Reducing Alcohol Use Among Patients With HIV-HCV Coinfection
In this podcast, Megan Pinkston-Camp, MA, PhD, talks about whether a “brief advice about drinking” intervention or a “motivational interview" intervention could help reduce alcohol use among patients with HIV and hepatitis C virus—a high-risk group for liver disease progression and liver cancer.
- Stein MD, Herman DS, Kim HN, et al. A randomized trial comparing brief advice and motivational interviewing for persons with HIV-HCV co-infection who drink alcohol. AIDS Behav. Published online October 12, 2020. https://doi.org/10.1007/s10461-020-03062-2
Megan M. Pinkston-Camp, MA, PhD, is a clinical psychologist at Lifespan Health System and an assistant professor in the Department of Psychiatry and Human Behavior and Department of Medicine at Warren Alpert Medical School of Brown University in Providence, Rhode Island.
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.
It is well known that alcohol consumption leads to the progression of liver disease in patients with HIV and hepatitis C virus (or HCV). However, alcohol interventions have never addressed low levels of alcohol use in this population. In a new study, a team of researchers aimed to compare brief advice and motivational interviewing in reducing the use of alcohol among patients with HIV-HCV coinfection.
My guest today is the lead author of the study, Dr Megan Pinkston-Camp, who is a clinical psychologist at Lifespan Health System and an assistant professor in the Department of Psychiatry and Human Behavior and Department of Medicine at Warren Alpert Medical School of Brown University in Providence, Rhode Island.
Thank you for joining me today, Dr Pinkston-Camp. For your study, you and your colleagues investigated whether even low levels of alcohol consumption could lead to increased liver disease in this population. Can you tell us more about how did this objective come about?
Megan Pinkston Camp: Sure. At the time when we were writing up this grant with my colleague Dr Michael Stein, it was at this exciting time before direct antiviral agents were available. So, we were still kind of in the era of interferon treatment. We were looking at this population that is most vulnerable to liver disease, progression of fibrosis, and it's these layers of insult to the liver from one being the hepatitis C infection.
Furthermore, we know that the combination of HIV on top of hep C also causes the progression of this liver disease. And then on top of this, we knew that within this population, they have higher rates of drinking among hepatitis C mono-infected as well as coinfected populations. We knew, therefore, that it was important to attend to the alcohol use in this population.
At the time, the majority of research was focused on individuals who endorsed drinking at high levels of drinking, whether it's problematic drinking or binge-level drinking. So, already we knew that at these hazardous levels of drinking, it was imperative to intervene and help individuals with their alcohol use.
What also started to come out through the research is these findings that even individuals at low levels of reported drinking were having fibrosis. They were showing levels of damage to the liver almost similarly to people with these hazardous levels of drinking.
Therefore, we started to think “Why are we just talking to people who are endorsing high levels of drinking? What if we were to also include these individuals at low levels of drinking?”
The other important piece is whenever we're talking about research findings, we have to be thoughtful about social desirability. We have to be thoughtful that individuals may underreport the amount of alcohol use that they are reporting, especially with any clinical context.
Before this time, many patients were reporting that they felt fearful to even report their alcohol use to their providers, because at one point, they were being held back from getting hepatitis C treatments because they endorsed drinking alcohol.
So, you had a population that was already vulnerable to minimize the amount that they were drinking. Therefore, we may not have even been touching on these individuals who may have reported low-level drinking but were in fact drinking higher levels.
So therefore, there are two pieces. One is that we were getting this large amount of information kind of spilling in that was informing medical practice that was saying, “Anybody with hepatitis C, and anybody with coinfected HIV and hepatitis C, should not be drinking at all.” We were starting to see that even low levels of drinking were harmful.
And then we have the social desirability piece where we were being thoughtful that some people may have underreported the amount that they were drinking. It really kind of rose up from those 2 pieces to highlight the importance of we needed to intervene on drinking at every level across the spectrum and not just target those individuals at hazardous levels of drinking.
