced their drinking was not significantly different (Cook et al., 2018).
This study was approved by all participating Institutional Review Boards and all participants provided informed consent.
Study measures
Demographics and covariates
We collected data on demographics, including age, race/ethnicity, marital status, employment status, and highest education obtained. We also collected data on experienced violence; for this analysis, experienced violence was assessed with the question “Have you been hit, kicked, punched, or otherwise hurt by someone in the past 12 months?”. The Mini International Neuropsychiatric Interview (M.I.N.I.) (Sheehan et al., 1998), a structured diagnostic interview instrument, was used to assess for alcohol use disorder at baseline.
Alcohol use
Our primary predictor was change in alcohol use and split into three categories: quitting drinking (0 drinks/week), reducing drinking (>0 drinks and ≤7 drinks/week), and continuing heavy drinking (>7 drinks/week). We used a 30-day TLFB to calculate alcohol use at each time point.
Alcohol-Related problems
We used the Short Inventory of Problems (SIP)(Miller et al., 1995) to measure our primary outcome, alcohol-related problems. The SIP is a 15-question scale derived from the Drinker Inventory of Consequences (DrInC). Each question is scored on a scale of zero to three (with a total score ranging from zero to 45), with zero indicating “never”, one indicating “once or a few times”, two indicating “once or twice a week”, and three indicating “daily or almost daily”. The SIP measures five different subscales of alcohol-related problems, including physical, interpersonal, intrapersonal, impulse control, and social responsibility consequences (Miller et al., 1995). The total score was calculated by summing up the scores of the 15 items, and subscale scores were calculated by summing up scores for items belonging to each subscale, with a higher score indicating more alcohol-related problems. Details of each subscale are described in Table 1 (Feinn et al., 2003; Miller et al., 1995).
Table 1.
Subscales of the Short Inventory of Problems (SIP).
| Physical |
| Because of my drinking I have not eaten properly |
| My physical health has been harmed by my drinking |
| My physical appearance has been harmed by my drinking |
| Interpersonal |
| My family has been hurt by my drinking |
| A friendship or close relationship has been damaged by my drinking |
| Drinking has damaged by social life, popularity or reputation |
| Intrapersonal |
| I have been unhappy because of my drinking |
| I have felt guilty or ashamed because of my drinking |
| My drinking has gotten in the way of my growth as a person |
| Impulse Control |
| I have taken foolish risks when I have been drinking |
| When drinking, I have done impulsive things that I regretted later |
| I have had an accident while drinking or intoxicated |
| Social Responsibilities |
| I have failed to do what is expected of me because of my drinking |
| I have had money problems because of my drinking |
| I have spent too much or lost a lot of money because of my drinking |
Statistical analysis
Of the 194 women who completed a baseline visit, 28 were excluded from the current analyses for not completing the 7-month follow-up visit and 3 were excluded for not reporting heavy drinking at baseline. Our final study sample for analysis consisted of 163 WLWH.
We conducted bivariate analyses to assess the baseline characteristics that were associated with SIP score and the change of SIP score (i.e. follow up SIP score minus baseline SIP score) from baseline. Kruskal-Wallis tests were used to examine group differences at the significance level of p < 0.05.
To address our first aim, we used multiple linear regression model with the mean change in total SIP score as the primary outcome, drinking status at 7 months as the primary predicter, and controlled for age, race/ethnicity, experienced violence, baseline SIP score. For our second aim, we used similar models but exchanged the total SIP score with specific SIP subscales (physical, interpersonal, intrapersonal, impulse control, or social responsibilities) for the primary outcome. Drinking status at 7 months remained the primary predictor and each model controlled for age, race/ethnicity, experiences violence, and baseline scores for each specific SIP subscale.
No multi-collinearity was found by examining the condition index. We calculated Cronbach’s alpha to assess internal reliability of the SIP constructs for our population; each individual subscale had a Cronbach α > 0.90 with a total Cronbach α = 0.94. All statistical analyses were conducted using SAS 9.4.
Post-Hoc analysis
Following the completion of our initial data analysis, we examined whether a reduction to ≤14 drinks/week per week would result in a significant reduction in alcohol-related problems, similar to that of a reduction to ≤7 drinks/week. We used multiple linear regression model with the mean change in total SIP score as the primary outcome, drinking status at 7 months as the primary predicter, and controlled for age, race/ethnicity, experienced violence, baseline SIP score.
