Transcript: Using an Alcohol Screening Tool for HIV Patients

Amanda Balbi: Hello everyone, and welcome to another installment of Podcasts360—your go-to resource for medical news and clinical updates. I’m your moderator, Amanda Balbi with Consultant360 Specialty Network.

In November 2018, the US Preventive Services Task Force (or USPSTF) advised screening for alcohol use disorder in primary care settings for all adults. Alcohol use or misuse can have serious health consequences, especially for immunocompromised patients.

To better understand the impact of alcohol use disorder among patients with HIV at their clinic, a research team implemented the Alcohol Use Disorders Identification Test self-administered questionnaire in each of their HIV-patient visits.

With me today to discuss their study and its implications are the lead author and presenting author:

Trini Mathew: I’m Dr Trini Matthew. I'm the hospital epidemiologist and medical director of infection prevention at Beaumont Hospital – Royal Oak in Michigan.

Evan Brickner: And I'm Evan Brickner. I'm a fourth-year medical student at Open University William Beaumont School of Medicine, which is in Rochester, Michigan.

Amanda Balbi: Thank you both for joining me today. To start, your abstract mentions a change in USPSTF screening recommendations for alcohol use disorder in primary care settings for all adults. Can you talk a little bit about those changes and how they influenced your study?

Trini Mathew: Yes. So, Evan and I were exploring discussing about screening for alcohol use disorders sometime in 2018, if so, I recall. Around that time, in fall of 2018, the US Preventive Services Task Force came with a recommendation statement that was published in JAMA with the recommendations based on the evidence review that all adults should be screened for alcohol use disorders in primary care clinic.

The recommendations of screening for unhealthy alcohol use in primary care settings in adults 18 years or older, including pregnant women, and providing these persons with brief behavioral counseling to reduce unhealthy alcohol use.

This in fact lent itself support further to incorporate screening in a systematic format within our own clinic that is actually led by the infectious disease fellows precepted by ID faculty.

Evan Brickner: Just according to the article, not only trying to identify all adults who might have alcohol use disorder, but also making a broader definition of what it means to engage in hazardous alcoholic drinking.

It might not have to be identification of a full-blown alcohol use disorder, but maybe something considered more mild on the spectrum and trying to identify people who are at risk of any sort of hazardous alcohol drinking, whether it's risky behavior here and there or full-blown alcohol use disorder. So, redefining it as a spectrum and then trying to identify as many adults as possible through routine screening for all adults.

Trini Mathew: I just want to give some background with regard to the work we initiated in the clinic. We know alcohol use disorders can impact adherence and also can impact the outcomes for non-HIV and HIV patients. So, this was a project that Evan expressed interest in addressing alcohol use disorders.

As he indicated, it's important to identify the at-risk by screening, because diagnostics is based on the DSM criteria and the ICD criteria, but even to identify at-risk drinking is important in a primary care setting.

This is where we were working toward establishing or initiating the project that Evan was deciding to get started on the US Preventive Services Task Force published this in JAMA.

Amanda Balbi: To screen patients with HIV specifically, your patients completed the Alcohol Use Disorders Identification Test self-administered questionnaire. Why did you choose this questionnaire to use?

Trini Mathew: The AUDIT-2 has been internationally validated, including in the US, and was part of the World Health Organization’s evaluation.

Since 2001, we have been aware about this, and there is a manual for use in primary care settings. And this is a screening and brief intervention tool in primary care setting. It’s easy to administer, it can be a self-administered questionnaire, or it can be by a person asking a patient.

We had discussed about what the tools are available. I had already used the AUDIT screening tool in the past. As an infectious disease fellow, I'd explored incorporating AUDIT-2 in TB patients in Siberia, Russia, where I was doing my work with partners in health. So, I was familiar with the AUDIT tool, its validation processes, and how it can be used as a self-administered questionnaire.

We thought we can incorporate this within the workflow of patients coming to our clinic and get an understanding on what is our issue or what might be our patient population concerns related to at-risk drinking? Again, given my prior experiences utilizing the AUDIT tool and the ease that it can be easily incorporated in the ease of administering as a self-administered questionnaire, we decided to incorporate this as a systematic screening tool within our population.

Evan Brickner: Other tools exist outside the AUDIT tool. There's the abbreviated AUDIT-C, which I believe only has 3 or so questions. And there's also the CAGE Questionnaire, which is 4 general questions related to alcohol use.

The AUDIT tool is nice because it's a little bit longer. It’s a 10-question survey. But it touches on not only how much is somebody drinking or how often is somebody drinking, which is what the brief questionnaires address, but it also dives a little bit deeper and paints a bigger picture of how somebody might be using alcohol in a in a hazardous way.

So by having a 10-question questionnaire, you get a sense of not only how often and how much, but also to what extent might it be influencing somebody's life. Are there any additional dependency issues at play? And just painting a better picture about alcohol misuse.