Amanda Balbi: Participants in your study were consuming at least 4 alcoholic beverages weekly and were enrolled in either a “brief advice about drinking” arm or a “motivational intervention” arm. Can you tell us more about these interventions?
Megan Pinkston Camp: We had this intervention with brief advise where every single person enrolled in our study got the brief advice script, which was delivered by an HIV care provider or infectious disease physician to the patient.
This was an opportunity across both conditions for the participant to hear this information from a care provider, from a physician. Then, following the this, the participants will randomize to one of two conditions. In one case, they were randomized to have brief advice. The same script that was read to them by HIV care provider was then given to them every 3 months for 18 months.
This was delivered over the phone. So, this is a 2-minute, if that, intervention that was a standardized script that read:
“Hepatitis C may have caused some damage to your liver, even if you've been treated. Having HIV and hepatitis C plus drinking alcohol is a risky combination. Drinking alcohol increases the chance of scarring the liver, called cirrhosis, and the risk of developing liver cancer. There is no safe level of drinking with HIV and hep C, and we recommend that you stop drinking all alcohol or use as little as you possibly can.”
So that script was read to participants every 3 months up to 18 months. That was a brief advice. There was no other part to that, except for reading that script.
The other intervention: the participant goes in, has that script read to them, and then if they're randomized into the motivational intervention, then they similarly receive 6 visits over the phone that were delivered at every 3 months up to 18 months.
These were delivered by psychologists and in a way that had components of motivational interviewing, as well as cognitive behavioral relapse prevention skills. I can give a little picture of what this may have looked like.
For the motivational intervention, in the very first session, the psychologist is sitting down with the participants, and they begin by having a conversation about what is most important to this person in their life. They start talking about values and explore those things that are very important to the person. This could range from what relationships look like, what hobbies look like, what goals that person has in their life, what our spirituality looks like. So really getting to know the person on a very individual and value-driven basis.
And then what you do is you take that person's values and you raise awareness about a person's drinking by asking a simple question of, “I'm wondering how alcohol use has helped you live a life that is in line with these things that are important to you.”
And then you start to create a dialogue around how alcohol abuse has either created a barrier to living the life that the person wants or perhaps in a different way. We really explore and look at those things as how alcohol has caused concerns for the person. That's maybe 20 minutes.
The brief intervention, 20 minutes, and it's much more looking at an individual level—the components for why a person is drinking or why the drinking is not in line with their stated values.
From there, what you do is you work with the person on where they are with their alcohol use and explore other changes they want to make with our alcohol use. If there were changes that they wanted to make, then a change plan was developed. That change plan was very specific to help the person be successful in making changes that they had.
We also approached this study on a broader level in that we did not make it out to be a study that said, “You have to want to make changes in your alcohol.” We were ready to meet with individuals who were not ready to make changes.
We were careful about this because, again, we were thinking about the range of people we were including in this study in that we had people who were at low levels of drinking and may not have wanted to change their drinking. That was okay.
We wanted to move at a pace that the person was ready to talk about their drinking. The other unique thing about this is that we followed them over 18 months.
So, with so with the motivational interviewing piece, you had the first anchored visit where the person met with us or met with a psychologist and really drilled down on what was most important to them, how alcohol use was keeping them from living a life that was in line with their values, and then worked to develop a plan that felt achievable for possibly making changes.
If the person was not in a place of wanting to make changes in their alcohol use, then we talked openly about other life changes that the person was interested in making and helped them make a change plans, wherever that person was.
Then we had the follow-up visits with them and the motivational sessions. What we did for each one of these was every 3 months, we would check in and kind of review how the past 3 months have been, how has their alcohol use been, how has their health been.
Also, we talked about how they were doing with getting treated for hepatitis C, because, again, this was important. “How are we helping these people get engaged in their care?” We followed up on those important things.
Then we just continued to anchor back to that very first important visit where we talked about what was most important to each individual, checked in about those relationships, checked in about their health, and then kept going back to how alcohol is in line with these to see if we can highlight some meaningful reasons for change.
Amanda Balbi: Overall, participants in the motivational intervention arm had larger reductions in alcohol use days than those in the brief advice arm at all follow-up assessments. How does this finding inform clinical practice?
