To your health!

Liz Highleyman investigates the research to date on alcohol and HIV.

Most people can drink alcohol with few or no ill effects, but if used unwisely it can be a major cause of health and social problems, ranging from liver cirrhosis to motor vehicle accidents. In fact, alcohol causes more deaths in the UK - more than 9000 in 2008 - than any other drug except tobacco.

There is little evidence that light or occasional drinking is a major concern for most people with HIV. But alcohol has been linked to increased risk of HIV transmission, and it can contribute to poor adherence to antiretroviral therapy.

Who drinks?

By country, the UK has the eighth-highest alcohol consumption in the world¹: men drink about 15 units per week on average, whilst women drink ten units.² A unit is defined as 10ml or 8g of pure alcohol.

That’s less than you might think: half a small (175ml) glass of wine, a third of a pint of beer (at 5 or 6% alcohol, as many lagers typically are now), or a single pub measure of spirits.The NHS recommends that men should not exceed three to four units per day on a regular basis and women should not exceed two to three units per day on a regular basis. That’s, respectively, about a pint of beer and a medium glass of wine a day – not what a lot of people think of as excessive.

Heavy alcohol use and binge drinking, or consuming a large amount at one time, are common. A recent study in Chester, Liverpool and Manchester found that one in seven men and one in 25 women said they intended to consume more than 40 units (equivalent to about twelve pints of beer) during their evening out.³

Several UK and US studies indicate that HIV-positive people are more likely to drink heavily, and to be classified as having an alcohol problem. Looked at from the other direction, people with problematic alcohol use (such as clients of rehabilitation programmes) are more likely to have HIV. Rates of alcohol use are high amongst several groups at particular risk of HIV, including young people, injecting drug users, gay men and African immigrants.

It is hard to verify whether gay men tend to drink more or less than heterosexual men as most large surveys have not asked about sexual orientation, but one UK survey found that 85% of gay men drank alcohol during the past year and 11% were concerned about their drinking.⁴ A 2001 survey of gay and bisexual men in four large US cities produced strikingly similar results: 85% used alcohol and 8% reported heavy or frequent use.⁵

A recent survey, spearheaded by the Black Health Agency, of 40, mostly heterosexual, HIV-positive African men and women living in the north of England found that about one-third drank alcohol more than four times a day, with some men consuming 10 to 15 cans of beer in an evening.⁶ Depression, a desire to forget about issues like being HIV-positive or lack of legal immigration status, financial issues and loneliness were cited as key reasons why people drank.

Alcohol and HIV transmission

Alcohol use can lead to a higher risk of HIV transmission. Research looking at both gay men and heterosexual men and women has shown that people who drink more tend to have more sexual partners, on average, and are less likely to use condoms. That doesn’t mean that alcohol causes you to have sex. It may make you less careful as well as less choosy, though. This may particularly apply to women and, in some circumstances, gay men; alcohol-impaired sexual performance may be less of an issue (and more of a cause of vulnerability, because while many think drunk men are best avoided, men may regard drunk women as targets).

How much you drink at one sitting appears to be a bigger risk factor than frequency of drinking. One US study found that HIV-negative gay and bisexual men who reported heavy alcohol use during the past six months or binge drinking right before or during sex were more likely to engage in unprotected anal intercourse with an HIV-positive partner or with a partner whose HIV status was unknown to them.⁷

Another US study found that women who reported binge drinking were twice as likely as other women to have multiple sexual partners, three times more likely to report having anal sex and five times more likely to be diagnosed with gonorrhoea.⁸

Alcohol is linked to risky sexual behaviour worldwide.⁹ What's more, drinking and sex - especially commercial sex - often take place in the same venues. Alcohol increases the likelihood of sexual violence and non-consensual sex and, for women, drinking can increase vulnerability to sexual victimisation.

The Black Health Agency survey suggested that drinking is associated with risky sexual behaviour amongst HIV-positive Africans, a particular concern since more than half had not disclosed their status to their regular partner.