Amanda Balbi: What was the impact of alcohol use disorder in HIV patients who were screened?

Trini Mathew: This is an ongoing work that we're doing. And we started also work with regard to addressing whether we could even screen for alcohol use disorder. We started off with incorporating the screening tool at the time of a clinic visit. We are still looking at follow-up and distributing this questionnaire repeatedly with each visit.

The process entails with, first of all, having the screening tool available at the time of registration when they were coming for in-patient visits. Subsequently, the patient receives the questionnaire and they'll sit out while they're in the waiting room, for example, waiting for the fellow and the faculty to start the visit. So, patients can provide the summary during the visit itself, and the scores can be tallied and the fellow and faculty can address that simultaneously, while they're at the visit.

Our study is more of a retrospective subsequent analysis based on, then, the AUDIT score and correlated CD4 count and HIV viral load that may be available at the time of the clinic visit. So, it's a longitudinal process that they looking at.

And Evan can describe further what are some of the challenges. But at this point, we have just done initial analysis that Evan can also speak to.

Evan Brickner: When I was kind of looking at the data analysis side of it and inserting all the numbers essentially as documents, as you were saying, patients would have completed an AUDIT form upon coming to their appointment.

And then whether or not they were high risk for hazardous drinking or not, the criteria we use was the criteria put forth by the National Institute on Alcohol Abuse and Alcoholism, which is itself a part of the Health and Human Services.

And so, for our study if a man in between the age of 18 and 60 scored 8 or higher, that would be considered a positive screen. If a man older than 60 or women of all ages screened above 4 or higher, then that would be considered at-risk drinking.

Those are the cutoff criteria that we used, because that's what it states in the clinician’s guide that we referenced, which is put together by the National Institute on Alcohol Abuse and Alcoholism and Health and Human Services.

So, if those scores were reached, it would be flagged as at-risk drinking, and then we would try to correlate the AUDIT form scores to their blood work, if their blood work was completed within one month of them filling out the AUDIT form.

Then we can try to see if there's any relationships between at-risk drinking and then health markers like CD4 count, HIV viral load, and a few other variables as well.

In terms of the results, the findings of this study, our initial hypothesis was that at-risk drinking would have no association with age, but would be associated with a decreased CD4 count and an increased HIV viral load.

Interestingly enough, it worked out to be a little bit different than that. We found a statistically significant relationship between at-risk drinking and age. People who screen positive for at-risk drinking were statistically more likely to be older. For example, at-risk drinkers, on average, were 54.93 years old or almost 55 years old, compared with their not-at-risk counterparts who are about 47.08 years old.

We got a statistically significant difference in terms of age, at-risk folks being much older in age. We did not find any statistically significant difference between CD4 count and viral load when it comes to looking at AUDIT scores of at-risk and not at-risk.

Amanda Balbi: How might your findings or initial findings inform clinical practice and how alcohol use disorder is screened in the future?

Trini Mathew: What's really important for us to understand is incorporating a screening tool—a systematic screening tool—within clinical practice. This can be incorporated with an EMR, and once that is incorporated, patients are able to themselves fill this questionnaire prior to the clinic visit.

I would like to pivot, a little bit, and incorporate the current scenario that we're working with, which is the COVID-19 pandemic. In-person clinic visits may not be feasible. However, during televisits, the screening tool, if incorporated within the EMR, is then available for both the patient and the provider to have a conversation about at-risk drinking.

I think what our study really poses a question is, “Can people utilize this tool in the current scenario that we're faced with?” And the answer is “yes.” We can incorporate this tool because always a hesitation by clinicians have been, “It's impossible to do everything within a brief clinic visit.”

And in a primary care setting, people are really having to address a lot of other factors that might be associated with poor outcomes in general. Having tool that's incorporated with an EMR is then available for both patient and provider to discuss at-risk drinking.

Our study shows that a systematic screening tool can be incorporated within a clinic visit. Of course, we were having an in-person visit, and now we have to work toward making sure it's incorporated/integrated with an EMR. And our hope is that this can be sustainable. Then, at that point, and that would be a goal to then analyze and look at and have conversations that the provider and the patient.

Evan Brickner: I think that’s well said. As Dr Mathew mentioned, unfortunately when the COVID-19 pandemic shut everything down in the initial phases back in March, it made it difficult, if not impossible, for patients to come in and fill out this form.

So, as Dr Mathew was saying, this study helps to lay the foundation in allowing the AUDIT tool to be converted into some sort of computerized format where patients can complete it online, or it can be all within a system in the patient's electronic medical record. Just trying to find ways to where we can ensure that it's able to be completed without necessarily sitting on the clinic day if not only to save time, but also to ensure that it's able to get completed. That's kind of one of the goals of the study as well, try to ease its accessibility and allowing patients to complete it electronically.