Results
Sample characteristics
The majority of participants were 50 years or older (50%), Black (85%), single (83%), unemployed (90.0%), and had less than a high school education (44%). Many experienced recent violence (20%), and the majority screened positive for alcohol use disorder (61%) and consumed more than 35 alcoholic drinks per week at baseline (58%). By the 7-month follow-up, 48% completely quit drinking, 28% reduced drinking to ≤7 drinks per week, and 25% continued heavy drinking. Detailed information on how baseline characteristics of the women are related to total baseline SIP score and change in SIP score are shown in Table 2.
Table 2.
Characteristics of sample in relation to mean baseline short inventory of problems (SIP) and change in SIP score among women with HIV who are heavy drinkers (n = 163).
| Characteristic | Frequency (%) | Mean Baseline SIP Score (SD) | Unadjusted P-valuea | Mean change in SIP Score (SD) | Unadjusted P-valuea |
|---|---|---|---|---|---|
| Age | 0.2307 | 0.4183 | |||
| 18–39 years | 21 (13%) | 8.3 (8.0) | 0.1 (26.4) | ||
| 40–49 years | 60 (37%) | 12.3 (10.7) | −5.2 (9.3) | ||
| 50+ years | 82 (50%) | 13.1 (11.1) | −7.1 (11.5) | ||
| Race/Ethnicity | 0.1596 | 0.1259 | |||
| Black | 138 (85%) | 11.6 (10.4) | −4.8 (13.8) | ||
| Other | 25 (15%) | 15.0 (12.0) | −9.2 (13.0) | ||
| Marital Status | 0.5986 | 0.1581 | |||
| Single | 135 (83%) | 12.0 (10.7) | −4.9 (14.6) | ||
| In relationship | 28 (17%) | 12.9 (10.5) | −8.0 (8.5) | ||
| Currently Employed | 0.0386 | 0.9566 | |||
| No | 146 (90%) | 12.6 (10.6) | −6.4 (10.5) | ||
| Yes | 17 (10%) | 7.9 (10.5) | −5.4 (14.1) | ||
| Highest Education | 0.0380 | 0.2517 | |||
| Less than high school | 72 (44%) | 14.1 (10.5) | −5.9 (17.2) | ||
| High school graduate | 54 (33%) | 11.4 (11.5) | −5.9 (11.2) | ||
| At least some college | 37 (23%) | 9.5 (9.1) | −4.0 (8.9) | ||
| Experienced Violence | <.0001 | 0.0237 | |||
| Yes | 32 (20%) | 19.9 (11.2) | −9.2 (12.4) | ||
| No | 131 (80%) | 10.5 (9.9) | −4.6 (14.0) | ||
| Alcohol use disorder | <.0001 | 0.0024 | |||
| None | 63 (39%) | 7.3 (7.5) | −2.8 (6.6) | ||
| Alcohol use disorder | 99 (61%) | 15.2 (11.2) | −7.3 (16.7) | ||
| Drinks per week at baseline | <.0001 | 0.0026 | |||
| 8–21 drinks/week | 28 (17%) | 5.8 (6.3) | −1.1 (5.7) | ||
| 22–35 drinks/week | 40 (25%) | 10.3 (9.9) | −2.7 (11.4) | ||
| 35+ drinks/week | 95 (58%) | 14.8 (11.1) | −7.9 (11.4) | ||
| Intervention | 0.8955 | 0.7193 | |||
| Placebo | 83 (51%) | 11.9 (10.1) | −5.1 (17.0) | ||
| Naltrexone | 80 (49%) | 12.4 (11.3) | −5;.8 (9.7) | ||
| Drinking status at 7 months | 0.3142 | 0.0003 | |||
| Quit drinking (0 drinks/week) | 78 (48%) | 13.1 (11.3) | −8.2 (11.3) | ||
| Quit heavy drinking (>0 and ≤ 7 drinks/week) | 45 (28%) | 12.3 (9.8) | −4.8 (19.8) | ||
| Continue heavy drinking (>7 drinks/week) | 40 (25%) | 10.3 (10.3) | −0.8 (7.3) |
P-values are from Kruskal-Wallis tests.
SD – standard deviation.
Total baseline SIP score
The mean total SIP score at baseline was 12.2 (SD = 10.6). Having a lower education and being unemployed was significantly associated with increased baseline total SIP scores (p = 0.04). Participants with a history of experienced violence had a mean baseline SIP score 9.4 points higher than those without domestic violence (p<.0001) (Table 2). Those with a positive baseline screen for alcohol use disorder had a mean baseline SIP score 8.1 points higher than those without alcohol use disorder (p<.0001).