"Alcohol and passion may not present the most favourable ground for clear thinking, better condom use and sexual equality in power decisions regarding sex," understates Gertrude Anyango-Wafula, the BHA's co-ordinator for HIV and sexual health services.

According to Sigma Research, most gay men said they drink alcohol to relax, to be more sociable, to boost their confidence, and to escape temporarily stress and worries. Others said drinking helped them overcome their inhibitions and made them more sexually adventurous. HIV-positive men also said alcohol helped them deal with feelings of isolation and concerns about disclosing their status.

Alcohol may make cells more susceptible to HIV infection…but it is not clear whether alcohol directly raises viral load, lowers CD4 cell counts or speeds up HIV disease progression, since laboratory and animal studies have produced mixed findings.

People may simply forget to practise safer sex when drinking, but more complex psychological processes are probably involved. People who are under the influence may give more weight to their immediate desires and feelings and less to negative future consequences - so-called ‘alcohol myopia’.¹⁰An alternative explanation is that some people have what have been called ‘type T’ (for thrill-seeking) personalities that predispose them to seek sensation and take chances, which can include both risky substance use and risky sex.

Seth Kalichman, from the University of Connecticut, and his co-workers found that sensation-seeking predicts HIV risk behaviour and alcohol use in studies conducted amongst both gay men in the US¹¹ and heterosexual men and women in South Africa.¹² "Men are more likely to drink and engage in higher risk behaviour whereas women's risks are often associated with their male sex partners' drinking," they concluded.

Health consequences

Alcohol affects every organ and system in the body from the brain, to the digestive system, to the skin and bones.

Alcohol and HIV

Light or moderate drinking does not appear to be harmful for most people with HIV unless they have other medical conditions such as hepatitis. But there is some evidence that heavy use may contribute to HIV disease progression.

Alcohol suppresses the activity of some defensive immune cells, which may explain why chronic heavy drinkers get more infections such as pneumonia. At the same time, alcohol promotes overall immune activation and inflammation - factors suspected of playing a role in non-AIDS-defining conditions such as cardiovascular disease amongst people with HIV.

Alcohol may make cells more susceptible to HIV infection, and increased immune activation and higher inflammatory cytokine (chemical messenger) levels can trigger HIV replication. But it is not clear whether alcohol directly raises viral load, lowers CD4 cell counts or speeds up HIV disease progression, since laboratory and animal studies have produced mixed findings.

Two studies involving monkeys found that the monkeys given alcohol developed viral loads that were 64 to 85 times higher in early infection in the blood and, in the first study, in the brain.^{21, 22} A later follow-up found that monkeys given alcohol at levels equivalent to binge-drinking progressed to AIDS more rapidly, in an average time of 374 days compared with 900 days for the non-alcohol group.²³

Turning to humans, most studies that have reported less robust viral load suppression or CD4 cell recovery amongst alcohol users have not adequately controlled for adherence, illegal drug use or other confounding factors.

There are some studies which have, though. Researchers looking at 1433 HIV-positive people seen at an urban clinic found that heavy alcohol use was associated with less viral load suppression after accounting for illegal drug use and poorer adherence.²⁴

Similarly, amongst 1691 participants in the US Women's Interagency HIV Study, both heavy alcohol use and crack cocaine independently predicted disease progression while on treatment, even after taking adherence differences into account.²⁵

A team in Boston found that amongst 595 HIV-positive people from two cohorts followed for up to seven years, heavy alcohol use was associated with a lower CD4 cell count only amongst untreated individuals – and there were no notable differences in CD4 count or viral load amongst people on antiretroviral therapy. This study suggests that adherence is not the only reason alcohol has an effect on disease progression. Untreated heavy drinkers had an average CD4 count of about 50 cells/mm³ less than teetotallers. CD4 cell percentages were similar, suggesting that alcohol had an effect not only on CD4 T-cells but on lymphocytes overall.

A recent study of more than 200 participants in Miami, HIV-positive people who drank two or more ‘standard drinks’ per day (that’s just one-and-a-quarter pints of UK pub-strength lager) were nearly three times more likely to see their CD4 cell count fall below 200 cells/mm³ than teetotalers, and drinkers not on ARVs had more than a sevenfold risk.²⁶ The researchers concluded that alcohol may have direct effect on CD4 count, while its effect on viral load was due reduced adherence.