Megan Pinkston Camp: That's a great question. What we found is that we saw these decreases in alcohol use across both interventions, whether they were in the brief advice or whether they were in the motivational intervention.
We also saw that within the “brief advice” that as we got to the 9-month time point that we started to see the drinking start to come back up, which is where we started to see the difference in the change that the motivational intervention started to have more impact on the reduction in drinking.
What we can take from this for clinical practice is it's important to note that continuous discussion, consistent discussion is important. It can cause discussions to happen. It can create greater dialogue with our patients to let them know that we are giving them brief advice. It doesn't take a lot of effort. It doesn't take a lot of time, and it shows our patients that we are being thoughtful about these risk factors for more damage to liver function.
What it means is that a small dose can cause change. Even if we just did the brief advice, we could take it one step further as clinicians. As clinicians, we know our patients well. We know what is important to them. So, with the motivational session, it may mean just taking it a step further and saying, “I'm wondering how the alcohol use is impacting your relationship with your kids, is impacting your health right now?”
So, it's just taking the motivation for change to a level where it becomes more intrinsic for the person to consider change. It's important that we are always thoughtful. As clinicians, we get very busy. Yet to know that we have these very simple brief interventions that may induce change is powerful and may induce change even in people who are underreporting their alcohol use. So, it highlights that discussion with our patients.
Amanda Balbi: Your study only enrolled 110 participants, which is a small sample size. What limitations or challenges arise when examining a small sample like this one?
Megan Pinkston Camp: Yes. This is an important question that is throughout the history of research in health care and prevention that small sample size can definitely cause concerns with how we interpret findings. What we have to be thoughtful about is if we have a small sample size, we run the risk of having a type 2 error or suggesting that we have clinically relevant results.
Because we don't have enough power necessarily to say that our findings are clinically meaningful. We cautioned, as we wrote this up, that we had some findings were it suggested that definitely brief advice, similar to other, does induce change and does contribute to drinking changes in individuals with coinfection.
So, we do know that. And then we also did see that some that individuals who were engaged in the motivational intervention that have greater decreases in their drinking, we have to also caution all of these results because of the fact that we had a small sample size. And that just is a statistical thing that happens in that we have to just be thoughtful about where we take these findings.
Amanda Balbi: What is the next step in this research?
Megan Pinkston Camp: I know that researchers, clinicians, everybody continues to have passion about drilling down in this population that is the most vulnerable. We think about HIV-HCV coinfected patients are the highest risk for continued damage to their liver, as well as risk of cancers behind drinking and just having HIV infection and hepatitis C infection. So, we are always thoughtful about what can we do next to help this most vulnerable population.
We know now as we continue to grow down on this is that individuals who continue to drink are less likely to engage in HIV care. By doing so, that limits their ability to get referred for hepatitis C treatment.
Where the research also is going is looking at how do we get these individuals who are not engaging in HIV care—how do we reach these individuals? Perhaps, that means reaching them and other locations.
We know that a lot of people are reaching to individuals in other settings. Perhaps it is the methadone clinics. One of our other investigators on this study, that's what she does—reaches these individuals within different settings.
Because we have such amazing treatments for hepatitis C today, the more we can get people on treatment, the more likely we can help heal their livers. I really think it's driven by continuing to work with this very vulnerable population that we often have to view now in this endemic framework, thinking about other comorbidities and how do we really continue to reach them and get them engaged in care.
Amanda Balbi: Thank you so much for speaking with me today, Dr Pinkston-Camp.
Megan Pinkston Camp: Thank you so much for having me. I really appreciated this and want to give thanks to all the participants who participated in this study. I also want to give thanks out to all of my colleagues, so of course the NPI on the study with me, which is Dr Michael Stein, other colleagues and coinvestigators including Dr Deborah Herman, Dr Nina Kim, Dr Lynn Taylor. So appreciative of all of their guidance on this and contributions and of course all the research assistants from the 3 different sites included on this study and the therapist. Thank you so much.