Change in total SIP score
The mean change in total SIP score between the 7-month follow-up visit and baseline visit was −5.5 (SD = 13.8) and ranged from −45 to 20. Negative scores indicate a decrease in total SIP score at the 7-month follow-up. Women who completely quit drinking had a mean baseline score of 13.1 and a follow-up score of 4.9, women who reduced drinking to ≤ 7 drinks per week had a mean baseline score of 12.3 and a mean follow-up score of 7.5, and women who continued heavy drinking had a mean baseline score of 10.3 and a mean follow-up score of 9.5. After adjustment, each level of decrease in drinking (i.e. heavy drinking to reducing drinking, reducing drinking to completely quit drinking) was associated with a 2.9 point decrease in SIP score (p = 0.01). Thus, quitting drinking resulted in a greater reduction in alcohol-related problems compared to reducing drinking. However, reduction in drinking still resulted in significant decreased in alcohol-related problems (Table 3). Participants with higher baseline SIP scores also experienced significantly greater reductions in SIP score at follow-up, with an average reduction of 0.6 points for each one-point increase in baseline score (p<.0001). Age, race/ethnicity, and experienced violence were not significantly associated with a change in total SIP score in our model (Table 3).
Table 3.
Linear regression model with mean change in SIP score as the primary outcome and drinking status at 7 months as the primary predictor (N = 163).
| Characteristic | β (SE) | 95% CI | Adjusted P-value |
|---|---|---|---|
| Drinking Status | −2.9 (1.2) | −5.2,−0.6 | 0.0129 |
| Age | −2.1 (1.4) | −4.8, 0.6 | 0.1238 |
| Race/Ethnicity | −1.6 (2.7) | −7.0,3.7 | 0.5497 |
| Experienced Violence | 0.3 (2.6) | −4.8, 5.4 | 0.9053 |
| Baseline SIP Score | −0.6 (0.1) | −0.7, 0.4 | <.0001 |
Controlling for age, race/ethnicity, experienced violence, baseline SIP score.
SE – standard error.
CI – confidence interval.
Change in SIP subscale scores
Figure 1 displays the means for each SIP subscale from baseline and follow-up, grouped by women who completely quit drinking, women who reduced drinking, and women who continued heavy drinking. After adjustment, reducing drinking was statistically significantly associated with the physical (β=−0.6, p = 0.0067) interpersonal (β=−0.6, p = 0.0248), intrapersonal (β=−0.8, p = 0.0029), and social responsibility constructs (β=−0.6, p = 0.0187), however a pattern among all subscales is present, with alcohol reduction consistently resulting in lower follow-up SIP subscale score. The magnitude of reduction in specific problems was similar for each subscale.
Figure 1.
*Significant P-values (<0.05); P-values represent comparison between women quit drinking completely, reduce drinking (>0 and ≤7 drinks/week), and continue heavy drinking (>7 drinks/week) in regard to change in Short Inventory of Problems (SIP) subscale scores. Women who quit and reduced drinking experienced significant reductions in the physical, interpersonal, intrapersonal, and social subscales, although a similar trend was observed for the impulse control subscale.
Post-Hoc results
Findings from the post-hoc analysis were similar to that of the a priori analysis (Table 4). That is, though complete abstinence resulted in the greatest reduction in alcohol-related problems, reducing to 14 or less drinks per week still resulted in a significant decrease in alcohol-related problems.
Table 4.
Post hoc analysis: Linear regression model with mean change in SIP score as the primary outcome and drinking status at 7 months as the primary predictor (N = 163).
| Characteristic | β (SE) | 95% CI | Adjusted P-value |
|---|---|---|---|
| Drinking Status | −3.1 (1.3) | −5.6,−0.7 | 0.0135 |
| Age | −2.0 (1.4) | −4.7,0.7 | 0.1483 |
| Race/Ethnicity | −1.8 (2.7) | −7.1,3.6 | 0.5119 |
| Experienced Violence | 0.1 (2.6) | −4.9,5.2 | 0.9602 |
| Baseline SIP Score | −0.6 (0.1) | −0.7,−0.4 | <.0001 |
Controlling for age, race/ethnicity, experienced violence, baseline SIP score.