These findings imply that heavy drinkers might need to start antiretroviral therapy sooner after infection because they lose CD4 cells faster. But the researchers emphasised that the effect of alcohol was modest and was not apparent for people on treatment, perhaps because the large benefit of therapy overshadows the smaller detrimental effect of alcohol.

Alcohol, HIV treatment and adherence

Research shows that people with alcohol problems are less likely to get tested for HIV and slower to seek care after testing positive, but it is difficult to tease out the influence of alcohol versus co-existing factors like illegal drug use, poverty and mental illness.

Alcohol has not been shown to interact in any major way with antiretroviral medications. But heavy drinking - and liver damage caused by chronic heavy use - can potentially interfere with enzymes in the liver that process certain drugs, including protease inhibitors. Heavy drinkers and people with liver damage are also more susceptible to drug-related liver toxicity.

Drinking quantity, more than frequency of drinking, is associated with non-adherence. Christian Hendershot

Alcohol can react badly with some medications used to treat opportunistic infections (for example, rifampicin and metronidazole). It also can interact dangerously with drugs for non-HIV-related conditions; using alcohol with sedatives or illegal narcotics can cause slowed breathing and heart rate and even cause coma or death. Paracetamol (acetaminophen) can cause liver damage when combined with even a small amount of alcohol, as can the TB drug isoniazid. Consult your clinic or a pharmacist about whether it is safe to drink whenever you are prescribed new drugs.

HIV treatment can only work if it is taken properly. If a bout of drinking leads to vomiting, it may be necessary to repeat a dose (generally if vomiting occurs within an hour of taking it).

Considerable research shows that alcohol use, especially binge drinking, increases the likelihood of poor adherence to HIV treatment. One study found that binge drinkers and heavy drinkers more often reported poor adherence due to forgetting or running out of medications.²⁷A meta-analysis of 40 studies looking at the link between alcohol and adherence found that people who drank alcohol were approximately 50% - and heavy drinkers 60% - less likely to be classified as adherent.²⁸

"Drinking quantity, more than frequency of drinking, is associated with non-adherence," said lead author, Christian Hendershot.

This supports prior research showing that alcohol seems to have more effect on adherence in women. A 2007 study, for example, found that alcohol use predicted decreased adherence amongst women, but not men.²⁹

HIV psychology researcher Seth Kalichman has uncovered another reason for reduced adherence.³⁰

"It is common for people to believe that they should not mix their medications with alcohol," he told HTU. "We have found that some people will stop taking their medications if they are drinking because they believe they should not mix them."

Kalichman and others^{31, 32} have shown that tailored alcohol interventions for people with HIV can be effective, both in industrialised countries and in Africa. Successful programmes not only help people reduce problem drinking, but also decrease high-risk sex and drug use behaviours and improve treatment adherence and response.

The good news is that most research has not shown that moderate drinking worsens HIV disease progression or interferes with treatment response. But studies focused on heavy drinking amongst socially marginalised groups have not really looked at the effects of typical social drinking within the larger HIV-positive population: problem drinking is often lumped in with other kinds of substance use, whilst moderate drinking receives little attention. Sigma’s Wasted Opportunities report³³ found that most gay men with problem alcohol use did not consider themselves alcoholics and only a minority sought help from social or health services. Healthcare providers may need to be more proactive in asking patients about how drinking affects their lives.

Alcohol use is an important consideration for people with HIV and warrants more awareness in both research and clinical practice.

Getting help

There is plenty of help available if you think you have an alcohol problem - or simply want to cut back on the amount you drink.

Talk to the healthcare team at your clinic. There are some services specifically for gay men and other people affected by HIV. Support groups such as Alcoholics Anonymous are available in most areas.

More information on alcohol, and on cutting down, is available from NHS Choices at www.drinking.nhs.uk or from Drinkline on 0800 9178282. Other useful contacts can be found at www.drinking.nhs.uk/more-information/useful-contacts/.