Intentional Non-Adherence to Medications among HIV Positive Alcohol Drinkers: Prospective Study of Interactive Toxicity
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BACKGROUND: Antiretroviral therapy (ART) adherence is key to successful treatment of HIV infection and alcohol is a known barrier to adherence. Beyond intoxication, ART adherence is impacted by beliefs that mixing alcohol and medications is toxic. PURPOSE: To examine prospective relationships of factors contributing to intentional medication nonadherence when drinking. METHODS: People who both receive ART and drink alcohol (N=178) were enrolled in a 12-month prospective cohort study that monitored beliefs about the hazards of mixing ART with alcohol (interactive toxicity beliefs), alcohol consumption using electronic daily diaries, ART adherence assessed by both unannounced pill counts and self-report, and chart-abstracted HIV viral load. RESULTS: Participants who reported skipping or stopping their ART when drinking (N=90, 51 %) demonstrated significantly poorer ART adherence, were less likely to be viral suppressed, and more likely to have CD4 counts under 200/cc3. Day-level analyses showed that participants who endorsed interactive toxicity beliefs were significantly more likely to miss medications on drinking days. CONCLUSIONS: Confirming earlier cross-sectional studies, the current findings from a prospective cohort show that a substantial number of people intentionally skip or stop their medications when drinking. Interventions are needed to correct alcohol-related interactive toxicity misinformation and promote adherence among alcohol drinkers.
KEY WORDS: medication adherence; alcohol use; HIV treatment beliefs. J Gen Intern Med 28(3):399–405 DOI: 10.1007/s11606-012-2231-1 © Society of General Internal Medicine 2012
ART depend closely on treatment adherence, with all ART regimens requiring at least 85 % adherence.1,2 Among the known impediments to medication adherence is alcohol use.3 Studies demonstrate that individuals who take ART and drink alcohol experience more missed doses, medication lapses, and HIV treatment failure.3,4 Most studies of alcohol’s effects on medication adherence have focused on alcohol-induced cognitive impairments.3,5,6 More recently, studies have suggested that as many as one in four patients who take ART and drink alcohol intentionally stop taking their medications when they are drinking.7,8 Although alcohol use can contribute to liver damage in people coinfected with HIV and Hepatitis C virus,5 there is no evidence that the hepatotoxicity of alcohol is amplified in combination with ART.9–11 Beliefs that mixing medications with alcohol results in a toxic blend (i.e., alcohol– ART interactive toxicity beliefs) are associated with poor treatment adherence, even to a greater extent than alcohol use itself.8 The current study was conducted to further examine alcohol–ART interactive toxicity beliefs and behaviors among drinkers who are currently treated with ART. We used a prospective study design to simultaneously examine adherence and drinking among persons who hold alcohol– ART interactive toxicity beliefs. Our aim was to test the following three hypotheses: (a) alcohol–ART interac
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