Post hoc analysis where drinking status refers to participants either abstaining, drinking ≤14 drinks/week, or >14 drinks/week.
SE – standard error.
CI – confidence interval.
Discussion
This study examined alcohol-related problems among a group of primarily Black women living with HIV who drink heavily, many of whom had a history of experienced violence. We aimed to determine whether complete reduction of alcohol use produced significantly greater improvement in alcohol-related problems than a partial reduction of alcohol use (reducing alcohol to ≤ 7 drinks per week; ≤14 in post host analysis) and to identify whether certain types of alcohol-related problems were more likely to improve than others. This population, especially vulnerable to alcohol-related problems (Kaiser Family Foundation, 2014), may need specialized alcohol-reduction interventions targeted toward them. This study serves as an important first step in informing future interventions for alcohol-reduction for women who may face a plethora of other structural and sociocultural problems, as well.
We found that WLWH with experienced violence reported significantly more alcohol-related problems at baseline, but experienced violence was not associated with reduction of alcohol-related problems. This suggests that while violence should be screened for in conjunction with alcohol use disorders, it may not be necessary to develop specific interventions for women who experience violence. Alcohol consumption has been proposed as a coping mechanism for experienced violence (Kaysen et al., 2007) which may explain the relationship between increased alcohol-related problems and previous experienced violence.
Quitting drinking was associated with the largest reduction in alcohol-related problems but reducing drinking to ≤14 drinks per week also resulted in a significant reduction in alcohol-related problems. A similar pattern was seen for specific types of alcohol-related problems (e.g. physical, interpersonal, intrapersonal, impulse control, and social responsibilities), although this relationship was not significant for the impulse control subscale. This suggests that while it is ideal to completely quit drinking to resolve alcohol-related problems, reducing drinking may be sufficient to produce meaningful improvements. Completely quitting drinking may not be possible for or desired by everyone undergoing alcohol reduction interventions, so it is important to consider the benefit of reducing, rather than quitting alcohol use. Our findings agree with past studies that suggest reducing drinking, but not necessarily quitting, can still result in clinically meaningful improvements in quality of life (Kraemer et al., 2002; Witkiewitz et al., 2018). The consistency is notable among this sample of WLWH, who may turn to alcohol as a coping mechanism for other life difficulties. It is important to note, however, that complete abstinence may be necessary for some populations; in other words, research has found that although drinking in moderation is possible to maintain sobriety, people with more severe alcohol use disorder are more likely to maintain long-term sobriety if they pursue total abstinence rather than drinking in moderation (Maisto et al., 2007; Udo et al., 2009).
Our data also supported the notion that alcohol-related problems may be just as or more important than number of drinks consumed when considering alcohol reduction interventions. Women with higher baseline SIP scores showed significantly greater change in both the total and all subscales of SIP scores than those with lower baseline SIP scores. However, this may be because those with higher baseline scores had more room for reduction than those with lower baseline scores.
The results of this study were consistent with others which investigated risk factors for alcohol-related problems, specifically in regards to the relationship between experienced violence and alcohol-related problems (Kaysen et al., 2007; Klein et al., 2016; Muthén & Muthén, 2000; Nolen-Hoeksema, 2004). We also found similar results in relation to reduction in alcohol-related problems and alcohol reduction (Kraemer et al., 2002).
This study was not without limitations. All women were recruited in Miami, Florida, thus the study results may not be generalizable to the entire population of WLWH. However, Miami has the highest incidence rate of HIV infection within the United States, and is an important area to study and focus efforts toward in regards to HIV (Florida Department of Health, 2020). As with most studies of this nature, the findings may be limited due to self-report bias, however, we attempted to minimize this by using private spaces and computer-administrated questionnaires. It is possible that women may have exaggerated how much they drank in order to participate in this study. A major strength of this study was the use of a longitudinally-measured, continuous outcome of interest (SIP score), which was assessed for most participants on multiple occasions. Additionally, this population of primarily Black women living with HIV have been historically underrepresented in alcohol-related studies, despite the unique challenges they may face.
Conclusions
This was among one of the first studies to assess alcohol-related problems among a large sample of primarily Black WLWH. Our findings support the notion that while complete abstinence may be ideal for alcohol-reduction interventions, reducing alcohol use to ≤ 14 drinks per week can significantly reduce alcohol-related problems.
Funding
This study was supported by the National Institute on Alcohol Abuse and Alcoholism by grants T32AA025877, U24AA022003, and U01AA020797.
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