Reducing hazardous alcohol use and optimizing treatment as prevention among men living with HIV in risk environments

PROJECT SUMMARY Heavy and hazardous alcohol use is inextricably linked to the HIV epidemic in fishing communities on Lake Victoria in Uganda. Among men living with HIV (LWH) in fishing communities, hazardous alcohol use is associated with suboptimal antiretroviral (ART) adherence and engagement in HIV care. Fishing communities are “risk environments'' with limited access to health services and norms reinforcing risky behavior. Contextually appropriate evidence-based interventions that address these issues in tandem among men LWH in fishing communities are urgently needed to ensure optimization of treatment as prevention. We developed Kisoboka (“It is Possible'') a behavioral intervention with a structural element to “reduce cash in the pocket" otherwise easily accessible for alcohol purchase. Kisoboka utilizes a behavioral economics (BE) approach and motivational interviewing (MI) to reduce hazardous drinking and improve ART adherence to achieve undetectable HIV viral load (VL). In the pilot RCT of the Kisoboka intervention, it demonstrated preliminary efficacy in reducing AUDIT- C scores and phosphatidylethanol (PEth) levels among the very hazardously drinking sample and a protective effect on ART adherence through 6-month follow-up. To inform future scale-up, we propose a factorial RCT (n=716) to test intervention efficacy and determine if effects are attributable to specific intervention components. Specific aims are: (1) Determine the efficacy of the Kisoboka intervention and its components among hazardously drinking men LWH in Uganda in a 2x2 factorial RCT. Arm 1: The Kisoboka intervention (BE+MI); Arm 2: the behavioral economic component of Kisoboka (BE); Arm 3: the MI-based alcohol reduction and ART adherence counseling component of Kisoboka (MI); and Arm 4: alcohol screening, referral, and brief intervention. Primary outcomes assessed at baseline, 6-, and 12-month follow-up include: PEth (alcohol biomarker), a combined AUDIT-C score—PEth outcome for hazardous drinking, HIV viral load, and ART adherence via biomarker. (2) Assess the impact of the Kisoboka intervention and its components on measures of psychological, physical, and socioeconomic well-being that capture frequent comorbidities of persons LWH and that are associated with achieving successful treatment as prevention. (3) Guided by the Exploration, Preparation, Implementation and Sustainment framework, engage key health sector stakeholders to understand barriers and facilitators in the inner and outer context and assess intervention and implementation costs for implementing Kisoboka components within the routine clinical setting to inform future widespread implementation. If effective, Kisoboka, or its components, will be poised for dissemination and scale-up, supporting treatment as prevention goals among a high-risk population and as one of a limited number of evidence-based HIV alcohol interventions in this setting.