Also, the other thing I would mention is more broadly, just trying to help highlight the fact that alcohol excessive alcohol consumption is a pretty common problem amongst patients in general, but specifically also people with HIV. There have been studies to suggest that people with HIV might be at higher risk of substance abuse or substance use, and other potentially deleterious side effects. So just trying to identify a problem that's pretty common, but also pretty elusive. So, I think that if nothing else, the study helps to highlight that this is a pressing issue, and it should be on every questions radar, frankly.

Trini Mathew: I echo that. And as I mentioned, this is something that I've been working on for many years and incorporated within different clinics structure, both in the US as well as internationally. I was working with a group identifying alcohol use disorders in HIV population in a clinic setting in Mumbai, if that can be incorporated and addressing it. Similarly, also in TB patients.

Even just having a conversation on what is at-risk drinking, what is a standard drink, I think that's something a clinician sometimes are unaware about.

And again, I've been involved on this project—actually as part of its EMBARK project as part of his medical school’s research activities even to talk about what is a standard drink and to think about incorporating screening for alcohol use disorders within a clinic infrastructure within a framework of a clinical setting. I think that's really important.

What is important also is to address the impact of alcohol consumption, not just in HIV patients, but in non-HIV patients. As we know, studies have already been done about issues related to alcohol use disorders and its impact on medication adherence, impact on the immune system and immunosuppression that can be potentially harmful to a person.

Therefore again, as I highlighted the US Preventive Services Task Force 2018 recommendations came up with regard to screening for alcohol use disorders that needs to be incorporated in primary care settings, including as we have in our ID-fellows clinic.

So, I just want to emphasize that clinicians need to have conversations with their patients on what’s a standard drink and calculating that out, even just addressing it. For example, a can of beer is 12 oz, right? So these kind of things are important for us to talk about and bring it forward with each clinical encounter we have so that patients are able to think about whether they’re at-risk or not.

Amanda Balbi: Yeah, absolutely. To summarize, what would you say are the overall key take-home messages for clinicians today?

Trini Mathew: I think the key take-home messages are we are able to incorporate a systematic screening tool in a clinical infrastructure, a framework, as part of a clinic visit.

We embarked on the AUDIT tool, because actually it can be a self-administered questionnaire that patients are able to review and themselves answer. There's always hesitation by clinicians that patients may not be able to answer these questions. Our study just did delve into that and was able to show that patients are able to allow these questionnaires by themselves while they're waiting for an appointment to start while sitting in the waiting room, for example.

A systematic screening tool can help us understand over a period of time as a longitudinal process, having conversations. And I think that's feasible. So, clinicians are able to engage in conversations about alcohol use and at-risk use in a longitudinal manner.

Evan Brickner: I think that take-home message, I already talked about, trying to identify hazardous alcohol drinking, because it is ever-still present in our society today, particularly among certain patient populations. So not only trying to identify its presence but also trying to take the initial steps and lending some sort of support to patients who might be suffering from hazardous drinking or at-risk drinking themselves.

Some patients might be drinking excessively and not even realize it. As Dr Mathew was mentioning, some people might not even understand what it means to have a standard drink, whether that's 12 oz of beer, 5 oz of wine, or 1.5 oz of hard liquor. These sorts of conversations are important to helping promote overall patient health and well-being. And it's just one aspect of care, I think, that should be thought of when treating the whole patient.

Another take-home point could be the fact that at-risk drinking may be associated with older age. If there's any patients who are older age, that’s something else to consider.

Another point is that our study, we used the cutoff that we talked about with a score of 8 or higher for men under the age 60 and then score of 4 or higher for men older than 60 and women of all ages, highlighting that there are different cutoff points you can use based on what source you're using as your primary source.

I suspect that if we were to lower our cutoff even more, we would identify even more at-risk drinkers. In our study, we have the results here that mentioned that 10.5% of our patients that we looked at had what would be considered at-risk drinking from our studies. But if we were to lower the threshold, just a little bit, that number would go up even more.

Trini Mathew: I just want to add on that talking about lowering the cutoff score would [indecipherable 20:46], using a score of greater than or equal to 4, as opposed to 8 for men.

It could, of course, indicate some false positives. We know that with screening to [indecipherable 20:59] when you lower your threshold, your cutoffs, you might have more false positives.

But that would just be a chance for again a clinician to have conversation with the patient and talk about what is at-risk drinking, what is concerned, how many drinks a day or how many drinks a week is allowed to be then at-risk youth. So those are conversations to be had.

Again, if you lower a screening tool’s threshold cutoff, you may have more false positives that we know about with the performance characteristics of any screening tool or any screening test. We are aware about that, but that gives an opportunity for clinicians to have conversations with your patients.

And again, this is an ongoing study. So, this is something that we will continue to be incorporated and then continue to follow our study participants.

Amanda Balbi: Very well said. Thank you both for joining me today and answering all my questions.

Trini Mathew: Thank you, Amanda, for this opportunity to share our work.

Evan Brickner: Thanks, Amanda. It's been a pleasure.